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

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

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

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

https://policybase.cma.ca/en/permalink/policy10045
Last Reviewed
2019-03-03
Date
2010-12-04
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2010-12-04
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association (CMA) has always recognized the unique requirements of those individuals suffering from a terminal illness or chronic disease for which conventional therapies have not been effective and for whom cannabis may provide relief. However, there are a number of concerns, primarily related to the limited evidence to support many of the therapeutic claims made regarding cannabis for medical purposes, and the need to support health practitioners in their practice.1,2,3,4 While the indications for using cannabis to treat some conditions have been well studied, less information is available about many potential medical uses. Physicians who wish to authorize the use of cannabis for patients in their practices should consult relevant CMPA policy5 and guidelines developed by the provincial and territorial medical regulatory authorities to ensure appropriate medico-legal protection. The CMA’s policy Authorizing Marijuana for Medical Purposes6, as well as the CMA’s Guidelines For Physicians In Interactions With Industry7 should also be consulted. The CMA makes the following recommendations: 1. Increase support for the advancement of scientific knowledge about the medical use of cannabis. The CMA encourages the government to support rigorous scientific research into the efficacy for therapeutic claims, safety, dose-response relationships, potential interactions and the most effective routes of delivery, and in various populations. 2. Apply the same regulatory oversight and evidence standards to cannabis as to pharmaceutical products under the Food and Drug Act, designed to protect the public by the assessment for safety and efficacy. 3. Increase support for physicians on the use of cannabis for medical purposes in their practice settings. As such, CMA calls on the government to work with the CMA, The College of Family Physicians of Canada, the Royal College of Physicians and Surgeons, 2 and other relevant stakeholders, to develop unbiased, accredited education options and licensing programs for physicians who authorize the use of cannabis for their patients based on the best available evidence. Background In 2001, Health Canada enacted the Marihuana Medical Access Regulations (MMAR). These were in response to an Ontario Court of Appeal finding that banning cannabis for medicinal purposes violated the Charter of Rights and Freedoms.8 The MMAR, as enacted, was designed to establish a framework to allow legal access to cannabis, then an illegal drug, for the relief of pain, nausea and other symptoms by people suffering from serious illness where conventional treatments had failed. While recognizing the needs of those suffering from terminal illness or chronic disease, CMA raised strong objections to the proposed regulations. There were concerns about the lack of evidence on the risks and benefits associated with the use of cannabis. This made it difficult for physicians to advise their patients appropriately and manage doses or potential side effects. The CMA believes that physicians should not be put in the untenable position of gatekeepers for a proposed medical intervention that has not undergone established regulatory review processes as required for all prescription medicines. Additionally, there were concerns about medico-legal liability, and the Canadian Medical Protective Association (CMPA), encouraged those physicians that were uncomfortable with the regulations to refrain from authorizing cannabis to patients. Various revisions were made to the MMAR, and then these were substituted by the Marihuana for Medical Purposes Regulations (MMPR) in 2013/ 2014 and subsequently by the Access to Cannabis for Medical Purposes Regulations (ACMPR) in 2016 and now as part of the Cannabis Act (Section 14)9. Healthcare practitioners that wish to authorize cannabis for their patients are required to sign a medical document, indicating the daily quantity of dried cannabis, expressed in grams. For the most part, these revisions have been in response to decisions from various court decisions across the country.10,11,12 Courts have consistently sided with patients’ rights to relieve symptoms of terminal disease or certain chronic conditions, despite the limited data on the effectiveness of cannabis. Courts have not addressed the ethical position in which physicians are placed as a result of becoming the gate keeper for access to a medication without adequate evidence. The CMA participated in many Health Canada consultations with stakeholders as well as scientific advisory committees and continued to express the concerns of the physician community. As previously noted, the Federal government has been constrained by the decisions of Canadian courts. 3 The current state of evidence regarding harms of cannabis use is also limited but points to some serious concerns. Ongoing research has shown that regular cannabis use during brain development (up to approximately 25 years old) is linked to an increased risk of mental health disorders including depression, anxiety, and schizophrenia, especially if there is a personal or family history of mental illness. Long term use has also been associated with issues of attention, impulse control and emotional regulation. Smoking of cannabis also has pulmonary consequences such as chronic bronchitis. It is also linked to poorer pregnancy outcomes. Physicians are also concerned with dependence, which occurs in up to 10% of regular users. From a public and personal safety standpoint, cannabis can impact judgement and increases the risk of accidents (e.g. motor vehicle incidents). For many individuals, cannabis use is not without adverse consequences.3,13,14 Pharmaceutically prepared alternative options, often administered orally, are also available and regulated in Canada.15 These drugs mimic the action of delta-9-tetra-hydrocannabional (THC) and other cannabinoids and have undergone clinical trials to demonstrate safety and effectiveness and have been approved for use through the Food and Drug Act. Of note is that in this format, the toxic by-products of smoked marijuana are avoided.16 However, the need for more research is evident. Approved by the CMA Board in December 2010. Last reviewed and approved by the CMA Board in March 2019. References 1 Allan GM, Ramji J, Perry D, et al. Simplified guideline for prescribing medical cannabinoids in primary care. Canadian Family Physician, 2018;64(2):111-120. Available: http://www.cfp.ca/content/cfp/64/2/111.full.pdf (accessed 2019 Jan 8). 2 College of Family Physicians of Canada (CFPC). Authorizing Dried Cannabis for Chronic Pain or Anxiety: Preliminary Guidance. Mississauga: CFPC; 2014. Available: https://www.cfpc.ca/uploadedFiles/Resources/_PDFs/Authorizing%20Dried%20Cannabis%20for%20Chronic%20Pain%20or%20Anxiety.pdf (accessed 2019 Jan 8). 3 The National Academies of Sciences, Engineering and Medicine. The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. Washington, DC: National Academies Press; 2017. 4 Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA 2015;313(24):2456-73. 5 Canadian Medical Protective Association (CMPA). Medical marijuana: considerations for Canadian doctors. Ottawa: CMPA; 2018. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2014/medical-marijuana-new-regulations-new-college-guidance-for-canadian-doctors (accessed 2019 Jan 8). 6 Canadian Medical Association (CMA). Authorizing marijuana for medical purposes. Ottawa: CMA; 2014. Available: https://policybase.cma.ca/en/permalink/policy11514 http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-04.pdf (accessed 2019 Jan 8). 7 Canadian Medical Association. (CMA) Guidelines for Physicians In Interactions With Industry. Ottawa: CMA; 2007. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD08-01.pdf. (accessed 2019 Jan22). 4 8 R. v. Parker, 2000 CanLII 5762 (ON CA). Available: http://canlii.ca/t/1fb95 (accessed 2019 Jan 8). 9 Cannabis Act. Access to Cannabis for Medical Purposes. Section 14. 2018. Available: https://laws-lois.justice.gc.ca/eng/regulations/SOR-2018-144/page-28.html#h-81 (accessed 2019 Jan 8). 10 Hitzig v. Canada, 2003 CanLII 3451 (ON SC). Available: http://canlii.ca/t/1c9jd (accessed 2019 Jan 8). 11 Allard v. Canada, [2016] 3 FCR 303, 2016 FC 236 (CanLII), Available: http://canlii.ca/t/gngc5 (accessed 2019 Jan 8). 12 R. v. Smith, 2014 ONCJ 133 (CanLII). Available: http://canlii.ca/t/g68gk (accessed 2019 Jan 8). 13 Volkow ND, Baler RD, Compton WM, Weiss SRB. Adverse health effects of marijuana use. N Engl J Med. 2014;370(23):2219–2227. 14 World Health Organization. The health and social effects of nonmedical cannabis use. Geneva: World Health Organization; 2016. Available: https://www.who.int/substance_abuse/publications/msbcannabis.pdf (accessed 2019 Jan 8). 15 Ware MA. Is there a role for marijuana in medical practice? Can Fam Physician 2006;52(12):1531-1533. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1952544/pdf/0530022a.pdf (accessed 2019 Jan 8). 16 Engels FK, de Jong FA, Mathijssen RHJ, et.al. Medicinal cannabis in oncology. Eur J Cancer. 2007;43(18):2638-2644. Available: https://www.clinicalkey.com/service/content/pdf/watermarked/1-s2.0-S0959804907007368.pdf?locale=en_US (accessed 2019 Jan 8).
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CMA Letter to the Legislative Committee on Bill C-30: Clean Air Act

