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2015 Pre-budget consultations: Federal leadership to support an aging population

https://policybase.cma.ca/en/permalink/policy11753
Date
2015-07-31
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2015-07-31
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
Helping physicians care for patients Aider les médecins à prendre soin des patients Canada is a nation on the precipice of great change. This change will be driven primarily by the economic and social implications of the major demographic shift already underway. The added uncertainties of the global economy only emphasize the imperative for federal action and leadership. In this brief, the Canadian Medical Association (CMA) is pleased to present four recommendations to the House of Commons Standing Committee on Finance for meaningful federal action in support of a national seniors strategy; these are essential measures to prepare for an aging population. Canada's demographic and economic imperative In 2011 the first of wave of the baby boomer generation turned 65 and Canada's seniors population stood at 5 million.1 By 2036, seniors will represent up to 25% of the population.2 The impacts of Canada's aging population on economic productivity are multi-faceted. An obvious impact will be fewer workers and a smaller tax base. Finance Canada projects that the number of working-age Canadians for every senior will fall from about 5 today to 2.7 by 2030.3 The projected surge in demand for services for seniors that will coincide with slower economic growth and lower government revenue will add pressure to the budgets of provincial and territorial governments. Consider that while seniors account for about one-sixth of the population, they consume approximately half of public health spending.4 Based on current trends and approaches, seniors' care is forecast to consume almost 62% of provincial/territorial health budgets by 2036.5 The latest fiscal sustainability report of the Parliamentary Budget Officer explains that the demands of Canada's aging population will result in "steadily deteriorating finances" for the provinces and territories and they "cannot meet the challenges of population ageing under current policy."6 Theme 1: Productivity A) New federal funding to provincial/territorial governments Canada's provincial and territorial leaders are aware of the challenges ahead. This July, the premiers issued a statement calling for the federal government to increase the Canada Health Transfer to 25% of provincial and territorial health care costs to address the needs of an aging population. To support the innovation and transformation needed to address these needs, the CMA recommends that the federal government deliver additional funding on an annual basis beginning in 2016-17 to the provinces and territories by means of a demographic-based top-up to the Canada Health Transfer (Table 1). For the fiscal year 2016-17, this top-up would require $1.6 billion in federal investment. Table 1: Allocation of the federal demographic-based top-up, 2016-20 ($million)7 Jurisdiction 2016 2017 2018 2019 2020 All of Canada 1,602.1 1,663.6 1,690.6 1,690.3 1,879.0 Newfoundland and Labrador 29.7 30.5 33.6 35.3 46.1 Prince Edward Island 9.1 9.7 10.6 10.6 11.5 Nova Scotia 53.6 58.6 62.3 61.9 66.6 New Brunswick 45.9 50.7 52.2 52.0 57.2 Quebec 405.8 413.7 418.8 410.2 459.5 Ontario 652.2 677.9 692.1 679.0 731.6 Manitoba 28.6 30.6 33.5 31.1 36.6 Saskatchewan 3.5 4.9 7.3 11.9 15.4 Alberta 118.5 123.3 138.9 134.9 157.5 British Columbia 251.6 258.7 270.3 258.4 291.3 Yukon 1.4 2.6 2.1 2.4 2.5 Northwest Territories 1.4 1.6 1.7 1.7 2.1 Nunavut 0.9 0.6 0.8 0.9 1.0 B) Federal support for catastrophic drug coverage A major gap in Canada's universal health care system is the lack of universal access to prescription medications, long recognized as the unfinished business of medicare. Canada stands out as the only country with universal health care without universal pharmaceutical coverage.8 According to the Angus Reid Institute, more than one in five Canadians (23%) report that they or someone in their household did not take medication as prescribed because of the cost during the past 12 months.9 Statistics Canada's Survey of Household Spending reveals that households headed by a senior spend $724 per year on prescription medications, the highest among all age groups and over 60% more than the average household.10 Another recent study found that 7% of Canadian seniors reported skipping medication or not filling a prescription because of the cost.11 In addition to the very real harms to individuals, lack of coverage contributes to the inefficient use of Canada's scarce health resources. While there are sparse economic data in Canada on this issue, earlier research indicated that this inefficiency, which includes preventable hospital visits and admissions, represents an added cost of between $1 billion and $9 billion annually.12 As an immediate measure to support the health of Canadians and the productivity of the health care sector, the CMA recommends that the federal government establish a new funding program for catastrophic coverage of prescription medication. The program would cover prescription medication costs above $1,500 or 3% of gross household income on an annual basis. Research commissioned by the CMA estimates this would cost $1.48 billion in 2016-17 (Table 2). This would be a positive step toward comprehensive, universal prescription drug coverage. Table 2: Projected cost of federal contribution to cover catastrophic prescription medication costs, by age cohort, 2016-2020 ($ million)13 Age cohort 2016 2017 2018 2019 2020 Share of total cost Under 35 years 107.0 107.6 108.2 108.8 109.3 7% 35 to 44 years 167.4 169.8 172.7 175.7 178.4 11% 45 to 54 years 274.2 270.2 270.2 265.7 262.8 18% 55 to 64 years 362.5 370.7 378.6 384.6 388.2 25% 65 to 74 years 292.1 304.0 315.8 328.4 341.9 21% 75 years + 286.3 292.0 299.0 306.6 314.4 20% All Ages 1,480.4 1,497.2 1,514.2 1,531.2 1,548.1 100% Theme 2: Infrastructure and communities All jurisdictions across Canada are facing shortages in the continuing care sector. Despite the increased availability of home care, research commissioned for the CMA indicates that demand for continuing care facilities will surge as the demographic shift progresses.14 In 2012, it was reported that wait times for access to a long-term care facility in Canada ranged from 27 to over 230 days. It is estimated that 85% of "alternate level of care" patients in hospitals (i.e., patients who do not require hospital-level care) are in these beds because of the lack of availability of long-term care. Due to the significant difference in the cost of hospital care (approximately $846 per day) versus long-term care ($126 per day), the CMA estimates that the shortages in the long-term care sector represent an increased cost of $2.3 billion. Despite the recognized need for infrastructure investment in the continuing care sector, to date, this sector has been excluded from the Building Canada Plan. The CMA recommends that the federal government amend the criteria of the Building Canada Plan to include capital investment in continuing care infrastructure, including retrofit and renovation. Based on previous estimates, the CMA recommends that $540 million be allocated for 2016-17 (Table 3). Table 3: Estimated cost to address forecasted shortage in long-term care beds, 2016-20 ($ million)15 Forecasted shortage in long-term care beds Estimated cost to address shortage Federal share to address shortage in long-term care beds (based on 1/3 contribution) 2016 6,028 1,621.5 540.5 2017 6,604 1,776.5 592.2 2018 8,015 2,156.0 718.7 2019 8,656 2,328.5 776.2 2020 8,910 2,396.8 798.9 Total 38,213 10,279.3 3,426.4 Theme 3: Jobs As previously mentioned, Canada's aging population will produce significant changes in the labour force. There will be fewer Canadian workers, each with a greater likelihood of having caregiving responsibilities for family and friends. According to the report of the federal Employer Panel for Caregivers, Canadian employers "were surprised and concerned that it already affects 35% of the Canadian workforce."16 This report highlights key findings of the 2012 General Social Survey: 1.6 million caregivers took leave from work; nearly 600,000 reduced their work hours; 160,000 turned down paid employment; and, 390,000 quit their jobs to provide care. It is estimated that informal caregiving represents $1.3 billion in lost workforce productivity. These costs will only increase as Canada's demographic shift progresses. In parallel to the increasing informal caregiving demands on Canadian workers, Canada's aging population will also increase the demand for personal care workers and geriatric competencies across all health and social care professions.17 Theme 4: Taxation The above section focused on the economic costs of caregiving on the workforce. The focus of this section will be on the economic value caregivers provide while they take on an increased economic burden. Statistics Canada's latest research indicates that 8.1 million Canadians are informal caregivers, 39% of whom primarily care for a parent.18 The Conference Board of Canada reports that in 2007 informal caregivers contributed over 1.5 billion hours of home care - more than 10 times the number of paid hours in the same year.19 The economic contribution of informal caregivers was estimated to be about $25 billion in 2009.20 This same study estimated that informal caregivers incurred over $80 million in out-of-pocket expenses related to caregiving in 2009. Despite their tremendous value and important role, only a small fraction of caregivers caring for a parent received any form of government support.21 Only 5% of caregivers providing care to parents reported receiving financial assistance while 28% reported needing more assistance than they received.22 As a first step to providing increased support for Canada's family caregivers, the CMA recommends that the federal government amend the Caregiver and Family Caregiver Tax Credits to make them refundable. This would provide an increased amount of financial support for family caregivers. It is estimated that this measure will cost $90.8 million in 2016-17.23 Conclusion The CMA recognizes that in the face of ongoing economic uncertainty the federal government may face pressures to avoid new spending initiatives. The CMA strongly encourages the federal government to adopt the four recommendations outlined in this submission rather than further delay making a meaningful contribution to meeting the future care needs of Canada's aging population. The CMA would welcome the opportunity to provide further information and its rationale for each recommendation. 1 Statistics Canada. Generations in Canada. Cat. No. 98-311-X2011003. Ottawa: Statistics Canada; 2012. Available: www12.statcan.gc.ca/census-recensement/2011/as-sa/98-311-x/98-311-x2011003_2-eng.pdf 2 Statistics Canada. Canada year book 2012, seniors. Available: www.statcan.gc.ca/pub/11-402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm 3 Finance Canada. Economic and fiscal implications of Canada's aging population. Ottawa: Finance Canada; 2012. Available: www.fin.gc.ca/pub/eficap-rebvpc/eficap-rebvpc-eng.pdf 4 Canadian Institute for Health Information. National health expenditure trends, 1975 to 2014. Ottawa: The Institute; 2014. Available: www.cihi.ca/web/resource/en/nhex_2014_report_en.pdf 5 Calculation by the Canadian Medical Association, based on Statistics Canada's M1 population projection and the Canadian Institute for Health Information age-sex profile of provincial-territorial health spending. 6 Office of the Parliamentary Budget Officer. Fiscal sustainability report 2015. Ottawa: The Office; 2015. Available: www.pbo-dpb.gc.ca/files/files/FSR_2015_EN.pdf 7 Conference Board of Canada. Research commissioned for the CMA, July 2015. 8 Morgan SG, Martin D, Gagnon MA, Mintzes B, Daw JR, Lexchin J. Pharmacare 2020: The future of drug coverage in Canada. Vancouver: Pharmaceutical Policy Research Collaboration, University of British Columbia; 2015. Available: http://pharmacare2020.ca/assets/pdf/The_Future_of_Drug_Coverage_in_Canada.pdf 9 Angus Reid Institute. Prescription drug access and affordability an issue for nearly a quarter of Canadian households. Available: http://angusreid.org/wp-content/uploads/2015/07/2015.07.09-Pharma.pdf 10 Statistics Canada. Survey of household spending. Ottawa: Statistics Canada; 2013. 11 Canadian Institute for Health Information. How Canada compares: results From The Commonwealth Fund 2014 International Health Policy Survey of Older Adults. Available: www.cihi.ca/en/health-system-performance/performance-reporting/international/commonwealth-survey-2014 12 British Columbia Pharmacy Association. Clinical service proposal: medication adherence services. Vancouver: The Association; 2013. Available: www.bcpharmacy.ca/uploads/Medication_Adherence.pdf 13 Supra at note 7. 14 Conference Board of Canada. Research commissioned for the CMA, January 2013. 15 Ibid. 16 Government of Canada. Report from the Employer Panel for Caregivers: when work and caregiving collide, how employers can support their employees who are caregivers. Available: www.esdc.gc.ca/eng/seniors/reports/cec.shtml 17 Stall S, Cummings G, Sullivan T. Caring for Canada's seniors will take our entire health care workforce. Available: http://healthydebate.ca/2013/09/topic/community-long-term-care/non-md-geriatrics 18 Statistics Canada. Family caregivers: What are the consequences? Available: www.statcan.gc.ca/pub/75-006-x/2013001/article/11858-eng.htm 19 Conference Board of Canada. Home and community care in Canada: an economic footprint. Ottawa: The Board; 2012. Available: http://www.conferenceboard.ca/cashc/research/2012/homecommunitycare.aspx 20 Hollander MJ, Liu G, Chappeel NL. Who cares and how much? The imputed economic contribution to the Canadian health care system of middle aged and older unpaid caregivers providing care to the elderly. Healthc Q. 2009;12(2):42-59. 21 Supra at note 16. 22 Ibid. 23 Supra at note 7.
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2020 pre-budget submission to the House of Commons Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy14131
Date
2020-02-25
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2020-02-25
Topics
Population health/ health equity/ public health
Text
Primary care is the backbone of our health care system in Canada and a national priority for this government. The echoing words of the Speech from the Throne certify that the Government will strengthen health care and “Work with provinces, territories, health professionals and experts in industry and academia to make sure that all Canadians can access a primary care family doctor.” The Health Minister’s mandate letter further confirms that the Government will work “with the support of the Deputy Prime Minister and Minister of Intergovernmental Affairs, the Minister of Finance and the Minister of Seniors, to strengthen Medicare and renew our health agreements with the provinces and territories” to “ensure that every Canadian has access to a family doctor or primary health care team”. We recognize that strengthening primary care through a team-based, inter-professional approach is integral to improving the health of all people living in Canada. This belief is consistent across our alliance of four major groups: the Canadian Medical Association, the Canadian Nurses Association, the Canadian Association of Social Workers and the College of Family Physicians of Canada. There is nothing more suiting or fortunate than for a team-based approach to be wholeheartedly supported by an even larger team of teams. We commend the Government’s commitment to increasing Canadians’ access to primary care. We have a model to make it happen. The Primary Health Care Transition Fund 2, a one-time fund over four years, would provide the necessary funding to help establish models of primary care based on the Patient’s Medical Home, a team-based approach that connects the various care delivery points in the community for each patient. This model is rooted in the networking of family physicians, nurse practitioners, nurses, social workers and other health professionals as a team. This is the only way to provide comprehensive primary care to patients. It will enable a more exhaustive approach to patient care, ultimately leading to increased prevention and better health outcomes for Canadians. Consider it the main artery in meeting the needs of patients and communities. A commitment to the Primary Health Care Transition Fund 2 gives substance to the promise of building a network of care that addresses immediate health needs while connecting to ongoing social and community health services. This Fund model bolsters Canadians. It is backed by doctors, nurses, and social workers. A phalanx of Canadian care providers stand behind it. An entire country will benefit from it. INTRODUCTION RECOMMENDATION 2 In support of the federal government’s commitment to improve Canadians’ access to primary care, we recommend a one-time fund in the amount of $1.2 billion over four years to expand the establishment of primary care teams in each province and territory.
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Accessibility: the solution lies in cooperation

https://policybase.cma.ca/en/permalink/policy11518
Date
2015-03-25
Topics
Health human resources
  1 document  
Policy Type
Parliamentary submission
Date
2015-03-25
Topics
Health human resources
Text
ACCESSIBILITY: THE SOLUTION LIES IN COOPERATION Joint Brief of The Quebec Medical Association and the Canadian Medical Association BILL no. 20: An Act to enact the Act to promote access to family medicine and specialized medicine services and to amend various legislative provisions relating to assisted procreation March 25, 2015 Preamble We would like to thank the members of the Committee on Health and Social Services for giving the Quebec Medical Association (QMA) and the Canadian Medical Association (CMA) the opportunity to express their preliminary views on Bill 20. We use the word "preliminary" deliberately because the bill in its current form sets out broad principles but is lacking in specifics. We would have liked to see more transparency on the government's part early in the process, whereas the regulatory guidelines were only made public on March 19. This shows a lack of respect or courtesy, or is a deliberate expression of the government's determination to ignore the opinion of the professionals concerned, that is to say, physicians. We have chosen not to critique the bill clause by clause, so we will not go that route for the regulatory guidelines either. We will instead limit ourselves to a few general comments. For example, how was it determined that an HIV-positive patient is "worth" two vulnerable patients, or that a patient receiving end-of-life care at home is worth 25? Why not 22, 26, or 30? Only ministry insiders know for sure, since neither of our organizations was consulted. And how many civil servants will it take to measure and monitor this new form of "mathematical" medical practice? The QMA is the only Quebec association whose members include general practitioners, specialists, residents and medical students. It calls on its vast network of members to consider the issues the medical profession faces, propose solutions and innovate in order to rethink the role doctors play in society and continually improve medical practice. The CMA is the largest national association of Canadian physicians and advocates on their behalf at the national level. The association's mission is to help physicians care for patients. The CMA is a leader in engaging and serving physicians and the national voice for the highest standards for health and health care. This brief is a historic first for both organizations. This is the first time that the CMA has submitted a brief in Quebec's National Assembly as well as the first time that the QMA and CMA have submitted a joint brief. This joint initiative says a lot about how concerned the country's physicians are about Bill 20. This attack on the professional autonomy of physicians is unprecedented in the history of Canadian organized medicine. Undoubtedly, the issues speak to the entire medical profession because of the consequences the bill could have on the profession itself. Our input is intended to be realistic, constructive and reflective of our member's opinions and legitimate concerns. Our two organizations-which, we note, are not negotiating bodies-have a profound understanding of the health community in Quebec, Canada and internationally. In keeping with the tradition of our two organizations, we are constantly seeking ways to improve the health care system in order to bring about patient-centred care. That said, we are also well aware of the budget constraints Quebec is currently facing. Our comments will mainly address the following points: o Access to family physicians and specialists; o The "productivity" of Quebec physicians; o Examples elsewhere in Canada; o Success factors. Physician access Obviously, access to health care and services in Quebec is a problem, particularly with regard to family physicians. Statistics Canada reported that, in 2013, an average 15.5% of Canadians did not have a regular medical doctor1. Quebec, with 25.1% of residents lacking a family physician, was well above the national average. All four of the Atlantic Provinces as well as Ontario provided better access than Quebec while Manitoba and British Columbia reported rates that were about the same as the national average. Despite considerable investment in recent years, plainly many Quebecers still do not have access to a family physician and other specialists. We do not believe the status quo is an option. Something must be done. Unlike as provided in Bill 20, however, we do not believe that imposing patient quotas on physicians is the solution. Quotas could have the adverse effect of leading physicians to choose quantity of care over quality, which could result in incomplete examinations, increased use of diagnostic tests and, ultimately, overdiagnosis. This is the sort of practice that the QMA and CMA have been trying to eliminate for 18 months with their "Choosing Wisely Canada"2 awareness campaign, which advocates for better medicine and fewer tests and procedures of no added value. Overdiagnosis has significant impacts on cost, quality, effectiveness, efficacy and patient access to health care and, as a result, on the efficiency of the entire health care network. In short, doing more is not always better. The campaign has been embraced both by physicians and patients, but Bill 20 risks not only undermining considerable effort but also sending the public a contradictory message. The "productivity" of Quebec physicians The services provided by Quebec physicians have been the subject of much debate in recent months. The government's claim that Quebec physicians are less "productive" than their colleagues in other provinces is based on a false premise. The reality is that billing methods are different and cannot be meaningfully compared. The national data shows that 8.5% of Canadian physicians are salaried, while 41.9% are paid a fee per service and 41.4% are paid lump sums or through capitation, or a combination of the two. Longitudinal analysis of the 2014 National Physician Survey-a partnership between the College of Family Physicians of Canada, the Canadian Medical Association and the Royal College of Physicians and Surgeons of Canada-offers a way to relativize the "productivity" of Quebec physicians compared to that of their colleagues in other provinces. For more than a decade, the survey has been a point of reference for researchers, governments and stakeholders interested in analyzing and improving health care in Canada. The Canadian database for this study clearly shows that the gap between the hours devoted per week to direct patient services by Quebec and other Canadian physicians is shrinking. Even though physicians in the rest of Canada still report working more than their Quebec colleagues, the difference decreased 44% between 2010 and 2014 to 1.37 hours per week. For family physicians, the gap decreased 23% to 2.41 hours in 2014. Plainly, we are far from the alarming situation that has been decried in recent weeks. Furthermore, the results show that, on average, Quebec physicians perform more than 20% more research-related activities per week than their Canadian counterparts, confirming a trend over the past 10 years. On-call work for health care establishments should also be considered in the productivity debate as family physicians who perform such work spend on average more than eight hours per week on related tasks compared to approximately six hours in the rest of Canada. Counting specialists, the figure rises to more than 11 hours per week, compared to a bit less than eight hours per week by family physicians and specialists in the rest of the country. In 2014 Quebec family physicians reported having to spend 23% more time each week on administrative tasks than their Canadian colleagues (2.8 hours versus 2.27 hours). This trend has become more pronounced over the past 10 years. In short, Quebec physicians work almost as much as their colleagues in the rest of Canada. Yet they appear to be less efficient. Why? Because of the shortcomings in the way our system is organized, physicians are busy doing administrative work, seeking out clinical information that should be at their fingertips, and performing tasks that could be left to other health care professionals. These figures, which show that the number of hours worked by physicians in direct patient care declined an average of 10% in the other provinces between 2004 and 2014, raise a question. How is it that, despite this decrease in hours worked, there is better accessibility to health care services? Because in collaboration with physicians, Alberta, Ontario and British Columbia have each successfully introduced measures in recent years to improve their services, particularly on the front line. Quebec would do well to examine those initiatives. Elsewhere in Canada A GP for Me A GP for Me is an initiative in British Columbia jointly funded by the provincial government and Doctors of BC to:
Enable patients who want a family doctor to find one;
Increase the capacity of the primary health care;