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

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

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

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

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

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

https://policybase.cma.ca/en/permalink/policy9837
Last Reviewed
2018-03-03
Date
2010-07-13
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2010-07-13
Topics
Health systems, system funding and performance
Text
Canada's prized Medicare system is facing serious challenges on two key fronts: in meeting the legitimate health care needs of Canadians and in being affordable for the public purse. The founding principles of Medicare are not being met today either in letter or in spirit. Canadians are not receiving the value they deserve from the health care system. In both 2008 and 2009, the Euro-Canada Health Consumer Index ranked Canada 30th of 30 countries (the U.S. was not included in the sample) in terms of value for money spent on health care. Canadians deserve better. Canada cannot continue on this path. The system needs to be massively transformed, a task that demands political courage and leadership, flexibility from within the health care professions and far-sightedness on the part of the public. It is a lot to demand, but nothing less than one of Canada's most cherished national institutions is at stake. Unwillingness to confront the challenges is not an option. With this report, "Health Care Transformation in Canada: Change that Works, Care That Lasts" the Canadian Medical Association (CMA) declares its readiness to take a leadership position in confronting the hard choices required to make health care work better for Canadians. The focus of reform must better serve the patient. The system must adjust to changing needs for care and do so without crowding out other societal needs; many of them determinants of health themselves, such as education and sanitation, and the challenges posed by Canada's geographic, cultural, economic and emerging demographic realities. This report sets out an ambitious but realizable roadmap to ready the system for the future. Its triple aim is to improve the health of the population at large, to improve the health care experiences of patients, and to improve the value for money spent on health and health care. The CMA seeks to spark a spirited discussion among physicians, other health care providers, governments and the public at large so that an urgent effort can be undertaken to put an improved system on a path to sustainability by the time the federal-provincial/territorial Health Accord expires on March 31, 2014. By so doing, a renewed Health Accord will be enabled to maximize value for patients and sustain a strong health care system for future generations. This report is divided into three parts: The Problem; Our Vision; and The Framework for Transformation. It is in this last section that the CMA puts forth a five-pillar transformational plan, including a Charter for Patient-Centred Care, for securing Canada's public health care future. These policy directions have been influenced by our consultations with patients, patient advocacy groups and the public. These initiatives are necessary to support the important work already underway in illness prevention and health promotion, in enhancing capabilities for diagnosis and treatment, and in monitoring system performance. They also represent directions we must take towards preparing for the needs of future generations of Canadians. The CMA, our partner provincial/territorial medical associations and the physicians of Canada are committed to the changes that will allow us to fulfill our objective to provide patients with optimal care within an effective, accountable and sustainable system today and for generations to come. EXECUTIVE SUMMARY Medicare has enjoyed the resounding support of Canadians for nearly half a century. But new times bring new challenges to the health care system and so it has been forced from time to time to adapt and evolve. This document is predicated on the belief of the CMA that new demands for adaptation must be addressed starting now, and in a manner consistent with the spirit and principles that have guided Medicare from the beginning. This report is divided into three Parts. The first lays out the underlying problem confronting the system; the second outlines a vision for Canada's health system by modernizing the guiding principles of Medicare, and the third provides the CMA's prescription for improving the system within and beyond the five original principles that are set out in the Canada Health Act (universality, accessibility, comprehensiveness, portability and public administration). Following the main report, Appendix A addresses the issue of health care funding and sustainability. This is meant to inform readers regarding the complexities inherent in the challenge of sustaining health care provision and funding for current and future populations. Part 1: The Problem Canada's health care system is valued by its citizens. At the same time, it is increasingly recognized that the system is inadequate to meet 21st Century needs and is in urgent need of reform. Canadians wait too long for care. Care providers feel overworked and discouraged. There are insufficient mechanisms to monitor system performance. Technical support needs modernizing. Closer examination of how the five Medicare principles are being met reveals a number of concerns. While there is universal coverage for a narrow range of medically-necessary services, access to other essential health care services is inconsistent, both within and across jurisdictions. Exceedingly long waits for necessary medical care is prevalent. Efficiencies in the management of our health care system must also be found as Canada has recently been ranked last out of 30 countries in terms of value for money spent. Part 2: Our Vision There are numerous steps required to transform Canada's health care system so that it becomes highly effective and meets the health needs of Canadians. A first step is to re-examine the five principles of the Canada Health Act and modernize them as they are no longer sufficient to meet current and evolving needs. All Canadians must have timely access to an appropriate array of medically-necessary services across the full continuum of care, independent of their ability to pay. All health care must be patient-centred. Care must be delivered effectively and must be well-coordinated among all care providers. The health care system must be properly resourced to deliver care in a sustainable way that can accommodate our ever-changing health care needs. Part 3: The Framework for Transformation The CMA's Health Care Transformation Plan has three core goals: improving population health, improving the patient experience of health care, and improving the value for money spent on health care. The CMA has created a Framework for Transformation listing the actions needed for change - organized under five pillars: 1. Building a culture of patient-centred care * Creation of a Charter for Patient-centred Care 2. Incentives for enhancing access and improving quality of care * Changing incentives to enhance timely access * Changing incentives to support quality care 3. Enhancing patient access along the continuum of care * Universal access to prescription drugs * Continuing care outside acute care facilities 4. Helping providers help patients * Ensuring Canada has an adequate supply of health human resources * More effective adoption of health information technologies 5. Building accountability/responsibility at all levels * Need for system accountability * Need for system stewardship The CMA recognizes that none of these directions, taken separately, will transform our health care system. Nor do they represent an exhaustive list of steps, as there are many other directions that can be taken to support our vision. This framework does, however, contain the necessary directions toward the more efficient, high-functioning, patient-focused system that Canadians deserve. Summary of CMA Recommended Directions Implementation of these recommendations will require the collaboration of all levels of government and medical and other health organizations. 1. Gain government and public support for the CMA's Charter for Patient-Centred Care. 2. Implement partial activity-based funding for hospitals, whereby facilities are funded based on the number of patients they treat and the types of illnesses they have, to improve timely access to facility-based care. 3. Implement appropriate pay-for-performance systems to encourage quality of care at both the clinician and facility level. 4. Establish an approach to comprehensive prescription drug coverage to ensure that all Canadians have access to medically necessary drug therapies. 5. Begin construction immediately on additional long-term care facilities. 6. Create national standards, with input from both federal and provincial/territorial governments, for continuing care provision in terms of eligibility criteria, care delivery and accommodation expenses. 7. Develop options to facilitate pre-funding long-term care needs. 8. Initiate a national dialogue on the Canada Health Act in relation to the continuum of care. 9. Explore ways to support informal caregivers and long-term care patients. 10. Develop a long-term health human resources plan through a national body using the best available evidence to support its deliberations. Within this plan: a) Increase medical school and residency training positions. b) Invest in recruitment and retention strategies for physicians, nurses and other health care workers. c) Ease the process of integration into our health care workforce for international medical graduates and Canadian physicians returning from abroad. d) Introduce new providers such as physician assistants to the health care workforce and enhance collaborative, team-based care where appropriate. 11. Adopt the CMA's five-year plan to set out clear targets for accelerating the adoption of Health Information Technology (HIT) in Canada. 12. Accelerate the introduction of e-prescribing in Canada to make it the main method of prescribing by 2012. 13. Require public reporting on the performance of the system, including outcomes. 14. Establish an arm's-length mechanism to monitor the financing of health care programs at the federal and provincial/territorial levels. PART 1: THE PROBLEM Summary: Canada's health care system is valued by its citizens. However, not only is our Medicare system failing to meet the five principles - universality, accessibility, portability, comprehensiveness and public administration - originally laid out in the 1984 Canada Heath Act, but those five principles, while still relevant, need to be expanded in scope to serve the current and future health needs of Canadians. Canadians believe that the relief of suffering and the promotion of health and human dignity are vitally important - for philosophical as well as pragmatic reasons. Simply stated, there is a broad recognition that health is a valued "good" allowing all Canadians to flourish as individuals and groups. Notwithstanding this fundamental belief, neither of the imperatives of our health care system - optimizing function and the compassionate relief of suffering and promotion of dignity - is being met for many people. Our population and our health providers encounter these failures on a daily basis. Polls show that most Canadians unwaveringly support the five principles laid out in the 1984 Canada Health Act - universality, accessibility, portability, comprehensiveness and public administration.1 In fact, since Medicare was first introduced - in Saskatchewan in 1962 and throughout the rest of Canada soon afterward - the idea of universal health care has become central to our national identity. Nearly half a century after Medicare was first introduced, however, Canada's health care system is falling short of the demands being placed on it from patients and providers. Canadians well understand that universal health care requires significant public resources to maintain. While the escalating costs of health care are often perceived as the overriding problem, there are other factors contributing to the crisis. Surveys have repeatedly shown that Canadians are highly satisfied with the care they receive once it is delivered. However, the general view among most Canadians is that their health care system is not as well managed as it must be. They are increasingly concerned about the lack of timely access to see their family physician, the long wait times for diagnostic testing, a widespread lack of access to specialists and specialized treatment, and the compromised quality of care in overburdened emergency rooms, or the unavailability of nearby ER facilities altogether. With our aging population, end of life issues are becoming increasingly important, yet many do not have access to expert palliative care. The founding principles of Medicare are not being met today either in letter or in spirit. Canadians are not receiving the value they deserve from the health care system. Issues such as quality of care, accountability and sustainability are now recognized as key aspects of a high-performing health system. "Health" by today's standards is not just the assessment and treatment of illness, but also the prevention of illness, and the creation and support of social factors that contribute to health. Also missing from our current system, but vitally important to proper care, is health information technology (HIT). In this area, Canada is woefully lacking in both resources and coordinated efforts toward a plan of HIT implementation. Before addressing the missing elements in Canada's health care system, a proper diagnosis of the current system requires a closer look at how the health care system fails to deliver on all five founding principles of Medicare. 1. Universality Studies have consistently shown that poorer, marginalized populations do not access necessary care. Wealthier populations use health care services more frequently than lower-income populations despite higher illness rates in low-income populations. Poorer communities have fewer services to support good health. The most vulnerable populations are least able to access and navigate the health care system. At the same time, these are the people most likely to need health care because the essential determinants of health - housing, education and food security - are often not available to them. Canada's system of universality resonates strongly with Canadians. However, while there is universal first-dollar coverage for insured hospital and medical services, there is uneven coverage of other services also essential to health and quality of life (e.g., prescription drugs and home care). 2. Accessibility The principle of accessibility in the Canada Health Act does not define "timely access" to necessary care. For many patients, the months of waiting for necessary treatment amount to a complete lack of "accessibility." While wait times have been reduced for a limited number of surgical procedures, many Canadians are still waiting far too long to receive necessary medical care for a wide variety of conditions. For many types of treatments, Canadians wait longer than citizens in most other industrialized countries that have similar universal health systems. Approximately five million Canadians do not have a family doctor, severely restricting access to adequate primary medical care. 3. Comprehensiveness Provincial/territorial health insurance plans must insure all "medically necessary" hospital and physician services. Canadians are entitled to all medically necessary (evidence-informed) services to the greatest extent possible. However, since Medicare was established in the 1960s, care patterns have shifted dramatically - away from being primarily acute care in nature, to broader health needs including prevention, treatment and long-term management of chronic illnesses. In addition, new technologies, treatments and medications that were not foreseen by the original planners of Medicare have been developed to diagnose and treat illnesses. At the time the Canada Health Act was passed, physician and hospital services represented 57% of total health spending; this has declined to 41% in 2008.2 Notwithstanding these changes, there is significant public spending beyond services covered by the Act (in excess of 25% of total spending) for programs such as seniors' drug coverage and home care; however, these programs are not subject to the Act's program criteria and are often subject to arbitrary cutbacks. While a majority of the working-age population and their families are covered by private health insurance, those with lower incomes are less likely to enjoy such benefits. Furthermore, the proportion of Canadians working in non-standard employment conditions (e.g., part-time, temporary or contract work) is increasing and these workers are less likely to have supplementary benefits.3 In addition, while most jurisdictions provide some form of seniors' drug coverage, access to other supplementary benefits post-retirement is most likely highly variable. Some of the more severe gaps in coverage include: * the lack of access to prescription medications for those without private health insurance or who are ineligible for government drug benefit programs; this problem is particularly significant for many residents in Atlantic Canada * the lack of continuing care, including both support for people to stay in their home (home care) or appropriate residential care (e.g., facility-based long-term care) * a lack of adequate mental health services. Mental illness is one of the leading burdens of illness in Canada. Access to mental health services for both children and adults is poor. Psychiatric hospitals are not covered under the Canada Health Act. Many essential services, such as psychological services or out-of-hospital drug therapies, are not covered under provincial/territorial health insurance plans. 4. Portability Canadians should receive coverage while travelling outside of their home province or territory. Portability under the Canada Health Act does not cover citizens who seek non-urgent and non-emergency care outside their home province or territory. Canadians who obtain such care in another province or territory are not covered by their health insurance program unless they receive prior approval (usually for services not available in their home province or territory). This principle is honoured by some jurisdictions but has never been fully implemented in Québec. Québec did not sign bilateral reciprocal billing agreements with the other provinces and territories stipulating that providers would be reimbursed at host-province rates. Consequently, Québec patients who receive medical care outside of their province must often pay cash for medical services received and then apply to recoup a portion of their costs from the Québec health insurance program. 5. Public administration Health care insurance plans must be administered and operated on a non-profit basis. The principle of public administration is often misinterpreted to mean public financing of publicly delivered services. In fact, while Medicare services (medically necessary hospital and physician services) are overwhelmingly publicly financed, most services are privately delivered. Most physicians are independent contractors while most hospitals are private organizations governed by community boards. This misconception of what constitutes public administration has inhibited the development of innovative models for publicly funded, privately delivered services. While Canada's system of Medicare is administered publicly, a case can certainly be made that Canada's health care system is not delivering value for the money spent: Canada is one of the highest spenders of health care when compared to other industrialized countries that offer universal care - Canada is the fifth-highest spender per capita on health care and sixth-highest in terms of spending on health as a percentage of GDP. Canadians spent an estimated $183 billion on health care in 2009, or $5452 per person.2 Of this amount, $3829, or 70%, is spent through the publicly funded system. Health care spending in Canada has increased by 6.8 annually over the past five years and has been increasing faster than the growth in the economy and more importantly faster than revenues at the federal and provincial/territorial levels. Canada's health care system is under-performing on several key measures, such as timely access, despite the large amounts we spend on health care. Experts agree that Canada's current health care system is not delivering the level of care that other industrialized countries now enjoy. The Conference Board of Canada4, the World Health Organization5, the Commonwealth Fund6 and the Frontier Centre for Public Policy7 have all rated Canada's health care system poorly in terms of "value for money" and efficiency. New governance models should be considered to improve both system effectiveness and accountability. FISCAL SUSTAINABILITY In addition to the need for improving the performance of our health system is the issue of fiscal sustainability. In 1998, the Auditor General of Canada, Denis Desautels, was among the first to sound an alarm about sustainability with a report on the implications of the aging population. His report projected that government spending on health as a share of GDP; if increases continued apace at an annual rate of 2% of real growth; could as much as double from its 1996 level of 6.4% to 12.5% by 2031.8 According to the most recent estimates from the Canadian Institute for Health Information (CIHI), government health spending as a percentage of GDP reached 8.4% in 2009i - a level which has already exceeded the 8.1% estimate for 2011 set out in the high-growth scenario of the 1998 report.2 Most recently, Parliamentary Budget Officer Kevin Page has again sounded the alarm in his February 2010 Fiscal Sustainability report.9 He projects that total provincial-territorial government health expenditure could rise to over 14% of GDP by 2040-41. This report presents estimates of the fiscal gap (which is defined as the increase in taxes and/or reduction in spending, measured relative to GDP) that is required to achieve sustainability over the long term. Under their baseline scenario, the government would need to increase revenue and/or reduce spending by $15.5 billion annually, starting immediately. Given that most commentators expect the demand for health care services to increase, reduced spending seems unlikely; hence the need to increase revenue is the most likely option. If there is no political appetite or public support for increasing public revenues for health on the basis of universality and risk pooling then we will be faced with choosing among options for raising funds from private sources. A more detailed analysis of health care funding and sustainability is contained in Appendix A. PART 2: OUR VISION Summary: There are numerous steps required to transform Canada's health care system so that it becomes highly effective and meets the health needs of Canadians. A first step is to re-examine the five principles of the Canada Health Act - universality, accessibility, comprehensiveness, portability, and public administration - and modernize them to meet current and evolving needs. MODERNIZING THE PRINCIPLES OF MEDICARE Change must be undertaken with the patients' interests at the centre. To the CMA, this means meaningful implementation and modernization of the Canada Health Act. Transformational change will refocus our system so that serves the patient - not the other way around as is so often the case today. Canada must follow the lead of other developed countries with universal health care systems that have succeeded in this fundamental objective. Below are the modernized principles for Canada's health system recommended by the CMA: 1. Universality All Canadians must have access to the full range of necessary (evidence-informed) health care services using a variety of funding options as necessary to ensure universal coverage regardless of ability to pay. This includes meeting the needs of vulnerable populations who may not be able to access services due to a variety of barriers (e.g., geographical, socio-economic and demographic). 2. Accessibility All Canadians must have timely access to the full array of health care services over their life span, from primary care (including health promotion and illness prevention) through institutionally based secondary and tertiary care, to community and home-based services that promote rehabilitation and health maintenance, and to palliation at the end of life. There should be clear, measurable wait-time targets/benchmarks for access to necessary care, with publicly funded alternatives available in situations where timely care is not locally available to patients in need. 3. Comprehensiveness All Canadians must have access to the full complement of health services, with incentives in the system to encourage the prevention of illness and to promote optimum health while addressing the complex causative pathways affecting health and disease (i.e., social determinants of health). A defined set of nationally comparable, publicly funded core services should be available to all Canadians chosen through an evidence-informed and transparent manner. There should be an ongoing monitoring of the comparability of access to a full range of medically necessary health services across the country. 4. Portability All Canadians must be eligible for coverage while travelling within Canada, outside of their home province/territory. This principle must be honored in all jurisdictions, and apply to all levels of necessary care. 5. Public administration Services must be appropriately, efficiently and effectively delivered, with providers and patients working together to determine how that is done. The system must ensure that care is integrated and coordinated among providers and services to maintain continuity of care. From the patients' perspective, care must be well-coordinated among providers and between levels (i.e., physician to hospital, hospital back to home, etc.), supported by a functional and secure electronic health information system. The system should be guided by properly structured incentives to reward efficient provision of timely, high-quality patient care. This would include incentives such as activity-based funding of hospitals (i.e., paying on the basis of services provided), and pay-for-performance measures for health care providers, with competition based on valid measures of quality and efficiency. The system would utilize both public and private service providers, and put uniform requirements and regulations in place for measuring quality.ii The system must be able to demonstrate good value for money. There must be accountability mechanisms and performance measurements in place to ensure responsibility for monitoring and managing system performance (e.g., efficiency and effectiveness) at all levels. Regular public reporting on system performance will be required. Societal health goals and targets focused on outcomes will be set and monitored. Health care providers and the community will be actively involved in system decision-making. 6. Patient-centred The system needs to be patient-centred. Patient-centred care is seamless access to the continuum of care in a timely manner, based on need and not the ability to pay, that takes into consideration the individual needs and preferences of the patient and his/her family, and treats the patient with respect and dignity. 7. Sustainability The system must be properly resourced in a sustainable manner. Funding must be sufficient to meet ongoing health care needs. The system must be resilient; that is, capable of withstanding or accommodating demand surges and fiscal pressures. It must have the capacity to innovate and improve and be able to anticipate emerging health needs. Prospective monitoring and documentation of emerging health needs and the burden of illness must be undertaken on an ongoing basis. Strategies must be developed and implemented to meet those needs properly. PART 3: THE FRAMEWORK FOR TRANSFORMATION Summary: The CMA's Health Care Transformation Plan has three core goals: improving population health, improving the patient experience of health care, and improving the value of money spent on health care. There are numerous steps required to transform Canada's health care system so that it becomes highly effective and meets the health needs of Canadians. The next steps are contained in a Framework for Transformation, organized under five pillars, with specific recommendations for action. 1. Building a culture of patient-centred care * Creation of a Charter for Patient-centred Care 2. Incentives for enhancing access and improving quality of care * Changing incentives to enhance timely access * Changing incentives to support quality care 3. Enhancing patient access along the continuum of care * Universal access to prescription drugs * Continuing care outside acute care facilities 4. Helping providers help patients * Ensuring Canada has an adequate supply of health human resources * More effective adoption of health information technologies 5. Building accountability/responsibility at all levels * Need for system accountability * Need for system stewardship The CMA recognizes that none of these directions, taken separately, will transform our health care system. Nor do they represent an exhaustive list of steps, as there are many other directions that can be taken to support our vision. This framework does, however, contain the necessary directions toward the more efficient, high-functioning, patient-focused system that Canadians deserve. For the transformation plan to succeed, the following key enablers must be in place: * leadership at all levels including strong political leadership * well-informed Canadians who understand the need for, and characteristics of, a high-performing health system * patients, physicians and other providers actively involved in the reform and management of the system * a commitment to sustainability with adequate levels of resources to ensure that services are in place * health information technology in place to improve service delivery, manage care within and between services, and monitor and evaluate organization and system performance * incentives properly aligned to support a variety of funding and delivery models that can meet system goals (e.g., to improve access, to improve quality) * co-ordinated health human resources planning at the provincial/territorial and national levels * a commitment to support continuous quality improvement and evidence-informed decision-making at both the policy and clinical levels. These five pillars contain the directions which the CMA believes are necessary to successfully transform our health care system. Many other reforms have been proposed in Canada and elsewhere but based on international experience, these should receive priority attention. 1. BUILDING A CULTURE OF PATIENT-CENTRED CARE The concept of "patient-centred care" is taking hold in other developed countries which are also in the process of reforming their health care systems. The essential principle is that health care services are provided in a manner that works best for patients. Health care providers partner with patients and their families to identify and satisfy the range of needs and preferences. Health providers, governments and patients each have their own specific roles in creating and moving toward a patient-centred system. Patients have consistently emphasized the importance of being respected, having open communication and confidentiality of personal information, in addition to quality medical care. While building a patient-centred system is clearly better for patients, it is also better for physicians and all health care providers and administrators. In a patient-centred system, physicians are provided the optimal environment to give the best possible medical care. From the perspective of health administrators, recruitment and retention of providers who are satisfied with their work and their environment can have many tangible benefits. For instance, hospitals employing patient-centred care principles have found improvements in patient outcomes in areas ranging from decreased length of stay and fewer medication errors to enhanced staff recruitment.10 It is recognized that health care providers strive to practise patient-centred care. Often the issue is that the system - intended to serve as a network of services - is where patient-centred care breaks down. CHARTER FOR PATIENT-CENTRED CARE An important first step in building a culture of patient-centred care is to establish a Charter for Patient-centred Care. As a vision statement, the Charter is built on a foundation of reasonableness and fairness, while acknowledging resource constraints. Notwithstanding resource constraints, governments have the duty to ensure availability of the resources required to provide high quality care. This Charter is a mutually reciprocal covenant among patients, physicians, other health care providers, funders and organizers of care. Dignity and respect * All persons are treated with compassion, dignity and respect. * Health care is provided in an environment that is free from discrimination and/or stigma of any kind. * Health care services respond to individual needs and give consideration to personal preferences. Access to care (timeliness, continuity, comprehensiveness) * Access to and timeliness of appropriate medical and psychiatric services is determined by health need. * Access to appropriate services is not limited by the patient's ability to pay. * Care is continuous between health care providers and across settings. Safety and appropriateness * Care is provided in accordance with the applicable professional standard of care, by appropriately qualified health care providers, regardless of the location of service. * Care is based upon the best available evidence and is provided in the safest possible environment. * The quality of all health care services is evaluated, monitored and improved proactively. * Care is informed and influenced by lessons learned from any critical incident or adverse event and by patient experiences. Privacy and security of information * Personal health information is collected, stored, accessed, used, disclosed and accessible to patients in accordance with applicable law and professional codes of ethics. * Providers and recipients of care share responsibility for the accuracy and completeness of information in personal health records. Decision-making * Patients participate actively with providers in decisions about their medical care and treatment. * Personal support and assistance with communication is available when required. * Patients may appoint another person (proxy decision-maker) to act on their behalf and to be aware of their personal health information. * Decisions for care are made with full disclosure of all relevant information. * Patients may consent to or refuse any examination, intervention or treatment, and may change or vary their decisions without prejudice. * Individuals may decline to participate in research without prejudice. Insurability and Planning of health services * All parties use health care resources appropriately. * Recipients and providers are informed and are able to be involved directly, or through representatives, in the planning, organization, delivery and evaluation of health care services. * Decisions about the provision and insurability of drugs and all other treatments or services are made in accordance with evidence and best practices. * Government decision-making with respect to the planning, regulation and delivery of health care products and services is transparent. Concerns and complaints * Patients may comment on any aspect of their personal health care and have concerns investigated and addressed without repercussions. * Patients receive timely information and an expression of regret and sympathy if there is any adverse event during their care, regardless of the reason for such event. * Providers speak publicly and advocate on behalf of Canadians for the provision of high quality care. Direction The creation of a Charter for Patient-centred Care, as presented above, is a solid foundation on which to build a culture of patient-centred care. In order for the Charter to work, it needs to have supporting mechanisms to ensure accountability. Metrics must be identified to track the elements of the Charter. The Charter needs to be accepted by governments, providers and patients to have an impact on the health system culture and care. Other examples of activities to promote a culture of patient-centred care may include: * increasing availability of programs to prevent illness * increasing involvement of patients and their families in the delivery of care when desired (e.g., if preferred by the patient, family and friends may be trained to help provide care for patients while in the hospital or community) * soliciting patients' feedback on health care services received, and readiness to make changes based on that feedback * establishing patient and family advisory councils for hospitals or health regions * establishing a process for patients or their family members to quickly and efficiently raise a concern about care * providing patients with information about how to access medical records while in the hospital or in the community Progress to date/Next steps The final report of Saskatchewan's Patient First Review, For Patients' Sake (2009),11 devoted considerable attention to the need to re-orient health care to a more patient-centred system. As Commissioner Tony Dagnone stated in his report, "patient-first must be embedded as a core value in health care and be ingrained in the 'DNA' of all health care organizations". The report recommended the adoption of a Charter of Patient Rights and Responsibilities for that province. More recently, an advisory committee to the Alberta Minister of Health has also recommended the creation of a Patient Charter for that province.12 Lessons can be learned from the effects of patient charters in other developed countries. The National Health Service in England recently adopted a constitution which establishes its principles and values: sets out the rights to which patients, public and staff are entitled; includes pledges that the National Health Service is committed to achieve; delineates the responsibilities which the public, patients and staff owe to one another to ensure that the National Health Service operates fairly and effectively.13 The Australian Charter of Healthcare Rights describes seven charter rights to which patients, consumers, carers and families are entitled and the ways they can contribute to ensuring their rights are upheld.14 Those rights are: access, safety, respect, communication, participation, privacy and a right to comment on care and have concerns addressed. 2. PROVIDING INCENTIVES TO ENHANCE ACCESS AND IMPROVE QUALITY OF CARE Canadians have consistently identified timely access as Canada's most pressing health issue. Many other health systems around the world have been successful in dealing with timely access and now are examining the quality of care being delivered. This direction looks at changing incentives to accomplish two related objectives: improving timely access and supporting quality care. A. Enhance timely access Most provinces have taken steps to improve timely access to certain components of their health system. For instance, the Saskatchewan Surgical Initiative has set a target for specialty wait times to be no longer than three months within the next four years.15 At the physician level, several initiatives are underway across Canada. In late 2009, the Primary Care Wait Time Partnership involving the College of Family Physicians of Canada (CFPC) and the CMA released its final report entitled, The Wait Starts Here.16 The report identifies several strategies for improving timely access to primary care. Efforts are also underway in some jurisdictions, such as in Manitoba, to improve the referral process from family physician to specialist (i.e., the timeliness and the appropriateness of referrals). Activity-based funding - an idea raised in the Kirby Commission's final report17 - is another strategy to improve timely access at the facility level. Activity-based funding is a reimbursement mechanism that pays hospitals for each patient treated on the basis of the complexity of their case. A reimbursement level is set for each type of case then applies to all hospitals within the jurisdiction. It is also known as service-based funding, case-mix funding or patient-focused funding. As such, funding is viewed as "following the patient" since the hospital is paid only if the service is provided, resulting in increased productivity and in some instances, competition among hospitals to treat patients. Financing of hospital services in most industrialized countries involves some portion of activity-based funding. Canada, although it has been a pioneer in the methodology that underlies activity-based funding, has had limited application for funding purposes. Most hospitals in Canada receive their funding in the form of a global budget that is usually based on historical funding levels. As a result, a well-performing hospital emergency room does not receive any additional funding for seeing more patients. Direction Canada should move toward partial activity-based funding for hospitals to improve hospital productivity. It is almost impossible to decrease wait times and reward productivity without this change in funding. While some countries have implemented 100% activity-based funding, other countries have shown that productivity can increase when even 25% of hospital funding is allocated in this manner. Progress to date/Next steps A number of provinces have taken steps to introduce activity-based funding for facility-based care. The government of British Columbia announced that it will provide "patient-focused funding" for the province's 23 largest hospitals.18 Ontario already has some limited activity-based funding for its hospitals and the government has announced that it will introduce patient-based payment for hospitals on April 1, 2011 as part of a multi-year implementation plan.19 Alberta announced in 2009 that it would be adopting a form of activity-based funding for long-term care facilities that started April 1, 2010 and for hospitals the year after.20 While not yet in place in Québec, the adoption of activity-based funding was recommended in the 2008 Castonguay report.21 Much of the work involved in supporting the adoption of partial activity-based funding has already been undertaken by CIHI and its well-developed Case Mix Group program supported by case-costing data from BC, Alberta and Ontario. B. Support quality care Timely access is one dimension of quality. But there are many other dimensions of quality including safety, effectiveness, appropriateness and acceptability. More recently in Canada, attention is now focused on incentives to improve quality in the processes of care to achieve better outcomes. Incentives for providers Pay-for-performance involves the use of an incentive payment to reward a hospital or physician provider for achieving a target for the quality of patient care. This may be linked to processes or outcomes of care and could be related to the attainment of a specified threshold and/or percentage improvement. Performance incentives may also be linked to the structure of health care delivery as well as the process of that delivery. 22 It is important to note that pay-for-performance, which refers to incentive payments for achieving quality targets, is not the same as activity-based funding, which is a reimbursement mechanism that pays hospitals for each patient treated on the basis of the complexity of their case. Performance incentives can be targeted at both group output provided by a team of providers (nurses, physical therapists, physicians, etc.) as well as individual members of the team. The incentives may also be targeted at measuring the process involved in delivering the desired health care output. Canada will likely follow the lead of other countries in increasing the focus on the outputs and outcomes of the health care system. The promise of pay-for-performance programs is that they can improve access, quality and accountability. Pink et al. 23 have tried to synthesize the international experience with pay-for-performance and its implications for Canada. Based on this assessment they offer four key considerations: 1. Pay-for-performance could potentially be used to target individual providers, provider groups/organizations, or health regions. 2. The selection of quality measures should consider provincial/territorial health goals and objectives, measures included in existing report cards, evidence and the ability to risk-adjust and the extent of provider acceptance. 3. Development of pay for performance should consider factors that are within the scope of control of providers, use positive incentives over disincentives and consider size/timing and perceived fairness of awards. 4. Program evaluation should consider the impact on patients and providers, quality measurement and how payments are used to improve quality. In addition, they cite the need to address enablers/barriers including information technology, consultation, implementation costs and resistance. Direction Implement appropriate pay-for-performance systems. Adopt principles that secure equity and efficiency in pay-for-performance programs in Canada that will ensure the best outcomes for patients, physicians and the health care system at large. Progress to date/Next steps Pay-for-performance has already started in a number of provinces as seen in the table below. Examples of pay-for-performance programs already in effect in Canada [SEE PDF FOR CORRECT DISPLAY OF TABLE INFORMATION] Province Type of program Nova Scotia Family Physician Chronic Disease Management Incentive Program Ontario Cumulative Preventive Care Bonuses for achieving specified thresholds of preventive care for their patients in five areas: influenza vaccine, pap smear, mammography, childhood immunizations and colorectal cancer screening Manitoba Physician Integrated Network has a Quality Based Incentive component24 Alberta Performance and Diligence Indicator (PDI) Fund for Family Physicians: The PDI Fund provides payments to family physicians who meet specific indicators in the care of their patients. The PDI program "will provide payments to individual family physicians, in and out of primary care networks, who meet specific performance and/or diligence indicators that deliver substantive clinical value"25 British Columbia Full Service Family Practice Incentive Program: this includes an obstetrical care bonus payment and an expansion of the Full Service Family Practice Condition Payments that were introduced in 2003. The condition-based bonus payments are related to the monitoring patients' course of care according to BC Clinical Guidelines for diabetes, congestive heart failure and hypertension26 Pay-for-performance programs will continue to expand in Canada. Governments and insurance companies are introducing pay-for-performance incentive programs throughout the industrialized world with the goal of improving health care delivery efficiencies and especially to improve patient care. These are lofty goals because measuring improvements in patient care is complicated. It is vital that physicians, patients and the health care system establish principles that can guide them to make the best decisions concerning pay-for-performance. The scope of the program and what is measured will surely evolve. Full-scale adoption requires an electronic medical record (EMR) to be in place. Incentives for patients At a macro level, public policies can be instituted to encourage healthy behaviours and environmental improvements (e.g., water quality standards). At the individual level, consideration should be given to empowering patients through the use of patient incentives. A rapidly emerging dimension of pay-for-performance is the use of incentives directed at the patient for health maintenance and healthy behaviours. Hall has reported that a number of US employers are offering tangible rewards to employees such as cash, merchandise, vacation days, and reductions in health care premiums or deductibles.27 These incentives are targeted variously at: * activity (e.g., completing a health risk assessment) * achievement (e.g., quitting smoking, lowering Body Mass Index) * adherence (e.g., remaining tobacco-free for 12 months) Positive incentives are used to promote healthy behaviours by transferring funds or alternate benefits to an individual. They work by providing immediate rewards for behaviours that usually provide only long-term health gains. Positive incentives have been shown to be effective in promoting singular, discrete behaviours, such as vaccinations, screening programs, and attending follow-up appointments. An example of an existing Canadian federal government incentive is the children's fitness tax credit. This credit is intended to promote physical activity among children by off-setting some of the cost incurred by families for sports and leisure programs. In Germany, bonuses for healthy behaviours are integrated into the health system. They are offered for both primary and secondary prevention, including check-up programs, achieving healthy weights, smoking cessation, memberships in sports clubs, and other health-promoting activities. The bonuses take the form of points that can be redeemed for items, including sports equipment, health books or reduction in insurance premiums, or in some cases cash. There are also bonuses, in the form of a reduction in co-payments, for adhering to the treatment plan and participating in special care plans.28 Negative incentives or disincentives by governments largely involve the use of regulation and taxation in order to change individual behaviour. This helps to create an environment in which healthy choices are easier to make. For example, the taxation of tobacco, alcohol or unhealthy foods (such as those high in fat, salt or sugar) are commonly cited interventions. Taxes on tobacco products have been highly effective in reducing use. Studies linking cost to consumption of high-sugar content beverages demonstrate a strong link between higher prices and reduced consumption.29 3. ENHANCING PATIENT ACCESS ALONG THE CONTINUUM OF CARE The continuum of care may be defined as the array of health services, regardless of the age of the recipient, ranging from primary care (including health promotion and illness prevention), through institutionally based secondary and tertiary care for acute medical situations, to community- and home-based services that promote health maintenance and rehabilitation for people with chronic problems, and finally to palliation at the end of life. There is a strong realization that Canada's Medicare system covers a decreasing portion of this continuum. An example of where deficits exist is mental health. The CMA's 2008 annual meeting (General Council) tackled the issue of improving access to mental health services as part of a greater effort led by the Mental Health Commission of Canada. The CMA is currently working toward the several resolutions that were adopted, but there are two other areas that are in urgent need of attention. Crucial to improved care is (A) universal access to comprehensive prescription drug coverage and; (B) improving access to continuing care (long-term care, home care and palliative care/hospice). Physicians currently spend a significant amount of time assisting patients to obtain access to necessary prescription drugs. Physicians and families are also heavily engaged in time-consuming efforts to place patients in long-term care facilities or secure assistance in the home. Improving access for Canadians in these two areas would help create a more patient-centred health care system, and enhance efficiency for providers. CMA approved a new policy on Funding the Continuum of Care in December 2009 that identifies a number of overall principles to enhance the continuum of care: * optimal management of the continuum of care requires that patients take an active part in developing their care and treatment plan, and in monitoring their health status * the issue of the continuum of care must go beyond the question of financing and address questions related to the organization of the delivery of care and to the shared and joint responsibilities of individuals, communities and governments in matters of health care and promotion, prevention and rehabilitation * support systems should be established to allow elderly and disabled Canadians to optimize their ability to live in the community * strategies should be implemented to reduce wait times for accessing publicly funded home and community care services * integrated service delivery systems should be created for home and community care services * any request for expanding the public plan coverage of health services, in particular for home care services and the cost of prescription drugs, must include a comprehensive analysis of the projected cost and potential sources of financing for this expansion A. Universal access to prescription drugs Prescription drugs represent the fastest-growing item in the health budget, and the second-largest category of health expenditure. It is estimated that less than one-half of prescription drug costs were publicly paid for in 2008.2 Moreover, Canada does not have a nationally coordinated policy in the area of very costly drugs that are used to treat rare diseases. The term "catastrophic" has been used by First Ministers and in the National Pharmaceutical Strategy to describe their vision of national pharmaceutical coverage. As defined by the World Health Organization, catastrophic expenditure reflects a level of out-of-pocket health expenditures so high that households have to cut down on necessities such as food and clothing and items related to children's education. From the CMA's perspective, the goal is comprehensive coverage for the whole population, pooling risk across individuals and public and private plans in various jurisdictions. Direction Governments, in consultation with the life and health insurance industry and the public, should establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. Such a program should include the following elements: * a mandate for all Canadians to have either private or public coverage for prescription drugs * uniform income-based ceiling (between public and private plans and across provinces/territories) on out-of-pocket expenditures on drug plan premiums and/or prescription drugs (e.g., 5% of after-tax income) * federal/provincial/territorial cost-sharing of prescription drug expenditures above a household income ceiling, subject to capping the total federal and/or provincial/territorial contributions either by adjusting the federal/provincial/territorial sharing of reimbursement or by scaling the household income ceiling or both * group insurance plans and administrators of employee benefit plans to pool risk above a threshold linked to group size * a continued strong role for private supplementary insurance plans and public drug plans on a level playing field (i.e., premiums and co-payments to cover plan costs) Furthermore the federal government should: * establish a program for access to expensive drugs for rare diseases where those drugs have been demonstrated to be effective * assess the options for risk pooling to cover the inclusion of expensive drugs in public and private drug plan formularies * provide adequate financial compensation to the provincial and territorial governments that have developed, implemented and funded their own public prescription drug insurance plans * provide comprehensive coverage of prescription drugs and immunization for all children in Canada * mandate the CIHI and Statistics Canada to conduct a detailed study of the socio-economic profile of Canadians who have out-of-pocket prescription drug expenses, in order to assess barriers to access and to design strategies that could be built into a comprehensive prescription drug coverage program Progress to date/Next steps Provinces and territories have begun to establish public programs of income-based prescription drug coverage. Québec was the first, starting in 1997, and it remains the only province to mandate universal coverage - that is, citizens must have either public or private coverage. Alberta is the most recent to move in this direction, with a seven-point pharmaceutical strategy that was introduced in 2009.30 Overall, however, there is significant variation between the coverage levels of the various plans across Canada. For example, the Manitoba Pharmacare Program is based on adjusted total income (line 150 of the Income Tax return). For families with incomes above $75,000 the deductible is set at 