Confirm and strengthen the continuous doctor-patient relationship; including better support for the needs of vulnerable patients. The mission of Doctors of BC3 is to make a meaningful difference in improving the health care for British Columbians by working to achieve quality patient care through engagement, collaboration and physician leadership. Its goal is to promote a social, economic and political climate in which members can provide the citizens of BC with the highest standard of health care, while achieving maximum professional satisfaction and fair economic reward. Ontario Ontario chose to tackle the access problem by obtaining the support and cooperation of faculties of medicine, health organizations and the College of Physicians and Surgeons of Ontario. Two hundred family health teams (the equivalent of Quebec's family medicine groups) were created. The groups promote access to care by bringing different health care providers together under the same roof. Ontario also has more specialized nurse practitioners than Quebec does. The result of all these efforts is that two million more Ontarians can now call on a family physician. The inspiring example of Taber, Alberta The Taber Integrated Primary Healthcare Project4 is an initiative launched in the early 2000s in the town of Taber, in rural Alberta. The goal of the project was to improve health care services delivery through integration of the services provided by a physician group and the Chinook Health Region. In light of the project's success, it was expanded to the entire region five years later. According to Dr. Robert Wedel, one of the people behind the project, four factors explain the initiative's success: a community assessment and shared planning; evidence-based, interdisciplinary care; an integrated electronic information system; and investment in processes and structures that support change. Community evaluation and shared planning: First, successful integration of primary health care depends on gaining an understanding of individual, family and community health care needs. Health services providers and users must also have a shared vision of optimal health care delivery. Evidence-based, interdisciplinary care: Second, the introduction of interdisciplinary teams (physicians, nurses, managers and other health professionals) facilitated the transition from a facility-based service delivery approach to a community-based wellness approach. Electronic information system: Third, the introduction of an integrated information system aided interdisciplinary care and access to patient information in various points of service. Alternative payment plan: Finally, processes and structures were put in place to support change over the long term. An alternative payment plan was implemented to clarify physician remuneration, define service and productivity expectations and protect organizational autonomy. The plan was also designed to enable physicians to delegate tasks to other professionals on the team in order to spend additional time with patients with more complex needs. The physicians now receive a fixed salary for specific services (in-clinic ambulatory services, emergencies, minor operations, prenatal care, and so on). However, some services continue to be billed on a fee-for-service basis (births, major operations and anaesthesia). Salaries are reduced when a registered patient receives care outside the physician group. Furthermore, organizational change strategies were put in place to address resistance to the changes. Modifications were made so that a common, integrated care site could eventually be established. All these changes had significant, positive consequences in Taber but also throughout the Chinook region. This approach enables better monitoring of chronic diseases and more prevention and education services for patients. Also noted was better accessibility to care, even for vulnerable and generally underserved patients. In the early 2000s, patients had to wait about 30 days before the first available appointment, but the wait has been completely eliminated since 2006. Physician services increased about 10% and those by other professionals, 50%. Patients visit their physicians less often (2.1 visits per year rather than 5.6 visits in other regions), and a marked decline in emergency room visits and laboratory tests has been observed. Quebec could capitalize on the Taber initiative by adapting it to the situation in Quebec and encouraging physicians to participate fully like the committed partners they are of patients and the health system. Success Factors Improvements from the Taber project and other initiatives in Alberta, Ontario and British Columbia-all of which provide greater health care access than Quebec-share three common features that are available to Quebec as well: o Electronic health records (EHRs) Quebec lags behind other provinces in adopting EHRs. A mere 25% of Quebec physicians order diagnostic and laboratory tests electronically. The 2014 National Physician Survey ranks Quebec almost last in health care system computerization. The Quebec Health Record Project promised for 2011 at a cost of $543 million has been, according the health minister himself, an abject failure. Recently he said that the Quebec government planned to deliver the project in 2021 at a cost of $1.6 billion before adding that he was not sure there would be money to pay for it. Physicians have nothing to do with this delay or the squandering of public funds. They're ready and waiting to make use of computerized records to improve health care access and communicate better with patients. The confusion and delays in switching to EHRs in Quebec are a big part of the reason for Quebec's poor results on the survey. Some of the problems might indeed be caused by the older generation's reluctance to embrace information technology, but that's not the whole story. We need to have a system that is absolutely reliable and accessible. Primary care organizations in Ontario are using electronic medical records to identify and support patient needs. All Ontario's primary care organizations mentioned using EHRs in descriptions they submitted on their quality improvement plans5-an example of how technology can be used to monitor patient needs and support improved delivery of care. Approximately 38% described using EHRs to identify specific diseases. We cannot overlook the fact that EHRs have been the cornerstone of the productivity improvements elsewhere in Canada. o Interdisciplinary work organization Quebec also lags behind in providing environments conducive to greater interdisciplinary work and enlisting contributions from other health professionals (nurse practitioners [NPs], nurses, managers and other health professionals). Certain Canadian provinces are far ahead in this area. Team care allows the various professionals to do their regular tasks and delegate when the situation calls for it. The solutions that have put most Canadian provinces on the road to solving the problem of frontline health care access have generally come through collaboration between the government and the medical profession. With effective information systems and the implementation of interdisciplinary approaches, in a spirit of cooperation and collaboration, such health care systems manage to provide the kind of accessible, high quality care patients and taxpayers are entitled to expect when they need it. The bottom line is that interdisciplinary work allows physicians to do what they do best: diagnose and treat. o Remuneration practices for population-based responsibility Quebec seems to be the Canadian province where physician remuneration is closest to a fee-for-service model. Quebec Health Insurance Plan data from 2013 shows that close to 80% of Quebec physicians' total compensation is fee-for-service.6 Elsewhere in the country, mixed remuneration methods appear to make it easier to foster population-based responsibility, i.e., not just covering a territory, but also incorporating the determinants of population health and well-being, among which are access to high quality services and the full participation of all stakeholders. In its 2011 support strategy for the practice of population-based responsibility7, MSSS spelled out the government's approach. However, that strategy was developed around local service networks managed through CSSSs, which were recently done away with by Bill 10, An Act to modify the organization and governance of the health and social services network, in particular by abolishing the regional agencies. The authors of the strategy define population-based responsibility collectively, as follows: * Using health and social services data to develop a shared picture of the reality on the ground; * Deciding, in consultation with the public, partners in the health and social services network and other sectors, on a basket of integrated, quality services to meet the needs of the local population; * Strengthening actions on health determinants in order to improve the health and well-being of the entire local population; and * Tracking performance and seeking ongoing improvements, in the interests of greater accountability Implementing population-based responsibility clearly requires a collective approach. Nothing in Bill 20 appears to indicate that the government might arrive at such an approach. No discussion of population-based responsibility would be complete without considering the Kaiser Permanente model. Kaiser Permanente is a nonprofit organization whose mission is to provide high quality, affordable health care services and improve the health of its members and the communities it serves. Approximately 9.9 million people receive health care from Kaiser Permanente, which has 17,000 physicians and 174,000 employees (including 48,000 nurses) working in 38 hospitals and medical centres and more than 600 clinics. The organization lists five keys to its model's success:8 1. Accountability for population 2. Transparency 3. Use of electronic health records and the Internet 4. Team care 5. Moving care out of doctor's office There are no provisions in Bill 20 for developing any of the above. Clearly, the fee-for-service model does not encourage population-based responsibility. We have seen in the Taber example a broad basket of services covered in the clinic's overall budget, with other things remaining fee-for-service (births, major operations, anaesthesia etc.). The way physicians are currently compensated stands in the way of any strategy whereby physician groups would receive fixed budgets to care for a given population. This is where Bill 20 goes off track-by individualizing patient targets instead of grouping them. Under group approaches, a physician who fails to meet commitments and does not see the required number of patients risks repercussions from colleagues and not the government, because the physician is responsible for contributing to the group's objectives. A physician in that same clinic who sees only complex cases will necessarily see fewer patients, but colleagues will be freed up to deal with more. We sincerely believe that physicians are in favour of a population-based responsibility approach. Yet the inescapable conclusion is that Bill 20, with its fee-per-service and individualized appointment targets, is taking us in a different direction entirely. We are convinced that physicians are overwhelmingly in favour of mixed compensation methods. The health and welfare commissioner launched a series of studies to assess the impact of remuneration on health system effectiveness and efficiency. As soon as RAMQ data becomes available, researchers will be able to complete their work and show how adjusting remuneration methods would contribute to improving health care access. Conclusion It is no coincidence that we have not attempted a clause-by-clause critique of Bill 20. The government's entire approach needs to be changed. It is high time the government understood that physicians are part of the solution to health service access problems, and that a coercive approach is counterproductive and demoralizing. History is full of examples in which working together in a climate of mutual respect led to impressive results. Both the QMA and CMA fully support the idea and purpose of the bill-to improve access to health care-but we believe Bill 20 is not the answer. We think changes worked out in partnership get the best results. All real improvements to the health care system have always been achieved in an atmosphere of dialogue and collaboration. To sum up, the QMA and CMA recommend first and foremost that the government work with the medical profession to improve access to health care, as well as the following measures: * Speed up the process of switching to electronic health records-an indispensable tool in 2015. * Reorganize tasks to accord a greater role to other health professionals (NPs, nurses, administrators and others) by forming care teams that can pool their knowledge and skills to better serve patients. * Reconsider Quebec's near-exclusive reliance on fee-for-service and consider bringing in a form of mixed remuneration that leads towards a population-based responsibility model. Elsewhere in Canada, this approach has contributed significantly to improvements in health care access, particularly on the front line. 1 http://www.statcan.gc.ca/pub/82-625-x/2014001/article/14013-eng.htm 2 http://www.choosingwiselycanada.org/ 3 https://www.doctorsofbc.ca/sites/default/files/strategicplan-doctorsofbc-web.pdf 4 Wedel R, Kalischuk RG, Patterson E, et al. Turning Vision into Reality: Successful Integration of Primary Healthcare in Taber, Canada. Healthcare Policy 2007; 3(1): 81-95. 5 http://www.hqontario.ca/portals/0/Documents/qi/qip-analysis-pc-en.pdf 6 Régie de l'assurance maladie du Québec. Évolution du coût des services médicaux et du nombre de médecins selon le mode de rémunération. Services médicaux, Québec, 2009-2013. 7 http://publications.msss.gouv.qc.ca/acrobat/f/documentation/2011/11-228-04W.pdf 8 Molly Porter. An Overview of Kaiser Permanente: Integration, Innovation, and Information Systems in Health Care. Presentation for the Canadian Medical Association, Kaiser Permanente International, March 2, 2015.
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Acting on today's and tomorrow's health care needs: Prebudget submission to the House of Commons Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy14123
Date
2019-08-02
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2019-08-02
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to provide the House of Commons Standing Committee on Finance this pre-budget submission. It provides recommendations to address major pan-Canadian challenges to the health of Canadians: improve how we provide care to our growing elderly population; improve access to primary care across the country; increase digital health literacy to take advantage of the benefits of new health information technologies; and better prepare for and mitigate the health impacts of a changing climate on Canadians. Seniors Care Health systems across the country are currently struggling to meet the needs of our aging population. People aged 85 years and over—many of whom are frail—make up the fastest growing age group in Canadai. Provincial and territorial health care systems (as well as care systems for populations falling under federal jurisdiction) are facing many challenges to meet the needs of an aging population. Canadians support a strong role for the federal government in leading a national seniors strategy and working with the provinces to ensure that all Canadians have the same level of access and quality of services, no matter where they live. The 2017 federal/provincial/territorial funding agreement involving $6 billion over 10 years to improve access to home care services is a welcomed building block. But without greater investment in seniors care, health systems will not keep up. To be truly relevant and effectively respond to Canadians’ present and future needs, our health care system must provide integrated, continuing care able to meet the chronic and complex care needs of our growing and aging population. This includes recognizing the increased role for patients and their caregivers in the care process. The federal government must ensure transfers are able to keep up with the real cost of health care. Current funding levels clearly fail to do so. Health transfers are estimated to rise by 3.6% while health care costs are expected to rise by 5.1% annually over the next decade.ii Recommendation: The federal government ensure provincial and territorial health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer.iii Providing care often comes with a financial cost such as lost income due to the caregiver’s withdrawal from the workforce to provide care. There are also increasing out-of-pocket costs for both caregivers and care receivers for health care-related expenses—privately covered expenditures on home and long-term care for seniors are projected to grow by an average of 5.8 per cent annually—nearly 1.5 times the pace of household disposable income growth. While the federal government offers tax credits that can be claimed by care receivers/caregivers, they are significantly under-utilized. While representing a significant proportion of caregivers, those with low or no income receive little to no federal government support through these programs. Middle-income earners also receive less than those earning high incomes. 4 Recommendation: The federal government create a Seniors Care Benefit that would be an easier, fairer and more effective way to support caregivers and care receivers alike.iv Access to Care Since the mid-1990s, the federal and provincial/territorial governments (FPT) have provided sustained leadership in promoting and supporting the transformation of primary care in Canada. In 2000, the First Ministers concluded the first of three Health Accords in which they agreed to promote the establishment of primary health care teamsv supported by a $800 million Primary Health Care Transition Fund (PHCTF) funded by the federal government, but jointly governed. The PHCTF resulted in large-scale sustained change in primary care delivery models in Ontario, Quebec and Alberta with interest in other jurisdictions as well. However, the job is far from finished. Across Canada, access to primary care is challenging for many Canadians with a persistent shortage of family physicians. In 2017, 4.7 million Canadians aged 12+ reported they did not have a regular health care provider.vi Even those who have a regular provider experience wait time issues. There has been widespread interest in primary care models since the development of the College of Family Physicians of Canada’s (CFPC) vision document Family Practice: The Patient’s Medical Home (PMH), initially launched in 2011vii and recently re-launched.viii The model is founded on 10 pillars depicted in Figure 1. Figure 1. The Patient’s Medical Home, 2019 The updated model places increased emphasis on team-based care and introduces the concept of the patient’s medical neighborhood that sets out connections between the primacy care practice and all delivery points in the surrounding community. While comprehensive baseline data are lacking, it seems 5 safe to conjecture that most Canadians are not enrolled in a primary care model that would measure up to the model’s 10 pillars. Recommendation: The federal government, in concert with provinces and territories, establish a targeted fund in the amount of $1.2 billion to support a new time-limited Primary Health Care Transition Fund that would build on the success of the fund launched in 2000 with the goal of widely introducing a sustainable medical home model across jurisdictions. This would include the following key elements:
Age-sex-weighted per capita allocation across the provinces and territories;
Joint governance of the FPT governments with meaningful stakeholder engagement;
Respect for the Canada Health Act principles;
Common objectives (e.g., modeled on the CFPC Patient’s Medical Home framework);
Operating Principles specifying eligible/ineligible activities;
Reporting provisions and agreed-upon metrics; and
Sustainability plans. Digital/Virtual Care Canada and most industrialized countries will experience a digital health revolution over the next decade with great potential to improve patient and population health. Digital health can be described as the integration of the electronic collection and compilation of health data, decision support tools and analytics with the use of audio, video and other technologies to deliver preventive, diagnostic and treatment services that promote patient and population health. While most Canadian physicians’ offices and health care facilities are now using some form of electronic record keeping and most households have internet access, there remains a large deficit in using virtual care, both within jurisdictions and across provincial/territorial boundaries. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify opportunities for digital health to improve health care delivery, including what regulatory changes are required for physicians to deliver care to patients within and across provincial/territorial boundaries. To take full advantage of digital health capabilities it will be essential for the population to have a functional level of digital health literacy: the ability to seek, find, understand and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.ix This also includes the capability of communicating about one’s health to health care professionals (e.g., e-consults), self-monitoring health (e.g., patient portals) and receiving treatment online (e.g., Web-based cognitive behavioral therapy).x There are no current data available on health literacy in Canada, let alone digital health literacy. One basic barrier to achieving digital health literacy is access to, and usage of the Internet, which has been termed the “digital divide” (e.g., older Canadians and low income households are less likely to have Internet access).Error! Bookmark not defined. 6 In 2001 the federal government established the Financial Consumer Agency of Canada (FCAC). Its mandate includes informing consumers about their rights and responsibilities in dealing with financial institutions and providing information and tools to help consumers understand and shop for financial products and services.xi In 2014 the FCAC appointed a Financial Literacy Leader who has focused on financial literacy, including activities such as conducting financial capability surveys and the development of a National Strategy for Financial Literacy.xii Considering the anticipated growth of digital/virtual care it would be desirable to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy could serve as a template for digital health literacy. Recommendation: The federal government establish a Digital Health Literacy Secretariat to:
Develop indicators and conducting surveys to measure and track the digital health literacy of Canadians;
Develop tools that can be used both by Canadians and their health care providers to enhance their digital health literacy; and
Assess and make recommendations on the “digital divide” that may exist among some population sub-groups due to a lack of access to information technology and lower digital health literacy. Climate Change and Health Climate change is the public health imperative of our time. There is a high level of concern among Canadians about their changing climate. A 2017 poll commissioned by Health Canada demonstrates a high level of concern among Canadians about their changing climate: 79% were convinced that climate change is happening, and of these, 53% accepted that it is a current health risk, with 40% believing it will be a health risk in the future. The World Health Organization (WHO) has identified air pollution and climate change as one of the biggest threats to global health. Health care professionals see first-hand the devastating health impacts of our changing climate including increased deaths from fine particulate matter air pollution and increased heat-related conditions. Impacts are most common in vulnerable populations such as adults over 65 years, the homeless, urban dwellers and people with a pre-existing disease. Canada’s health care system is already treating the health effects of climate change. A lack of progress in reducing emissions and building adaptive capacity threatens both human lives and the viability of Canada’s health system, with the potential to disrupt core public health infrastructure and overwhelm health services, not to mention the economic and social costs. The federal government must provide leadership to deal with the impact already being felt in Canada and around the world. Recommendation: 7 The federal government make strong commitments to minimize the impact of climate change on the health of Canadians by:
Ensuring pan-Canadian and inter-jurisdictional coordination to standardize surveillance and reporting of climate-related health impacts such as heat-related deaths, develop knowledge translation strategies to inform the public, and generate clinical and public health response plans that minimize the health impacts;
Increasing funding for research on the mental health impacts of climate change and psychosocial adaptation opportunities; and
Ensuring funding is provided to the health sector to prepare for climate change impacts through efforts to increase resiliency (i.e., risk assessments, readiness to manage disease outbreaks, sustainable practice). 8 i Statistics Canada. The Chief Public Health Officer's Report on the State of Public Health in Canada, 2014: Public Health in the Future. Ottawa: Statistics Canada; 2015. Available: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2014/chang-eng.php; (accessed 2016 Sep 19). ii The Conference Board of Canada. Meeting the care needs of Canada’s aging population. Ottawa: The Conference Board; 2018. iii Canadian Medical Association. Meeting the demographic challenge: Investments in seniors care. Pre-budget submission to the House of Commons Standing Committee on Finance. August 3, 2018. https://policybase.cma.ca/documents/Briefpdf/BR2018-16.pdf iv The Conference Board of Canada. Measures to Better Support Seniors and Their Caregivers. March 2019. https://www.cma.ca/sites/default/files/pdf/health-advocacy/Measures-to-better-support-seniors-and-their-caregivers-e.pdf v Canadian Intergovernmental Conference Secretariat. News release – First Ministers’ meeting communiqué on health. September 11, 2000. http://www.scics.ca/en/product-produit/news-release-first-ministers-meeting-communique-on-health/. Accessed 04/22/19. vi Statistics Canada. Primary health care providers, 2017. https://www150.statcan.gc.ca/n1/en/pub/82-625-x/2019001/article/00001-eng.pdf?st=NGPiUkM5. Accessed 04/21/19. vii College of Family Physicians of Canada. A vision for Canada. Family Practice: the patient’s medical home. http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf. Accessed 04/22/19. viii College of Family Physicians of Canada. The patient’s medical home 2019. https://patientsmedicalhome.ca/files/uploads/PMH_VISION2019_ENG_WEB_2.pdf. Accessed 04/21/19. ix Norman C, Skinner H. eHealth literacy: essential skills for consumer health in a networked world. J Med Internet Res 2006;8(2):e9. Doi:10.2196/jmir.8.2.e9. x Van der Vaart R, Drossaert C. Development of the digital health literacy instrument: measuring a broad spectrum of health 1.0 and health 2.0 skills. J Med Internet Res. 2017;19(1):e27. Doi:10.2196/jmir.6709. xi Financial Consumer Agency of Canada. About FCAC. xii Financial Consumer Agency of Canada. National Strategy for Financial Literacy. Phase 1: strengthening seniors’ financial literacy. https://www.canada.ca/content/dam/canada/financial-consumer-agency/migration/eng/financialliteracy/financialliteracycanada/documents/seniorsstrategyen.pdf. Accessed 06/24/19. https://www.canada.ca/en/financial-consumer-agency/corporate/about.html. Accessed 07/01/19.
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Advancing Inclusion and quality of life for seniors

https://policybase.cma.ca/en/permalink/policy13729
Date
2017-10-26
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2017-10-26
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
Canadians are living longer, healthier lives than ever before. The number of seniors expected to need help or care in the next 30 years will double, placing an unprecedented challenge on Canada’s health care system. That we face this challenge speaks to the immense success story that is modern medicine, but it doesn’t in any way minimize the task ahead. Publicly funded health care was created about 50 years ago when Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 36 million and the average life expectancy is 10 years longer. People 85 and older make up the fastest growing age group in our country, and the growth in the number of centenarians is also expected to continue. The Canadian Medical Association is pleased that the House of Commons Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities is studying ways Canada can respond to these challenges. Here, for your consideration, we present 15 comprehensive recommendations that would help our seniors remain active, contributing citizens of their communities while improving the quality of their lives. These range from increasing capital investment in residential care infrastructure, to enhancing assistance for caregivers, to improving the senior-friendliness of our neighbourhoods. The task faced by this committee, indeed the task faced by all of Canada, is daunting. That said, it is manageable and great advances can be made on behalf of seniors. By doing so, we will ultimately deliver both health and financial benefits to all Canadians. Dr. Laurent Marcoux, CMA President The Canadian Medical Association (CMA) is pleased to submit this brief to the Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities as part of its study regarding how the Government can support vulnerable seniors today while preparing for the diverse and growing seniors population of tomorrow. This brief directly addresses the three themes considered by this Committee:
How the Government can improve access to housing for seniors including aging in place and affordable and accessible housing;
How the Government can improve income security for vulnerable seniors; and
How the Government can improve the overall quality of life and well-being for seniors including community programming, social inclusivity, and social determinants of health. Improving access to housing for seniors As part of a new National Housing Strategy, the federal government announced in the 2017 Budget that it will invest more than $11.2 billion in a range of initiatives designed to build, renew, and repair Canada’s stock of affordable housing and help to ensure that Canadians have adequate and affordable housing that meets their needs. While a welcome step, physicians continue to see the problems facing seniors in relation to a lack of housing options and supports — problems that cascade across the entire health care system. A major hindrance to social equity in health care delivery and a serious cause of wait times is the inappropriate placement of patients, particularly seniors, in hospitals. Alternate level of care (ALC) beds are often used in acute care hospitals to accommodate patients — most of whom are medically stable seniors — waiting for appropriate levels of home care or access to a residential care home/facility. High rates of ALC patients in hospitals affect all patients by contributing to hospital overcrowding, lengthy waits in emergency departments, delayed hospital admissions, cancelled elective surgeries, and sidelined ambulance services waiting to offload new arrivals (often referred to as code gridlock).1 Moreover, unnecessarily long hospital stays can leave patients vulnerable to hospital-acquired illnesses and disabilities such as delirium, deconditioning, and falls. Daily costs - Ontario $842: acute care hospital, per patient $126: long-term care residence, per patient $42: home care, per patient # of acute care hospital beds = 18,571 14% waiting for placement = 2,600 beds Providing more cost-effective and appropriate solutions will optimize the use of health care resources. It has been estimated that it costs $842 per day for a hospital bed versus $126 per day for a long-term care bed and $42 per day for care at home.2 An investment in appropriate home or residential care, which can take many forms, will alleviate inappropriate hospital admissions and facilitate timely discharges. The residential care sector is facing significant challenges because of the rising numbers of older seniors with increasingly complex care needs. The demand for residential care will increase significantly over the next several years because of the growing number of frail elderly seniors requiring this service. New facilities will need to be constructed and existing facilities will need to be upgraded to comply with enhanced regulatory requirements and respond to residents’ higher care needs. The Conference Board of Canada has produced a residential care bed forecast tied to population growth of age cohorts. It is estimated that Canada will require an average of 10,500 new beds per year over the next 19 years, for a total of 199,000 new beds by 2035. This forecast does not include the investments needed to renovate and retrofit existing long-term care homes.3 A recent report by the Canadian Institute for Health Information indicated that residential care capacity must double over the next 20 years (assuming no change in how care is currently provided), necessitating a transformation in how seniors care is provided across the continuum of care.4 These findings provide a sense of the immense challenges Canada faces in addressing the residential care needs of older seniors. Investments in residential care infrastructure and continuing care will improve care for seniors while significantly reducing wait times in hospitals and across the system, benefiting all patients. Efforts to de-hospitalize the system and address the housing and residential care options for Canada’s aging population are key. The federal government can provide significant pan-Canadian assistance by investing in residential care infrastructure. RECOMMENDATION 1 The CMA recommends that the federal government include capital investment in residential care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure. Improving income security for vulnerable seniors Income is a key factor impacting the health of individuals and communities. Higher income and social status are linked to better health.5 Adequate Income: Poverty among seniors in Canada dropped sharply in the 1970s and 1980s but it has been rising in recent years. In 2012, the incidence of low income among people aged 65 years and over was 12.1%. This rate was considerably higher for single seniors at 28.5%.6 Incidence of low income (2012) Seniors overall: 12.1% Single seniors: 28.5% Most older Canadians rely on Old Age Security (OAS), the Canada Pension Plan (CPP), and their personal pensions or investments to maintain their basic standard of living in retirement. Some seniors are also eligible for a Guaranteed Income Supplement (GIS) to improve their financial security. The CMA recognizes the federal government’s actions to strengthen these programs and initiatives to ensure their viability and to provide sustainable tax relief. These measures must continue and evolve to support aging Canadians so they can afford to live at home or in age-friendly communities as they get older. The government’s actions to ensure adequate income support will also assist aging Canadians to take care of their health, maintain independence, and continue living safely without the need for institutional care. On the topic of seniors’ income security, the financial abuse of seniors cannot be overlooked. Elder abuse can take many forms: financial, physical, psychological, sexual, and neglect. Often the abuser is a family member, friend, or other person in a position of trust. Researchers estimate that 4 to 10% of Canadian seniors experience abuse or neglect, but that only a small portion of this is reported. The CMA supports public awareness initiatives that bring attention to elder abuse, as well as programs to intervene with seniors who are abused and with their abusers. RECOMMENDATION 2 The CMA recommends that the federal government take steps to provide adequate income support for older Canadians, as well as education and protection from financial abuse. Improving the overall quality of life and well-being for seniors Improving how we support and care for Canada’s growing seniors population has been a priority for CMA over the past several years. For the first time in Canada’s history, persons aged 65 years and older outnumber those under the age of 15 years.7 Seniors are projected to represent over 20% of the population by 2024 and up to 25% of the population by 2036.8 People aged 85 years and over make up the fastest growing age group in Canada — this portion of the population grew by 127% between 1993 and 2013.9 Statistics Canada projects, on the basis of a medium-growth scenario, that there will be over 11,100 Canadians aged 100 years and older by 2021, 14,800 by 2026 and 20,300 by 2036.7 Though age does not automatically mean ill health or disability, the risk of both increases with age. Approximately 75 to 80% of Canadian seniors report having one or more chronic conditions.10 Because of increasing rates of disability and chronic disease, the demand for health services is expected to increase as Canada’s population ages. The Conference Board of Canada has estimated 2.4 million Canadians 65 years and older will need continuing care, both paid and unpaid, by 2026 — a 71% increase since 2011.11 When publicly funded health care was created about 50 years ago, Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 36 million and the average life expectancy is 10 years longer. The aging of our population is both a success story and a pressing health policy issue. National seniors strategy Canada needs a new approach to ensure that both our aging population and the rest of Canadians can get the care they need, when and where they need it. The CMA believes that the federal government should invest in seniors care now, guided by a pan-Canadian seniors strategy. In doing so, it can help aging Canadians be as productive as possible — at work, in their communities, and in their homes. The CMA is pleased with the June 2017 Report of the Standing Senate Committee on National Finance that called for the federal government to develop, in collaboration with the provinces and territories and Indigenous partners, a national seniors strategy in order to control spending growth while ensuring appropriate and accessible care.12 The CMA is also pleased that MP Marc Serré (Nickel Belt) secured support for his private members’ motion calling for the development of a national seniors strategy. Over 50,000 Canadians have already lent their support to this cause (see www.DemandaPlan.ca). RECOMMENDATION 3 The CMA recommends that the federal government provide targeted funding to support the development of a pan-Canadian seniors strategy to address the needs of the aging population. Improving assistance for home care and Canada’s caregivers Many of the services required by seniors, in particular home care and long-term care, are not covered by the Canada Health Act. Funding for these services varies widely from province to province. The disparity among the provinces in terms of their fiscal capacity in the current economic climate will mean improvements in seniors care will advance at an uneven pace. The funding and delivery of accessible home care services will help more aging Canadians to recover from illness, live at home longer, and contribute to their families and communities. Multi-year funding arrangements to reinforce commitment to and financial investment in home care should be carefully considered.13 The development of innovative partnerships and models to help ensure services and resources for seniors’ seamless transition across the continuum of care are also important. RECOMMENDATION 4 The CMA recommends governments work with the health and social services sectors, and with private insurers, to develop a framework for the funding and delivery of accessible and sustainable home care and long-term care services. Family and friend caregivers are an extremely important part of the health care system. A 2012 Statistics Canada study found that 5.4 million Canadians provided care to a senior family member or friend, and 62% of caregivers helping seniors said that the care receiver lived in a private residence separate from their own.14 According to a report by Carers Canada, the Canadian Home Care Association, and the Canadian Cancer Action Network, caregivers provide an array of services including personal and medical care, housekeeping, advocacy, financial management, and social/emotional support. The report also indicated that caregivers contribute $25 billion in unpaid labour to our health system.15 Given their enormous contributions, Canada’s caregivers need support in the form of financial assistance, education, peer support, and respite care. A pan-Canadian caregiver strategy is needed to ensure caregivers are provided with the support they require.15 Caregivers provide... Personal and Medical Care Housekeeping worth $25 billion in Advocacy unpaid labour Financial Managemen Social-emo ional Suppor RECOMMENDATION 5 The CMA recommends that the federal government and other stakeholders work together to develop and implement a pan-Canadian caregiver strategy, and expand the support programs currently offered to informal caregivers. Canadians want governments to do more to help seniors and their family caregivers.16 The federal government’s new combined Canada Caregiver Credit (CCC) is a non-refundable credit to individuals caring for dependent relatives with infirmities (including persons with disabilities). The CCC will be more accessible and will extend tax relief to more caregivers by including dependent relatives who do not live with their caregivers and by increasing the income threshold. Making the new CCC a refundable tax credit for caregivers whose tax owing is less than the total credit would result in a refund payment to provide further financial support for low-income families. RECOMMENDATION 6 The CMA recommends that the federal government improve awareness of the new Canada Caregiver Credit and amend it to make it a refundable tax credit for caregivers. The federal government’s recent commitment to provide $6 billion over 10 years to the provinces and territories for home care, including support for caregivers, is a welcome step toward improving opportunities for seniors to remain in their homes. As with previous bilateral funding agreements, it is important to establish clear operating principles between the parties to oversee the funding implementation and for the development of clear metrics to measure performance. RECOMMENDATION 7 The CMA recommends that the federal government develop explicit operating principles for the home care funding that has been negotiated with the provinces and territories to recognize funding for caregivers and respite care as eligible areas of investment. The federal government’s recent funding investments in home care and mental health recognize the importance of these aspects of the health care system. They also signal that Canada has under-invested in home and community-based care to date. Other countries have more supportive systems and programs in place — systems and programs that Canada should consider. RECOMMENDATION 8 The CMA recommends the federal government convene an all-party parliamentary international study that includes stakeholders to examine the approaches taken to mitigate the inappropriate use of acute care for elderly persons and provide support for caregivers. Programs and supports to promote healthy aging The CMA believes that governments at all levels should invest in programs and supports to promote healthy aging, a comprehensive continuum of health services to provide optimal care and support to older Canadians, and an environment and society that is “age friendly”.17 The Public Health Agency of Canada (PHAC) defines healthy aging as “the process of optimizing opportunities for physical, social and mental health to enable seniors to take an active part in society without discrimination and to enjoy independence and quality of life.”18 It is believed that initiatives to promote healthy aging and enable older Canadians to maintain their health will help lower health care costs by reducing the overall burden of disability and chronic disease. Such initiatives should focus on physical activity, good nutrition, injury (e.g. falls) prevention, and seniors’ mental health (including depression). RECOMMENDATION 9 The CMA recommends that governments at all levels support programs to promote physical activity, nutrition, injury prevention, and mental health among older Canadians. For seniors who have multiple chronic diseases or disabilities, care needs can be complex, and they may vary greatly from one person to another and involve many health care providers. Complex care needs demand a flexible and responsive health system. The CMA believes that quality health care for older Canadians should be delivered on a continuum from community-based health care (e.g. primary health care, chronic disease management programs), to home care (e.g. visiting health care workers to give baths and foot care), to long-term care and palliative care. Ideally, this continuum should be managed so that the senior can remain at home and out of emergency departments, hospitals, and long-term care unless appropriate; easily access necessary care; and make a smooth transition from one level of care to another when necessary. RECOMMENDATION 10 The CMA recommends governments and other stakeholders work together to develop and implement models of integrated, interdisciplinary health service delivery for older Canadians. Every senior should have the opportunity to have a family physician or to be part of a family practice that serves as a medical home. This provides a central hub for the timely provision and coordination of the comprehensive menu of health and medical services. A medical home should provide patients with access to medical advice and the provision of, or direction to, needed care 24 hours a day, seven days a week, 365 days a year. Research in 2014 by the Commonwealth Fund found that the percentage of Canadian seniors who have a regular family physician or place of care is very high (98%); however, their ability to get timely access based on same-day or next-day appointments was among the lowest of 11 nations.19 Compared to seniors in most other countries surveyed, Canadian seniors were also more likely to use the emergency department and experience problems with care coordination. RECOMMENDATION 11 The CMA recommends governments continue efforts to ensure that older Canadians have access to a family physician, supported by specialized geriatric services as appropriate. Prescription drugs represent the fastest-growing item in the health budget and the second-largest category of health expenditure. As the population of seniors grows, there will be an ongoing need for detailed information regarding seniors’ drug use and expenditure to support the overall management of public drug programs.20 Despite some level of drug coverage for seniors in all provinces and territories, some seniors still skip doses or avoid filling prescriptions due to cost, and more research into the extent of this problem is required.21 The CMA supports the development of an equitable and comprehensive pan-Canadian pharmacare program. As a step toward comprehensive, universal coverage, the CMA has repeatedly called on the federal government to implement a system of catastrophic coverage for prescription medication to reduce cost barriers of treatment and ensure Canadians do not experience undue financial hardship. Moreover, with more drugs available to treat a large number of complex and chronic health conditions, the CMA supports the development of a coordinated national approach to reduce polypharmacy among the elderly. RECOMMENDATION 12 The CMA recommends governments and other stakeholders work together to develop and implement a pan-Canadian pharmaceutical strategy that addresses both comprehensive coverage of essential medicines for all Canadians, and programs to encourage optimal prescribing and drug therapy. Optimal care and support for older Canadians also depends on identifying, adapting, and implementing best practices in the care of seniors. PHAC’s Best Practices Portal22 is one noteworthy initiative, and the system needs to spread and scale best practices by leveraging and enhancing pan-Canadian resources that build capacity and improve performance in home care and other sectors.13 RECOMMENDATION 13 The CMA recommends that governments and other stakeholders support ongoing research to identify best practices in the care of seniors, and monitor the impact of various interventions on health outcomes and costs. An environment and society that is “age friendly” One of the primary goals of seniors policy in Canada is to promote the independence of older Canadians, avoiding costly institutionalization for as long as feasible. To help older Canadians successfully maintain their independence, governments and society must keep the social determinants of health in mind when developing and implementing policy that affects seniors. It is also important to eliminate discrimination against seniors and promote positive messaging around aging. An age-friendly society respects the experience, knowledge, and capabilities of its older members and accords them the same worth and dignity as it does other citizens. Employment is also important for seniors who need or desire it. Many seniors are choosing to remain active in the workplace for a variety of reasons, such as adding to their financial resources or staying connected to a social network.23 The CMA recognizes the federal government’s support for seniors who opt to continue working. And, while many employers encourage older workers and accommodate their needs, employment may be difficult to find in workplaces that are unwilling to hire older workers. RECOMMENDATION 14 The CMA recommends that governments at all levels and other partners give older Canadians access to opportunities for meaningful employment if they desire. The physical environment, including the built environment, can help to promote seniors’ independence and successful, healthy aging. The World Health Organization defines an “age-friendly environment” as one that fosters health and well-being and the participation of people as they age.24 Age-friendly environments are accessible, equitable, inclusive, safe and secure, and supportive. They promote health and prevent or delay the onset of disease and functional decline. They provide people-centered services and support to enable recovery or to compensate for the loss of function so that people can continue to do the things that are important to them.24 These factors should be taken into consideration by those who design and build communities. For example, buildings should be designed with entrance ramps and elevators; sidewalks could have sloping curbs for walkers and wheelchairs; and frequent, accessible public transportation should be provided in neighbourhoods with large concentrations of seniors. RECOMMENDATION 15 The CMA recommends that governments and communities take the needs of older Canadians into account when designing buildings, walkways, transportation systems, and other aspects of the built environment. Conclusion The CMA recognizes the federal government’s commitment to support vulnerable seniors today while preparing for the diverse and growing seniors’ population of tomorrow. The CMA’s recommendations in this submission can assist the government as it seeks to improve access to housing for seniors, enhance income security for vulnerable seniors, and improve the overall quality of life for seniors in ways that will help to advance inclusion, well-being, and the health of Canada’s aging population. To maximize the health and well-being of older Canadians, and ensure their active engagement and independence for as long as possible, the CMA believes that the health care system, governments, and society should work with older Canadians to promote healthy aging, provide quality patient-centred health care and support services, and build communities that value Canadians of all ages. References 1 Simpson C. Code Gridlock: Why Canada needs a national seniors strategy. Address to the Canadian Club of Ottawa by Dr. Christopher Simpson, President, Canadian Medical Association; 2014 Nov. 18; Ottawa, Ontario. Available: https://www.cma.ca/En/Lists/Medias/Code_Gridlock_final. pdf#search=code%20gridlock (accessed 2016 Sep 22). 2 North East Local Health Integration Network. HOME First shifts care of seniors to HOME. LHINfo Minute, Northeastern Ontario Health Care Update. Sudbury: The Network; 2011. Cited by Home Care Ontario. Facts & figures - publicly funded home care. Hamilton: Home Care Ontario; 2017 Jun. Available: http://www.homecareontario.ca/home-care-services/facts-figures/publiclyfundedhomecare (accessed 2016 Sep 22). 3 Conference Board of Canada. A cost-benefit analysis of meeting the demand for long-term care beds. Ottawa: Conference Board of Canada; Manuscript submitted for publication. 4 Canadian Institute for Health Information (CIHI). Seniors in transition: exploring pathways across the care continuum. Ottawa: The Institute; 2017. Available: https://www.cihi.ca/sites/default/files/document/seniors-in-transition-report-2017-en.pdf (accessed 2017 Jun 30). 5 World Health Organization. Health Impact Assessment (HIA). The determinants of health. Available: http://www.who.int/hia/evidence/doh/en/ (accessed 2017 Oct 23). 6 Statistics Canada. Persons in low income (after-tax low income measure), 2012. The Daily. Ottawa: Statistics Canada; 2014 Dec 10. Available: http://www.statcan.gc.ca/daily-quotidien/141210/t141210a003-eng.htm (accessed 2017 Oct 17). 7 Statistics Canada. Population projections: Canada, the provinces and territories, 2013 to 2063. The Daily. Ottawa: Statistics Canada; 2014 Sep 17. Available: http://www.statcan.gc.ca/daily-quotidien/140917/dq140917a-eng.pdf (accessed 2016 Sep 19). 8 Statistics Canada. Canada Year Book 2012, seniors. Ottawa: Statistics Canada; 2012. Available: https://www.statcan.gc.ca/pub/11­ 402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm (accessed 2017 Oct 18). 9 Public Health Agency of Canada. The Chief Public Health Officer’s report on the state of public health in Canada, 2014: public health in the future. Ottawa: Public Health Agency of Canada; 2014. Available: https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/ cphorsphc-respcacsp/2014/assets/pdf/2014-eng.pdf (accessed 2016 Sep 19). 10 Canadian Institute for Health Information (CIHI). Health Care in Canada, 2011: A Focus on Seniors and Aging. Ottawa: The Institute; 2014 Nov. Available: https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf (accessed 2016 Sept 19). 11 Stonebridge C, Hermus G, Edenhoffer K. Future care for Canadian seniors: a status quo forecast. Ottawa: Conference Board of Canada; 2015. Available: http://www.conferenceboard.ca/e-library/abstract.aspx?did=7374 (accessed 2016 Sep 20). 12 Report of the Standing Senate Committee on National Finance. Getting ready: For a new generation of active seniors. Ottawa: The Committee; 2017 Jun. Available: https://sencanada.ca/content/sen/committee/421/NFFN/Reports/NFFN_Final19th_Aging_e.pdf (accessed 2017 Oct 18). 13 Canadian Home Care Association, The College of Family Physicians of Canada, Canadian Nurses Association. Better Home Care in Canada: A National Action Plan. 2016. Ottawa: Canadian Home Care Association, The College of Family Physicians of Canada, Canadian Nurses Association; 2016. Available: http://www.thehomecareplan.ca/wp-content/uploads/2016/10/Better-Home-Care-Report-Oct-web.pdf (accessed 2017 Oct 23). 14 Turcotte M, Sawaya C. Senior care: differences by type of housing. Insights on Canadian society. Cat. No. 75-006-X. Ottawa: Statistics Canada; 2015 Feb 25. Available: http://www.statcan.gc.ca/pub/75-006-x/2015001/article/14142-eng.pdf (accessed 2016 Sep 22). 15 Carers Canada, Canadian Home Care Association, Canadian Cancer Action Network. Advancing Collective Priorities: A Canadian Carer Strategy. 2017. Mississauga: Canadian Home Care Association, Canadian Cancer Action Network; 2017. Available: http://www.cdnhomecare.ca/media. php?mid=4918 (accessed 2017 Oct 23). 16 Ipsos Public Affairs, HealthCareCAN, Canadian College of Health Leaders. National Health Leadership Conference report. Toronto: Ipsos Public Affairs; 2016 Jun 6. Available: http://www.nhlc-cnls.ca/assets/2016%20Ottawa/NHLCIpsosReportJune1.pdf (accessed 2016 Jun 06). 17 Canadian Medical Association. Health and Health Care for an Aging Population. Ottawa: The Association; December 2013. Available: https:// www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_Health_and_Health_Care_for_an_Aging-Population_ PD14-03-e.pdf (accessed 2017 Oct 20). 18 Government of Canada. The Chief Public Health Officer’s Report on the State of Public Health in Canada 2010 – Canada’s experience in setting the stage for healthy aging. Ottawa: Government of Canada; 2014. Available: https://www.canada.ca/en/public-health/corporate/publications/ chief-public-health-officer-reports-state-public-health-canada/annual-report-on-state-public-health-canada-2010/chapter-2.html (accessed 2017 Oct 23). 19 Commonwealth Fund. 2014 International Health Policy Survey of Older Adults in Eleven Countries. 2014. New York: Commonweath Fund; 2014. Available: http://www.commonwealthfund.org/~/media/files/publications/in-the-literature/2014/nov/pdf_1787_commonwealth_fund_2014_intl_ survey_chartpack.pdf (accessed 2017 Oct 23). 20 Canadian Institute for Health Information. Drug Use among Seniors on Public Drug Programs in Canada, 2002 to 2008. (2010). Ottawa: The Institute; 2010. Available: https://secure.cihi.ca/free_products/drug_use_in_seniors_2002-2008_e.pdf (accessed 2017 Oct 23). 21 Law MR, Cheng L, Dhalla IA, Heard D, Morgan SG. The effect of cost on adherence to prescription medications in Canada. CMAJ. 2012 Feb21;184(3):297-302. Available: http://www.cmaj.ca/content/184/3/297.short. (accessed 2017 Oct 23). 22 Public Health Agency of Canada. Canadian Best Practices Portal. Ottawa: Public Health Agency of Canada; 2016. Available: http://cbpp-pcpe. phac-aspc.gc.ca/public-health-topics/seniors/ (accessed 2017 Oct 23). 23 Government of Canada. Action for Seniors report. 2014. Ottawa: Government of Canada; 2014. Available: https://www.canada.ca/en/ employment-social-development/programs/seniors-action-report.html (accessed 2017 Oct 23). 24 World Health Organization (WHO). Age-friendly environments. Geneva: WHO; 2017. Available: http://www.who.int/ageing/projects/age­ friendly-environments/en/ (accessed 2017 Oct 23).