6.08% of total family income.31 In Newfoundland and Labrador, the ceiling on drug costs is set at 10% of net family income (line 236 of the Income Tax return).32 There is wide variation in the burden of out-of-pocket expenditure on prescription drugs in Canada. In 2006 there was almost five-fold variation in the percentage of households spending more than 5% of net income on prescription drugs between PEI (10.1%) and Ontario (2.2%).33 There is some concern about access to cancer drugs, particularly those that are administered outside of hospital. The Canadian Cancer Society has recently reported that of the 12 cancer drugs approved since 2000 that are administered outside a hospital or clinic, three-quarters cost $20,000 or more annually.34 In 2009, Ontario Ombudsman André Morin issued a report critical of the Ministry of Health's decision to limit public funding of the colorectal cancer drug Avastin to 16 cycles.35 Subsequently the government announced that it would cover the cost beyond the 16 cycles if medical evidence from a physician indicates that there has been no disease progression.36 Most, if not all, key national health stakeholders (hospitals,37 pharmacists,38 nurses,39 brand name pharmaceuticals,40 life and health insurance industry41 plus the health charities) have adopted policy statements on catastrophic coverage. There seems to be an unprecedented consensus among health stakeholders on this issue. The most likely window of opportunity to urge the federal government to take action in this area will be the renegotiation of the Health Accord that is set to expire on March 31, 2014. B. Continuing care Continuing care includes services to the aging and to the disabled of all ages provided by long-term care, home care and home support.42 Because continuing care services are excluded from the Canada Health Act, they are, for the most part, not provided on a first-dollar coverage basis. As this kind of care moves away from hospitals and into the home, the community or into long-term care facilities, the financial burden has shifted from governments to the general public. Furthermore, there is tremendous variation across the country in the accessibility criteria for both placement in long-term care facilities and for home care services. According to Statistics Canada's most recent population projections, the proportion of seniors in the population (65+) is expected to almost double from its present level of 13% to between 23% and 25% by 2031.43 While the impact of an aging population on our health care system must not be overlooked, the continuing care needs of the disabled population at all ages must also be appropriately addressed. In the 2004 Health Accord, the provinces and territories agreed to publicly fund two weeks of acute home care after hospital discharge, two weeks of acute community mental health care and end-of-life care.44 Outside of these areas, the types of services offered and funding models vary widely. Continuing care in Canada faces three key challenges: 1. Lack of capacity and access: There is tremendous variation among regions in the levels of public funding for facility-based long-term care. Part of the reason is the lack of national standards for home care services, which results in a wide range of the types of services available, their accessibility, wait times and eligibility for funding. The widespread scarcity of long-term care facilities and home care services has had deleterious consequences: emergency departments are being used as holding stations while admitted patients wait for a bed to become available, surgeries are being postponed, and the care for Alternate Levels of Care patientsiii is compromised in areas that may not suit each patient's specific needs. Major investment is required in community and institutionally based care. 2. Lack of support for informal caregivers: Much of the burden of continuing care falls on informal (unpaid) caregivers. More than one million employed people aged 45-64 provide informal care to seniors with long-term conditions or disabilities45 and 80% of home care to seniors is provided by unpaid informal caregivers.46 3. Lack of funding for long-term care: It is impractical to expect future requirements for long-term care to be funded on the same "pay-as-you-go" basis as other health expenditures. While there is general agreement that, wherever possible, residents should contribute at least a partial payment toward the cost of accommodation at a long-term care facility, the calculation for these charges is inconsistent across the country. Direction Ensure that all Canadians have affordable and timely access to all elements of any continuing care they require. The CMA recommends the following actions: * Construction should begin immediately on additional long-term care facilities. With the senior population projected to increase to around 24% of the population by 2031, and with 3.5% of seniors currently living in these facilities, in order to simply maintain the same occupancy rates, we will need roughly 2,500 additional homes by then. The Building Canada Fund is an ideal source of initial infrastructure funding. * The federal government should work with the provinces and territories to create national standards for continuing care provision in terms of eligibility criteria, care delivery and accommodation expenses, using the Veterans Independence Plan as a starting point. * The federal government should make long-term care insurance premiums tax deductible, introduce a Registered Long-term Care Plan and/or consider adding a third special provision for the Registered Retirement Savings Plan (RRSP) that is similar to the Lifelong Learning Plan and the Home Buyers' Plan, which will allow working adults to draw from their RRSP, without penalty, to pay for their long-term care or home care needs; and consider adding a third payroll tax for continuing care purposes. * Governments initiate a national dialogue on the Canada Health Act in relation to the continuum of care. * Governments should adopt a policy framework and design principles for access to publicly funded medically necessary services in the home and community setting that can become the basis of a "Canada Extended Health Services Act". * Governments and provincial/territorial medical associations review physician remuneration for home- and community-based services. * Governments undertake pilot studies to support informal caregivers and long-term care patients, including those that a) explore tax credits and/or direct compensation to compensate informal caregivers for their work b) expand relief programs for informal caregivers that provide guaranteed access to respite services in emergency situations c) expand income and asset testing for residents requiring assisted living and long-term care d) promote information on advance directives and representation agreements for patients Progress to date/Next steps Many other groups have released reports on this issue, including the Canadian Healthcare Association's 2009 reports on home care and long-term care. Among many other recommendations, both of these reports call for the introduction of national minimum standards for care and additional support for caregivers.47, 48 New Brunswick announced an ambitious long-term care strategy in early 2008 and the province has invested $167 million in long-term care facilities since 2007. There are plans to open 318 nursing home beds over the next three years, with plans to open a total of 700 in the next 10 years.49 The federal government should use New Brunswick as an example to encourage all other provinces and territories to follow suit. In its final report released in April 2009, the Special Senate Committee on Aging made 32 recommendations; eight of them specifically address health care for seniors in terms of care provision, accommodation and affordability.50 As with improving access to prescription drugs, the most likely window of opportunity to press the federal government to take action in the area of continuing care will be the renegotiation of the 2004 Health Accord that is set to expire on March 31, 2014. 4. HELPING PROVIDERS HELP PATIENTS The fourth pillar of health care transformation speaks to creating necessary resources to support patient-centred care. Two areas that are absolutely essential are: (A) an adequate supply of health human resources; and (B) health information technology at the level in which care is provided or point of care. A. Health human resources Every high-performing health system begins with a strong primary care system in place. Yet roughly 5 million Canadians do not have a regular family physician, and once Canadians do access primary care, they often face long waits to see consulting specialists, and further waits for advanced diagnostics and ultimately treatment. Part of the reason for these delays is the shortage of health care professionals in Canada. An Organization for Economic Co-operation and Development (OECD) study of countries with wait times shows that the availability of physicians has the strongest association with lower wait times than any other factor.51 Notably, Canada's physician supply relative to the population is far below the OECD average. Statistics indicate that in 2006 Canada had only 2.15 practising physicians per 1,000 population compared to the OECD average of 3.07.52 With the number of medical graduates similarly low in comparison to the OECD average, Canada cannot expect to make up the difference without some new sources for physicians. Nurses and other health professionals are also in short supply, in Canada and across the globe. The Canadian Nurses Association is projecting a shortage of 60,000 full-time equivalent nurses in Canada by 2022 if no new policies are adopted,53 and Western Europe is also experiencing a significant nursing shortage. The global shortage of health professionals compounds the problem - while Canadian training programs still lack sufficient seats to produce enough new providers to meet current and future demands, Canadian-educated physicians, nurses, technicians, etc, are being lured away by ample opportunities to train and work outside of Canada. Initiatives such as the Nursing Sector Study,54 Task Force Two,55 the 2004 Federal/Provincial/ Territorial 10-year Plan to Strengthen Health Care44 and the 2005 Framework for Collaborative Pan-Canadian Health Human Resources Planning56 have all yielded abundant information and recommendations, yet Canada still seems unable to maintain a stable supply of physicians, nurses, technicians or other health care professionals to provide the care and treatment patients need. In its 2008 election platform, the federal government announced that it would contribute funds to the provinces and territories to create 50 new residency positions ($10 million/year for four years), ease repatriation of Canadian physicians living abroad ($5 million/year for four years) and help fund the development of nursing recruitment and retention pilot projects ($5 million over three years). On May 10, 2010, Health Minister Leona Aglukkaq announced funding of $6.9 million for 15 additional family medicine residents in the University of Manitoba's Northern and Remote Family Medicine Program. This is a promising start.57 Collaborative care models - whereby health professionals work together with, and in the best interests of, the patient - can help address some of the gaps in health human resources. Over the past decade there have been three key trends pertinent to collaboration in health care: * the contention/recognition that collaboration is an important element of quality patient-centred care * the growing interest in inter-professional education among health professions * the sustained efforts by governments to foster multidisciplinary teams by creating competitive conditions in primary care through expanding the scope of other non-physician providers Physicians recognize the value of collaboration. The Royal College of Physicians and Surgeons of Canada (RCPSC), the CFPC and the CMA have all released policy documents that identified collaboration with other health professionals as a key role of the physician.58,59,60 The RCPSC has since been working to incorporate these roles and competencies in postgraduate medical training programs across Canada. In 2006, the national boards of ten health professional organizations including CMA and CFPC each ratified the principles and framework for interdisciplinary collaboration in primary health care that were developed by a consortium of staff of these organizations, sponsored by the federal Primary Health Care Transition Fund.61 In an effort to find ways to better distribute the workload and improve access to care, much attention has been turned to the role of physician extenders such as physician assistants. Physician assistants can be trained to work autonomously to evaluate, diagnose and treat patients in a partnership and with the supervision of a licensed physician. In Canada, four programs exist to train physician assistants. The Canadian Forces Medical Services School at the Canadian Forces Base Borden in Ontario trains Canadian Forces members while civilian physician assistants can train at McMaster University, the University of Toronto and the University of Manitoba. After the CMA Board approved the inclusion of the physician assistant profession as a designated health science profession within the accreditation process in 2003, its Conjoint Accreditation Services accredited the Canadian Forces' Physician Assistant Program in 2004. Although this program is currently the only one accredited, the other three schools are undergoing the process. Working smarter, Canada needs to be more systematic about innovations and adoption of health sector resources. There is no national body in Canada equivalent to the Institute for Healthcare Improvement in the US, or the National Health Service's Institute for Innovation and Improvement in England, that is charged with promoting innovation in the delivery of health services. In Canada, the $800-million 2000 Primary Health Care Transition Fund and its fore-runner the $150-million 1997 Health Transition Fund were intended to buy transformation in areas linked to primary care. For the most part, this resulted in short-term pilot demonstration projects that ended when the money ran out. Arguably only Ontario and Alberta have achieved lasting results through the development and proliferation of new models of primary care delivery. Direction Ensure Canada's health care system has an adequate supply of human resources. Addressing health human resource shortages is critical to ensuring a sustainable, accessible and patient-centred health care system. The evaluation of and long-term planning for health human resources needs to be performed by a national body using the best available evidence to support its deliberations. Based on the defined need, there are four main mechanisms to address the shortage of health human resources in the Canadian health care system. These are: 1. increase medical school and residency positions to replenish and increase our physician supply for the future 2. invest in recruitment and retention strategies for physicians, nurses and other health care workers 3. ease the process of integration into our health care workforce for international medical graduates and Canadian physicians returning from abroad 4. introduce new providers such as physician assistants to the health care workforce Progress to date/Next steps Immediate specific steps for increasing Canada's supply of health human resources are as follows: 1. Urge the federal government to honour the remainder of its 2008 commitment to fund residency positions, repatriation of Canadian physicians abroad and pilot projects to recruit and retain nurses. 2. Secure comprehensive funding plans for physician assistant compensation. 3. Continue to work with the Federation of Medical Regulatory Authorities of Canada and provincial/territorial medical associations to monitor the impact of the new labour mobility provision of the Agreement on Internal Trade on the distribution and mobility of physicians. 4. Work with provincial/territorial medical associations to carry out an inventory and assessment of the payment arrangements across Canada that foster the emergence of new practice models based on an interdisciplinary approach and the use of new information technologies. 5. Work with other stakeholders to promote the idea of a national locus for innovation in the delivery of health care. Since it can take ten years or longer to train a new physician depending on specialty, the results of increasing medical school placements and residency positions will not be immediate. However, this plan would ultimately increase the future supply of physicians, and serve as a step toward becoming more self-sufficient in the future. As medical education and postgraduate training extend beyond academic health science centres to the community, and as inter-professional education takes on greater emphasis, educational programs need to ensure quality training experiences. Physicians-in-training require adequate human, clinical and physical resources to train appropriately. Programs must ensure that all new teaching sites are properly equipped to take learners. Training new providers, such as physician assistants, is a medium-term option since it takes fewer years (as few as two depending on the program) to train them. Increasing their numbers within the health workforce and permitting them to share some tasks will allow physicians to devote more one-on-one time with patients. Similarly, integrating international medical graduates and repatriating Canadian physicians currently practising outside the country could be a quicker method of increasing physician numbers than training new physicians, provided that appropriate immigration policies and licensure processes are in place. Removing certain constrains, such as limited operating room times, and providing support for collaborative models of care would allow the health human resources currently available to optimize their ability to practise. These options could see results in the shorter term. B. More effective adoption of health information technologies (HIT) Over the past decade, Canada's ministers and deputy ministers of health have been developing strategies to relieve mounting pressures within the health care sector. In all of these strategies, HIT has been viewed as a foundational component. Five main reasons for implementing HIT have been identified: improved health outcomes (patient safety, wait time reduction), increased accessibility, better integration of health care "silos," cost efficiencies and improved patient-provider satisfaction. Multi-billion dollar investments made in Canada on HIT, however, have not yet resulted in significant benefits to providers or patients. In large measure this is due to the fact that all jurisdictions have taken a top-down approach to their HIT strategies and focused their investment on large-scale HIT systems and architecture, with very little investment being made at the points of care where the actual benefits of HIT will be realized. The majority of health care occurs at the local level. Some 400 million patient encounters take place in Canada each year with most occurring in primary care settings with physicians, clinical teams, in home care and long-term care facilities.62 Patient-physician office interactions outnumber patient-hospital interactions by a ratio of 18 to 1. In Ontario (Diagram 1), just 3,000 out of an average of 247,000 patient visits per day - or 1.2% - are made in hospitals. Diagram 1. Patient visits per day in Ontario (Canada Health Infoway) Compared to a select group of other industrialized countries, Canada ranks last in terms of "health information practice capacity" (i.e., the use of EMRs in primary care practice). According to the most recent Commonwealth Fund study (Figure 1) conducted in 2009, only 37% of Canadian primary care physicians use some form of EMR. That compares to 99% in the Netherlands, 97% in New Zealand, 96% in the UK and 95% in Australia. 63 Direction We need to move from a top-down approach to one that gives all providers, and in particular physicians, the lead role in determining how best to use HIT to improve care, improve safety, improve access and help alleviate our growing health human resource issue. HIT adoption needs to be accelerated, but in a way that focuses on the individual patient and where he or she interacts with the health care delivery system, with the intent of improving quality of care and patient safety. An important priority must be a clear, target-driven plan that meets the needs of Canadian physicians and their patients. The CMA and provincial/territorial medical associations will develop a five-year plan with clear targets for accelerating the adoption of HIT in Canada. This includes working with governments to accelerate the introduction of e-prescribing in Canada to make it the main method of prescribing by 2012. Progress to date/Next steps In February 2009, the federal government announced a $500 million investment in HIT, with specific focus on EMRs and point of care integration, as part of their Economic Stimulus package. Transfer of these funds to Canada Health Infoway was delayed due to concerns over accountability and lack of progress on the electronic health record (EHR) agenda on the part of Infoway and most jurisdictions. The Office of the Auditor General's report on Infoway, and six provincial audits on jurisdictional EHR progress addressed these concerns and the funds were finally transferred in spring 2010. CMA is working to ensure that the bulk of this investment is allocated to physician EMRs, as well as local interoperability solutions and applied research on EMR use and patient tools. How to achieve this goal will be described in detail in the CMA's upcoming five-year strategy for HIT investment in Canada, a plan to connect the delivery points at the front lines of care. Provincially, BC, Alberta, Saskatchewan, Ontario and Nova Scotia have established EMR funding programs and are the most likely to meet targets and realize the value of HIT. The addition of $500 million federal stimulus funding to this environment will allow the remaining provinces and territories to implement similar programs. The key will be to focus HIT efforts and investment directly at the point of care. The CMA five-year HIT plan takes a grassroots, bottom-up approach and identifies ways to quickly implement local and regional solutions that will deliver short-term, tangible benefits without building un-scalable, expensive point-to-point solutions. The five-year HIT plan in and of itself is not the goal of this undertaking. The key to effectiveness lies in ensuring any HIT plan sets clear benchmarks and targets for reporting progress and demonstrating value of accelerated HIT adoption in terms of patient care - access, quality and safety. The CMA five-year HIT strategy will set out clear targets and metrics for benchmarking progress and demonstrating value. Tracking and reporting on progress against these targets would occur over the following three to five years, with a final report card to be released at the end of this period. 5. BUILDING ACCOUNTABILITY/RESPONSIBILITY AT ALL LEVELS Two key issues confronting the Canadian health care system are (A) the lack of accountability for system quality of care and performance, and (B) the lack of stewardship for the integrity of the public health insurance program and its long-term financial sustainability. A. Need for system accountability The past decade has seen growing demand for accountability for performance and outcomes at all levels of the health care system, which has been impossible to deliver due to a lack of direction, resources or accountability. As a result, Canada's ability to report publicly on the performance of the Canadian health care system has been piecemeal at best. A main stumbling block is the federal/provincial/territorial dynamic, with provinces and territories being primarily responsible for health care. In 2000, First Ministers made a commitment to develop common indicators to report to their citizens and in 2003 they set out some 40 indicators in the areas of timely access, quality, sustainability and health status and wellness. Subsequently, the Health Council of Canada was set up to monitor the 2003 Health Accord, but since 2004 only the federal government has honoured its commitment to produce indicators, and Québec and Alberta do not participate on the Health Council. The December 2008 report of the federal Auditor General criticized Health Canada for a lack of interpretation in its report and on the limited number of indicators specific to the First Nations and Inuit Health, for which Health Canada is responsible.64 Some national organizations and private organizations are reporting on health system performance at the macro level. CIHI has been producing annual wait time reports in the past years. Think tanks that have also reported on health system performance include: the Commonwealth Fund, the Conference Board of Canada (which has ranked Canada as a middle-of-the-pack performer) and the Euro-Canada Health Consumer Index, which has ranked Canada 30th out of 30 countries in terms of value for money spent on health care in both 2008 and 2009 (the US was not included).7 The Wait Time Alliance65 has produced five report cards on wait times, assessing national and provincial/territorial performance on access to elective care. The CMA has been releasing an annual report card as part of the General Council meetings for the past nine years. At the provincial/territorial level, reporting on health system performance varies widely. All provinces and territories have been reporting wait times, albeit in varying degrees and quality, for some elective surgical care. Several provinces have quality health councils which are producing reports on the quality of care being received. The Ontario Health Quality Council has released several reports on the performance of Ontario's health system, reporting on nine attributes of a high-performing health system.66 Many of these reports call for the need to accelerate the adoption of electronic health records to acquire better data and properly assess health system performance. Ontario has been a leader in health care reporting within Canada. Since the early 1990s, the Ontario Cardiac Care Network has been the gold standard for the comparison of cardiac centres on the basis of wait time and crude and risk adjusted mortality and length of stay data.67 In 1997, a research team at the University of Toronto, funded by the Ontario Hospital Association, began developing a hospital report that focused on key areas of hospital activity including patient perceptions of hospitals.68 In 2007, CIHI released Canada-wide Hospital Standardized Mortality Ratios (HSMR) for the first time. The HSMR is the ratio of actual (observed) deaths to expected deaths, and is adjusted for several factors that affect in-hospital mortality.69 Most recently, the Saskatchewan Health Quality Council issued its first Quality Insight report which reports at the health region (and, in some cases, hospital) level on 121 indicators in the areas of chronic diseases (asthma, diabetes, post heart attack), drug management and patient experience.70 The quest to improve quality of care is a dominant issue in European health systems. The UK, Denmark and the Netherlands have all implemented mechanisms to monitor the performance of their health system. Accountability and monitoring instruments in place in these three countries include: ratings of hospitals, ratings of doctors and system performance reports. In addition, the UK has organizations devoted to monitoring and improving the quality of its health care system. Public reporting on health system performance enjoys high public acceptability. This was the finding of CMA's consultation process for its health care transformation project. Seventy percent of the public surveyed by Ipsos Reid supported independent reviews of hospitals on quality and performance. National Health Goals were developed by the Government of Canada and approved in a broad consensus by all of the provinces and territories in 2005.71 While there was universal acceptance of these goals at the time, there has been limited action on developing a framework and indicators for monitoring achievements. Comprehensive approaches to population health require coordinated action across governments, supported by a common vision, such as national health goals. The CMA strongly supports the advancement of the National Health Goals agenda and believes that public reporting of supporting indicators reflecting the determinants of health as well as health services and outcomes are an important component of improving the health status of Canadians.72 Direction Improve the accountability of the Canadian health care system by reporting publicly on the performance of the system including outcomes. What is needed is a systemic approach to public reporting that shifts the focus from "blame and shame" to quality improvement. Progress to date/Next steps Based on the foregoing, the most likely opportunity for advancing the idea of increased public reporting in the short term will be to work with existing national and provincial/territorial organizations involved in acquiring and analyzing data related to health system performance. At the federal level, the renegotiation of the Health Accord in the lead-up to March 31, 2014 is the best opportunity to see a heightened commitment to improve public reporting at a coordinated federal-provincial-territorial level. Provincially, Québec's recent budget devoted considerable attention to the issue of system accountability. That government announced the annual publication of health accounts to improve transparency and public awareness on health care spending. The accounts, released with the budget, list health and social services spending and revenues. It also includes a breakdown of health sector resources including the number of physicians and nurses and hospitalization days. B. Need for system stewardship To ensure accountability and responsibility, it will be necessary to establish an arm's-length, independent body to monitor, in a transparent manner, the medium to longer-term prospects of the comparability and financing of health care programs for Canada and the provinces and territories. Since its establishment, Canada's national Medicare program has been a funding partnership between the federal and provincial/territorial governments. Since the mid-1990s, this partnership has been beset by problems, due in part to the exclusive jurisdiction of the provinces/territories to administer health programs and to the federal government's unilateral cut to cash transfers of some $6 billion with the implementation of the Canada Health and Social Transfer in 1996. Three broad concerns have been expressed: 1. Lack of accountability of the provincial/territorial governments for use of health transfer funds: at the provincial level, the reports of both the Ménard (2005)73 and Castonguay (2008)21 commissions in Québec called for the establishment of a health account which would provide accountability for how revenues collected for health are used and to inform the public about issues such as financial sustainability of health programs. 2. Canada is a "patchwork quilt" in terms of the continuum of care: there is increasing concern about the wide variation in the level of services provided across the country. The Canada Health Act program criteria only apply to hospital and medical services, and those represent just 41% of total health spending. There is roughly a further 25% of health spending that is public but there is wide variability across jurisdictions with respect to coverage of broader continuum care, such as home care and prescription drugs. For example, Statistics Canada estimates that there was almost five-fold variation in the proportion of households spending more than 5% of net income on prescription drugs in 2006, ranging from 2.2% in Ontario to 10.1% in PEI.33 3. Canada may not be able to sustain Medicare on a "pay-as-you-go" basis: in 1998 the Auditor General of Canada published a report on the implications of the aging population which projected that government spending on health as a share of GDP could as much as double from its 1996 level of 6.4% to 12.5% by 2031 if it increased at an annual rate of 2% real growth.8 In 1998 the Auditor General recommended that the government produce long range financial projections on the basis of status quo policies and alternatives that would be presented to Parliament. In its response, the government indicated that it would continue its fiscal planning on the basis of setting and meeting short-run targets. Clearly we need to be able to look beyond year-over-year budgeting and reporting. The Parliamentary Budget Officer has recently published a report on Canada's emerging "structural deficit" that estimated this shortfall will reach a level of $19 billion in 2013-14.74 The Parliamentary Budget Officer's mandate does not extend to the provincial/territorial governments. While a number of agencies and organizations are doing work related to long-term system sustainability, each is constrained in some manner from carrying out the forward looking cross-jurisdictional analyses that are required. Direction Establish an arm's-length mechanism to monitor the financing of health care programs for the federal and provincial/territorial levels, to assess the comparability of coverage across jurisdictions, to assess value for money and to make recommendations to governments on the sustainability of the current Medicare program and mechanisms to fund additional programs that cover the continuum of care. Progress to date/Next steps At the federal level, the renegotiation of the Health Accord in the lead-up to March 31, 2014 is the best opportunity to see if such a concept could be acceptable at the federal/provincial/territorial level. The CMA met with federal and provincial auditors general on March 16, 2010 to discuss system accountability and sustainability. The auditors general were very interested in this issue and some anticipate examining the matter in the coming months. PART 4: AN ACTION PLAN FOR 2010-2014 With the CMA's ambitious triple aim of improving the health of the population at large, patients' health care experience and value for money spent, the transformation of health care will inevitably be a multi-year and multi-pronged initiative. The first priority has been the release of this document, with its emphasis on adopting a Charter for Patient-centred Care. The final goal is to ensure that the First Ministers' Agreement in 2014 addresses longer-term fundamental issues, such as providing appropriate access to comprehensive pharmaceuticals and continuing care for all Canadians, and implementing a proper accountability framework. As a multi-year initiative, the CMA will pursue the actions described under the health care transformation directions between now and 2013, in time for the negotiation of the next potential Health Accord expected to take effect after the current 2004 agreement expires. As previously mentioned, the directions listed do not represent an exhaustive list. Rather, they are intended to serve as a foundation for change that will build momentum for health care transformation leading to better care. It will be important to demonstrate tangible results - early wins - so that the public, health care providers and system funders can sense the move toward a more patient-focused system and become energized to implement subsequent actions. Summary timeline of key health care transformation deliverables Release of Framework and Charter for Patient-centred Care Summer 2010 IT: Federal support for EMRs 2010 Partial Activity-Based Funding Beginning 2010 Interoperability/e-prescribing 2011-2012 Health human resources - new funding models (physician assistants) 2011 Comprehensive pharmacare/long-term care 2014 Accord Accountability Framework 2014 Accord PART 5: CONCLUSION The policy directions contained in this document, while fundamental, do not represent the entire array of possible choices. This document focuses on the "what" of health care transformation. The "how to" of implementation will require considerable further work, tailored to the needs and circumstances of the various jurisdictions and their populations. Some of the directions in this document are meant to be carried out by government, some by providers, and some by patients. Many, but not all, of the ideas set out in this document will require additional investment by governments. It will not be possible to implement all of these policy directions at the same time. Much of what is outlined here will be put in place at the provincial/territorial level and will be phased in as each jurisdiction deems fit. Provinces and territories must be encouraged to share the lessons they learn as changes are made so that other jurisdictions can build on their successes. Provision must be made for evaluation and mid-course correction to ensure that the proposed directions achieve their intended objectives. The CMA, our partner provincial/territorial medical associations and the physicians of Canada are committed to inspiring change, for the benefit of the patients we serve and in the interests of our members. The aspirations embodied in this document will foster transformation that allows us to accomplish our goals as physicians - to serve the public, provide for our patients' health needs optimally, and to make our health care system more effective, accountable and sustainable now and for the generations to come. APPENDIX A - HEALTH CARE FUNDING AND THE SUSTAINABILITY CHALLENGE Highlights: The ability to pay for health care, which is in competition with all the other legitimate uses for public funds, and the ability to maintain a health workforce are both central to the concept of sustainability. While there is ample evidence that health spending continues to outpace other areas of public expenditure and the growth of government revenue, there is no consensus that we need to act on it. The section notes the necessity of raising funds from private sources if there is no political appetite or public support for increasing public revenues for health. Other key points in this section: * Appropriate investments in health care result in improved health, which reduces health care demand in the future by decreasing the burden of illness in the population. Better health and the resultant improved productivity of the population pays economic dividends for the country. * Given our changing population demographics, governments in Canada will face challenges finding new revenue streams to fund appropriate initiatives such as long-term care, home care or enhanced pharmaceutical coverage over the next two decades. * A large unfunded liability will be created as a consequence of the need to address our growing, aging population that is increasingly burdened with multiple chronic illnesses. Only recently have a few jurisdictions recognized the unfairness of saddling this economic burden on future generations. * Overall health spending is consuming a rising proportion of total government program spending. It also is rising faster than the growth in our GDP, so our ability to pay for health care is increasingly in question. Other important societal programs will be increasingly jeopardized in order to pay for health care programs. * Methods to manage the gap between current levels of expenditure and what will be required to maintain and respond to future health care demands include, a) reducing services and therefore reducing expenditures, b) raising taxes and c) developing new sources of revenue (such as patient co-payments, population health premiums and private insurance). * Our system and culture relies on the principle of collective risk-pooling so as to lessen individual burden. To sustain health care for current and future Canadians and to expand the basket of required coverage, given our changing demographic reality, creative approaches to managing and funding our health system are necessary. The ability to pay for health care is increasingly in question. The challenge of sustaining our health care system is what makes it imperative to move forward now with health care transformation. Sustainability in health care may be defined as the ability to deliver universal publicly funded health care services without compromising other government programs or the ability of future generations to pay. In 2001 the Honourable Roy Romanow was tasked by the federal government to study and make recommendations in order to "ensure over the long-term the sustainability of a universally accessible, publicly funded health system." The Romanow Commission put forward 47 recommendations in 2002 with a view to "buying change".75 Similarly, the Kirby Commission in its review of the Canadian health care system recommended an additional $5 billion of federal funding per year to restructure and renew Medicare.17 These reports were followed by additional federal funding in the amounts of $34.8 billion and $41.3 billion in the 200376 and 200444 First Ministers' Accords respectively. Eight years later it is evident that, for the most part, these Accords bought time, not change. The directions set out in Part 3 of this report rest on two critical assumptions with respect to sustainability. The first is that there is a business case for quality. That is to say, investments in quality today will pay off in improved health that, in turn, will reduce health care demand and expenditures down the road. The resultant improved productivity from the reduction of illness in the population will generate economic dividends for the country. A second assumption is that timely and appropriate interventions will relieve access bottlenecks currently generating unproductive costs. A study conducted for the CMA in 2008 makes the case: it estimated the cost of excess waiting for four procedures at almost $15 billion.77 Hence, the introduction of activity-based funding for hospitals might not reduce hospital costs in total, but if it increases throughput and timely access there will be offsets in improved quality of life and productivity of the population. Clearly, the gains resulting from these assumptions will not be realized in the short term. All the numbers on sustainability, including the projections by Desautels and Page (highlighted in Part 1), assume the status quo in terms of publicly funded programs. But the current system is hardly sustainable on a quality of care basis, particularly given the demographic changes that will see fewer working-age Canadians supporting more and more elderly citizens weighed down by drug costs and the need, over time, for nursing home care. Given our changing population demographics, governments in Canada cannot avoid the challenge of finding new revenue streams to fund appropriate initiatives, such as long-term care, home care or enhanced pharmaceutical coverage over the next two decades. Since the 1990s, there have been repeated recommendations for expanded public coverage of prescription drugs and home care. Health ministers have estimated it would cost $5 billion for governments to provide "catastrophic" pharmaceutical coverage, meaning no household has to spend more than 5% of net income on prescription drugs.78 In contrast, there has been no national policy discussion about the funding of long-term care. Alberta made an exploratory move in this direction in 2005 when it commissioned Aon Consulting to develop health insurance models for continuing care.79 Aon estimated that in order to pre-fund projected costs to 2050, a flat dollar charge of $779 per capita, indexed at 4% per year, would be required for all Albertans aged 16 or over.80 Similarly, the Organization for Economic Co-operation and Development (OECD) has estimated that long-term care accounted for 1.2% GDP in Canada in 2005 and that, at a minimum, the burden will double to 2.4% by 2050.81 A significant amount of this share will almost certainly be publicly funded. Canada will soon have to grapple with how to finance a more comprehensive - and expensive - system of health and continuing care. This, in turn, raises issues about intergenerational equity, that is to say the fairness with which the costs of the system are distributed between generations. If these escalating costs are not addressed now, future generations will be unfairly, and possibly untenably, saddled with the burden flowing from today's growing elderly population. Academics have developed a technique called generational accounting to measure this effect.82 Hagist has applied generational accounting to estimate the revenue gap for health expenditures in six countries. The revenue gap is the percentage increase in taxes that would have to be applied immediately for both living and future generations to bring current fiscal policy on a sustainable track. The same study also estimated a delayed revenue gap, which is the percentage increase that will be required if increases are postponed until 2050. The results for the six countries are shown in Table 1. [SEE PDF FOR CORRECT DISPLAY OF TABLE INFORMATION] Table 1 Estimates of current and delayed revenue gap for health expenditures Selected countries (% increase) Country Switzerland Austria France Germany UK US Revenue Gap 27.1 13.2 9.0 25.9 23.6 27.0 Delayed Revenue Gap 63.1 28.0 17.4 60.7 47.7 46.9 Source: Hagist, C. Demography and Social Health Insurance. Baden-Baden:Nomos, 2008. As one can see, significant immediate increases in revenues are required in all six countries and much more drastic increases will be required if action is delayed. Klumpes and Tang have also applied generational accounting to the funding of the UK National Health Service. They found that under the base assumption of a 2% real interest rate, future tax payers will need to contribute about ten-fold what 2005 new tax payers did.83 In Canada, Robson has applied similar methods to estimate the "unfunded liability" that will result from an aging population. He estimates that between 2007 and 2050, provincial and territorial health budgets will experience an aggregate liability of almost $1.9 trillion if things continue along as they are.84 Total health spending in Canada reached an historic high of 11.9% of GDP in 2009. While this reflects, in part, the effect of the recession in lowering GDP, health spending grew by 5.5% in nominal terms and 3.3% in real terms over 2008. Table 2 shows the average percentage increases in health and total program spending from 1999 to 2008 and the most recent experience of the provinces and territories as presented in their 2010-11 budgets. Table 2? Health and Program Spending 1999-2008 and Selected Indicators 2010 Provincial Territorial Budgets Province / Territory 1999-2008 Average Annual % Increase in Health Spendinga 1999-2008 Average Annual % Increase in Program Spendinga Health as % Program Spending 2010-11 % Increase in Health Spending 2010-11 over 2009-10 % Increase in Program Spending 2010-11 over 2009-10 % Increase in Revenue 2010-11 over 2009-10 NL 6.2 6.9 37.8 12.4 8.4 3.8 PE 8.4 5.9 37.3 3.9 0.3 2.9 NS 7.2 5.9 46.4 6.8 -0.3 3.5 NB 7.0 4.5 36.7 3.5 1.2 1.8 QC 6.4 5.4 44.7 3.7 2.9 2.9 ONb 7.7 6.0 39.8 6.0 6.5 10.8 MB 6.7 5.4 45.1 5.0 0.8 1.8 SK 7.2 6.6 43.4 6.4 0.6 -0.8 AB 10.2 10.2 44.7 16.6 5.6 1.3 BCc 6.4 3.6 45.6 5.1 4.8 5.8 NT 5.2 4.9 25.2 0.3 5.7 5.0 YT 8.1 7.4 21.9 -7.6 -0.8 8.0 NU 9.3 9.1 24.3 -3.7 1.9 5.9 Average 7.4 6.3 37.9 4.5 2.9 4.1 Data sources available upon request a Source: Canadian Institute for Health Information b Note the budget also contains an estimate that health is 45% of program spending in 2010-11 c Total health spending by function is estimated at 42.1% of all government spending The evidence is incontrovertible that health spending has continuously outpaced other areas of public expenditure. All provinces are expecting further health spending increases in 2010-11 - ranging from 3.7% in Québec to 16.6% in Alberta. In eight out of ten provinces, increases in health spending exceed increases in both total program spending and provincial/territorial revenue. As a percentage of program spending, health stands near or just over 45% in six provinces. Aside from Québec (which is discussed below), few measures have been taken to address the problem. It may well require a province or territory to exceed the psychological barrier of 50% to incite a concerted response. This is suggested by a February 2010 poll done for CMA by Ipsos Reid in which respondents were also asked to estimate the actual, appropriate and maximum proportions of their provincial/territorial budget that are or should be devoted to health. The averages estimated by the public are as follows: * actual current percentage - 38% * appropriate percentage - 47% * maximum percentage - 52%. The prospect of going beyond the 50% threshold of the share of government program spending on health might be likened to the proverbial "crossing the Rubicon," which means following a course of action on which there is no turning back. To follow the 50%+ trajectory under the current parameters of Medicare, taxes will surely have to increase, either through general taxation or a dedicated health premium or some variant thereof. Another option that would still pool risk would be the establishment of a contributory social insurance fund. If, however, there is no political appetite or public support for increasing public revenues for health on the basis of universality and risk pooling then we will be faced with options for raising funds from private sources. These could include co-payments for publicly insured services, private insurance or out-of-pocket payment for uninsured/deinsured services, and deductibles linked to utilization. Québec has been the first among the provinces and territories to acknowledge that the current approach to funding health care is neither sustainable in the long term nor fair to future generations - and to announce measures to address the problem. It has taken three major task forces over the past decade to get to this point. In 2001 the Clair Commission recommended a capitalized (pre-funded) insurance plan to cover loss of autonomy.85 Clair also put forward the idea of the creation of a provincial health insurance corporation apart from the Health Ministry. In 2005 the Ménard Committee again recommended the establishment of an insurance scheme for persons experiencing loss of autonomy, as well as the creation of a health and social services account that would provide transparency and accountability for the sources and uses of funds.73 In 2008 the Castonguay Task Force recommended a dedicated "health stabilization fund" that would be funded in part by a deductible linked to medical visits that would be collected at year-end through the income tax system. Castonguay also recommended a health account.21 In response to these studies, the 2010-11 Québec budget contained the following measures: * starting July 1, 2010 a health contribution (premium) will be introduced, to be collected through the tax system; starting at $25 per adult, this will increase to $200 by 2012 at which time it is expected to raise $945 million * further study of the introduction of a health deductible as proposed by Castonguay * the introduction of an annual health account86 Other jurisdictions will also need to give consideration to options for at least partially pre-funding future health care expenditures. The findings of the February 2010 survey conducted for CMA by Ipsos Reid suggest that Canadians would prefer an option that would assure that funds raised would be dedicated to health care over an option that would simply add additional funds to the consolidated revenue account (Figure 2). In considering such options, however, one must be mindful of the current experience with existing mechanisms that are available to Canadians to accumulate savings. According to Canada Revenue Agency Statistics for the 2007 tax year, one in four (26.4%) Canadians with a taxable return reported making a RRSP contribution.87 The likelihood of making RRSP contributions was strongly correlated with income - 15% or fewer with those with incomes less than $25,000 reported one, rising to greater then 60% among those with incomes of $80,000 or greater. There may be greater uptake with the Tax-free Savings Account (TFSA) that was introduced in 2009. A poll done by Ipsos Reid in June 2009 found that 21% of households had opened a TFSA.88 No research has been done on the salience of saving for future health needs as compared to RRSPs and TFSAs. 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Hospital contacts: Trends in Acute Inpatient Hospitalizations and Day surgery Visits in Canada 1995-1996 to 2005-2006 and National Ambulatory Care Reporting System: Visit Disposition by Triage Level for All Emergency Visits - 2005-2006. 63 Schoen C, Osborn R, Doty MM, Squires D, Peugh J, Applebaum S. A survey of primary care physicians in eleven countries, 2009: Perspectives on care, costs and experiences. Health Affairs 2009; 28(6):1179-83. 64 Auditor General of Canada. 2008 December report of the Auditor General of Canada. Chapter 8 - reporting on health indicators - Health Canada. www.oag-bvg.gc.ca/internet/docs/parl_oag_200812_08_e.pdf. Accessed 06/27/2010. 65 www.waittimealliance.ca 66 www.ohqc.ca 67 www.ccn.on.ca 68 www.hospitalreport.ca 69 Canadian Institute for Health Information. HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada. secure.cihi.ca/cihiweb/products/HSMR_hospital_mortality_trends_in_canada.pdf. Accessed 06/09/09. 70 Saskatchewan Health Quality Council. Quality Insight, 2008. www.hqc.sk.ca/download.jsp?oLYnotVGsC60FgKBEcq12DBIzBf0QfLQkUwK4QBZaJtXhmSAKqZibA==. Accessed 06/07/10 71 Public Health Agency of Canada. Health goals for Canada. www.phac-aspc.gc.ca/hgc-osc/pdf/goals-e.pdf. Accessed 06/20/2010. 72 Canadian Medical Association. National Health Goals for Canada: A Review of Successes, Challenges, and Opportunities for the Canadian Medical Association. Ottawa 2010 73 Comité de travail sur la pérennité du système de santé et des services sociaux du Québec. Pour sortir de l'impasse : la solidarité entre nos générations. Québec : Ministère de la santé et des services sociaux du Québec, 2005. 74 Parliamentary Budget Officer. Estimating potential GDP and the government's structural budget balance. www2.parl.gc.ca/Sites/PBO-DPB/documents/Potential_CABB_EN.pdf. Accessed 01/26/10. 75 Romanow, R. Building on values: the future of health care in Canada. Ottawa: Commission on the Future of Health Care in Canada, 2002. 76 Canadian Intergovernmental Conference Centre. 2003 First Ministers' Accord on Health Care Renewal. February 5, 2003. www.scics.gc.ca/pdf/800039001_e.pdf. Accessed 04/27/10. 77 The Centre for Spatial Economics. The economic cost of wait times in Canada 2008. www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/pdf/2008/EconomicReport.pdf Accessed 07/06/2010. 78 Canadian Intergovernmental Conference Centre. National Pharmaceutical Strategy decision points. http://www.scics.gc.ca/cinfo08/860556005_e.html. Accessed 04/27/10. 79 Aon Consulting. Health benefit design options for Alberta Health & Wellness: Executive summary 29 March 2006. http://www.health.alberta.ca/documents/Options-Aon-2006-summary.pdf. Accessed 04/27/10. 80 Aon Consulting. Continuing care. http://www.health.alberta.ca/documents/Options-Aon-2006-Care.pdf. Accessed 04/27/10. 81 Organization for Economic Cooperation and Development. Projecting OECD health and long-term care expenditures: what are the main drivers? Economics Department Working Papers No. 477. http://www.oecd.org/dataoecd/57/7/36085940.pdf. Accessed 04/28/10 82 Auerbach A., Gokhale J., Kotlikoff L. Generational accounts: a meaningful alternative to deficit acccounting. Tax Policy and the Economy 5. Cambridge, MA: MIT Press and the NBER, 1991. 83 Klumpes P, Tang L. The cost incidence of the UK's National Health Service system. Geneva Papers 2008;33:744-67. 84 Robson W. Boomer bulge: dealing with the stress of demographic change on government budgets in Canada. www.cdhowe.org/pdf/ebrief_71.pdf. Accessed 04/28/10. 85 Commission d'étude sur les services de santé et les services sociaux. Emerging solutions : report and recommendations. Québec : Gouvernement du Québec, 2001. 86 Finances Québec. For a more efficient and better funded health-care system. www.budget.finances.gouv.qc.ca/Budget/2010-2011/en/documents/MoreEfficient.pdf. Accessed 04/27/10. 87 Canada Revenue Agency. Income Statistics 2009 - 2007 tax year. Interim Table 2 - Universe data. www.cra-arc.gc.ca/gncy/stts/gb07/pst/ntrm/pdf/table2-eng.pdf. Accessed 04/28/10. 88 Ipsos Reid. Canadians embracing tax-free savings accounts. October 20, 2009. www.ipsos-na.com/news-polls/pressrelease.aspx?id=4557. Accessed 04/28/10. 89 Canadian Medical Association. It's about access: informing the debate on public and private health care. Ottawa, 2006.
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Lessons from the frontlines: A collaborative report on Pandemic H1N1