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Aligning health and economic policy in the interest of Canadians : CMA’s 2004 Pre-Budget Submission to the Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy1949
Last Reviewed
2012-03-03
Date
2004-11-18
Topics
Health systems, system funding and performance
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2012-03-03
Date
2004-11-18
Topics
Health systems, system funding and performance
Text
For the past several years, the Canadian Medical Association (CMA) has been delivering two overall messages to the Standing Committee on Finance. First, we believe that Canadians’ health and their health care system must be recognized as ongoing priorities. Second, we have been making the case that economic policy, including tax policy, must be better aligned with national health policy. This year’s brief provides specific examples of how the federal government can take action to address both of these issues. We begin with an assessment or a “check up” of the health of our health system. We then provide constructive suggestions on how to successfully implement the health agreement reached at the September 13-15, 2004 meeting of First Ministers. Finally, we draw attention to the need for continued investments in public health and healthy public policy. Canadians remain increasingly concerned about the future state of their health care system, particularly in terms of accessing essential care. While their health status has improved over the past decades, international comparisons suggest there is considerable room for improvement. The significant announcements made over the past year related to reinvestments in health care and public health are a welcomed start to support health stakeholders in facing these challenges. The next steps must build on this progress. INVESTING IN HEALTH CARE Build on The First Ministers Meeting Agreement In terms of health care, we must begin by noting that the First Ministers Meeting Agreement (FMM Agreement) was a significant achievement. It represents a positive policy framework to run with, but it must now receive the necessary fiscal, political and legislative follow-through. Legislation should be enacted that specifies the accountability framework for the Agreement. The Wait Times Reduction Fund should be subject to contribution agreements that specify how provinces and territories will use their share of this fund to reduce wait times. Critical to future success is the need for health care stakeholders to be actively involved with all facets of the Agreement, particularly in developing clinically derived wait time benchmarks. Make Health Human Resources a Priority At the same time, the federal government can do more to address accessibility to health care services by making a stronger commitment to increasing Canada’s health human resources capacity. Several strategies are outlined in this brief, beginning with the need to ensure that the Wait Times Reduction Fund in the FMM Agreement is used immediately to address the crisis in health human resources rather than in the last four years of the ten-year Agreement as currently projected. One specific health human resources strategy that the federal government should pursue is providing greater support for the training of students in health care professions as part of an overall health human resources strategy. High student debt is a key health human resource issue. It is estimated that, by the time medical students enter their pre-practice postgraduate training period, many are doing so with a debt of at least $120,000 or more. This high debt load is affecting both the kind of specialty that physicians-in-training choose, and ultimately where they decide to practice. As a result, the CMA calls upon the federal government to implement a national strategy to extend the Canada Student Loans interest payment benefit to eligible health professional students pursuing postgraduate training. Such action would provide a fairer approach and would alleviate some of the problems associated with our current training system of health professionals. ALIGNING TAX POLICY WITH HEALTH POLICY The CMA has highlighted the need to better align tax policy with national health policy goals for some time and we believe this challenge remains a priority. One example of where tax policy and health policy can be better aligned is how the GST is currently applied to the health care sector and to physicians—something the Finance Committee has acknowledged in previous reports. Hospitals in Canada must still pay a portion of the GST on their purchase of goods and services siphoning away millions of dollars that would otherwise be used for patient care. The federal government recognized in the 2004 budget the need to provide a full GST rebate to municipalities, one of the four sectors covered by the so-called “MUSH” formula (Municipalities, Universities, Schools and Hospitals). We call on the government to apply the same logic and provide a full GST rebate to the health care sector. Another problem exists with how the GST is applied to independent health professionals, such as physicians, providing care to Canada’s publicly funded system. By virtue of being “tax exempt” under The Excise Act, physicians cannot claim any input tax credits to offset the GST costs they pay on their purchases of equipment, rent and utilities. Unlike other self-employed people, physicians cannot pass on any of these additional costs. This is a fundamental issue of tax fairness. It can be resolved by zero rating the GST on publicly funded health services provided by independent health providers thereby making them eligible to receive input tax credits. INVESTING IN HEALTH This past year saw many positive developments made to Canada’s public health system. The CMA was pleased to see the creation of the position of Minister of State, Public Health. We commend the Government of Canada for its establishment of the Public Health Agency of Canada and for its selection of Dr. David Butler-Jones as the new Chief Public Health Officer of Canada. However, the government must continue to reinvest in public health to ensure that the country has a system that earns the trust of Canadians. Investing in public health also makes good economic policy. We have seen in recent years the incredible economic impact that public health outbreaks can have on a country’s economy. Close the Naylor Gap in Public Health The National Advisory Committee on SARS and Public Health (the Naylor Report) estimated that approximately $1 billion in annual funding is required to implement and sustain the public health programming that Canada requires. While representing an important reinvestment in this country’s public health system, the funding announced in the 2004 Budget falls well short of this basic requirement. Accordingly, the CMA calls on the federal government to address the $450 million “Naylor Gap” as soon as possible. Establish National Health Goals Guiding this country’s efforts to improve the health of Canadians should be the establishment and monitoring of national health goals. Thus, the CMA fully supports the First Ministers’ call to establish a Pan-Canadian Public Health Strategy that includes the setting of health goals that are independently monitored. These goals should also cover environmental health goals given their direct implication on Canadians’ health status. Invest in Health Not Tobacco Another key area for the CMA where current economic policy is not aligned with national health policy is the Canada Pension Plan’s investment in tobacco stocks. Despite the fact that tobacco continues to kill approximately 45,000 Canadians a year and costs Canadian society approximately $11 billion per year in net cost, the Canada Pension Plan continues to invest millions ($94 million) in the tobacco industry. We strongly believe that the CPP Investment Board should be prohibited from investing in the tobacco industry and that it divest its current tobacco holdings. Other major pension and investment plans have successfully executed this policy including the MD Funds held for Canada’s physicians at MD Management Ltd. a wholly-owned subsidiary of CMA. Accordingly, we call on the Standing Committee on Finance along with the Standing Committee on Health to jointly review the CPP investment policy as it relates to investments in tobacco. The FMM Agreement and last year’s funding announcements for public health must be seen as for what they are—first steps to sustaining Canada’s health care system and its public health infrastructure. Canada’s physicians and the CMA are committed to working with governments and other health care stakeholders to ensure that these financial investments lead to positive and enduring change, and ultimately improved health for all Canadians. RECOMMENDATIONS Recommendation 1 The federal government move quickly to enact legislation to implement the funding and accountability provisions of the First Ministers’ Agreement. The legislation should specify that the $4.5 billion Wait Times Reduction Fund be subject to contribution agreements with the provinces and territories. Recommendation 2 The federal government work with relevant stakeholders to extend interest free status on Canada Student Loans for all eligible health professional students pursuing postgraduate training. Recommendation 3 As part of an effort to ensure that its tax policy is consistent with the goals of its health policy and the sustainability of Canada’s health care system, the federal government should: - increase the GST rebate for publicly funded health care institutions and clinics to 100% ($90 million annually for hospitals) - zero rate GST on publicly funded health services provided by independent health care providers ($75 million annually for medical services). Recommendation 4 The Standing Committees on Finance and Health hold a joint review of the CPP policy as it relates to investments in tobacco (both current and potential) by the CPP Investment Board. II. CMA’S ANNUAL CHECKUP Much has happened over the past year in regards to Canada’s health and health care systems. First, we witnessed the creation of the Health Council of Canada, an institution that can play a significant role in improving the accountability of Canada’s health system. Second, we saw several announcements aimed at rebuilding Canada’s public health system including the establishment of the Public Health Agency of Canada and the subsequent appointment of Canada’s first Chief Public Health Officer. And in September, federal, provincial and territorial First Ministers reached a historic agreement on a 10-year plan to strengthen health care. Canadians no doubt welcome these developments. They have made it known to governments and health care providers alike that access to health care has become their top public policy issue. Not surprisingly, health was the top issue during the recent federal election campaign. For four years, the CMA has been tracking Canadians’ assessment of our health care system through our National Report Card on the Sustainability of Health Care. We are sad to report that the number of Canadians giving the nation's health care system a grade of C or F this year increased by a dramatic 9% over last year. While Canadians still give the system an overall B grade, the percentage of C and F grades was the highest since Ipsos-Reid began conducting the survey on behalf of the CMA in 2001. Moreover, our survey results found that 97% agreed that any discussion to make the system more sustainable needs to guarantee timely access for essential health services. As our fact sheet on Canadians’ health and their health care system illustrates (see Appendix A), improving access remains a major challenge for our health care system. Canada has one of the poorest physician-to-population ratios among all OECD countries. It is therefore not surprising that in 2003, 14% of Canadians reported not having a regular family physician (25% in Quebec). A recent Statistics Canada survey on wait times found that the proportion of patients who considered their wait time unacceptable was 17% for non-emergency surgery, 21% for diagnostic tests and 29% for specialist visits. 1 Over the past year, CMA has been very active in bringing attention to the issue of access and wait times. The CMA co-sponsored a colloquium on managing wait times last April that culminated in the recently released report, The Taming of the Queue: Toward a Cure for Health Care Wait Times. 2 But what about the state of Canadians’ health itself? Certainly our health status has improved greatly over the past decades. However, while Canadians are among the healthiest people in the world, citizens in several industrialized countries are enjoying better health status. For example, disability-free life expectancy, that is quality of life years lived, for Canadian males is 18th among the 30 OECD countries and 16th for Canadian females. Canada’s rate of infant mortality—deaths during the first year of life—is among the highest in the OECD. But we need not compare ourselves to other countries to find differences in levels of health status. Significant discrepancies in health status also exist among Canadians, be it between provinces, between regions, between communities or between neighbourhoods. For example, there remain significant inequities in health status between Aboriginal Canadians and non-Aboriginal Canadians—the incidence of hepatitis and tuberculosis among Aboriginal Canadians are five and ten times higher respectively than for other Canadians. It has now been over a year since the Report of the National Advisory Committee on SARS and Public Health or the “Naylor Report” was released. The report has lead to some positive developments in rebuilding Canada’s public health system. It will be needed as some serious public health issues continue to face the country including: * the spread of infectious diseases (e.g., C. difficile bacterium); * the rise in the number of Canadians with unhealthy body weights including rising levels of obesity; * high levels of physical inactivity; * smoking, particularly among youth; * relatively low rates of immunization; and * threats to environmental health including those that threaten our clean air, and safe food and drinking water. In summary, notwithstanding all that has transpired this year, Canadians’ health and their health care system remain high public priorities. While their health status has improved over the past decades, there is considerable room for improvement, some of which can be addressed through public health measures and better access to care. The significant announcements made over the past year related to health system and public health financing are a welcomed start to support health stakeholders in facing these challenges. III. THE FIRST MINISTERS’ MEETING AGREEMENT The CMA closely followed the September 13-15, 2004 First Ministers Meeting on the Future of Health Care. In fact, we worked with our health care colleagues leading up to the meeting to identify possible strategies for improving the system. 3 For instance, we recommended the development and adoption of pan-Canadian benchmarks for wait times based on clinical evidence and the creation of a special Canada Health Access Fund to support Canadians’ access to medically necessary care in other regions. While not all of our proposals were accepted, the September First Ministers’ Meeting Agreement (herein referred to as the FMM Agreement) features many aspects that the CMA has been championing for some time and is certainly a positive achievement. In particular, we are happy to see a desire “to make timely access to quality care a reality for all Canadians.” We applaud the leadership shown by the government in this regard. We also believe that the Agreement provides an opportunity for a new era of cooperative medicare by engaging physicians and other providers meaningfully. Contrary to belief, health care providers have not been offered many opportunities to participate at federal, provincial and territorial planning tables. We therefore welcome the opportunity to work collaboratively on identifying clinically derived wait time benchmarks. Canada’s physicians can and desire to play a significant role in this regard. We therefore believe the FMM Agreement is a necessary first step or “a framework to go with” towards strengthening our health care system. But as we said in September following the release of the Agreement, “the real heavy lifting begins now.” Accordingly, we believe that a number of requirements are necessary to ensure this Agreement fulfills its objectives. We see these requirements as putting words to actions for realizing the full potential of the FMM Agreement. Enact Legislation to Confirm Financial Support and Accountability Provisions The CMA supports enacting federal legislation to confirm the budgetary allocations in the Agreement ($18 billion over 6 years and $41 billion over 10 years). This includes a 6% escalator to the Canada Health Transfer (CHT) that will provide predictable funding for provincial and territorial health care systems. This is a provision that we have been recommending for many years. While $41 billion is a lot of money, we must remind ourselves that this amounts to little more than a 3% increase over 10 years of provincial government health expenditures based on projections of current government spending. Moreover, we estimate that the Agreement will add only .2% to Canada’s spending levels per GDP during this period. In other words, the FMM Agreement, while necessary and appreciated, will not propel Canada into the top echelon of health care spenders among the leading industrialized countries. As health care has become a dominant public policy issue, we expect to see future high level discussions in coming years on both future funding levels and on the direction of health care reform efforts. We are also pleased to see a new Equalization agreement that will complement the FMM Agreement. The Equalization program plays a key role in ensuring that all provinces have adequate and comparable levels of health care and other social services. The issue of Equalization payments to the provinces was identified in discussions leading up to the September First Ministers Meeting over concern that increased federal transfers to health care could be offset by decreases in Equalization payments. The subsequent agreement on Equalization will therefore serve to support the FMM Agreement given that increases in health care transfers to provinces will not be offset by decreases in equalization payments while providing predictable multi-year funding. A strong accountability framework also needs to be included in the legislation. The FMM Agreement specifies several process accountabilities such as a commitment by governments to report on access indicators and establish wait time benchmarks by December 31, 2005. The CMA believes that the Wait Times Reduction Fund should be subject to contribution agreements that specify how provinces and territories will use their share of this fund to reduce wait times. For the Agreement to mean something commitments have to backed up—financial and/or political consequences must follow if commitments are not met. It will be important to have an independent, third party organization assess progress in an open and transparent manner. The Health Council of Canada, identified in the FMM Agreement, could be the body to undertake an annual independent assessment, providing it receives the necessary resources to do so. The Canadian Institute for health Information also has an important role to play in ensuring comparable indicators are used to measure progress. It is essential to involve practicing physicians throughout the implementation of the FMM Agreement, particularly in the development of clinically derived wait time benchmarks. The determination of clinically derived wait time benchmarks means just that—they must be clinically derived and must not be based on political or financial considerations. To this end, the CMA will play a leadership role in developing consensus with physicians and other expert organizations on acceptable wait-time standards and protocols based on the best available clinical evidence. RECOMMENDATION 1 The federal government move quickly to enact legislation to implement the funding and accountability provisions of the First Ministers’ Agreement. The legislation should specify that the $4.5 billion Wait Times Reduction Fund be subject to contribution agreements with the provinces and territories. Improve Access by Addressing Health Human Resources The CMA is pleased to see the First Ministers acknowledge for the first time the current and worsening shortage of health human resources (HHR) in this country. However, the FMM Agreement does not adequately provide a strategy for addressing this crisis beyond the development of health human resources action plans and support for an Aboriginal Health Human Resources Initiative. The CMA believes that the lack of immediate action on HHR is one area where the Agreement falls short. As noted in our fact sheet, Canada is currently experiencing a shortage in health human resources. Canada’s ratio of 2.1 physicians per 1,000 population remains one of the lowest among OECD countries and below the OECD average of 2.9. Initial results from the 2004 National Physician Survey—the largest census survey of physicians ever conducted in Canada—find that up to 3,800 physicians will retire in the next two years, more than double the existing rate. Furthermore, 26% of physicians intend to reduce the number of hours they work. 4 One must remember that timely access to health care services is first and foremost about the people who provide quality care and the tools and infrastructure they need to meet the growing demand for medical services in Canada. In order for the FMM Agreement to be successful in improving access to care, governments must make health human resources a major priority beginning by ensuring that the Wait Times Reduction Fund is used immediately to address the crisis in health human resources rather than in the last four years of the ten-year Agreement as currently projected. 5 Given the current shortages in health human resources, action on HHR must begin now—not in 2010. In addition, the CMA calls upon the federal government to play a key role in improving the availability of health human resources by developing a pan-Canadian HHR strategy that includes the involvement of health care providers. Specifically, we need a three pronged pan-Canadian HHR strategy that would address: (1) HHR planning; (2) increasing the supply of health professionals; and, (3) retention issues. Planning Despite the large sum of funding that governments invest in health care, they do so without having the benefit of a national long-term health human resources strategy. Canada has 14 provincial/territorial and federal health care systems in operation. Yet, our immigration policies are largely conducted on a national basis and there is a high degree of labour mobility between provinces. Presently, there is no overall national coordinating committee to assist provinces and territories in the planning of health human resources, particularly one that includes all pertinent stakeholders including physicians and other health care professionals. We believe a National Coordinating Committee for Health Human Resources involving representation from health care professions should be established for such purposes—something both the Romanow and Senator Kirby reports recommended. Research is required to support long-term planning in HHR. The CMA has previously proposed the creation of an arm’s length Health Institute for Human Resources (HIHuR) that would promote collaboration and the sharing of HHR research among the well-known university-based centres of excellence as well as research communities within professional associations and governments. Supply Canada’s HHR policy goal should be to ensure Canada is self-sufficient in the supply of physicians and other health care professionals. Several strategies are required to fulfill this goal. They include: * Dedicating a specific fund to increase enrollment in undergraduate and postgraduate medical education (especially re-entry positions). Medical school enrollment should be increased to a minimum of 2,500 positions by 2007. * Expanding the post-MD system to accommodate the increase in graduates for training including the several hundred international medical graduates (IMGs) in Canada who have been deemed eligible for post-MD training here. The goal should be to increase the number of first-year residency training positions to a level of 120% of the graduates produced annually by Canadian medical schools. See Appendix B for how this can be implemented. The estimated cost of adding 500 positions is $75 million over five years. In fact, this government’s election platform included a commitment to provide funding to top-up training for 1,000 foreign trained medical professionals. * Expediting the integration of international medical graduates by funding a fast-track on-line assessment program administered by the Medical Council of Canada. It would determine the suitability and eligibility of IMGs for completion of post-MD training (estimated cost $20 million over 5 years). * Implementing a national strategy to extend the Canada Student Loans interest payment benefit to postgraduate trainees in medicine. High student debt impacts both the kind of specialty that physicians-in-training choose, and ultimately where they decide to practice—making it a key health human resource issue (see box below). The Canadian Medical Association commends the federal government for its commitment to reduce the financial burden on students in health care professions, as announced in the FMM Agreement. Did you know? Becoming a full-fledged, practicing physician is an arduous and expensive endeavor. It requires a minimum of 9 years (6) of post-secondary education and training that is often financed through sizeable government and private loan debt, such as lines of credit. It is estimated that, by the time medical students enter their pre-practice postgraduate training period, many are doing so with a debt of at least $120,000 (7) or more. RECOMMENDATION 2 The federal government work with relevant stakeholders to extend interest free status on Canada Student Loans for all eligible health professional students pursuing postgraduate training. Retention Retention remains a major concern for the health care workforce including physicians. We speak not only in terms of losing physicians to other countries but to other professional pursuits as well (i.e., opportunities away from the front line delivery of care). There is little point in recruiting new physicians at the front end if we lose sight of how to keep them once they are highly skilled and are in their most productive years. Retention issues are crosscutting. Indeed, a major frustration for physicians today are the difficulties faced trying to access other types of care for their patients such as diagnostic testing, specialty care or community services. Thus, improving access to a comprehensive range of health care providers and services and reducing wait times—as previously addressed—can help. We also believe that investments in information technologies (IT) can help improve the coordination of health care and allow physicians to spend more time with their patients to provide quality care. There is currently limited connectivity among community-based physicians, community based services, specialists, hospitals and diagnostic facilities. IT investments can improve the integration of care, improve patient safety and improve the management of wait times. They can link regional and provincial wait time management systems while supporting more comprehensive scheduling systems. Prescriptions can be sent electronically to the local pharmacist while public health warnings can be sent electronically to physicians’ offices. We recognize that investments in IT are already occurring and systems will be put in place over the next decade. However, we believe that by accelerating IT investments today, system efficiencies and savings can be achieved sooner along with improvements to health care delivery and coordination. The application of tax policy to the health care sector is another retention issue that greatly frustrates physicians. This issue is discussed in the next section. Align Tax Policy With Health Policy The CMA continues to advocate for a review of the relationship between federal tax policy and health care policy in Canada. Taxation is a powerful instrument of public policy. Good tax policy should reinforce and support good health care policy. Yet, it has been 40 years since the federal government last undertook an overarching review of Canada’s tax system (the 1962-1966 Royal Commission on Taxation -the Carter Commission). Standard public finance theory suggests that two objectives of effective tax policy are distributive equity and correcting inefficiencies in the private sector. 8 For some time, the CMA has expressed concern over inequities in tax policy and inconsistencies between national health policy goals and tax policy. We are aware that the committee is looking for ideas on tax changes that can lead to a more productive economy. At the same time, we recognize that the government is committed to improving Canadians’ access to health care. Ensuring this country’s tax policy is supporting our health care system is a good way to achieve both objectives. Specifically, the CMA calls on the federal government to remove the application of the Goods and Services Tax (GST) to the health care sector. Currently, not-for-profit hospital services receive an 83% rebate on the GST they pay on goods and services, while not-for-profit health organizations receive a rebate of 50%. Health care professionals working in free-standing clinics do not qualify for any GST relief (discussed below). The estimated portion of funding paid by hospitals alone back to the federal government in the form of GST revenue is estimated to be $90 million per year. That is the equivalent of the purchase cost of almost 40 MRI machines! The CMA believes that all publicly funded health care services should be spared from having to use scarce health care resources to remit GST and should receive the full GST rebate. Would this be setting a precedent? The answer is “no”. Prescription drugs, a significant proportion of total health care costs, have been zero-rated since 1996. Furthermore, the 2004 federal budget confirmed that municipalities would be able to recover 100% of the GST and the federal component of the harmonized sales tax (HST) immediately. As part of the “MUSH” sector (municipalities, universities, schools and hospitals), we believe the time has come to extend the full rebate to the health care sector. The federal government must stop taxing publicly funded health care. The uneven application of the GST rebate to different health services is also impeding efforts to renew and reorient the delivery of health services. Currently, community-based services such as clinics and nursing homes receive a GST rebate of only 50% while hospitals receive a rebate of 83%. Does it make sense that a nursing home or a home care service should pay more for GST than a hospital, particularly when trying to move to a more accessible community-based system? The variability of GST rebates makes no sense for organizations such as regional health authorities that oversee a range of health services but which pay differing rates. The government acknowledged in its 2003 Budget that there was a need to review how the GST is applied to care settings outside of hospitals. We await this review. Such inconsistencies distort the efficiency of the health care sector yet are relatively simple to address. 9 Physician services, on the other hand, are deemed “tax exempt” under The Excise Act. This means that physicians cannot claim any input tax credits despite the fact they must pay GST on their purchases of equipment, rent and utilities. And unlike other self-employed individuals or small businesses, physicians cannot pass on any of these additional costs as approximately 98% of physician compensation is from government health insurance plans. To date, provincial governments have been unwilling to provide funding to reflect the additional costs associated with the GST (insisting that it is a federal matter). Physicians are not asking for special treatment. They are looking for fairness within the tax system. If physicians, as self-employed individuals, are considered small businesses for tax purposes, then it only seems reasonable that they should have the same tax rules extended to them that apply to other small businesses (i.e., eligibility to receive input tax credits). This is a fundamental issue of tax fairness. In fact, this committee has twice before acknowledged the need to reassess the application of the GST on physician services. 10 The unfair manner in which the GST is applied to the health care sector has been an on-going source of major frustration to the physician community and remains unresolved. We believe that addressing this matter would be helpful in the country’s efforts to retain its physicians. Other self-employed health care providers that provide publicly funded services face a similar problem. RECOMMENDATION 3 As part of an effort to ensure that its tax policy is consistent with the goals of its health policy and the sustainability of Canada’s health care system, the federal government should: - increase the GST rebate for publicly funded health care institutions and clinics to 100% ($90 million annually for hospitals) - zero rate GST on publicly funded health services provided by independent health care providers ($75 million annually for medical services). IV PUBLIC HEALTH: HEALTHY PUBLIC As previously noted, much has happened over the past year with respect to Canada’s public health system. The CMA was pleased to see the creation of the position of Minister of State, Public Health. We commend the Government of Canada for its establishment of the Public Health Agency of Canada and for its selection of Dr. David Butler-Jones as the new Chief Public Health Officer of Canada. The 2004 Budget’s commitment to approximately $665 million for investments for public health over the next 3 years was also a welcomed announcement. The CMA will provide its full support to work with Dr. Butler-Jones and the Public Health Agency of Canada, Ministers Bennett and Dosanjh to develop a coordinated and integrated plan to manage and improve public health in Canada. These developments certainly represent a good step towards rebuilding the country’s public health system. Address the “Naylor Gap” In spite of these initiatives, it remains essential to remind this government and Canadians that further attention to public health is necessary. As a member of the Canadian Coalition for Public Health in the 21st Century (CCPH21), the CMA calls on the federal government to enhance its financial commitment to the renewal of Canada’s public health system The public health system is a vital component of a sustainable health system by reducing pressures on the health care system and providing a net benefit to society. 11 Two thirds of total deaths in Canada are due to chronic diseases such as cardiovascular disease, cancer, lung disease and diabetes (Type II melitus)—many of which are preventable. Investing in public health also makes good economic policy. We have seen in recent years the incredible economic impact that public health outbreaks can have on a country’s economy. For instance, it has been estimated that the SARS outbreak cost the Canadian economy over $1.5 billion in 2003 alone with its impact still being felt. 12 As stated in the Report of the National Advisory Committee on SARS and Public Health (the Naylor Report), “we are constantly a short flight away from serious epidemics.” 13 Accordingly, we were pleased to hear the government’s Speech from the Throne state that the government will proceed with the development of the Pan-Canadian Public Health Network. But we have to overcome several years of inattention to public health issues and the public health infrastructure—something that cannot be rectified in a year. Spending levels on public health in Canada are meager. International comparisons are difficult to find and to compare, but it appears that this is one instance where Canada could learn from its neighbour to the south with its higher level of spending on public health (see Box comparing public health spending between Canada and the United States). 14 While the role of public health was referred to in the FMM Agreement, no additional funding for public health was included. Comparing Levels of Public Health Spending: Canada vs. the United States Using data from CIHI and the US Centers for Medicare and Medicaid Services, the CMA has developed the following comparative estimates of spending on public health in Canada versus the United States in 2002. [TABLE CONTENT DOES NOT DISPLAY POPERLY. SEE PDF FOR PROPER DISPLAY] Canada United States 1. Per capita spending on public health services ($CDN, PPP adjusted) $138 $207 2. Share of spending on public health as a % of public health care spending 5.5% 7.2% 3. Share of spending on public health as a % of total health care spending 3.9% 3.3% [TABLE END] The United States spends approximately 50% more on public health than Canada when comparing per capita payments. The United States also spends more on public health when considering public health spending as a percentage of all publicly funded services (due in part to a proportionately smaller publicly funded sector). Conversely, Canada spends more on public health if looking at the percentage of spending on public health as a percentage of total health care spending. This is due in part to a proportionately larger privately funded sector in the United States. Since public health is predominately a public good paid by governments, we believe it is most appropriate to compare the results from the first two indicators. The Naylor Report estimated that public health in Canada accounted for 2.6% to 3.5% of total publicly funded health expenditures in Canada and 1.8% to 2.5% of total health expenditures. While these estimates are lower than those provided above, they still support our observation that public health spending in Canada is lower than in the United States. The Naylor report provided a blue print for action and reinvestment in the public health system for the 21st century. It estimated that approximately $1 billion in annual funding would be required to implement and sustain the public health programs that Canada requires. In its submission to the National Advisory Committee on SARS and Public Health, the CMA also identified an essential range of comprehensive public health programming and initiatives totaling an estimated $1.5 billion over 5 years. 15 The federal government has thus far committed approximately $665 million in new programming (one-time funding, over 2 years, and over 3 years), well short of Dr. Naylor’s $1 billion per year. This “Naylor Gap” of approximately $450 million per year is identified below in Table A. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table A: Estimating “The Naylor Gap” Naylor Funding Recommendations (by 2006-07) Budget 2004 Naylor Gap Public Health Agency of Canada Related Funding - $300 million per year core budget of PPHB and other related federal services to be transferred to new agency - core functions to be expanded by $200 million per year within 3-5 years - $404 million transferred from Health Canada to Agency - $165 million over 2 years to assist in setting up new agency, increase emergency response capacity, enhance surveillance, establish regional centres of excellence, expand laboratory capacity, strengthen international coordination and collaboration $117.5 million per year ($200 million by Naylor minus $82.5 million per year committed by the federal government averaged out). Moreover, nothing earmarked beyond 2005-06. System Funding 3 programs of transfers at a cost of $500 million per year: - $300 million for Public Health Partnerships Program to build capacity at local level - $100 million for communicable disease surveillance - $100 million to bolster national immunization strategy - $100 million (one-time) to Canada Health Infoway to pay for real-time public health surveillance system - $400 million over three years for: - $300 million for national immunization strategy - $100 million for provinces to address immediate gaps in capacity Approximately $333 million per year ($500 million per year request by Naylor less Budget 2004 commitments of $500 million over 3 years or $167 million per year averaged out.) Total: $1 billion per year $404 million annually plus $665 million in new programming (one-time funding, over 2 years, or over 3 years) Total “Naylor Gap”: $450.5 million per year [TABLE END} We acknowledge that the Public Health Agency of Canada is just being created. We also recognize that Budget 2004 noted that: “The Government of Canada expects to make further investments once the new Canada Public Health Agency is operational, the Chief Public Health Officer has developed a comprehensive public health plan, and the Government has had the opportunity to evaluate the need for additional resources.” 16 Nevertheless, it is critical that reinvestment in Canada’s public health system continue as soon as possible to protect and promote the health of Canadians. These additional investments are needed to fully implement Dr. Naylor’s recommendations. This includes operating costs for a real time communication system for front line public health providers during health emergencies. It would ensure a two-way flow of information between front-line health care providers and public health professionals at the local public health unit, the provincial public health department and the Public Health Agency of Canada. The CMA has recently submitted a proposal to Canada Health Infoway to develop a system (the Health Emergency Communication and Co-ordination Initiative) that would link Canada’s physicians with governmental authorities. The additional investments should also be used to help address the recruitment and retention of public health practitioners. 17 In contrast with other areas of health expenditures, we know very little about how public health dollars are allocated and with what results. Presently, public health expenditures are lumped together with some health system administration costs. We believe there is a need for a better tracking and public reporting of public health expenditures. Set and Meet National Health Goals The CMA was pleased to see support by First Ministers in the FMM Agreement to establish a Pan-Canadian Public Health Strategy and health goals that are independently monitored. We believe health goals are a key component in addressing the serious public health challenges that lie ahead. Goals stimulate action and improve system accountability. Unlike Canada, many other countries—including the United States, the UK and Australia—have set health goals for their populations at the national level. At the CMA’s August 2004 General Council meeting, physicians agreed on health goals for physical activity, healthy body weights and obesity (see box below). These goals are already having an effect. Recently, the BC Minister of Health, Colin Hansen, accepted the challenge from the President of the British Columbia Medical Association, Dr. Jack Burak, to increase fitness levels by 10 per cent by 2010. We also need to be more preoccupied with setting, meeting and monitoring environmental health goals. Let us look at drinking water for example. As hard as it may be for Canadians to believe, a safe supply of water is a key health concern for Canadians today just as it was at the turn of the 20th century. The polluting of our water supply—including the presence of antibiotic-resistant bacteria through the use of antibiotics in human and animal health—and a lack of adequate water treatment infrastructure systems have contributed to the problem. Above all, we as Canadians need to recognize that a large natural supply of water and other natural resources do not eliminate the need for strong environmental governance. Public health officials play an important role in this respect. But it is pointless to set goals without any intention of meeting them. Resources will be necessary to meet the selected health goals such as the training and hiring of public health workers, as well as funding to support public advertising and marketing campaigns. Physical Activity and Healthy Body Weight Goals for Canada (Endorsed at CMA General Council, August 2004, Toronto) The Canadian Medical Association urges all levels of government to commit to a comprehensive, integrated and collaborative national strategy for increasing the physical activity levels of all Canadians, with a target of a 10% increase in each province and territory by the year 2010. The Canadian Medical Association calls on all stakeholders to develop, as an urgent priority, an action plan to address the obesity epidemic in Canada, with a goal of increasing by 15% within ten years the proportion of Canadians who are at a healthy weight. Invest in Health Not in Tobacco Improving health status is more than promoting healthy lifestyle behaviour. A healthy society also requires public policy that supports health (e.g. adequate income and education, proper housing, adequate nutrition, a clean and safe environment.) Tobacco use is a good example of a health risk that has been significantly reduced with the help of public policy measures, such as higher tobacco taxes, continued restrictions on tobacco advertising and promotion, and restrictions on smoking in public places. But there remains inconsistency in Canada's public policies—in this case between the investment policies of the CPP Investment Board and Canada's health policy goals. Canadians are very proud of their public pension plan, the Canada Pension Plan (CPP). It is a well-supported social program that has been viewed as a best practice model by several countries. Yet, despite the fact that tobacco continues to kill approximately 45,000 Canadians a year and costs Canadian society approximately $11 billion per year in net cost, (18) the Canada Pension Plan holds $94 million worth of tobacco investments. Canada’s physicians see the toll that tobacco consumption creates. We see the physical and mental suffering that tobacco-caused diseases bring to patients and their families. Accordingly, the CMA has consistently recommended a wide range of measures to control tobacco use such as higher tobacco taxes, continued restrictions on tobacco advertising and promotion, restrictions on smoking in public places, enforcement of bans on sales to minors, reduction of the level of toxic ingredients in tobacco and the provision of smoking cessation programs. We are pleased with the efforts to date but we are by no means finished in our battle. As our fact sheet shows, there are still segments of the population, particularly among our youth, that have high rates of smoking. The federal government in recent years has spent hundreds of millions of dollars on a tobacco reduction strategy that, when combined with efforts being taken by the provinces and municipalities, is making a difference for Canadians. However, the CPP Investment Board is investing and voting as shareholders in a pattern that is inconsistent with both public health policy, and the tobacco reduction measures being implemented across Canada. It is inconsistent and illogical for one arm of government to expend many millions of dollars of public money in an effort to reduce tobacco use, while another arm invests many millions of dollars of money in tobacco companies and supports these companies in their drive to be profitable. Resolution of the Canadian Medical Association General Council, August 2004: …the government amend the Canada Pension Plan Investment Board Act so that CPP investments in the tobacco industry are prohibited and the CPP Investment Board divests itself of existing tobacco holdings. The CMA is prepared to back up what it is prescribing—MD Management Ltd’s “MD Funds” which are managed for Canada’s physicians has followed this policy for almost ten years. Other major pension and investment plans have successfully followed this policy as well including several US State retirement and pension funds and the American Medical Association Pension Fund. While the CMA clearly believes that the CPP Investment Board should not invest in the tobacco industry and that existing tobacco holdings should be divested, we recognize that this committee might want to look at the matter in greater context to assess its full impact. We suggest that this be done in conjunction with the Standing Committee on Health. RECOMMENDATION 4 The Standing Committees on Finance and Health hold a joint review of the CPP policy as it relates to investments in tobacco (both current and potential) by the CPP Investment Board. IV. CONCLUSION The Finance Committee’s last report on the pre-budget hearings noted that the CMA’s submission identified relatively small, one-time investments that can support the health care system. 19 This year’s submission once again puts forward strategic investments that we believe support Canada’s health policy goals and which serve to effectively implement the FMM Agreement. Our recommendations are also directed at improving the alignment of Canada’s economic policy with its health policy. It is natural to think of an agreement as an end point. But in reality, the FMM Agreement and last year’s funding announcements for public health must be seen as for what they are—first steps to sustaining Canada’s health care system and its public health system. Canada’s physicians and the CMA are committed to working with governments and other health care stakeholders to ensure the financial investments announced over the past year lead to positive and enduring change, and ultimately improved health for all Canadians. END NOTES 1 Claudia Sanmartin et al. Access to Health Care Services in Canada, 2003. Statistics Canada, 2004. 2 Canadian Medical Association. The Taming of the Queue: Toward a Cure for Health Care Wait Times. Discussion Paper. July 2004. Ottawa. 3 CMA, Better Access for Better Health, September 2004; Canadian Healthcare Association, Canadian Medical Association, Canadian Nurses Association, Canadian Pharmacists Association. “Common Vision for the Canadian Health System,” September, 2004. 4 National Physician Survey, “Initial Data Release of the 2004 Physician Survey”, October 2004. 5 A note listed under the funding schedule indicates that moneys flowing to the Wait Times Reduction Fund for health human resources ($250 million for four years) will come only during the final four years of the Agreement. 6 Average duration. Only 2/16 medical schools have a 3 (versus 4) year program. 7 This estimate is based on federal government actual and estimated costs as well as current actual national average tuition fees in undergraduate programs in medicine. Data sources: (1) Statistics Canada, The Daily, April 26, 2004, National Graduates Survey: Student Debt, p. 3. (2) Government of Canada, Canlearn. Saving for your child's education, The projected cost of your child's education. University Tuition. Typical 1996 university cost living away from home: $13,000 - $3,500 tuition = $9,500 x 24% (8 years x 3% inflation cited in reference above) = $11 780. see: http://www.canlearn.ca/financing/saving/guaranteefuture/clcos.cfm?langcanlearn=en (3) Association of Canadian Medical Colleges for tuition 8 For a further discussion of the role of taxation in public policy, refer to Musgrave, Richard A. and Peggy B. Musgrave’s Public Finance in Theory and Practices. 1973. New York: McGraw-Hill. 9 Canadian Medical Association, Tax and Health—Taking Another Look. Discussion Paper, May 2002. 10See Keeping the Balance, 1997 Report of the Standing Committee on Finance; Facing the Future: Challenges and Choices for a New Era, 1998 Report of the Standing Committee on Finance. 11 See for example, Laurie J. Goldsmith, Brian Hutchinson and Jeremiah Hurley, Economic Evaluation Across the Four Faces of Prevention: A Canadian Perspective. (Hamilton: Centre for Health Econoimcs and Policy Analysis, McMaster University), May 2004. 12 The Conference Board of Canada, “The Economic Impact of SARS”, Ottawa, May 2003. 13 Report of the National Advisory Committee on SARS and Public Health, Learning From SARS: Renewal of Public Health in Canada, October 2003. 14 Based on data from the Center for Medicare and Medicaid Services (http://www.cms.hhs.gov/statistics/nhe/). 15 Canadian Medical Association, Answering the Wake Up Call: CMA’s Public Health Action Plan. Submission to the National Advisory Committee on SARS and Public Health, June 2003. 16Government of Canada, Department of Finance Canada, The Budget Plan 2004, p. 101. 2004. 17 See Answering the Wake-up Call: CMA’s Public Health Action Plan for other initiatives that should be funded to rebuild Canada’s public health system. 18 Adapted from estimates provided by Murray J. Kaiserman, “The Cost of Smoking in Canada, 1991”, Chronic Diseases in Canada, Vol. 18, No. 1, 1997. Available at http://www.phac-aspc.gc.ca/publicat/cdic-mcc/18-1/c_e.html. 19 Report of the Standing Committee on Finance, Canada: People, Places and Priorities, November 2002.
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Amendments to PIPEDA, Bill S-4

https://policybase.cma.ca/en/permalink/policy11194
Date
2014-06-09
Topics
Health information and e-health
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Date
2014-06-09
Topics
Health information and e-health
Ethics and medical professionalism
Text
The Canadian Medical Association (CMA) is pleased to make submissions on Bill S-4. CMA has followed the history of PIPEDA and participated in the studies of various Standing Committees, most notably and recently in 2007 to the House of Commons Standing Committee on Access to Information, Privacy and Ethics. CMA is pleased that amendments to PIPEDA are once again being considered. The Canadian Medical Association represents over 80,000 physicians in Canada. Privacy is an important value to physicians and the patients to whom they serve. This is reflected in our Code of Ethics and policies, in particular, Principles for the Protection of Patients' Personal Health Information and Statement of Principles: The Sale and Use of Data on Individual Physicians' Prescribing. Physicians are also required to abide by privacy and confidentiality standards of practice. Thus, the CMA has a strong interest and valuable insights into the topic of personal information and privacy with respect to health information. We thank the Standing Committee for the opportunity to comment on the proposed amendments to PIPEDA. Our key comments are outlined below: Issue 1: CMA supports the existing legislative framework on the collection, use and disclosure of personal information produced by an individual in the course of their employment, business or profession ("work product") and suggests further amendments focus on strengthening it further. CMA supports the current standing of work products, that work products are considered to be personal information. That is, we support the framework defining personal information as information about an identifiable individual and that there is no carved out definition or exemption for "work product". CMA supports the position of the Office of Privacy Commissioner's following its 2007 investigation on work products, that they should not be exempted for two main reasons: * The exemption is not needed, and it would be inconsistent with the balanced approach in the current definition of personal information. The current definition of personal information and the approach to deciding issues based on that definition have worked well. They have promoted a level of privacy protection that balances the right of privacy in personal information with the needs of organizations for the reasonable and appropriate collection, use and disclosure of personal information. ...Because the concept of "work product" is ambiguous, excluding it from the definition of personal information could have unpredictable consequences that would diminish privacy unnecessarily. * (http://www.priv.gc.ca/parl/2007/sub_070222_03_e.asp) It is the CMA's position that work products should be considered personal information and given the section 7 amendments, work products should only be collected, used or disclosed without consent only if it is consistent with the purposes for which the information was produced. In the case of physicians, a prime example of a physician's work product is prescribing information. Prescribing information is a synthesis of assessing patients - by probing into their health, familial, social and sometimes financial background - infused with medical knowledge, skill and competencies resulting in a diagnosis and treatment plan, which often includes prescribing a medication or test. Not only is the physician's prescribing information a product of physicians' work but would not exist but for a trusting physician-patient relationship wherein the patient's private and personal information are shared under circumstances of vulnerability and trust. The outcome is that this is personal information. Prescribing information is about an individual: it includes the name of the patient, the name of the prescribing physician, and the drug name, dosage, amount and frequency; giving major clues as to what the patient's health issue(s) are. For further clarity, however, CMA recommends that physician information, and physician work products, should be specifically recognized within the legislation as personal information. To this end, we would propose that the following addition be made to the definition section under personal health information: Section 2.(1) "personal health information", with respect to an individual, whether living or deceased, means .....(d) information that is collected or is the outcome of collecting information in the course of providing health services to the individual; CMA supports the amendments to subsections 7(1)-(3) of the Act that any subsequent collection, use and disclosure of work products without consent must be related to the original purpose (of collection, use and disclosure). This relationship reflects the government's understanding and faithfulness to privacy principles. This is particularly critical when dealing with health information, and is even more critical in today's world given the ease of linking information through advancements in technology. In the absence of a causal relationship, personal information should not be used for system performance, commercial enterprise, data brokering, research, assessment or other purposes. CMA recommends that the legislation should go further and allow persons who believe that protection cannot be afforded under the legislation that they have the authority to refuse to communicate the information. This is the conceptual approach taken in Quebec's Act Respecting the Protection of Personal Information in the Private Sector wherein persons have an opportunity to refuse that professional information (as defined therein) be used for commercial purposes. Physicians are constantly writing prescriptions and such information should only be used for other purposes in the interests of patients and the health care system, and not to serve commercial interests or marketing strategies. If physicians do not feel that such protection is afforded patients, then they should be permitted to refuse that such information be collected, used or disclosed. Patient privacy should be primary. And finally, addressing work products in legislation clears up past differences of interpretation by Privacy Commissioners thus, providing certainty and clarity to the public. Recommendation 1: That Section 2. (1) "personal health information", be amended to read as follows: "personal health information", with respect to an individual, whether living or deceased, means .....(d) information that is collected or is the outcome of collecting information in the course of providing health services to the individual; Issue 2: CMA is pleased to see a section on breaches of security safeguards and recommends greater specificity. As noted above, physicians have responsibilities as data stewards and custodians of health information. As such, CMA supports breach notification measures that would enhance and protect patient privacy. In principle, we support the proposed amendments of breach disclosures to the Privacy Commissioner, to individuals and to organizations. However, CMA is concerned that meeting the requirements may be confusing. For example, in the health care context, it is easy to surmise that all health information is "sensitive". A far more difficult matter is determining whether the risk reaches the threshold of "significant harm" and the "probability" that the information "will be misused". The result being that incidental disclosures will be reported causing unnecessary concern and confusion in the patient population. Further specificity is recommended and we suggest something akin to Ontario's Personal Health Information Protection Act, 2004 (PHIPA). The PHIPA is an act specifically dealing with personal health information. One of its purposes is "to establish rules for the collection, use and disclosure of personal health information about individuals that protect the confidentiality of that information and the privacy of individuals with respect to that information, while facilitating the effective provision of health care" (section 1a ). The PHIPA notification provision states that the individual shall be notified "...at the first reasonable opportunity if the information is stolen, lost or accessed by unauthorized persons", [section 12(2)]. CMA is unaware of any concerns with this approach. The language of PIPIEDA is one of reasonable belief of real risk of significant harm to an individual. The issue is the test for required notification of patients for incidental inadvertent breaches and decreasing "notification fatigue". To illustrate the issue, if physicians were told today that patient data could be retrieved from the drums of discarded photocopiers and printers, it would be inappropriate for legislation to suggest that the entire patient population during the life of the photocopier or printer be notified. To this end, we recommend that there be acknowledgement that in some circumstances notification may not be required. The probability of misuse under PIPEDA is more ambiguous than the PHIPA test. Under PHIPA, the approach is more objective in that the data must be stolen, lost or accessed by unauthorized persons. To our knowledge, the Ontario model has been in place for almost a decade with no significant issues and thus we submit is one that works. In other jurisdictions (eg., Newfoundland and Labrador, Nova Scotia, New Brunswick) with health privacy legislation, there is acknowledgement of trying to balance notification and those breaches unlikely to result in harm by directly indicating when notification is not required. Recommendation 2: CMA recommends that the statute move towards a more objective test and acknowledge that there are situations when notice is not required. Issue 3: CMA supports disclosure without consent under limited circumstances, but finds the current list of disclosures overly inclusive. Health information is considered highly sensitive information and is initially collected for the purpose of individual patient health care. It should only be disclosed with consent and in only some exceptions without consent. The PIPEDA amendments for disclosure without consent have been broadened. Privacy, confidentiality and trust are the foundations of the patient-physician relationship. Without these fundamental values in play, open and honest communications cannot occur and patients would not receive the care they require. Both the patient and the physician have significant investment in the relationship. CMA respects the requirements to disclose information without consent under certain premises, such as required by court order or statute. However, any kind of activity requiring physicians to disclose patient's information without consent for the purposes of advancing a government or institution's goal could jeopardize the relationship. Both the patient's consent and the physician's consent should be required if there is potential to disturb this relationship. The physician is fiduciary of the relationship and is appropriately situated to assess and determine whether disclosure will disturb the relationship. While CMA acknowledges that certain situations may require that disclosure occur without consent (eg. purposes of investigating fraud, national security, abuse or as legally required), disclosure for less malicious activities (e.g., breaches of an agreement, insurance claims) ought to require a court order or warrant. For example, under the proposed section 7(3)(d.1) if a physician were in default of a contract with a technology company supplying electronic medical record software or app to his/her clinic, the company could disclose health information without consent for the "purposes of investigating a breach of an agreement". While we appreciate that there is a caveat that disclosure without advising the patient can only occur if there is a reasonable expectation that the disclosure would compromise the investigation, we submit that leaving the determination of what is "reasonable" to an interested party to the breach is unfair to all. Another example, if a physician is a witness to a dispute between an employer and union representing an employee for denial of long term disability by an insurance company, and has filed a witness statement which includes a medical report he/she wrote to the employer's insurance company, under the proposed section 7(3)(e.1) disclosure of health information without consent is permitted in order to assess, process or settle an insurance claim. CMA is concerned that the disclosure amendments are overly broad and do not differentiate sufficiently between highly time sensitive or grossly malicious situations, and those where it is merely expedient or an administrative encumbrance to seek consent. In addition, the disclosure requirements are framed in permissive (ie., may) and not mandatory language (ie., shall). This is very problematic when the "organization" is a physicians' clinic unless the physician's own consent is made as a pre-condition. CMA believes this suggestion is a progressive one in keeping with the broadened disclosure amendments. Physicians are in a relationship of trust and take seriously the protection of patient privacy and confidentiality, for which they are trained and are ethically and legally required to protect. To place physicians in a position which might entail breaching this trust may impact the confidence of the physician and the patient in the patient-physician relationship which is required to properly formulate appropriate treatment plans; thus, negatively impacting the health of Canadians. Recommendation 3: That disclosures of health information without consent require a warrant or subpoena or court order. Furthermore, disclosures of health information require the physician's consent that in his/her opinion the disclosure does not harm the patient-physician relationship. And, finally any broadened disclosure situations be restricted to criminal activity or that impacting national security. Conclusion Once again, CMA appreciates the opportunity to provide comment as part of the committee's study of Bill S-4. CMA is prepared to work with Parliament, governments, health professionals and the public in ensuring legislative frameworks for the collection, usage and disclosure of personal information for legitimate and reasonable purposes.