https://policybase.cma.ca/en/permalink/policy9840
Last Reviewed
2018-03-03
Date
2010-08-26
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2010-08-26
Topics
Population health/ health equity/ public health
Text
Lessons from the frontlines: A report on Pandemic H1N1 from Canadian Medical Association, The College of Family Physicians of Canada, National Specialty Society for Community Medicine One year ago, a novel influenza virus claimed its first victim in Mexico, and soon the world was plunged into its first influenza pandemic in 40 years. Although pandemic H1N1 (pH1N1) swept across the globe, we were fortunate this time as the virus was far less virulent than first feared. Now that pH1N1 has peaked and faded, it is time to look at what we learned and how it will help us plan for the next national public health emergency. The College of Family Physicians of Canada, the National Specialty Society for Community Medicine and the Canadian Medical Association have joined together to present a picture of lessons learned from the front lines of the pandemic. Together we represent over 80,000 physicians, of whom almost 50,000 are family physicians, engaged in all aspects of Canada's health care and public health systems. Canada's experience with SARS in 2003 was a "wake-up call"; much changed in its aftermath. The creation of the Public Health Agency of Canada led by a chief public health officer and the Pan-Canadian Public Health Network increased Canada's ability to respond to a public health emergency like pH1N1. The Canadian Pandemic Influenza Plan for the Health Sector, as well as complementary provincial and territorial plans, provides a framework and approach to responding to a pandemic. In many ways, this planning paid off. Canada mobilized quickly in response to the pH1N1 threat. Morbidity and mortality were lower than feared, and 45% of the population was vaccinated. But this response can also be seen as a "dress rehearsal" for a more severe influenza pandemic or some other national public health emergency: a test of our plans and an opportunity to learn from experience, with the time to incorporate these lessons into our strategic planning. Those on the front lines of response understand how health emergencies test our entire system - public health, acute and primary care and the community-based family physician. The success of our response depends on planning and practice, the effectiveness of public health and clinical countermeasures, our health human resources, the surge capacity within our health care and public health systems and our ability to reach the public. One of our greatest challenges in Canada is also to establish a coherent national and provincial/territorial strategy that can be implemented at a local level. Although we believe that Canada's overall response to pH1N1 produced many success stories, there were circumstances that challenged us as health professionals. Both health care and public health need further strengthening, and their separate infrastructures and the interdependence between these structures need attention and bolstering. The following comments focus on two overarching areas that influenced our ability to respond to the pandemic: communications and health system integration. Communications Communication was a consistent source of concern. Channels of communication among the various levels of public health providers were stronger than those for primary care providers, especially family physicians. On 9 Aug. 2009, following the first wave of pH1N1, our leaders wrote to chief public health officer of Canada Dr. David Butler-Jones on behalf of our members to share their thoughts and recommendations on how to improve communications with physicians. Family physicians in particular, but also other front-line health care providers, needed communication that was tailored to the practice setting, resources that were easy to access, and clear messages written in a manner that allowed rapid implementation into clinical practice during health emergencies because the timing of clinical response was critical. We recommended that front-line clinical practitioners be involved in the development of guidelines and the strategies for their dissemination, so that the content could be linked directly to the clinical setting. Family physicians are part of our first line of defence during infectious disease outbreaks. To ensure optimum patient care, they need clinical guidance quickly. Many physicians felt that the urgent need to provide consistent, clinically relevant information was not well recognized by the Public Health Agency of Canada (PHAC), the Public Health Network and, in some cases, provincial, territorial, regional or local levels. It took three months after recognition of the emerging pandemic to publish Interim Guidance for Ambulatory Care of Influenza-like Illness in the Context of H1N1. The current Public Health Network process of federal/provincial/territorial (FPT) consultation and consensus building seemed ill-suited to the acute national need for clinical information on issues such as the use and prescription of anti-viral medications. As provincial authorities and professional medical organizations moved to fill the void, different approaches and recommendations arose independent from one another. Better integration of primary care response by a national organization such as PHAC and the provincial/territorial health ministries could address the needs of clinical practitioners in concert with public health responses. This would also ensure that care directives are translated into user-friendly formats appropriate to clinical settings. We were pleased to be able to work with PHAC in fall 2009 to produce Pandemic H1N1: Fast Facts for Front-line Clinicians. This resource was highly valued by many of our members, and the collaboration demonstrated how health organizations can work effectively with government to contribute their expertise to the development and distribution of appropriate, clinically relevant information. Nevertheless, our critics declared that it was too little, too late. In situations where scientific evidence is rapidly changing, the processes used to distribute information to both front-line public health and clinical professionals must be designed to avoid confusion. Coordinated, unified communication strategies are needed at the national, provincial/territorial and local levels. Regardless of the official source, the information must be consistent. During the pandemic, many physicians and public health workers complained that multiple levels of government provided similar, but not the same advice. The differences led to skepticism, and the inundation of messages led to overload. The bottom line is that clinically relevant and trustworthy information should be provided on a timely basis, even if levels of certainty are fluctuating. Jurisdictions with effective communication to the primary care sector were characterized by cooperation and consultation between the medical community and the provincial, territorial and regional health authorities, both before and during the crisis. We recommend: 1. That the Public Health Agency of Canada, with the provinces and territories, evaluate the effectiveness of pH1N1 communications between public health and physicians and other front-line primary health care providers, and use the finding of this evaluation to research options for future response to a public health crisis. 2. That federal, provincial/territorial public health authorities and health care professionals and their associations work together in the inter-pandemic period to develop a pan-Canadian communication strategy to be used during health emergencies. 3. The establishment of a pan-Canadian centre within the Public Health Agency of Canada - similar to the Centre for Effective Practice - to undertake timely knowledge translation of clinical management guidelines for clinicians during public health crises. Surveillance and electronic communications The national response to infectious disease would have been greatly facilitated if system-wide communicable disease surveillance had been in place to support the sharing of data between public health and the rest of the health care system, particularly at the regional and local levels of pandemic response. Clinicians' practices are highly influenced by illness patterns that develop regionally and locally within their practice populations; thus, surveillance data are useful in determining appropriate treatment. Real-time data were not available to most physicians and when data did become available, they were already several weeks old. Delayed clinical guidelines were not a suitable substitute for timely surveillance information. Expansion of the use of electronic medical records (EMRs) in primary care, with bi-directional links to public health electronic health records (EHRs), could have facilitated surveillance and communications. Family practice clinics with EMRs were able to quickly identify high-risk patients, communicate with them to schedule vaccination appointments and collect the required data for public health. The varied levels of success of public pH1N1 vaccination clinics were further proof of the need to move to standard use of EMRs and EHRs in the health system. Communications can be enhanced through the sharing of data between the public health and primary care systems. EMRs may help resolve the challenge of collecting data from primary care sites. Collaboration among the PHAC, the Canadian Medical Association and the Information Technology Association of Canada's Health Division led to development of a pilot project to demonstrate the use of primary care EMRs as real-time sentinel surveillance tools for public health action to supplement existing surveillance mechanisms. In addition, after a successful two-year pilot project, the College of Family Physicians of Canada is working with the PHAC, in association with the Canadian Institute for Health Information, to conduct surveillance for five chronic diseases using EMRs, local networks across Canada and a national central repository for standardized data. These studies represent the increasingly important role of electronic information in surveillance and the value of collaboration between public health and primary care. We recommend: 4. That the federal and provincial/territorial governments provide EMR funding to enable clinical care and public health authorities to build interconnectedness and allow real-time information collection and analysis. System issues FPT responsibilities The division of responsibility between federal and provincial/territorial authorities for health care and emergency response influences how we respond to public health emergencies. Provincial/territorial governments have a primary role to play in regulating health matters within their boundaries. At the same time, the federal government has responsibilities related to national public safety and health protection. There can be no disputing the legitimacy of federal involvement in public health matters of an interprovincial/territorial nature. Under International Health Regulations, the federal government also has a responsibility to report and monitor public health emergencies of potential harm to other countries. Since Canada's SARS experience, there has been much progress in building FPT cooperation and increasing consultation on public health matters. However, the division of responsibility has led us to a situation where public health and clinical guidance in each province and territory was similar, yet different. Although the Pandemic Influenza Committee and the Special FPT Advisory Committee on H1N1 Influenza strove for consensus at the national level, individual provinces and territories were under no obligation to implement the guidance agreed to at the FPT level. Consultative and collaborative processes at the FPT level created delays in decision-making and directly interfered with the capacity of front-line professionals to respond to the urgent health needs of their patients. This led to a sense of confusion in the media and a loss of trust among the public and health professionals regarding Canada's capacity to respond to pH1N1. System capacity Canada's health system lacks surge capacity and can be sorely tested during a public health emergency, such as the recent experience with pH1N1. The underdeveloped public health infrastructure also means that it is a challenge to handle more than one national crisis at a time. To mount a response to pH1N1, public health units pulled human resources from other programs and many critical ones were delayed, suspended or cancelled altogether. During the first wave of pH1N1, Manitoba experienced a severe outbreak that stretched the resources of its critical care infrastructure to its limits. Front-line health care providers were inundated with telephone calls from the worried well and an increase in visits from those with flu symptoms. If pH1N1 had been the severe pandemic that was expected and for which Canada had been preparing, our health system would have been brought to its knees. In 2008, the Canadian Coalition for Public Health in the 21st Century noted that Canada remains vulnerable to the risks presented by epidemics and pandemics. This vulnerability remains today, and a long-range plan to build our public health capacity and workforce and to address the lack of surge capacity in our health system must become a priority if we are to be prepared for the next emergency. We recommend: 5. That the federal government increase infrastructure funding to provinces/territories to assist local health emergency preparedness planning and response, to reduce variation across the country and to integrate clinical care structures into public health structures at the local level. 6. That the Public Health Agency of Canada review the recommendations of the 2003 report of the National Advisory Committee on SARS and Public Health (Naylor report) in light of the pH1N1 experience and develop a national action plan to address the persistent gaps. Public health/primary care partnership Family physicians, in particular, understand that primary health care happens at the local level. In fact, so does all public health. During times of public health crisis, it is crucial for public health and primary care to work together, each respecting, supporting and bolstering the efforts of the other. Strengthening local public health and primary care structures and the interface between them would have resulted in improved, shared understanding of each sector's roles and responsibilities during the pH1N1 epidemic, better communications, improved data sharing and, most important, better served populations. Public health measures are directed toward the mitigation of disease through surveillance, research and outbreak management activities, while physicians provide information, education and clinical treatment to their patients. A commitment from both sectors at the local and provincial levels - and the professionals within each sector - to work together in the inter-pandemic period to build on processes that allow sharing of perspectives and information is essential. It is crucial that local public health authorities receive financial resources to increase their ability to collaborate effectively with family physicians, specialist physicians and other front-line providers. A number of the challenges faced by front-line public health workers and front-line physicians during the pH1N1 outbreak could have been lessened if there had been stronger links within the health system. We recommend: 7. That the Public Health Agency of Canada develop a focus on improving the interrelationship between primary care and public health to support collaboration during public health crises. Vaccination A key measure to combat pandemic influenza is mass vaccination. On the whole, Canada mounted an effective campaign: 45% of Canadians were vaccinated, and the proportion was even higher in First Nations communities - a first in Canadian history. Canada was one of the first countries with sufficient vaccine for the population and, with one domestic vaccine supplier, Canada avoided the confusion of multiple formulations as seen in the United States. The outcome was positive, but many public health units were stretched as expectations exceeded the pre-existing constrained resources. Although we recognize that the provinces and territories have quite different approaches to the delivery of their routine immunization programs, there is agreement that the pandemic immunization process did not adequately engage physicians in planning and delivery. A number of difficulties, such as the impact of bulk packaging, manufacturing delays that affected the agreed "sequencing" of patients and the logistics of inventory management, led to friction between front-line public health practitioners and family physicians. These could have been avoided with strengthened interdependence and mutual understanding before this crisis. The great variation in mass vaccination programs between provinces/territories, and even between local public health units, led to public confusion. Recognition of the diversity of primary care settings in which physicians work and bilateral planning in advance of the event is essential, because it is simply not feasible to tailor responses to myriad settings in the heat of the moment. Television broadcasts of long lines of people waiting to be vaccinated contributed to a loss of confidence in the system at a time when public confidence was sorely needed to encourage vaccination. Nationally promulgated clinical practice guidelines had great potential to create consistent clinical responses across the country. Instead, the variation and lack of coordination in providing important clinical information during this crisis eroded the public's confidence in the federal, provincial and territorial response. Ensuring future consistency in clinical approaches will require examination of ethical principles for the allocation of resources, such as anti-virals, vaccines and hospital treatment. Public engagement in the discussion of ethical principles is essential and, as much as possible, the consultative process should be transparent and undertaken in advance. We recommend: 8. That the Public Health Network seek advanced pan-Canadian commitment to a harmonized and singular national response to clinical practice guidelines, including mass vaccination programs, during times of potential public health crisis. Conclusion In 2003, in its submission to the National Advisory Committee on SARS, the Canadian Medical Association noted that the uptake of new information is influenced by many qualitative factors, and that research is needed to determine how best to communicate with individual physicians and other health care providers in emergency situations. Communication processes should be based on sound research and build on existing communication networks and relationships. The College of Family Physicians of Canada has recommended that information networks be strengthened to promote the sharing of the most relevant information among family physicians, other primary care providers and public health at the local level. We believe that PHAC is well positioned to undertake research on how health professionals can best receive information and to catalogue existing communication networks to build them into a well-coordinated national emergency response communication system. We must work together to translate pandemic information into practical messages relevant to front-line providers and employ trusted channels to deliver key messages to our patients and the public. Broad consensus is developing that our experience with the pH1N1 outbreak has shown that one of our greatest needs in preparing for the next public health emergency is for a national communications strategy that involves all levels of government, targets all sectors of our health system and uses the channels with which these targets are most familiar. An effective response to infectious disease outbreaks depends on effective surveillance, data collection and sharing and tracking of clinical interventions. The absence of a national communicable disease/immunization monitoring system is an ongoing problem. In 2003, the report of the National Advisory Committee on SARS and Public Health recommended that "the [Public Health] Agency [of Canada] should facilitate the long term development of a comprehensive and national public health surveillance system that will collect, analyze, and disseminate laboratory and health care facility data on infectious diseases... to relevant stakeholders." In 2010, Canada still does not have a comprehensive national surveillance and epidemiological system. A pan-Canadian electronic health information system is urgently needed and must become a priority during the inter-pandemic phase, with adequate federal funding and provincial/territorial collaboration. Greater adoption of the EMR in primary care and better public health EHRs with the ability to link systems will augment existing surveillance capacity and should be considered essential to a pan-Canadian system. Many of the challenges front-line health practitioners faced during the pH1N1 were also challenges during the SARS outbreak in 2003. The Naylor report proposed a number of measures to improve Canada's readiness and strengthen public health. Although a great deal of work and effort has gone into building links with and between provinces/territories and the federal government within the public health and the health emergency management system, little has trickled down to the front lines. This is not to devalue the much-improved spirit of FPT cooperation and the important achievements that have been made. Rather it is to suggest that, as the roof is no longer leaking, it is time to focus attention on the foundation - the response at the local level. Embedding primary care expertise in public health planning within the PHAC and at provincial/territorial and local levels will help circumvent problems and improve the effectiveness of our health system to respond to public health emergencies. A dialogue between primary care and the emergency management structures will help the response team understand and value the capabilities within primary care and build them into their planning and response systems. At the end of the day, we need to nurture collaborative relations between public health and primary care. Our shared objective is protecting the health of Canadians, recognizing that, in reality, neither system can be successful in isolation. It is essential that we trust each other's professionalism and expertise and work together to ensure that a strong foundation is in place to protect Canadians from future health threats. We have the will and expertise. We need the resources and a firm commitment to move forward. We have had two "wake-up calls" - SARS and pH1N1. Let's not wait for a third to find that we are not yet prepared. Recommendations 1. That the Public Health Agency of Canada, with the provinces and territories, evaluate the effectiveness of pH1N1 communications between public health and physicians and other front-line primary health care providers, and use the finding of this evaluation to research options for future response to a public health crisis. 2. That federal, provincial/territorial public health authorities and health care professionals and their associations work together in the inter-pandemic period to develop a pan-Canadian communication strategy to be used during health emergencies. 3. The establishment of a pan-Canadian centre within the Public Health Agency of Canada - similar to the Centre for Effective Practice - to undertake timely knowledge translation of clinical management guidelines for clinicians during public health crises. 4. That the federal and provincial/territorial governments provide EMR funding to enable clinical care and public health authorities to build interconnectedness and allow real-time information collection and analysis. 5. That the federal government increase infrastructure funding to provinces/territories to assist local health emergency preparedness planning and response, to reduce variation across the country and to integrate clinical care structures into public health structures at the local level. 6. That the Public Health Agency of Canada review the recommendations of the 2003 report of the National Advisory Committee on SARS and Public Health (Naylor report) in light of the pH1N1 experience and develop a national action plan to address the persistent gaps. 7. That the Public Health Agency of Canada develop a focus on improving the interrelationship between primary care and public health to support collaboration during public health crises. 8. That the Public Health Network seek advanced pan-Canadian commitment to a harmonized and singular national response to clinical practice guidelines, including mass vaccination programs, during times of potential public health crisis.
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Canada’s child and youth health charter