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Answering the Wake-up Call: CMA’s Public Health Action Plan : CMA submission to the National Advisory Committee on SARS and Public Health

https://policybase.cma.ca/en/permalink/policy1960
Last Reviewed
2010-02-27
Date
2003-06-25
Topics
Health systems, system funding and performance
Health care and patient safety
Population health/ health equity/ public health
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2010-02-27
Date
2003-06-25
Topics
Health systems, system funding and performance
Health care and patient safety
Population health/ health equity/ public health
Text
The public health system in Canada lies at the heart of our community values. It is the quintessential “public good” and is central to the continued good health of our population. When the public health system is working well, few are even aware that it is at work! Only when something goes terribly wrong — like the Walkerton tragedy or when we are faced with a new threat like SARS — is the integral, ongoing role of public health really recognized. The Canadian Medical Association (CMA) has been warning that our public health system is stretched to capacity in dealing with everyday demands, let alone responding to the latest crises. Canada’s physicians have repeatedly called for governments to enhance public health capacity and strengthen the public health infrastructure throughout Canada. Our public health system is the first — and often the only — line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. As most health threats know no boundaries, our public health armaments must be in a constant state of “battle readiness.” In today’s climate of SARS, West Nile Virus, mad cow disease and monkey pox, even the thought that the public health system may be stretched beyond capacity strikes fear into the hearts of Canadians. Physicians have always been an integral part of the public health system serving as medical officers of health, community health specialists and other related roles. Indeed public health cannot successfully fulfill its mandate without the cooperation and commitment of front-line clinicians. In this submission, we reflect on the lessons to be learned from our recent experience with SARS and reflect on the longer-term needs of the public health system as a whole. The objectives of the pan-Canadian Public Health Action Plan proposed by the CMA are, first to realize a clearer alignment of authority and accountability in times of extraordinary health emergencies; and, second, to enhance the system’s capacity to respond to public health threats across the country (see recommendations, below, and Appendix 1). To achieve these twin objectives, three broad strategies are presented for immediate attention. They are legislative reform; capacity enhancement; and research, surveillance and communications. Legislative reform (see recommendations 1–3) The country’s response to SARS has brought into stark relief the urgent need for national leadership and coordination of public health activity across the country, especially during a health crisis. The apparent reluctance to act quickly to institute screening at airports, the delay in unifying the practice community for a concerted response and the appalling communications confusion worked against optimum handling of the outbreak — despite the best efforts of health care professionals. This is a wake-up call that highlights the need for comprehensive legislative reform to clarify the roles of governments with respect to the management of public health threats. A renewed and enhanced national commitment to public health should be anchored in new federal legislation to be negotiated with the provinces and territories. Specifically, the CMA recommends an Emergency Health Measures Act, to deal with emergent situations in tandem with the creation of a Canadian public health agency headed by a Chief Public Health Officer of Canada. Capacity enhancement (see recommendations 4–7) The SARS crisis has demonstrated the diminished capacity within the public health system. The Greater Toronto Area (GTA), with one of Canada’s most sophisticated public and acute health systems, has not been able to manage the SARS crisis adequately and carry on other health programs. The acute care system virtually ground to a halt in dealing with SARS. There was little or no surge capacity in Canada’s largest city. We should be grateful that SARS did not first strike a smaller centre in a far less-advantaged region of Canada. A critical element of the public health system is its workforce and the health professionals within the acute care system, such as hospital-based infectious disease specialists and emergency physicians who are the front-line interface. Let there be no doubt that the ongoing efforts of the GTA front-line providers are nothing short of heroic. However, the lack of coordinated contingency planning of hospital and community-based disease control efforts was striking. The overall shortage of critical care professionals and the inability of governments to quickly deploy the required professionals to areas of need contributed to the enormous strain on the public and health care system. Considering the importance of the public health system and its clearly limited capacity to protect and promote the health of Canadians, it is incomprehensible that we do not know how much is actually spent on the system. It is imperative that public health expenditures and capacity, in terms of both physical and human resources, be tracked and reported publicly. The CMA recommends a $1-billion, 5-year capacity-enhancement program to be coordinated with and through the new Canadian public health agency. Research, surveillance and communications (see recommendations 8–10) Canada’s ability to respond to public health threats and acute events, such as SARS, and to maintain its effective public health planning and program development depends on sound research, surveillance and rapid, real-time communications. A concerted pan-Canadian effort is required to take full advantage of our capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. New-millennium challenges require moving beyond old-millennium responses. Enhanced surveillance is an overdue and integral part of public health, performing an essential function in early detection and response to threats of infectious diseases. Mandatory national reporting of identified diseases by all provinces and territories is critical for national and international surveillance. During times of crisis, rapid communication to the public, public health staff and front-line clinicians is of critical importance, but in many jurisdictions impossible. We tested our systems during the SARS outbreak and they came up short. The CMA recommends a one-time federal investment to enhance technical capacity to allow for real-time communication. Conclusion The CMA believes that its proposed three-pronged strategy, as set out in the attached recommendations, will go a long way toward addressing shortfalls of the Canadian public health system. Action now will help to ensure that Canadians can once again be confident that they are protected from any future threat of new infectious diseases. Action now will help Canada regain its position as a leader in public health. We wish the advisory committee well in its deliberations and offer the CMA’s assistance at any time in clarifying the strategies set out in our submission. Recommendations to the National Advisory Committee on SARS and Public Health Legislative reform ($20 million / 5 years*) 1. The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada. 2. The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm’s length from government. 3. The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan. Capacity enhancement ( $1.2 billion / 5 years*) 4. The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals. 5. The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies. 6. Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the proposed Canadian Office for Disease Surveillance and Control. 7. Federal government funding in the amount of $1 Billion over 5 years to build adequate and consistent surge capacity across Canada and improve coordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions. Research, surveillance and communications ($310 million / 5 years*) 8. An immediate, sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. 9. The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and intervention. 10. The one-time infusion of $100 million, with an additional $2 million a year, for a “REAL” (rapid, effective, accessible and linked) Health Communication and Coordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies. *See Appendix 2: Estimated cost of implementing recommendations. PURPOSE The CMA prepared this submission in response to an invitation from Dr. Naylor to provide input to the National Advisory Committee on SARS and Public Health. We applaud this initiative and welcome the opportunity to present the views of Canada’s medical community to the committee. The CMA’s basic message is that our health protection laws are woefully outdated and the public health system is stretched beyond capacity. This submission draws on our long history of engagement in public health in Canada and our experience both post-September 11, 2001 and with SARS. It builds on the knowledge and experience of our members, national specialist affiliated societies and provincial and territorial divisions. (We acknowledge, in particular, the outstanding efforts of the Ontario Medical Association and the Canadian Association of Emergency Physicians in battling SARS.) In this submission, we examine the lessons to be learned from our experience with the SARS outbreak and reflect on both the immediate and longer-term needs of the public health system as a whole. The objectives of the public health action plan proposed by the CMA are, first, to realize a clearer alignment of authority and accountability in times of extraordinary health emergencies and, second, to enhance the system’s capacity to respond to public health threats across the country, including those posed by preventable chronic disease. INTRODUCTION The public health system in Canada lies at the heart of our community values. It is the quintessential “public good” and is central to the continued good health of the population. When the public health system is working well, few are even aware that it is at work! Only when something goes terribly wrong — like the contamination of the blood supply in the 1980s, the Walkerton tragedy or SARS — is the integral, ongoing role of public health recognized. Our public health system is the first — and often the only — line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. As most health threats know no boundaries, our public health system must be in a constant state of “battle readiness.” We can ill afford any weakness in our public health preparedness. In today’s climate of SARS, West Nile Virus, mad cow disease and monkey pox, the mere thought that the public health system may be stretched beyond capacity strikes fear into the hearts of Canadians. Physicians have always been an integral part of the public health system serving as medical officers of health, specialists in infectious disease and community medicine (who will not remember the stalwart efforts of Dr. Donald Low on SARS?) and in other related roles. Indeed, public health cannot successfully fulfill its mandate without the cooperation and commitment of front-line clinicians. The CMA has been warning for some time that our system is stretched to capacity in dealing with everyday demands, let alone responding to crises. Canada’s physicians have repeatedly called for governments to enhance public health capacity and strengthen the public health infrastructure throughout Canada. For example, the CMA’s submission to the House of Commons Standing Committee on Finance’s prebudget consultations on October 22, 2001 called for substantial investments in public health and emergency response as a first step to improve the public health system infrastructure and its surge capacity. This submission not only reiterates our previous recommendations, but also outlines specific actions that the CMA believes must be taken to ensure a strong public health system in Canada. The Enduring Impact of Severe Acute Respiratory Syndrome SARS (Severe Acute Respiratory Syndrome): in February 2003, these four letters sent massive shock waves around the world, causing widespread fear and confusion among health care officials and citizens of many countries. The “fear factor” extended across Canada as people realized the full threat of SARS. Since SARS was first identified in a patient in Toronto in March 2003, 438 probable or suspected cases have been reported to Health Canada and 38 people have died (as of June 23, 2003). However, these numbers do not reflect the full impact of the outbreak. The number of indirect deaths due to system shutdown will never be known. Local public health authorities across the country went on high alert. Those in the Greater Toronto Area (GTA) as well as their provincial counterparts diverted almost all of their resources to respond to the crisis. Acute care services were adversely affected as stringent infection-control and screening measures were put into place to control the spread of SARS. In the GTA, the health system — acute and public — was brought to its knees. Over half of the reported SARS cases involved front-line providers as the outbreak largely affected health care settings. Approximately 20 physicians in Ontario contracted SARS and close to 1000 were quarantined. Thousands of nurses and other health care workers also faced quarantine, some more than once. Institutions closed their doors, limiting access to emergency departments, clinics and physicians’ offices. Intensive care units were full and surgeries were cancelled. Front-line health care professionals involved in critical care were stretched to their physical and mental limits. Others found themselves underutilized due to the impact of the infection-control measures on their practice settings. Feast and famine co-existed. Although the outbreak was mainly confined to health care settings, the entire GTA felt the effects. Upwards of 20,000 people entered voluntary quarantine. Businesses were affected. The tourism industry is still reeling. The disruption that SARS caused continues to reverberate through health care systems and economies. In response to urgent requests from both the Ontario Medical Association and Health Canada, the CMA mobilized its membership and assisted in the country’s response to SARS. Everything that could be done was done to facilitate bringing in qualified personnel to relieve those on the front line and make appropriate information available in real time. The CMA has learned its own lessons, both positive and negative. A full chronology of CMA activity is attached as Appendix 3. It has become abundantly clear that Canada’s public health system was ill prepared to deal with the SARS outbreak. If not for the heroic efforts of public health officials, health care providers and research scientists, Canada’s experience would have been much worse. Public health in Canada Public health is the science and art of protecting and promoting health, preventing disease and injury, and prolonging life. It complements the health care system, which focuses primarily on treatment and rehabilitation, sharing the same goal of maximizing the health of Canadians. However, the public health system is distinct from other parts of the health system in two key respects: its primary emphasis is on preventing disease and disability and its focus is on the health needs of populations rather than those of specific individuals. Public health is the systematic response to infectious diseases. It also ensures access to clean drinking water, good sanitation and the control of pests and other disease vectors. Further, it is immunization clinics and programs promoting healthy lifestyles. But it is also there to protect Canadians when they face a public health crisis like SARS. If the public health system is fully prepared to carry out essential services, then communities across the country will be better protected from acute health events. The reality in Canada today is that a strong, consistently and equitably resourced and integrated public health system does not exist. Public health systems across Canada are fragmented — a patchwork of programs, services and resources across the county. In reality, it is a group of multiple systems with varying roles, strengths and linkages. Each province has its own public health legislation. Most legislation focuses on the control of communicable diseases. Public health services are funded through a variable mix of provincial and municipal funding formulae, with inconsistent overall strategies and results, and with virtually no meaningful role for input from health professionals via organizations such as the CMA, or the federal level, in terms of strategic direction or resources. Federal legislation is limited to the blunt instrument of the Quarantine Act and a variety of health protection-related acts. (e.g., Food and Drugs Act, Hazardous Products Act, Controlled Drugs and Substances Act, Radiation Emitting Devices Act) Some of the laws, such as the Quarantine Act, date back to the late 19th century. Taken as a whole, the legislation does not clearly identify the public health mandate, roles and responsibilities of the different levels of government. In many cases, the assignment of authorities and accountabilities is anachronistic. Moreover, there is little information available on the functioning and financing of Canada’s public health system. There is no “one-stop shopping” for authoritative information on public health issues. In 2001, a working group of the Federal, Provincial and Territorial Advisory Committee on Population Health assessed the capacity of the public health system through a series of key informant interviews and literature reviews. The consistent finding was that public health had experienced a loss of resources and there was concern for the resiliency of the system infrastructure to respond consistently and proactively to the demands placed on it. Significant disparities were observed between “have” and “have-not” provinces and regions in their capacity to address public health issues. The report’s findings are consistent with previous assessments by the Krever Commission and the Auditor General of Canada. In 1999, the Auditor General said that Health Canada was unprepared to fulfill its responsibilities in public health; communication between multiple agencies was poor; and weaknesses in the key surveillance system impeded the effective monitoring of injuries and communicable and non-communicable diseases. In 1997, Justice Horace Krever reported that the “public health departments in many parts of Canada do not have sufficient resources to carry out their duties.” The Challenges Ahead The 21st century brings with it an awesome array of new public health risks and ancient foes. Not all of them can be identified at the present time. New diseases (e.g., SARS, West Nile Virus) will likely continue to emerge. Dr. Alan Bernstein, President of the Canadian Institutes of Health Research, recently noted that SARS is here to stay. Old threats, such as contamination of a community water supply (e.g., Walkerton), can strike quickly if vigilance is relaxed or delegated to third parties. This century will likely bring greater focus on threats from the physical environment. Our social environment is also a source of illness as shown by the recent epidemic trends in obesity and type 2 diabetes mellitus. A substantial minority of Canadians continue to smoke. In short, there is no lack of public health threats to Canadians. Although for each of these issues, there is a clear role for clinical care, it is the public health system that will identify and monitor health threats and provide interventions to prevent disease and injury and improve health. The system will also be at the front lines in any response to a biological, chemical or nuclear event. The public health system must have the infrastructure to respond to a range of threats to health, including emergencies. The experience with SARS has reaffirmed that we do not have the system flexibility to respond to these events after they have occurred. It is vital that we take steps now “to embrace not just the essential elements of disease protection and surveillance but also new strategies and tactics capable of addressing global challenges.”<1> CMA’S PROPOSED PUBLIC HEALTH ACTION PLAN No one policy instrument can possibly address the multiple factors involved in meeting the public health challenge head on. Similarly, no one level of government or constituency (e.g., community medicine) can or should shoulder all of the responsibilities. Although we need to restore public confidence quickly, we must also do what it takes to get it right. Accordingly, the CMA is proffering a three-pronged approach to meet the challenge: * A legislative reform strategy * A capacity enhancement strategy * A research, surveillance and communication strategy. These three broad strategies make up the CMA’s proposed 10-point Public Health Action Plan. Taken together, the CMA believes the Plan, if adopted, will serve us very well in the future. Legislative Reform Our experience with SARS — and the seeming lack of coordination between international, federal, provincial and local system levels — should be a massive wake-up call. It highlights the need for legislative reform to clarify the roles of governments with respect to the management of public health issues and threats. Four years ago, national consultations on renewing federal health protection legislation<2> resulted in a recommendation that * “The federal government must be given, either through legislation or through memoranda of understanding among provincial and territorial governments, the authority it needs to effectively address any outbreak of a communicable disease, where the health risk extends beyond provincial borders. * “Federal health protection legislation should be amended to give Health Canada authority to act quickly and decisively in the event of a national health emergency... if it poses a serious threat to public health; affects particularly vulnerable segments of the population; exceeds the capacity of local authorities to deal with the risk; and involves pathogens that could be rapidly transmitted across national and international borders.” Such legislative reform is consistent with the federal government’s well-recognized responsibility to act to protect public health and safety. It fits well with Health Minister McLellan’s recently announced plans to act now to review and update health protection legislation. The SARS outbreak has provided further experience to support these, and in our view, even stronger recommendations. There is ample historical evidence to support the federal government’s role in the management of communicable disease, a role that dates back to the time of confederation. The quarantine power was the initial manifestation of this authority in 1867 under Section 91 of the British North America Act and it gave the federal government the responsibility for ensuring the containment of infectious diseases. The outbreak of the Spanish Flu epidemic in 1918 further highlighted the need for coordinated national efforts and (at the urging of the CMA and others) resulted in the creation of the federal Department of Health in 1919. It would be reasonable to assume that legislators at the time had an expansive view of the need for centralized authority to deal with pan-Canadian health threats. One hundred and thirty-five years after confederation, we have a highly mobile global community. This mobility and the attendant devastating speed with which diseases can spread demand a national response. Currently, there is tremendous variation in public health system capacity among the various provinces and territories and, more particularly, among municipalities and local authorities. Inconsistencies in provincial approaches to public health matters have resulted in significant disparities between and within the provinces.<3> Health Canada’s mandate as set out in its enabling legislation states that “[t]he powers, duties and functions of the Minister extend to and include all matters over which Parliament has jurisdiction relating to the promotion and preservation of the health of the people of Canada.” The CMA believes that it is time for the federal government to take responsibility for public health matters that touch the lives of all Canadians. The legal staffs at CMA, in consultation with external experts, have conducted a detailed review of existing legislation. We have concluded, as Health Minister McLellan recently announced, that there is a long overdue need to consolidate and rationalize current related laws. We also believe there is now public support and a demonstrable need to enhance the powers afforded the federal government. We recognize that the government has put forward Bill C-17, the Public Safety Act and a review of health protection legislation is underway. We believe that amending and updating existing legislation is necessary but not sufficient to address today’s public health challenges. The CMA is calling for the enhancement of the federal government’s “command and control” powers in times of national health emergencies. Specifically we are recommending a three-pronged legislative approach. 1. The CMA recommends The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada. The existing Emergencies Act gives the federal government the authority to become involved in public welfare emergencies when regions of the country are faced with “an emergency that is caused by a real or imminent... disease in human beings... that results or may result in a danger to life or property... so serious as to be a national emergency.” However, to use this power, the federal government must declare a “national emergency,” which itself has political and economic ramifications, particularly from an international perspective, and mitigates against its use. The CMA believes that this all-or-nothing approach is not in the public’s best interest. The concept of emergency in the context of public health requires a different response from governments in the future. Although we recognize that provincial and municipal governments currently have preplanned sets of responses to health threats, the CMA is proposing new legislation to allow for a rapid federal response to public health emergencies. The proposed Emergency Health Measures Act clarifies the roles and authority of governments and ensures a consistent and appropriate response with sufficient human and financial resources to protect Canadians faced with a public health emergency. Of utmost importance, all Canadians, regardless of their location, can be assured that the response to a health emergency will be delivered systematically by experts who can sustain the effort as needed. The proposed legislation would be founded on a graduated approach that would give the federal government the powers necessary to deal with a crisis, in an appropriately measured way, as it escalates. As the emergency grows, the government could implement stronger measures as required to meet the challenge — in principle, akin to the Unites States’ homeland security levels, which increase as the level of threat increases (see Appendix 4 for a description of the Canadian Emergency Health Alert System). The CMA strongly believes that the federal government must have jurisdiction to act when the ability of the provinces to respond to public health emergencies is so disparate. The inability of one province to stop the spread of virulent disease would have serious implications for the health of residents in the rest of the country. The federal government and the provinces must work together to ensure the safety of all our citizens. 2. The CMA recommends The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm’s length from government. Although some provinces have established centres of public health expertise, considering the breadth of public health issues, the relative population sizes and differences in wealth, it will never be feasible to have comprehensive centres of public health expertise for each province and territory. Even if one achieved this, there would increasingly be issues of economies of scale and unnecessary duplication among centres. This issue is not unique to Canada.1 The CMA is proposing the development of a Canadian Office for Disease Surveillance and Control (CODSC) operating at arm’s length from any level of government. CODSC would have overall responsibility for protecting the health of Canadians. The Office would provide credible information to enhance health decisions and promote health by developing and applying disease prevention and control, environmental health and health promotion and education activities. CODSC would enable a consistent and coordinated approach to public health emergencies as well as play a key role in the prevention and control of chronic diseases and injuries. It would provide national health surveillance, apolitical scientific expertise, system development including standards and guideline development, development and dissemination of an evidence base for public health interventions, skills training and transfer of expertise (i.e., through secondment of staff) and resources, including funding for core programs, to other levels of the system (e.g., provincial and local). 3. The CMA recommends The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan. Many national or federal–provincial–territorial committees play an important role in recommending public health strategies or actions. The National Advisory Committee on Immunization and the Federal, Provincial and Territorial Advisory Committee on Population Health are two excellent examples. But there is currently no single credible public health authority in whom is vested, through legislation or federal–provincial–territorial agreement, the overall responsibility for pan-Canadian public health issues. Therefore, the CMA is recommending the appointment of a Chief Public Health Officer of Canada. Potential roles for this officer may include: * Serve as the head of the Canadian Office for Disease Surveillance and Control * Serve as the national spokesperson for public health with the independence to comment on critical public health issues * Report annually on the health of the population * Develop, implement and report independently to parliament on public health system performance measures * Lead processes to identify and address gaps in the nation’s public health system. Capacity enhancement The public health system infrastructure is the foundation that supports the planning, delivery and evaluation of public health activities. In March 2001, the Federal, Provincial and Territorial Advisory Committee on Public Health<3> reported, In the view of respondents the system ‘is lacking in depth.’ This means that a sustained crisis would seriously compromise other programming. While the research does not indicate that the public health system in Canada is strained beyond capacity, there does appear to be agreement that there is a capacity to manage just one crisis at a time. However, just 2 years later, the GTA, an area with one of Canada’s most sophisticated public and acute care health systems, was not able to manage the SARS crisis and carry on any other programs. The Ontario government recognized this state of affairs when, on 12 June, Ontario’s Health Minister Tony Clement said, “I was concerned that if we had one additional large-scale crisis, that the system would crash.” Important public health issues ranging from immunization to suicide prevention went virtually unaddressed, as the public health capacity in Toronto was overwhelmed. In the absence of a mechanism to share resources within the system and a general lack of overall system surge capacity, the city of Toronto and the province competed with each other to recruit trained staff from other health departments. The SARS outbreak has shown there is no surge capacity in Canada’s largest city. The acute care system in Toronto virtually ground to a halt in dealing with SARS. We must ask ourselves what would have happened if SARS had struck first in a smaller centre in a far less-advantaged region of Canada. Clearly Canada is not fully prepared. We should not have needed a crisis to tell us this. The CMA sees several components to rebuilding the capacity of the public health system. Public health human resources For the essential functions of the public health system to be realized, public health agencies need a workforce with appropriate and constantly updated skills. Canada’s public health workforce is extremely thin. There appear to be too few graduate-level public health professionals (i.e., those holding a master’s degree and physicians who are certified specialists in community medicine); those who do exist are not distributed equitably across jurisdictions. The scarcity of hospital-based infection control practitioners and emergency physicians within the acute care system and the lack of integration of hospital and community-based disease control efforts have been particularly striking during the SARS outbreak. The knowledge and skills required for effective public health practice are not static. They continually evolve as new evidence is identified. However, continuing education programming for public health practitioners is woefully underdeveloped in Canada. Health Canada has made some limited progress in this area, but the issue needs to be addressed much more substantively. 4. The CMA recommends The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals. Canada has world-class expertise in public health. However, it does not have the depth of other countries, partly because we do not have a national multidisciplinary school of public health of the calibre of Harvard in Boston, Johns Hopkins in Baltimore and the School of Hygiene and Tropical Medicine in London. A national school of public health, which might be based on a virtual network of centres nationwide, could * Develop a plan to assess and address the substantial educational needs of new and existing public health staff * Address the coordination of the various academic training programs to meet the needs of the field * Ensure self-sufficiency of our public health workforce. 5. The CMA recommends The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies. The SARS outbreak clearly demonstrated the need for a pre-planned approach to supporting and augmenting the public health and acute care workforce during a crisis. When health professionals in the GTA were overwhelmed, we were ill prepared to move health professionals in from other jurisdictions to help. Health professional associations like the CMA took the first steps in investigating and overcoming obstacles regarding licensure and insurance. We were taken aback when we found that the Ontario government had unilaterally awarded an exclusive contract to a for-profit company to arrange for emergency relief. The further delay caused by concerns about privacy, confidentiality and harmonizing fees hampered relief efforts. The deployment of health professionals during health emergencies is too important to be left in the hands of for-profit organizations as it was during the SARS experience. An established Canadian Public Health Emergency Response Service, operating on a non-profit basis, would * Maintain a “reserve” of public health professionals who are fully trained and could be deployed to areas of need during times of crisis * Co-ordinate the logistics of issues such as portable licensing, malpractice and disability insurance * Identify funding for staff training and a more equitable distribution of numbers and skills among jurisdictions. Investment in public health Considering the importance of the public health system and its capacity to protect and promote the health of Canadians, it is amazing that we have no reliable or comprehensive information about how much money is actually spent on the system or what public health human resources are available across Canada. This is partially due to the lack of uniform definitions, service delivery mechanisms and accounting practices. Even in the absence of reliable data on public health expenditures, there is ample evidence that the public health system continues to operate under serious resource constraints across Canada. 6. The CMA recommends Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the Canadian Office for Disease Surveillance and Control. In its latest report on health system expenditures, the CIHI states that 6% of total expenditures in 2000 were spent on “public health and administration.”<4> The inclusion of administrative costs in this figure means that public health funding is substantially less than 6% of health system expenditures.2 Federal Government Estimates report that Health Canada allocated $433 million in 2003–2004 for health promotion and prevention activities with spending scheduled to decrease to $308 million by 2005–2006 or by almost 30%. This decrease in spending exemplifies a decade that has seen tremendous fluctuations in spending on public health activities. The situation is alarming when looked at from a current-dollar basis; there was an 8.8% decrease in funding of public health activities between 1994–1995 and 1997–1998. In fact, federal spending on public health on a constant dollar basis did not regain its 1994–1995 level until 2000–2001. Although the late 1990s saw some reinvestment in public health initiatives, the most recent 2003–2004 estimates suggest that, once again, federal investment in public health will decrease dramatically over the next few years. Indeed, public health continues to represent only a small fraction of total federal direct spending on health (9.7% in 2002–2003). At the provincial level, although we cannot distance public health from administration, we know that it fell victim to the brutal climate of fiscal retrenchment of the 1990s, when in real terms provincial–territorial per capita health spending declined for 5 consecutive years after 1991–1992. During this period, public health was further destabilized by regionalization. According to the Survey of Public Health Capacity in Canada most provincial and territorial officials reported reductions in programming as a result of the transfer of funding and responsibility to regional structures. Although Ontario did not regionalize, in 1997 public health funding was downloaded to municipalities, which left public health departments scrambling to find funds to meet existing programs as well as new services that were mandated by the provincial Health Protection and Promotion Act. Whether talking about federal or provincial–territorial jurisdictions, we can no longer afford to have funding for health and safety subject to the vagaries of financial cycles. However, what perhaps is most alarming is the potentially large economic impact of underinvestment in this area. Although the net cost of the SARS outbreak in Ontario is not yet known, recent estimates suggest that it could be as high as $2.1 billion.3 Given this, the proverbial ounce of prevention that is worth a pound of cure comes to mind suggesting that a relatively modest increase in funding for public health could potentially result in substantial savings in the longer term. 7. The CMA recommends Federal government funding in the amount of $1 billion over 5 years to build adequate and consistent surge capacity across Canada and improve coordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions. The best way to ensure that the public health system is capable of addressing the range of public health threats, including emergencies, is to significantly increase investment in its capacity. This investment must assist all levels of the system to fulfill essential public health functions, with particular attention to local and regional agencies. The strategic national leadership that we are calling for includes the development of new mechanisms for federal cost sharing of basic public health services and the guarantee of a basic core set of local programs serving everyone in Canada, regardless of where they live. The system also needs to receive targeted funds so that it can do its work smarter and more effectively. Priority areas for this targeted funding should include development of an integrated information system and staff training. Research, surveillance and communications Canada’s ability to respond to emerging public health threats and acute events, such as the SARS outbreak, and to maintain its effective public health planning and program development depends on sound research, surveillance and rapid, real-time communications. 8. The CMA recommends An immediate sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. Similar to the efforts in clinical care to support the use of evidence-based practices, interventions in public health must be based on research, evidence and best practices. A national effort should be undertaken to develop and make widely available, on an ongoing basis, a comprehensive and up-to-date review of the evidence base for public health programs. This information would support effective practice, enhance public health research capacity and support other infrastructure elements (e.g., minimum programs and services, performance measurement, system funding). It could also reduce unnecessary duplication of efforts by different public health agencies. We applaud the tremendous work of the unique trans-Canada partnership of 4 CIHR-funded research teams who, in just 11 weeks, discovered the complete DNA sequence of the coronavirus associated with SARS. This is a perfect example of what can be accomplished when our talented research teams work together. The recent announcement by the CIHR of an integrated national strategy for research on SARS reflects the intent of this recommendation for other public health challenges. 9. The CMA recommends The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and interventions. Public health surveillance is defined as the ongoing, systematic collection, analysis and interpretation of health data necessary for designing implementing and evaluating public health programs. It is an integral part of the public health system and performs an essential function in early detection and response to threats to human health. Current surveillance systems for communicable and noncommunicable diseases are inadequate to allow public health professionals to detect and react to major health issues. For effective public health management, surveillance must be a continuous process covering a range of integrated data sources to provide useful and timely information. 10. The CMA recommends The one-time infusion of $100 million, with an additional $2 million a year, for a “REAL” (rapid, effective, accessible and linked) Health Communication and Coordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies. In today’s world, international travel, business and migration can move infectious diseases around the world at jet speed. But during the SARS experience, governments and public health authorities were unable to communicate in real time with health professionals on the front lines. Gaps in the basic communication infrastructure prevent public health agencies from talking with each other in real time, and also hinder exchanges between public health staff, private clinicians and other sources of information about emerging new diseases. In response to requests from both the Ontario Medical Association and Health Canada, the CMA mobilized its communication networks to provide physicians with critical information about public health management of SARS. In less than 48 hours, via email and fax, we reached over 45,000 physicians with authoritative information. Through the good offices of the Canadian Council of Health Services Accreditation, this information was also made available to over 1500 accredited health facilities across Canada. Although necessity caused the limits of the system to be tested, SARS highlighted the fact that we do not have information systems in place to facilitate real-time communication with health professionals. Information is the key to effective response during times of emergency. Information in real time is also essential for effective day-to-day health care to provide, for example, information on adverse drug reactions. CONCLUSION SARS brought out the best in Canada and Canadians’ commitment to one another. It also turned a bright, sometimes uncomfortable spotlight on the ability of this country’s health care system to respond to a crisis, be it an emerging disease, a terrorist attack, a natural disaster or a large-scale accident. We must learn from the SARS experience and quickly move to rebuild the infrastructure of a strong public health system. The CMA believes that this 10-point Public Health Action Plan will go a long way toward addressing shortfalls in the Canadian public health system. Action now will help to ensure that Canadians can be confident once again that their governments are doing all they can to protect them from the threat of new infectious diseases. We wish the advisory committee well in its deliberations and offer the CMA’s assistance at any time in clarifying the strategies set out in our submission. APPENDIX 1: THE CMA’S PUBLIC HEALTH ACTION PLAN [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [TABLE END] APPENDIX 2: ESTIMATED COST OF IMPLEMENTING THE RECOMMENDATIONS [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Recommendation Estimated cost over 5 years Legislative and institutional reform 1. Canada Emergency Health Measures Act N/A 2. Canadian Office for Disease Surveillance and Control (CODSC) ? $20 million 3. Chief Public Health Officer of Canada Capacity enhancement 4. Canadian Centre of Excellence for Public Health $100 million 5. Canadian Public Health Emergency Response Service $35 million 6. Canadian Institute for Health Information and Statistics Canada $35 milliona 7. Surge capacity $1 billionb Research, surveillance and communications 8. Canadian Institutes of Health Research $200 millionc 9. Mandatory reporting Included under 2 and 3 above 10. Enhanced reporting $110 million TOTAL $1.5 billion a. Work is currently underway to break-out public health from the current category of “public health and administration.” b. This is an incremental investment in addition to funding currently available under Health Canada’s Health Promotion and Prevention Strategic Outcome area. c. Funding must be sequestered specifically for new initiatives related to public health. Additional money could also be acquired through funding from the Canadian Foundation for Innovation, which received an additional $500 million in 2002–2003 (announced in the 2003 federal budget) to enhance the Foundation’s support of public health infrastructure. [TABLE END] APPENDIX 3: CHRONOLOGY OF THE CMA’S RESPONSE TO SARS 2002 November 16 * First known case of atypical pneumonia (SARS) occurs in Guangdong province, China 2003 February 11 * World Health Organization (WHO) receives reports from the Chinese Ministry of Health about SARS; 305 persons affected and 5 deaths February 13 * Canadian index case arrives in Hong Kong for a family visit February 18-21 * Canadian index case is a guest at the Metropole hotel in Kowloon February 21 * A medical doctor from Guangdong checks into Metropole hotel in Kowloon. The physician, who became ill a week before staying at the hotel, is considered to be the original source of the infection * This leads subsequently to outbreaks in Vietnam, Hong Kong, Singapore and Canada after guests leave the hotel and return home February 23 * Canadian index case returns home to Toronto March 5 * Canadian index patient dies in Toronto, 9 days after the onset of her illness March 12 * WHO issues global alert about SARS March 13 * National and international media reports begin appearing about SARS * The Canadian index patient’s son, Canada’s second SARS victim, dies 15 days after the onset of his illness March 14 * First reports from Toronto about deaths from SARS March 16 * Health Canada receives notice of SARS patients in Ontario and British Columbia; begins regular updates on SARS on its website * Health Canada initiates its pan-Canadian communication infrastructure, based on its pandemic influenza contingency plans March 17 * CMA calls Health Canada to offer assistance and request “real time information.” CMA immediately placed on list of participants in daily pan-Canadian teleconferences. * CMA adds a SARS page to its website home page (cma.ca) with CMA Shortcuts to expert information and daily updates March 19 * CMA alerts all its divisions and affiliates to the Health Canada and CMA SARS web pages * eCMAJ includes SARS updates on its website March 20 * CMA divisions add a link to SARS information for health professionals to their websites * Health Canada requests CMA’s assistance to inform physicians of the public health management guidelines for SARS March 28 * CMA sends an email to 33,000 members (copied to divisions and affiliated societies) to alert them to Health Canada’s SARS public health management documents and SARS web page April 1 * CMA CEO initiates cross-directorate task force and deploys dedicated staff resources. Some other CMA programs deferred/delayed. Task force begins daily staff SARS Working Group meetings * CMA communicates with the Ontario Medical Association on a daily basis April 2 * CMA holds teleconference with divisional communication directors re: SARS April 3 * CMA contacts the British Medical Association to establish whether we can secure a supply of masks from European sources * CMA organizes a teleconference among national health care organizations to discuss SARS developments April 7 * CMA posts electronic grand rounds on SARS for clinicians on cma.ca; * CMA sends email and fax communication to physicians to raise awareness of SARS e-grand rounds on cma.ca * Working with the Mental Health Support Network of Canada, CMA prepares and posts on cma.ca, fact sheets for health professionals and the public on coping with the stress caused by SARS April 9 * CMA hosts second teleconference among national health care organizations to discuss SARS developments April 17 * Electronic grand rounds on SARS updated and promoted through cma.ca April 23 * CMA sends email to membership requesting volunteers for the CMA Volunteer Emergency SARS Relief Network April 24 * CMA consults with the American Medical Association regarding the possibility of US physicians volunteering for the relief network April 25 * CMA CEO sends letter to deputy minister of health about the urgent need to create a national ministerial SARS task force April 30-May 1 * CMA participates in Health Canada-sponsored international SARS conference in Toronto May 6 * Health Canada announces the National Advisory Group on SARS and Public Health, headed by Dr. David Naylor May 12 * Opinion editorial by Dr. Dana Hanson, CMA president, on SARS and public health surge capacity published in The Ottawa Citizen; May 28 * CMA organizes a meeting of national health care organizations to discuss lessons learned from SARS June 3 * CMA receives an invitation to submit a brief to the National Advisory Group on SARS and Public Health June 6 * CMA sends e-mail to targeted segment of its membership (community medicine, public health, infectious disease and medical microbiology) requesting volunteers for the CMA Volunteer Emergency SARS Relief Network June 25 * CMA president outlines the CMA’s Public Health Action Plan during a speech at the Canadian Club in Toronto * CMA submission to the National Advisory Committee on SARS and public health APPENDIX 4: CMA’S PROPOSED HEALTH EMERGENCY ALERT SYSTEM [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Health alert may be declared in: Level 1 Level 2 Level 3 Level 4 Level 5 * Any area under federal jurisdiction * Any community or province/territory with a risk of transmission to other provinces/territories or countries * Any community or province/territory with insufficient resources to manage the public health emergency within the capacity of the local public health authorities Definition of the area of concern Voluntary quarantine for individuals or property Increasing surveillance Chief public health officer takes the lead in coordinating the response Regulation or prohibition of travel Facilitating communication Reviewing and updating health emergency procedures Determination of local capacity to lead and respond Coordinating necessary response efforts with national disaster relief agencies, armed forces or law enforcement agencies at the federal–provinical–territorial level Medium to significant limitations of civil rights and freedoms Mandatory surveillance Assessing future resource requirements Deployment of a national response team Medium to significant limitations of civil rights and freedoms Evacuation of persons and the removal of personal property Providing the public with necessary information. Discretionary deployment of the national response team or on request of local authorities Quarantine of individuals and/or property with enforcement by law Implementing interventions, as appropriate, and emergency response actions Regulation of the distribution and availability of essential goods, services and resources Assessing further refinement of actions Restricting access to the area of concern Requisition, use or disposition of property Required consent of governor in council No No Yes Yes Yes Lead response team Municipal or provincial Provincial or national Provincial or national National or international International [TABLE END] REFERENCES 1. Garrett, L. Betrayal of trust: the collapse of global public health. New York: Hyperion; 2000. 2. Health Canada. National consultations, summary report: renewal of the federal health protection legislation. Ottawa: Health Canada; 1999. 3. Federal, Provincial and Territorial Advisory Committee on Population Health. Survey of public health capacity in Canada: highlights. Ottawa: The Committee; 2001. 4. Canadian Institutes for Health Information. National health expenditure trends: 1975–2002. Ottawa: CIHI; 2002. 5. Lévesque M. The economic impact of SARS. TD Economics Topic Paper. TD Bank Financial Group; 6 May 2003. Available: http://www.td.com/economics/topic/ml0503_sars.html (viewed: 20 June 2003). 1 Many countries (e.g., United States, United Kingdom, Norway and the Netherlands) have developed critical masses of public health expertise at the national level. The Centers for Disease Control and Prevention in the United States, which has a critical mass, great depth of scientific expertise and the tools and fiscal resources to fund public health programs at both state and local levels through demonstration projects, is a sterling example of the effectiveness of such a central agency. 2 A review by the Canadian Institute for Health Information recognizes the problem with current expenditure tracking systems and has recommended separating public health from government administrative costs and prepayment administration in future health system cost estimates. 3 On 6 May, the TD Bank released a paper<5> suggesting that the cost of SARS to the Canadian economy may be between $1.5 and $2.1 billion.
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Avoiding negative consequences to health care delivery from federal taxation policy

https://policybase.cma.ca/en/permalink/policy11957
Date
2016-08-31
Topics
Health human resources
Physician practice/ compensation/ forms
  1 document  
Policy Type
Response to consultation
Date
2016-08-31
Topics
Health human resources
Physician practice/ compensation/ forms
Text
The Canadian Medical Association (CMA) provides this submission in response to Finance Canada’s consultation on Legislative Proposals Relating to Income Tax, Sales Tax and Excise Duties (Draft Tax Legislative Proposals). The CMA is the national voice of Canadian physicians. On behalf of its more than 83,000 members and the Canadian public, the CMA’s mission is helping physicians care for patients. In fulfillment of this mission, the CMA’s role is focused on national, pan-Canadian health advocacy and policy priorities. As detailed in this brief, the CMA is gravely concerned that by capturing group medical structures in the application of Clause 13 of the Draft Tax Legislative Proposals, the federal government will inadvertently negatively affect medical research, medical training and education as well as access to care. To ensure that the unintended consequences of this federal tax policy change do not occur, the CMA is strongly recommending that the federal government exempt group medical and health care delivery from the proposed changes to s.125 of the Income Tax Act regarding multiplication of access to the small business deduction in Clause 13 of the Draft Tax Legislative Proposals. Relevance of the Canadian Controlled Private Corporation Framework to Medical Practice Canada’s physicians are highly skilled professionals, providing an important public service and making a significant contribution to our country’s knowledge economy. Due to the design of Canada’s health care system, a large majority of physicians – more than 90% – are self-employed professionals and effectively small business owners. As self-employed small business owners, physicians typically do not have access to pensions or health benefits, although they are responsible for these benefits for their employees. Access to the Canadian-Controlled Private Corporation (CCPC) framework and the Small Business Deduction (SBD) are integral to managing a medical practice in Canada. It is imperative to recognize that physicians cannot pass on any increased costs, such as changes to CCPC framework and access to the SBD, onto patients, as other businesses would do with clients. In light of the unique business perspectives of medical practice, the CMA strongly welcomed the federal recognition in the 2016 budget of the value that health care professionals deliver to communities across Canada as small business operators. Contrary to this recognition, the 2016 budget also introduced a proposal to alter eligibility to the small business deduction that will impact physicians incorporated in group medical structures. What’s at risk: Contribution of group medical structures to health care delivery The CMA estimates that approximately 10,000 to 15,000 physicians will be affected by this federal taxation proposal. If implemented, this federal taxation measure will negatively affect group medical structures in communities across Canada. By capturing group medical structures, this proposal also introduces an inequity amongst incorporated physicians, and incentivizes solo practice, which counters provincial and territorial health delivery priorities. Group medical structures are prevalent within academic health science centres and amongst certain specialties, notably oncology, anaesthesiology, radiology, and cardiology. Specialist care has become increasingly sub-specialized. For many specialties, it is now standard practice for this care to be provided by teams composed of numerous specialists, sub-specialists and allied health care providers. Team-based care is essential for educating and training medical students and residents in teaching hospitals, and for conducting medical research. Put simply, group medical structures have not been formed for taxation or commercial purposes. Rather, group medical structures were formed to deliver provincial and territorial health priorities, primarily in the academic health setting, such as teaching, medical research as well as optimizing the delivery of patient care. Over many years, and even decades, provincial and territorial governments have been supporting and encouraging the delivery of care through team-based models. To be clear, group medical structures were formed to meet health sector priorities; they were not formed for business purposes. It is equally important to recognize that group medical structures differ in purpose and function from similar corporate or partnership structures seen in other professions. Unlike most other professionals, physicians do not form these structures for the purpose of enhancing their ability to earn profit. It is critical for Finance Canada to acknowledge that altering eligibility to the small business deduction will have more significant taxation implication than simply the 4.5% difference in the small business versus general rate at the federal level. It would be disingenuous for Finance Canada to attempt to argue that removing full access to the small business deduction for incorporated physicians in group medical structures will be a minor taxation increase. As taxation policy experts, Finance Canada is aware that this change will impact provincial/territorial taxation, as demonstrated below in Table 1. Table 1: Taxation impacts by province/territory, if the federal taxation proposal is implemented In Nova Scotia, for example, approximately 60% of specialist physicians practice in group medical structures. If the federal government applies this taxation proposal to group medical structures, these physicians will face an immediate 17.5% increase in taxation. In doing so, the federal government will establish a strong incentive for these physicians to move away from team-based practice to solo practice. If this comes to pass, the federal government may be responsible for triggering a reorganization of medical practice in Nova Scotia. Excerpts from physician communiques The CMA has received as well as been copied on a significant volume of correspondence from across our membership conveying deep concern with the federal taxation proposal. To provide an illustration of the risks of this proposal to health care, below are excerpts from some of these communiques:
“Our Partnership was formed in the 1970s…The mission of the Partnership is to achieve excellence in patient care, education and research activities….there would be a serious adverse effect on retention and recruitment if members do not have access to the full small business deduction…The changes will likely result in pressure to dissolve the partnership and revert to the era of departments services by independent contractors with competing individual financial interests.” Submitted to the CMA April 15, 2016 from a member of the Anesthesia Associates of the Ottawa Hospital General Campus
“The University of Ottawa Heart Institute is an academic health care institution dedicated to patient care, research and medical education…To support what we call our “academic mission,” cardiologists at the institute have formed an academic partnership…If these [taxation] changes go forward they will crippled the ability of groups such as ours to continue to function and will have a dramatic negative impact on medical education, innovative health care research, and the provision of high-quality patient care to our sickest patients.” Submitted to the CMA April 19, 2016 from a member of the Associates in Cardiology
“We are a general partnership consisting of 93 partners all of whom are academic anesthesiologists with appointments to the Faculty of the University of Toronto and with clinical appointments at the University Health Network, Sinai Health System or Women’s College Hospital…In contrast to traditional business partnerships, we glean no business advantage whatsoever from being in a partnership…the proposed legislation in Budget 2016 seems unfair in that it will add another financial hardship to our partners – in our view, this is a regressive tax on research, teaching and innovation.” Submitted to the CMA April 14, 2016 from members of the UHN-MSH Anesthesia Associates Recommendation The CMA recommends that the federal government exempt group medical and health care delivery from the proposed changes to s.125 of the Income Tax Act regarding multiplication of access to the small business deduction, as proposed in Clause 13 of the Draft Tax Legislative Proposals. Below is a proposed legislative amendment to ensure group medical structures are exempted from Clause 13 of the Draft Tax Legislative Proposals: Section 125 of the Act is amended by adding the following after proposed subsection 125(9): 125(10) Interpretation of designated member – [group medical partnership] – For purposes of this section, in determining whether a Canadian-controlled private corporation controlled directly or indirectly in any manner whatever by one or more physicians or a person that does not deal at arm's length with a physician is a designated member of a particular partnership in a taxation year, the term "particular partnership" shall not include any partnership that is a group medical partnership. 125(11) Interpretation of specified corporate income – [group medical corporation] – For purposes of this section, in determining the specified corporate income for a taxation year of a corporation controlled directly or indirectly in any manner whatever by one or more physicians or a person that does not deal at arm's length with a physician, the term "private corporation" shall not include a group medical corporation. Subsection 125(7) of the Act is amended by adding the following in alphabetical order: "group medical partnership" means a partnership that: (a) is controlled, directly or indirectly in any manner whatever, by one or more physicians or a person that does not deal at arm's length with a physician; and (b) earns all or substantially all of its income for the year from an active business of providing services or property to, or in relation to, a medical practice; "group medical corporation" means a corporation that: (a) is controlled, directly or indirectly in any manner whatever, by one or more physicians or a person that does not deal at arm's length with a physician; and (b) earns all or substantially all of its income for the year from an active business of providing services or property to, or in relation to, a medical practice. "medical practice" means any practice and authorized acts of a physician as defined in provincial or territorial legislation or regulations and any activities in relation to, or incidental to, such practice and authorized acts; "physician" means a health care practitioner duly licensed with a provincial or territorial medical regulatory authority and actively engaged in practice;
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Best Practices and Federal Barriers: Practice and Training of Healthcare Professionals

https://policybase.cma.ca/en/permalink/policy11513
Date
2015-03-17
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2015-03-17
Topics
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) is pleased to present its brief to the House of Commons Standing Committee on Health for consideration as part of its study of "Best Practices and Federal Barriers: Practice and Training of Health Professionals". The subject under discussion is relevant to both parts of the CMA's mission. The CMA has undertaken considerable activity on the issue. For example, in 2012 and 2013 we participated, with the Canadian Nurses Association and the Health Action Lobby (HEAL) on the Council of the Federation's (CoF) working group on Team-based Care. For many years, the CMA has conducted the National Physician Survey, which develops comprehensive information on physician demographics and practice patterns. In the past decade a number of health professions have expanded their scopes of practice. In most provinces, for example, pharmacists can now renew prescriptions or provide emergency prescription refills. Ontario has established nurse-practitioner-led primary health care clinics which collaborate with family physicians and others in the community. Nova Scotia has experimented with using paramedics as first-contact primary caregivers in rural or remote areas. Governments expand scopes of practice for a number of possible reasons: cost-effectiveness (i.e. replacing one health professional with a less expensive one); improving access, particularly in areas underserviced by physicians; increasing convenience for patients (for example, allowing a neighbourhood pharmacist to give a flu shot may save the patient from taking time off work for a doctor's appointment): or responding to lobbying by health provider groups. The CMA believes that ideally, every health care provider should have a scope of practice that is consistent with his or her education and training, and that the health care system should enable them to practice to the fullest extent of this scope. More importantly, the scope of practice of every health professional should enable them to contribute optimally to providing high quality patient-centered care without compromising patient safety. Indeed, the primary reason for expanding the scope of practice of a health professional should be to improve Canadians' health and health care. In the following pages we will discuss several specific topics related to the Scope of Practice issue, and make recommendations for a possible federal role in supporting best practices among health professionals. 1. A Canada-Wide Approach to Scopes of Practice Scopes of practice are determined largely by provincial and territorial governments, and each jurisdiction has developed its own regulations regarding what health professional groups may do and under what circumstances. This has led to inconsistency across the country. For example, about half the jurisdictions in Canada allow pharmacists to order laboratory tests and prescribe for minor ailments; provinces vary in the degree to which they fund nurse practitioner positions; and there is wide variation in how, and even if, physician assistants are regulated. While recognizing that the authority to determine scopes of practice rests with provincial/territorial governments, CMA believes that it is desirable to work toward consistency in access to health services across Canada. Recommendation 1: that the federal government work with provincial/territorial governments and with health professional associations to promote a consistent national approach to scope-of-practice expansions 2. Promoting and Facilitating Team-Based Care The scopes-of-practice issue is closely related to the development of models for team-based care, a development that CMA supports. When Canadians seek health care today, it is mainly to help them maintain their health or to manage chronic diseases. This trend is expected to continue as the population ages and the rate of chronic disease rises correspondingly. For patients who have multiple chronic diseases or disabilities, care needs can be complex and a number of different health and social-services professionals may be providing care to the same person. A patient might, for example, be consulting a family physician for primary health care, several medical specialists for different conditions, a pharmacist to monitor a complex medication regime, a physiotherapist to help with mobility difficulties, health care aides to make sure the patient is eating properly or attending to personal hygiene, and a social worker to make sure his or her income is sufficient to cover health care and other needs. The complexity of today's health care requires that the system move away from the traditional "silo" method of delivering care and encourage health professionals to work collaboratively to effectively meet patients' needs. The CMA believes that the following factors contribute to the success of inter-professional care: Patient access to a primary care provider who is familiar with the patient's needs and preferences, and has responsibility for the overall care of the patient, co-ordinating the various providers involved in this care. For more than 30 million Canadians, that primary care provider is a family physician. The College of Family Physicians of Canada believes that family practices can serve as patient's "medical home," in which care is anchored and co-ordinated by a family physician, with access to other health care providers as required. Mechanisms that encourage collaboration and communication among providers. These include: o Interdisciplinary primary care practices, such as Family Health Networks in Ontario, which permit patients to access a variety of different health professionals and their expertise from one practice setting; Widespread use of the electronic health record, which can facilitate information sharing and communication among providers. A smooth, seamless process for referral from one provider to another. Role clarity and mutual trust. Each health professional on a care team should have a clear understanding of their own roles and the roles of other team members. The CoF's Team-Based Care Working Group investigated the critical factors for successful team based care, and identified models in certain provinces that it believed should be considered for rollout across Canada. This rollout could be enhanced if it were encouraged by all governments, including the Government of Canada. In the past, Health Canada has supported demonstration projects in health system reform through the National Primary Care Research Group. The CMA believes that the federal government could take a similar role in future, in supporting and disseminating promising models of inter-professional practice. The dissemination process should be accompanied by a process to rigorously evaluate the effect of such models on health outcomes, quality of patient care, and health care costs. Recommendation 2: that the Government of Canada support research into and evaluation of innovative models of team-based care, and actively promote the dissemination of successful models nationwide. Recommendation 3: that Canada Health Infoway work with provinces and territories to increase the adoption of electronic medical records at the point of care and build connectivity among points of care. 3. A Health-Care System That Supports Best Practices in Team-Based Care We have already discussed the part that governments could play in identifying, disseminating and evaluating models of inter-professional practice. The health care system's planners, funders and managers can also foster team-based care in other ways, such as: Promoting education in inter-professional care. As the Committee has heard, the Association of Faculties of Medicine of Canada's guiding principles for medical education include valuing inter-professionalism and incorporating it into residency learning and practice. CMA encourages the development of programs to help new physicians and other health professionals acquire the skills needed to function optimally an in inter-professional setting. Improving access to health services not funded under the Canada Health Act. At present, patients who do not have private health care coverage must pay out of pocket for physiotherapy, dietitian services, mental health care and most social services. This works against the principles of inter-professional care by hindering access to necessary services; this could compromise patient health and safety. Undertaking an open and meaningful consultation process when changes to scopes of practice are proposed. CMA's experience has been that physicians are more accepting of changes in other professions' scopes of practice if their medical associations have been involved in negotiation on these changes. Ensuring that the supply of health professionals in Canada is sufficient to the needs of Canadian patients, by developing, implementing and monitoring human resource plans for all major health professions. Recommendation 4: that the federal government work with provincial/territorial government and national health professional associations to develop and implement a health human resources plan that ensures Canadians' access to all appropriate health care providers. In conclusion, the Canadian Medical Association recognizes that the great majority of decisions regarding scopes of practice are made at the provincial/territorial level. But we believe that in order to encourage a Canadian health-care system in which all providers work together, contributing their unique skills and expertise to providing patient-centered, seamless, cost-effective care, the support and encouragement of the federal government will be extremely beneficial.