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

https://policybase.cma.ca/en/permalink/policy10352
Last Reviewed
2018-03-03
Date
26-08-2010
Topics
Health care and patient safety
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
26-08-2010
Topics
Health care and patient safety
Text
CMA Statement on Emerging Therapies The CMA is keenly aware of the heart-rending suffering experienced by MS patients and the devastating impact it has on families and we recognize how desperately they are seeking treatments to alleviate their symptoms. Physicians and researchers dedicate their lives to finding new treatments to prevent and ease the suffering of patients while supporting those battling disease. Along with the physician's care and compassion, clinical research is a key weapon in the battle to manage and treat disease. The CMA believes that all medical decisions must be based upon scientific evidence. That is at the heart of our commitment to patient-centred care. The CMA is committed to the principle that, before any new treatment is adopted and applied by the medical profession, it must first be rigorously tested and recognized as evidence-based. This principle is highly relevant in the case of the Canadian Institutes of Health Research (CIHR) recent recommendations. The CMA concurs with the CIHR's position on the need for an evidence-based approach to the development of clinical trials of the recently proposed condition called "chronic cerebrospinal venous insufficiency" (CCSVI). We would hope that the findings of the seven diagnostic studies that are underway will be shared and analyzed as soon as they become available, and that clinical intervention trials would be supported as indicated by the evidence and if researchers come forward with scientifically sound ethical protocols. If additional Canadian funding bodies initiate clinical research in the area, we would encourage CIHR to provide advice if requested.
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Policy Summary: Managing the Public-Private Interface to Improve Access to Quality Health Care

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

https://policybase.cma.ca/en/permalink/policy8828
Last Reviewed
2018-03-03
Date
2007-05-29
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2007-05-29
Topics
Health systems, system funding and performance
Text
It's Still About Access Medicare Plus: CMA Policy Statement July 2007 Toward a Sustainable Publicly Funded Health Care System in Canada Medicare is now 40 years old in Canada, and by all accounts it continues to be highly valued by Canadians. However, there is evidence suggesting that in its present state, Medicare will not be able to effectively deliver timely access to high quality care that reflects the needs of our changing health care landscape. In order to sustain Canada's health care system for the next generation, changes need to be made to bring about a new vision for Medicare. The CMA identifies this future vision as "Medicare Plus." This policy statement expresses the views of the Canadian Medical Association (CMA) at the present time and reflects, in the CMA's opinion, a future vision of Medicare which respects the current Canadian values, legislative frameworks and commitments from government. Three key steps must be undertaken to implement this vision: a) the current Medicare program must be shored up to deliver timely access to care; b) a guarantee that provides individual recourse to timely treatment must be put in place; and c) the basket of services must be expanded along the continuum of care through a variety of means. a) The public system must commit to timely access to care according to relative need for all necessary hospital and medical services. Governments have made a good start by providing for a stable funding base and by making strategic investments in medical equipment and health information technology. They have begun to deliver on their 2004 wait-time commitments by establishing national benchmarks in 2005 and by agreeing to implement a wait-time guarantee in at least one of the five priority areas by 2010. However, the job is far from finished. Governments have yet to set out the timelines for achieving their benchmarks, and there are many other procedural areas beyond the initial five for which benchmarks need to be established. Moreover the benchmark approach now needs to be expanded beyond the specialist-patient decision to treat to include access to primary care and specialist consultation. Delivering on timely access will not be achievable without an adequate supply of doctors, nurses and other health care professionals. Canada must adopt a pan-Canadian planning approach to health human resources with a goal of national self-sufficiency that engages key stakeholders on an early, meaningful and ongoing basis. Just as the 1966 Health Resources Fund Act was instrumental in expanding the health education and research infrastructure in the 1960s and 70s, further federal and provincial/territorial investments are critical now, in light of the recent expansion of medicine, nursing and other health professional enrolment and the establishment of new health disciplines. Considerable further investment is also required in health information technology. While the establishment of the Canadian Institutes for Health Research has been a positive step, further investment is necessary, particularly in the area of knowledge transfer - from bench to bedside. b) It is essential to implement a means of guaranteeing that Canadians can obtain timely access to care. As the Supreme Court found in the Chaoulli decision, the Canada Health Act and provincial/territorial health insurance legislation provide for a virtual monopoly for public health insurance, which "on the evidence, results in delays in treatment that adversely affect the citizen's security of the person," hence it does not conform to the principles of fundamental justice. The CMA has called for a Canada Health Access Fund that would provide for a means of individual recourse to patients facing waits that exceed benchmark thresholds. When the wait time is exceeded the patient and their physician would be able to seek timely treatment where it is available, ideally close to home, but potentially in another city, another province/territory, or country. The $612 million Patient Wait Times Guarantee Trust established in the 2007 budget is a step in this direction. To the extent that the current public infrastructure constrains capacity, governments should consider contracting publicly funded services to the private sector. Failing the enactment of a publicly funded safety valve, the Chaoulli decision has established that patients cannot be denied a private sector insurance and treatment option. The Quebec government has since made provisions in its legislation to comply with the decision, however it has so narrowly circumscribed the terms and conditions under which private insurance contracts might be offered and delivered that it is highly unlikely private coverage will be offered. Nonetheless the Chaoulli decision put governments on notice, as evidenced by their progress on benchmarks and reduced wait times. Governments may be further stimulated by the fact that a case similar to Chaoulli has been filed in Alberta and another is about to be filed in Ontario. c) Medicare must be modernized to reflect the current reality of the delivery of care. In 1975, just after Medicare was fully adopted, hospital and physician expenditures represented 60% of total health expenditures; as of 2006, this share has dropped by almost one-third to 43%. Over the past two decades, prescription drugs as a proportion of total health spending have doubled from 7% in 1986 to an estimated 14.2% in 2006. While a majority of Canadians have prescription drug coverage from either private or public plans, it is estimated that some 3.5 million are either uninsured or underinsured for prescription drug costs. Looking ahead, we can expect to continue to see a mix of public and private plans and out-of-pocket payments (e.g., co-payments) and greater use of tax policy. This is the experience of most European and other industrialized countries. In Canada and internationally, the prospects for additional health programs funded on a first-dollar basis out of general taxation revenues are slim. However, there is a clear consensus as reflected in the Romanow and Kirby reports on the need for catastrophic prescription drug coverage and a growing concern about how to address the issue of very costly "orphan" drugs for rare diseases, and expensive treatments for common diseases such as breast cancer. In 2003, first ministers committed to having catastrophic drug coverage in place by the end of 2005-06, and while this is one of the elements of the National Pharmaceutical Strategy, little collective action has taken place beyond further study. Similarly a 2003 commitment by first ministers to first-dollar coverage for a basket of short-term acute home care, community mental health and end-of-life care services remains unmet. The issue of long-term care (LTC) of the elderly looms on the horizon as the first cohort of the baby boom generation turns 65 in 2011. Indeed hospitals are already feeling the pinch of a lack of alternative level of care beds. International experience suggests that LTC cannot nor should not be financed on the same pay-as-you-go basis as medical/hospital insurance. Germany has implemented a social insurance approach to pre-funding LTC. In its 2007 budget, the federal government introduced a Registered Disability Savings Plan (RDSP) to help parents of children with a severe disability to ensure their children's future financial security by investing after-tax income on which the investment income will accumulate tax-free. Consideration should be given to implementing a similar program for LTC. (NOTE - to see "Medicare Plus" table -- see PDF) In summary, we must first ensure that the current Medicare system is on sustainable footing for future generations. Second, Canadians must have a measure of certainty that not only will they receive quality care, but that they will receive it in a timely fashion. Third, recognizing the boundaries of our current Medicare program, we must address the terms and conditions under which Canadians will be able to access the broader continuum of care. Finally, it must be recognized that the health policy landscape is not static, a fact of which governments are aware. For example, in its 2007 budget, Quebec announced that former health minister Claude Castonguay will chair a task force to address sustainable health funding. In addition, British Columbia has been holding a "Conversation on Health" with its citizens that will wrap up in the fall of 2007. As the debate on the future of Medicare changes over time, the CMA's policy will continue to be redeveloped and redefined. CMA Board of Directors May 2007
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CMA Patient Safety Policy Framework (Update 2010)

https://policybase.cma.ca/en/permalink/policy9747
Last Reviewed
2018-03-03
Date
2010-02-27
Topics
Health care and patient safety
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2010-02-27
Replaces
CMA Patient Safety Policy Framework (2001)
Topics
Health care and patient safety
Text
CMA PATIENT SAFETY POLICY FRAMEWORK (Update 2010) BACKGROUND The CMA’s mission is to promote the highest standard of health and health care for Canadians. This means, among other things, ensuring that the health care system is safe for patients and providers and effective in achieving good health outcomes for individuals and society. Unfortunately, studies published in recent years have raised concern that health care is not as safe as it could be; data collected by researchers in various countries has shown that there are unacceptably high levels of preventable adverse events, as high as 16% in one study of adverse events associated with hospital admissions. A study conducted by G. R. Baker, P.G. Norton et al, “The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada” showed an adverse event rate of 7.5 per 100 hospital admissions. (1) This suggests that of the nearly 2.5 million hospital admissions yearly in Canada, approximately 185,000 are associated with an adverse event and 70,000 of those possibly preventable. These studies have focused attention on health care error and adverse events, but patient safety requires that participants in the health care system are constantly aware of the risks present in the system, and that risks are addressed proactively - preferably before an adverse event occurs. If a preventable adverse event does occur, it provides an opportunity to learn about and correct sources of error. The CMA considers that a national patient safety strategy, aimed at building a culture of safety, is a priority. This Policy Framework has been developed to provide a clear statement of the CMA’s views on the principles that should underpin a patient safety strategy and to ensure clear support and direction for CMA members and staff involved in patient safety initiatives. PRINCIPLES The Health Care System Outcomes Errors and adverse events are inevitable in any complex system and more complex systems are more prone to errors. Nevertheless, studies have demonstrated an unacceptably high level of preventable adverse events associated with management of health care. 1. Patient safety initiatives should aim to improve health outcomes for patients by minimizing the rate of preventable adverse events and improving the management of events when they occur. Quality 2. Patient safety is one aspect of quality health care; activities relating to patient safety should result in a net increase in the quality of health care. Systemic factors 3. Patient safety initiatives should recognize that error and adverse events occur because of qualities of the system within which individuals operate. A primary concern of initiatives should be to prevent future errors by addressing the system rather than blaming and punishing individuals. Accountability The Canadian public has a reasonable expectation that health care will not result in avoidable injury. 4. Patient safety initiatives should support the accountability of the health sector, including providers, funders and regulators, to patients and the wider public for the safety of health care. Participants in Health Care Patients as partners 5. Patient safety initiatives should promote the role of patients as partners in the provision of safe care, including the prevention and management of adverse events. 6. Patient safety initiatives should encourage and anticipate the full and appropriate disclosure to patients of relevant information that is material to their health and healthcare, including information about adverse events or effects. Professional responsibility and support With a very few exceptions, health care is delivered by competent, caring professionals who are striving to achieve a good outcome for patients. 7. Patient safety initiatives should recognize the responsibility of professionals for achieving and maintaining the standard of their own practice. 8. Patient safety initiatives, while responding appropriately to adverse events, should be sensitive to the professional role and personal well being of individual physicians and other health care providers. Learning and Collaboration 9. Patient safety initiatives should promote and reflect teamwork, communication and collaboration at all levels. 10. Patient safety initiatives should support learning from one’s own experience and the sharing of knowledge so that it is possible to learn from the experience of others. Legal and Regulatory Environment 11. Patient Safety initiatives should promote a legal and regulatory environment that supports open communication and effective management of adverse events. 12. The protection afforded to the opinions expressed within quality assurance committees must be upheld Evidence Base and Evaluation Patient safety initiatives should be based on sound evidence. Patient safety initiatives should contain provision for appropriate evaluation. Patient safety initiatives should contain provision for broad dissemination of findings. PATIENT SAFETY INITIATIVE AREAS Building a culture of safety in Canadian health care will require the collaboration of many different groups and organizations. The CMA can play a leadership role within this larger group and within its own constituency of over 70,000 physicians. In some instances, it will be the CMA’s role to advocate for initiatives that can be delivered only by another provider or through a consortium; in other instances, CMA can assume sole responsibility for taking action. The CMA has identified that, as priorities, it will support: Advocacy for changes to legislation and regulation that would remove disincentives for health care providers to share information about adverse events. Raising awareness of patient safety and changing attitudes towards risk, error and adverse events within the health care community. Developing and providing resources such as clinical practice guidelines and information technology systems that have been shown to standardize practice and reduce adverse events. Reporting systems that collect and aggregate data on risks so that good practices can be developed and shared. Education and training for health care professionals and managers to provide them with the conceptual and practical tools to introduce change into their practice and organizations. Advocacy for, and development of, an agenda for patient safety research in Canada. The involvement of government at all levels in supporting and committing resources to initiatives for improved patient safety. GLOSSARY Adverse event – any unintended injury or complication that is caused by health care management rather than the patient’s disease and that leads to prolonged hospital stay, morbidity or mortality. Adverse events do not necessarily result from error, for example a toxic reaction to a drug in a patient without apparent risk factors for the reaction. Error – the failure of a planned action to be completed as intended (“error of execution”) or the use of a wrong plan to achieve an aim (“error of planning”). An error may not result in an adverse event if the error does not result in harm or is intercepted. Risk – the chance of injury or loss as defined as a measure of the probability and severity of an adverse effect to health, property, the environment or other things of value. (1) G. Ross Baker, Peter G. Norton, Virginia Flintoft, Régis Blais, Adalsteinn Brown, Jafna Cox, Ed Etchells, William A. Ghali, Philip Hébert, Sumit R. Majumdar, Maeve O'Beirne, Luz Palacios-Derflingher, Robert J. Reid, Sam Sheps, and Robyn Tamblyn. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada Can. Med. Assoc. J., May 2004; 170: 1678 - 1686.
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Climate Change and Human Health

https://policybase.cma.ca/en/permalink/policy9809
Last Reviewed
2018-03-03
Date
2010-06-09
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2010-06-09
Topics
Population health/ health equity/ public health
Text
Climate Change and Human Health Background Climate change is increasingly recognized as a significant threat facing society and has the potential to be one of the greatest threats to human health in the 21st Century1. While the damage is being done now, many of the health effects may arise only decades in the future2. Possible impacts could include some or all of the following: * Increased mortality, disease and injuries from heat waves and other extreme weather events; * Continued change in the range of some infectious disease vectors (i.e. 260-320 million more cases of malaria predicted by 2080, with six billion more at risk for dengue fever); * Effects on food yields- increased malnutrition; * Increased flooding in some areas and increased droughts in others, along with other impacts on freshwater supply; * Increases in foodborne and waterborne illnesses; * Warming and rising sea levels adding to displacement and also impacting water supply through salination; * Impaired functioning of ecosystems; * Negative effects on air quality associated with ground level ozone, including increases in cardio-respiratory morbidity and mortality, asthma, and allergens; * Displacement of vulnerable populations (especially in coastal areas)1; and * Loss of livelihoods3. Most of the impacts of climate change will result from amplifying the existing health hazards found in populations4. How susceptible a population is to the effects of climate change is dependent on their existing vulnerabilities (i.e. disease burden, resources etc.) as well as their adaptive capacity5. The World Health Organization has projected that countries that have, and will likely continue to suffer the greatest effects, are those who have contributed the smallest amount to the causes of climate change.6 While the vast majority of climate change deaths will occur in developing countries with systemic vulnerabilities, a recent Health Canada report has noted that Canada is likely to experience higher rates of warming in this century than most other countries in the world. Climate change scenarios predict an increased risk of extreme weather and other climate events for all regions of Canada, with the exception of extreme cold7. Canadians most vulnerable to climate change include seniors, children and infants, socially disadvantaged individuals, and those with pre-existing medical conditions such as cardiovascular disease8. Those living in cities could be especially vulnerable due to the impact of the heat island effect. However, given their greater access to emergency, health, social, and financial resources, they might also have the greatest adaptive capacity9. The health consequences of climate change have the potential to be more severe in far northern regions. Populations in Canada's north including aboriginals have already begun to see differences in their hunting practices as a result of changing ice patterns10, and the melting of permanent snowpacks11. Changes in ice patterns have also led to increased injuries12. In some places in the North, climate changes have led to greater risks from avalanches, landslides and other hazards13. Further problems are related to the infrastructure in Northern Canada, with some communities already noticing degradation of structures due to the thawing of the permafrost14. Given that much of the Northern infrastructure is already in disrepair, this represents a considerable problem. Geographic isolation, and a lack of resources may further exacerbate the situation15. What CMA has done? Physicians have a critical role to play in advancing public understanding of the potential impact of climate change on health and promoting health protecting responses. The CMA has been working on the issue of climate change and human health for a number of years. CMA was supportive of Canada's ratification of the Kyoto Protocol, and urged the Government of Canada to commit to choosing a climate change strategy that satisfied Canada's international commitments while also maximizing the clean air co-benefits and smog-reduction potential of any greenhouse gas reduction initiatives. In 2007, a number of resolutions were passed at General Council calling on government to properly plan for the health impacts of climate change and put in place measures to mitigate the impact of climate change on vulnerable populations in Canada's north. In that same year, CMA and the Canadian Nurses Association updated a joint position statement first entered into in 1994 calling for environmentally responsible activity in the health-care sector. Most recently, the CMA has been an integral part of the drafting of the World Medical Association (WMA) policies on health and climate change. The WMA Declaration of Delhi on Health and Climate Change was adopted at its annual General Assembly in New Delhi, India in October 2009, The declaration calls for action in five main areas; advocacy to combat global warming; leadership-help people be healthy enough to adapt to climate change; education and capacity building; surveillance and research; and collaboration to prepare for climate emergencies. This policy is written to complement the WMA declaration. What needs to be done? Climate change may lead to significant impacts on human health. While it is unlikely that these outcomes can be avoided, there are some strategies that can be employed to help limit the negative consequences. Education and Capacity Building There is a need for greater public and health professional awareness and education about climate change in order to gain understanding of the health consequences and support for strategies to reduce green house gases and mitigate climate change effects. CMA recommends: 1. A national public awareness program on the importance of the environment and global climate change to personal health; 2. Encouraging health sciences schools to enhance their provision of educational programs on environmental health; and fostering the development of continuing education modules on environmental health and environmental health practices. Surveillance and Research There are important gaps in our knowledge on the health impacts of climate change as well as the effectiveness of various mitigation and adaptation strategies. Surveillance and reporting functions need to be strengthened to allow for greater accuracy in modeling of future impacts. CMA recommends: 3. That the federal government must address the gaps in research regarding climate change and health by undertaking studies to - quantify and model the burden of disease that will be caused by global climate change - identify the most vulnerable populations, the particular health impacts of climate change on vulnerable populations, and possible new protections for such populations; - increase the collection and accuracy of health data, particularly for vulnerable and underserved populations; - report diseases that emerge in conjunction with global climate change, and participate in field investigations, as with outbreaks of infectious diseases; and - develop and expand surveillance systems to include diseases caused by global climate change. Reducing the Burden of Disease to Mitigate Climate Change Impacts How susceptible a population is to the effects of climate change is dependent on their existing vulnerabilities. Therefore, work needs to be done to reduce the burden of diseases and improve upon the social determinants of health for vulnerable populations in Canada and globally. CMA recommends: 4. That the federal and provincial/territorial governments work together to improve the ability of the public to adapt to climate change and catastrophic weather events by - Encouraging behaviours that improve overall health, - Creating targeted programs designed to address specific exposures, - Providing health promotion information and education on self-management of the symptoms of climate-associated illness, - Ensuring physical infrastructure that allows for adaptation; 5. That the federal government develop concrete actions to reduce the health impact of climate-related emissions, in particular those initiatives which will also improve the general health of the population; 6. That the federal government support the Millennium Development Goals and support the principles outlined in the WHO Commission on the Social Determinants of Health report; and Preparing for Climate Emergencies To deal with the future burden of climate change related health issues there is a need to ensure adequate health capacity and infrastructure. Rebuilding of public health capacity globally is seen as the most important, cost-effective, and urgently needed response to climate change16. Domestically, there is a need to ensure adequate surge capacity within the health care system to be prepared for an increase in illness related to climate change effects. There is also a need to strengthen not only the health systems, but the infrastructure (i.e. housing) for vulnerable populations including Aboriginals and those in the North. CMA recommends that the federal and provincial /territorial governments work together to: 7. Strengthen the public health system both domestically and internationally in order to improve the capacity of communities to adapt to climate change; 8. Ensure adequate surge capacity within Canada's health system to handle the increase in climate change related illness; 9. Ensure the health of vulnerable populations is adequate to handle climate change related situations; 10. Develop knowledge about the best ways to adapt to and mitigate the health effects of climate change; 11. Integrate health professionals into the emergency preparedness plans of government and public health authorities so that front-line providers are adequately informed and prepared to properly manage any health emergencies. Advocacy to Combat Climate Change Finally, there is a need to take action to reduce the damaging effects of climate change. The global community needs to come together to reduce the levels of green house gases being released in the atmosphere, and focus on safer more environmentally friendly energy sources. Investments in cuts to greenhouse gas emissions would greatly outweigh their costs, and could help to reduce the future burden of climate change related illness17. CMA recommends: 12. That the government of Canada become a global leader in promoting equitable, carbon neutral economic, industrial, and social policies, and practices that fight global warming and adopt specific green house gas reduction targets as determined by the evolving science of climate change. 13. That health care professionals act within their professional settings to reduce the environmental impact of medical activities and to develop environmentally sustainable professional settings; 14. That all Canadians act to minimize individual impacts on the environment, and encourage others to do so, as well. Conclusions The CMA believes that Canada must prepare now for the potential health threat that climate change poses to its population. While many of these effects will take decades to materialize, certain populations, such as those in Canada's north, or those in low lying coastal areas, are already starting to experience the impact of climate change. A focus on education and health promotion, as well as advocacy for improved public policy and primary health care resources will be a good start in dealing with this issue. Additionally, further research and data collection is necessary to improve our understanding of climate change and the effectiveness of adaptation and mitigation strategies. Finally, the global community needs to act together to address the health and environmental impacts of climate change. By working together, in an international response, strategies can be implemented to mitigate any negative health effects of climate change. Canada's physicians believe that: What is good for the environment is also good for human health. It is past time for those of us in the health sector in Canada to engage fully in the debate and discussions within our own house, as well as in the broader body politic to ensure that protecting human health is the bottom line of environmental and climate change strategies. Bibliography 1 Currently a third of the world's population lives within 60 miles of the shoreline and 13 of 20 biggest world cities located on the coast- more than a billion people could be displaced (Costello et.al., 2009) 1 Costello, Anthony et.al. "Managing the health effects of climate change.' The Lancet Volume 373 May 16, 2009. pp.1693-1733. 2 World Health Organization, World Meteorological Organization & United Nations Environment Programme (2003) Climate Change and Human Health- Risks and Responses, Summary. Available at: http://www.who.int/globalchange/climate/en/ccSCREEN.pdf 3 Confalonieri et.al., (2007) Human Health. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Available at: http://www1.ipcc.ch/pdf/assessment-report/ar4/wg2/ar4-wg2-chapter8.pdf ; Epstein, Paul R. "Climate Change and Human Health." The New England Journal of Medicine 353 (14) October 6, 2005.; Friel, Sharon; Marmot, Michael; McMichael, Anthony J.; Kjellstrom, Tord & Denny Vagero. "Global health equity and climate stabilization: a common agenda." The Lancet Volume 372 November 8, 2008. pp.1677-1683. 4Confalonieri et.al., (2007) Human Health. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Available at: http://www1.ipcc.ch/pdf/assessment-report/ar4/wg2/ar4-wg2-chapter8.pdf; World Health Organization (2009) Protecting Health From Climate Change: Global research priorities. Available at: http://whqlibdoc.who.int/publications/2009/9789241598187_eng.pdf 5 Health Canada (2001) Climate Change and Health & Well-being: A Policy Primer Available at: http://www.hc-sc.gc.ca/ewh-semt/pubs/climat/policy_primer-abecedaire_en_matiere/index-eng.php 6 Campbell-Lendrum, Diarmid; Corvalan, Carlos & Maria Neira "Global climate change: implications for international public health policy." Bulletin of the World Health Organization. March 2007, 85 (3) pp.235-237 7 Seguin, Jacinthe & Peter Berry (2008) "Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity, Synthesis Report." Health Canada Available at: http://www.nbhub.org/hubfiles/pdf/HealthinChangingClimate_Synthesis_english_low.pdf 8 Health Canada (2002) Climate Change And Health & Well-Being: A Policy Primer for Canada's North. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/H46-2-02-290E.pdf 9 Seguin, Jacinthe & Peter Berry (2008) "Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity, Synthesis Report." Health Canada Available at: http://www.nbhub.org/hubfiles/pdf/HealthinChangingClimate_Synthesis_english_low.pdf 10 Ibid 11 Health Canada (2002) Climate Change And Health & Well-Being: A Policy Primer for Canada's North. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/H46-2-02-290E.pdf 12 Epstein, Paul R. "Climate Change and Human Health." The New England Journal of Medicine 353 (14) October 6, 2005. 13 Seguin, Jacinthe & Peter Berry (2008) "Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity, Synthesis Report." Health Canada Available at: http://www.nbhub.org/hubfiles/pdf/HealthinChangingClimate_Synthesis_english_low.pdf 14 Field, Christopher B. et.al. (2007) North America. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Available at: http://www1.ipcc.ch/pdf/assessment-report/ar4/wg2/ar4-wg2-chapter14.pdf 15 Health Canada (2002) Climate Change And Health & Well-Being: A Policy Primer for Canada's North. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/H46-2-02-290E.pdf 16 World Health Organization, World Meteorological Organization & United Nations Environment Programme (2003) Climate Change and Human Health- Risks and Responses, Summary. Available at: http://www.who.int/globalchange/climate/en/ccSCREEN.pdf 17 Campbell-Lendrum, Diarmid; Corvalan, Carlos & Maria Neira "Global climate change: implications for international public health policy." Bulletin of the World Health Organization. March 2007, 85 (3) pp.235-237
Documents
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Patient-focused funding

https://policybase.cma.ca/en/permalink/policy9843
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Health systems, system funding and performance
Resolution
GC10-11
The Canadian Medical Association will work with provincial/territorial medical associations and governments to ensure that patient-focused funding initiatives are based on data that are scientifically valid, accurate and publicly available.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Health systems, system funding and performance
Resolution
GC10-11
The Canadian Medical Association will work with provincial/territorial medical associations and governments to ensure that patient-focused funding initiatives are based on data that are scientifically valid, accurate and publicly available.
Text
The Canadian Medical Association will work with provincial/territorial medical associations and governments to ensure that patient-focused funding initiatives are based on data that are scientifically valid, accurate and publicly available.
Less detail

Collaborative development of patient-focused funding initiatives

https://policybase.cma.ca/en/permalink/policy9844
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Ethics and medical professionalism
Health systems, system funding and performance
Resolution
GC10-12
The Canadian Medical Association will work with provincial/territorial medical associations to ensure meaningful consultations by governments with physicians who are accountable to the medical profession in the collaborative development of patient-focused funding initiatives.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Ethics and medical professionalism
Health systems, system funding and performance
Resolution
GC10-12
The Canadian Medical Association will work with provincial/territorial medical associations to ensure meaningful consultations by governments with physicians who are accountable to the medical profession in the collaborative development of patient-focused funding initiatives.
Text
The Canadian Medical Association will work with provincial/territorial medical associations to ensure meaningful consultations by governments with physicians who are accountable to the medical profession in the collaborative development of patient-focused funding initiatives.
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