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Bill C-2 An Act to amend the Controlled Drugs and Substances Act (Respect for Communities Act)

https://policybase.cma.ca/en/permalink/policy11297
Date
2014-10-28
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2014-10-28
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association (CMA) provides this brief for consideration as part of House of Commons Standing Committee on Public Safety and National Security's study of Bill C-2, An Act to amend the Controlled Drugs and Substances Act (Respect for Communities Act).1 Prior to a discussion on CMA's position regarding the substance of Bill C-2, the CMA firstly recommends that legislation pertaining to harm reduction services requires study by parliamentary committees responsible for health or social matters in addition to public safety. Bill C-2 (formerly Bill C-65) is subsequent to the 2011 unanimous ruling of the Supreme Court of Canada2 that recognized the significant evidence on the benefits of Insite, Vancouver's supervised injection site. The Supreme Court ordered that the federal government grant the exemption for medical and scientific purposes to Insite. The ruling left decisions regarding future applications for exemptions to the Controlled Drugs and Substances Act (CDSA) for Insite and other potential supervised injection sites up to the discretion of the Minister of Health, with the provision that the Minister seek to strike the appropriate balance between the public health and public safety goals, and suggests the decision be based on five elements: "evidence, if any, on the impact of such a facility on crime rates, the local conditions indicating a need for such a supervised injection site, the regulatory structure in place to support the facility, the resources available to support its maintenance and expressions of community support or opposition." 3 In response, the Minister of Health proposed Bill C-2, which amends the CDSA to include section 56.1, and provides a federal regulatory framework for supervised consumption sites.* CMA is deeply concerned with the proposed legislation, as it has the potential to create unnecessary obstacles and burdens that would ultimately deter the creation of new supervised consumption sites, even in municipalities where the need and cost-effectiveness has been well researched and the health and safety benefits clearly established. Moreover, it does not strike the appropriate balance between public health and public safety, as is the spirit and intent of the Supreme Court of Canada ruling on Insite. This will make the renewal of exemptions for Insite, the very facility which the Supreme Court ruled "saves lives", very difficult. Public health approach to addiction Addiction should be recognized and treated as a serious, chronic and relapsing medical condition for which there are effective treatments. The CMA has long called for a comprehensive national drug strategy that addresses addiction, and includes prevention, treatment, harm reduction and enforcement components. Public health objectives in addressing addictions will vary depending upon the circumstances: preventing drug use in those who have not initiated use (e.g. pre-teens); avoiding use in circumstances associated with a risk of adverse outcomes (e.g. drug use and driving motor vehicle); assisting those who wish to stop using drugs (e.g. treatment, rehabilitation); and assisting those who continue to use drugs to do so in such a manner as to reduce the risk of adverse effects (e.g. needle distribution program). Despite drug use being primarily a health and social issue, the focus of the federal National Anti-Drug Strategy is heavily skewed towards a criminal justice approach, as evidenced by a recent evaluation.4 This approach does not address the determinants of drug use, treat addictions, or reduce the harms associated with drug use. Other models are more effective in achieving the desired objectives and more investments need to be made in prevention, harm reduction and treatment, keeping individuals out of the criminal justice system.5 Drug use is a complex issue, and collaboration among health and public safety professionals, and society at large, is essential. Harm reduction is part of health practice Harm reduction is not restricted to services for people who use drugs; it is an approach that is adopted routinely in every health and social program. For example, seat belts, air bags and helmets are encouraged and even mandated to reduce some of the possible harmful consequences of driving or cycling - regardless of who is at fault. Many medications do not cure diseases, and are essential to prevent complications. An example is the use of insulin by people with diabetes.6 There are many programs created to reduce the harms created by alcohol, a legal substance that contributes to a significant burden of disease, disability and deaths. Examples include low risk drinking guidelines, designated driver or alternate driver programs for drinkers, graduated licenses and changes in the hours of liquor stores to reduce the use of non-beverage alcohol.7 While the risk is still present, this approach reduces harms. Harm reduction related to psychoactive substances, "refers to policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families and the community".8 They are part of a comprehensive approach which also includes abstinence-based programs. The CMA fully supports harm reduction strategies as they aim to reduce mortality and morbidity even in the face of continued exposure to a potentially harmful substance. Addiction is an illness, and harm reduction is a clinically mandated and ethical method of care and treatment. Physicians must treat patients as a matter of good medical practice and ethical obligation, whether the patient is believed to contribute to his or her injury or not. Section 31 of CMA's Code of Ethics provides that all physicians must "recognize the responsibility of physicians to promote fair access to health care resources".9 Harm reduction information, services and interventions are respectful and non-judgmental, and have the purpose of promoting health and safety. These strategies were developed in response to critical situations and high costs to the health, social and criminal justice systems. Harm reduction approaches are evidence-based, cost effective and have a high impact on individual and community health. Such programs for injection drug users are now well established within every province and territory in Canada, in the form of needle and syringe distribution programs, methadone maintenance and the provision of sterilized equipment.10 Supervised Consumption Sites are evidence-based Supervised consumption sites, within a comprehensive drug strategy, are another example of a harm reduction program. They were developed to reduce the harms of Injection drug use, which are an increased incidence and prevalence of infectious diseases including HIV/AIDS, Hepatitis C, and skin- and blood-borne infections; frequent drug overdoses resulting in significant morbidity and mortality; and increased hospital and emergency service utilization. Many of these health problems are not due to the drugs themselves, but to the injection method and equipment. Supervised consumption sites are "specialized facilities that provide injection drug users with a clean, safe, unhurried environment. Sterile injection equipment is provided and health care and social service professionals are available to deal with health issues, provide counselling, and facilitate access to detoxification and treatment programs. Supervision is provided by health professionals trained in low-risk injection techniques and overdose intervention."11 The drugs are acquired elsewhere, and they are located in areas of concentrated and highly visible drug scenes. Such services have existed for many years in many countries, and there are over 90 sites operating in countries such as Australia, Germany, Luxembourg, the Netherlands, Norway, Spain and Switzerland.12 Clients of these sites have complex histories of trauma, mental illness and drug use, and live at the margins of society, unreached by traditional health and social services. Supervised consumption sites are developed as low threshold services for hard-to-reach populations which are experiencing unacceptable levels of deaths and diseases. Existing outreach and treatment programs are insufficient to meet the needs of this population, and these sites are a point of entry into health and social services. Insite, the first supervised injection site in North America, operates in Vancouver's downtown east side as part of the 'four pillars' drug strategy: prevention, treatment, harm reduction, and enforcement.13 14 In 2012, Insite had an average of 1028 visits per day. There were 497 overdose incidents with no fatalities and 3418 clinical treatment interventions. Insite staff made 4564 referrals for further health care, housing and social supports, and the vast majority was for detox and addiction treatment.15 Insite has been one of the most researched public health interventions to date.16 Research was conducted by the BC Centre for Excellence on HIV/AIDS, funded partially by Health Canada, and there are over 30 publications in leading peer-reviewed scientific and medical journals.17 18The evidence shows that there has been: * A reduction in the overall rate of needle sharing in the area;19 * A reduction in deaths due to overdose in the area, with no overdose deaths in the facility;20 21 * Increased access to addiction counseling and increased enrolment in detox programs;22 23 * Opportunities for HIV prevention through education, and increased links between patients and HIV treatment and services;24 * Improvements in measures of public order including reduced public drug injections and publicly discarded syringes;25 and * No increase in levels of drug dealing or other drug related crime in the area in which the facility is located. 26 * Cost savings to health and social systems, reducing risks of infectious diseases, intervening early when there are issues, and reducing the need for emergency care.27 28 Reports from other countries show similar results.29 30 However, "research evidence, even if it meets rigorous academic standards, might be insufficient to sway opinions among those who hold a firm view of addiction as a moral failure."31 Assertions that supervised consumption sites will not reduce disease transmission, exacerbate crime, encourage drug use, have destructive effects on local businesses and residents are not based on evidence. Physicians believe that medical decisions must be based on evidence, not ideology or public opinion, and the evidence shows that supervised injection reduces the spread of infectious diseases, decreases the incidence of overdose and death and increases access to much needed services, without increasing problems with public safety. Significantly, the Court accepted the evidence that "Insite has saved lives and improved health without increasing the incidence of drug use and crime in the surrounding area."32 It also stated that Insite is supported by the Vancouver police, the city and provincial governments. Supervised consumption rooms aim to address problems of specific, high-risk populations of people who use drugs, particularly those who consume in public and other high risk situations. They seek to meet the needs of those who use drugs, but also of the communities that are struggling with a crisis situation. The CMA has the following concerns with Bill C-2: 1. Bill C-2 does not strike a balance between the public health and public safety goals of the CDSA. As written, Bill C-2 disregards the strong evidence of important positive impacts on public health and public safety and giving undue emphasis on public opinion, which might not be fully informed or experienced. Although public opinion might initially be against the introduction of such facilities, public acceptance of supervised consumption sites is considerably high in most of the locations where they have been established, in both Vancouver sites (Insite and the Dr Peter Centre) and in European countries. "Health problems have been reduced, and law and order have been improved. Communities, neighbourhoods and local authorities are usually involved in the good functioning of the facilities through cooperation and communication."33 The Supreme Court states that there has been "no discernible negative impact on the public safety and health objectives of Canada during its [Insite's] eight years of operation." 2. Bill C-2 contradicts the spirit and intent of the unanimous decision of the 2011 Supreme Court of Canada regarding Insite which states that "the potential denial of health services and the correlative increase in the risk of death and disease to injection drug users outweigh any benefit that might be derived from maintaining an absolute prohibition on possession of illegal drugs".34 Bill C-2 does not acknowledge the extensive evidence that exists regarding supervised consumption sites both internationally and in Canada, as discussed previously. Passing Bill C-2 in its current form could potentially prevent the renewal of the exemption to Section 56 of the CDSA for Insite. A likely consequence will be further costly litigation. 3. Bill C-2 would impose multiple and significant barriers that providers of health services to obtain an exemption to section 56 of the CDSA. From five criteria in the Supreme Court decision concerning Insite, Bill C-2 lists 27 requirements (Section 56(1)(3)), which include demographic and scientific data, letters of opinions from representatives of local police and local and provincial governments, information about proposed staff, descriptions of planned procedures and reports from community consultations. Such evidence could require extensive resources and funding by local public health units and community agencies. Some of the data required may only be available in the context of a research project. The data is not only influenced by the existence or not of a supervised consumption site, but by many other factors, such as poverty, enforcement resources and others. Community opinion of supervised consumption sites can also change to be significantly positive after experiencing months of its operation. Finally, Bill C-2 does not address how the Minister is to weigh the information submitted, to guarantee impartiality, or even if he or she must consider an application. Even after meeting all those requirements, the Minister has the sole discretion to decide whether a site can open, and the preamble states that exemptions will only be granted in "exceptional circumstances". 4. Bill C-2 did not involve consultation with provincial and territorial ministries of health, community agencies and professional associations, such as the CMA. Public health authorities and particularly health professionals, who work with people with addictions on a daily basis, recognize the dire need for complementary approaches to substance use that address different needs. The exemption to section 56 is for medical purposes, and public health agencies have the competency to determine when there is a need. It is the CMA's ultimate position that Bill C-2, the Respect for Communities Act must be withdrawn, and that it be replaced with legislation that recognizes the unequivocal evidence of benefits of supervised consumption sites, that was accepted by the Supreme Court. Legislation would enhance access to health services, which include prevention, harm reduction and treatment services in communities where the evidence has shown they would benefit from such health services. * "Supervised consumption site" is the term used in Bill C-2, section 56.1, and defined as "a location specified in the terms and conditions of an exemption, granted by the Minister under subsection (2) for a medical purpose, that allows any person or class of persons described in the exemption to engage in certain activities in relation to an illicit substance within a supervised and controlled environment." The Supreme Court of Canada and other documents use terms such as "supervised injection site" "supervised injection services", "drug consumption rooms" or "safer injection site". In the literature, supervised consumption sites could also include supervised inhalation services. 1 Bill C-2: An Act to amend the Controlled Drugs and Substances Act. 2nd Session, 41st Parliament. Retrieved from: http://www.parl.gc.ca/HousePublications/Publication.aspx?Language=E&Mode=1&DocId=6256959&File=4 2 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. Retrieved from: http://scc-csc.lexum.com/scc-csc/scc-csc/en/item/7960/index.do 3 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. supra. p.192-3 4 Department of Justice (2013) National Anti-Drug Strategy Evaluation. Retrieved from: http://www.justice.gc.ca/eng/rp-pr/cp-pm/eval/rep-rap/12/nas-sna/p1.html#sec23 5 Day, Brian (2008) "Ottawa's bad prescription on addiction." Toronto Star, Sunday June 8, 2008. Retrieved from: http://www.thestar.com/comment/article/438967 6 Canadian Centre on Substance Abuse (2008) Harm reduction: what's in a name? Retrieved from: http://www.ccsa.ca/Resource%20Library/ccsa0115302008e.pdf 7 National Alcohol Strategy Working Group (2007) Reducing Alcohol-Related Harm in Canada: toward a culture of moderation. Recommendations for a National Alcohol Strategy. Retrieved from: http://ccsa.ca/Resource%20Library/ccsa-023876-2007.pdf 8 International Harm Reduction Association (2010) Harm Reduction: A position statement from the International Harm Reduction Association. IHRA Briefing. Retrieved from: http://www.ihra.net/files/2010/08/10/Briefing_What_is_HR_English.pdf 9 Canadian Medical Association (2010) Factum of the Intervener. Supreme Court of Canada (Appeal from the British Columbia Court of Appeal) between the Attorney General of Canada and Minister of Health for Canada and PHS Community Services Society, Dean Edward Wilson and Shelly Tomic, Vancouver Area Network of Drug Users. Retrieved from: https://www.cma.ca/Assets/assets-library/document/en/advocacy/CMA-Factum_filed14April2011.pdf 10 Canadian Centre on Substance Abuse (2008) Harm reduction: what's in a name? Retrieved from: http://www.ccsa.ca/Resource%20Library/ccsa0115302008e.pdf 11 Canadian Centre on Substance Abuse (2008) Harm reduction: what's in a name? Retrieved from: http://www.ccsa.ca/Resource%20Library/ccsa0115302008e.pdf 12 Schatz, E. & Nougier, M. (2012) Drug consumption rooms: evidence and practice. International Drug Policy Consortium Briefing Paper. Retrieved from: http://www.drugsandalcohol.ie/17898/1/IDPC-Briefing-Paper_Drug-consumption-rooms.pdf 13 City of Vancouver Four Pillars Drug Strategy (2008) Limiting the harms of drug use. Retrieved from: http://vancouver.ca/fourpillars/harmReduction/limitHarmDrugUse.htm 14 Vancouver Coastal Health. Supervised Injection Site (N.D.) Services. Accessed September 19, 2014 at: http://supervisedinjection.vch.ca/services/services 15 Vancouver Coastal Health. Supervised Injection Site (N.D.). Accessed September 19, 2014 at: http://supervisedinjection.vch.ca/research/supporting_research/user_statistics 16 Urban Health Research Initiative (2010). Insight into Insite. Retrieved from: http://www.cfenet.ubc.ca/sites/default/files/uploads/publications/insight_into_insite.pdf 17 Health Canada. Vancouver's Insite service and other supervised injection sites: what has been learned from Research? Final Report of the Expert Advisory Committee. Ottawa: Health Canada, 2008. Prepared for the Hon. Tony Clement, Minister of Health, Government of Canada. Retrieved from: http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php 18 Wood, E. et al. (2006) Summary of findings from the evaluation of a pilot medically supervised safer injecting facility. Canadian Medical Association J, 175(11): 1399-1404. 19 Kerr, T. et al. (2005) Safer injection facility use and syringe sharing in injection drug users. The Lancet 366: 316-18. 20 Milloy M.J., Kerr, T., Tyndall, M., Montaner, J., & Wood E. (2008) Estimated drug overdose deaths averted by North America's first medically-supervised safer injection facility. PLoS ONE 3(10):e3351. 21 Marshall B. D. L., Milloy, M.-J., Wood, E., Montaner, J. S. G., & Kerr, T. (2011). Reduction in overdose mortality after the opening of North America's first medically supervised safer injecting facility: A retrospective population-based study. Lancet. Published online April 18, 2011. doi: 10.1016/S0140-6736(10)62353-7. 22 Wood, E. et al. (2007) Rate of detoxification service use and its impact among a cohort of supervised injecting facility users. Addiction 102: 916-919. 23 Tyndall, M.W. et al. (2005) Attendance, drug use patterns, and referrals made from North America's first supervised injection facility. Drug and Alcohol Dependence. 24 Tyndall, M.W. et al. (2006) HIV seroprevalence among participants at a medically supervised injection facility in Vancouver Canada: Implications for prevention, care and treatment. Harm Reduction J 3:36. 25 Wood, E. et al. (2004) "Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users." Canadian Medical Association J 171(7): 731-34. 26 Health Canada. Vancouver's Insite service and other supervised injection sites: what has been learned from Research? Final Report of the Expert Advisory Committee. Ottawa: Health Canada, 2008. Prepared for the Hon. Tony Clement, Minister of Health, Government of Canada. Retrieved from: http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php 27 Andresen, M.A. & Boyd, N. (2010) A cost-benefit and cost-effectiveness analysis of Vancouver's supervised injection facility. Int.J.DrugPolicy 21(1): 70-76. 28 Pinkerton, S.D. (2010) Is Vancouver Canada's supervised injection facility cost-saving? Addiction 105(8): 1429-36. 29 Schatz, E. & Nougier, M. (2012) Drug consumption rooms: evidence and practice. International Drug Policy Consortium Briefing Paper. 30 Hedrich, D. (2004) European report on drug consumption rooms. Report prepared for the European Monitoring Centre on Drugs and Drug Addiction. 31 Watson, T.M. et al. (2012) Police Perceptions of Supervised Consumption Sites (SCSs): A Qualitative Study. Substance Use & Misuse, 47:364-374. 32 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. supra. p. 136 33 Schatz, E. & Nougier, M. (2012) Drug consumption rooms: evidence and practice. International Drug Policy Consortium Briefing Paper. (p.20) 34 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. supra (p.188).
Documents
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Bill C-2 An Act to amend the Controlled Drugs and Substances Act (Respect for Communities Act)

https://policybase.cma.ca/en/permalink/policy11519
Date
2015-05-14
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2015-05-14
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Bill C-2 An Act to amend the Controlled Drugs and Substances Act (Respect for Communities Act) Canadian Medical Association Submission to the Senate Standing Committee on Legal and Constitutional Affairs On behalf of its more than 82,000 members and the Canadian public, CMA performs a wide variety of functions. Key functions include advocating for health promotion and disease prevention policies and strategies, advocating for access to quality health care, facilitating change within the medical profession, and providing leadership and guidance to physicians to help them influence, manage and adapt to changes in health care delivery. The CMA is a voluntary professional organization representing the majority of Canada's physicians and comprising 12 provincial and territorial divisions and 51 national medical organizations. The Canadian Medical Association (CMA) provides this brief for consideration as part of the Senate Standing Committee on Legal and Constitutional Affairs study of Bill C-2, An Act to amend the Controlled Drugs and Substances Act (Respect for Communities Act).1 Bill C-2 (formerly Bill C-65) is subsequent to the 2011 unanimous ruling of the Supreme Court of Canada2 that recognized the significant evidence on the benefits of Insite, Vancouver's supervised injection site. The Supreme Court ordered that the federal government grant the exemption for medical and scientific purposes to Insite. The ruling left decisions regarding future applications for exemptions to the Controlled Drugs and Substances Act (CDSA) for Insite and other potential supervised injection sites up to the discretion of the Minister of Health, with the provision that the Minister seek to strike the appropriate balance between the public health and public safety goals, and suggests the decision be based on five elements: "evidence, if any, on the impact of such a facility on crime rates, the local conditions indicating a need for such a supervised injection site, the regulatory structure in place to support the facility, the resources available to support its maintenance and expressions of community support or opposition." 3 In response, the Minister of Health proposed Bill C-2, which amends the CDSA to include section 56.1, and provides a federal regulatory framework for supervised consumption sites.* CMA is deeply concerned with the proposed legislation, as it has the potential to create unnecessary obstacles and burdens that would ultimately deter the creation of new supervised consumption sites, even in municipalities where the need and cost-effectiveness has been well researched and the health and safety benefits clearly established. Moreover, it does not strike the appropriate balance between public health and public safety, as is the spirit and intent of the Supreme Court of Canada ruling on Insite. This will make the renewal of exemptions for Insite, the very facility which the Supreme Court ruled "saves lives", very difficult. Public health approach to addiction Addiction should be recognized and treated as a serious, chronic and relapsing medical condition for which there are effective treatments. The CMA has long called for a comprehensive national drug strategy that addresses addiction, and includes prevention, treatment, harm reduction and enforcement components. Public health objectives in addressing addictions will vary depending upon the circumstances: preventing drug use in those who have not initiated use (e.g. pre-teens); avoiding use in circumstances associated with a risk of adverse outcomes (e.g. drug use and driving motor vehicle); assisting those who wish to stop using drugs (e.g. treatment, rehabilitation); and assisting those who continue to use drugs to do so in such a manner as to reduce the risk of adverse effects (e.g. needle distribution program). Despite drug use being primarily a health and social issue, the focus of the federal National Anti-Drug Strategy is heavily skewed towards a criminal justice approach, as evidenced by a recent evaluation.4 This approach does not address the determinants of drug use, treat addictions, or reduce the harms associated with drug use. Other models are more effective in achieving the desired objectives and more investments need to be made in prevention, harm reduction and treatment, keeping individuals out of the criminal justice system.5 Drug use is a complex issue, and collaboration among health and public safety professionals, and society at large, is essential. Harm reduction is part of health practice Harm reduction is not restricted to services for people who use drugs; it is an approach that is adopted routinely in every health and social program. For example, seat belts, air bags and helmets are encouraged and even mandated to reduce some of the possible harmful consequences of driving or cycling - regardless of who is at fault. Many medications do not cure diseases, and are essential to prevent complications. An example is the use of insulin by people with diabetes.6 There are many programs created to reduce the harms created by alcohol, a legal substance that contributes to a significant burden of disease, disability and deaths. Examples include low risk drinking guidelines, designated driver or alternate driver programs for drinkers, graduated licenses and changes in the hours of liquor stores to reduce the use of non-beverage alcohol.7 While the risk is still present, this approach reduces harms. Harm reduction related to psychoactive substances, "refers to policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families and the community".8 They are part of a comprehensive approach which also includes abstinence-based programs. The CMA fully supports harm reduction strategies as they aim to reduce mortality and morbidity even in the face of continued exposure to a potentially harmful substance. Addiction is an illness, and harm reduction is a clinically mandated and ethical method of care and treatment. Physicians must treat patients as a matter of good medical practice and ethical obligation, whether the patient is believed to contribute to his or her injury or not. Section 31 of CMA's Code of Ethics provides that all physicians must "recognize the responsibility of physicians to promote fair access to health care resources".9 Harm reduction information, services and interventions are respectful and non-judgmental, and have the purpose of promoting health and safety. These strategies were developed in response to critical situations and high costs to the health, social and criminal justice systems. Harm reduction approaches are evidence-based, cost effective and have a high impact on individual and community health. Such programs for injection drug users are now well established within every province and territory in Canada, in the form of needle and syringe distribution programs, methadone maintenance and the provision of sterilized equipment.10 Supervised Consumption Sites are evidence-based Supervised consumption sites, within a comprehensive drug strategy, are another example of a harm reduction program. They were developed to reduce the harms of Injection drug use, which are an increased incidence and prevalence of infectious diseases including HIV/AIDS, Hepatitis C, and skin- and blood-borne infections; frequent drug overdoses resulting in significant morbidity and mortality; and increased hospital and emergency service utilization. Many of these health problems are not due to the drugs themselves, but to the injection method and equipment. Supervised consumption sites are "specialized facilities that provide injection drug users with a clean, safe, unhurried environment. Sterile injection equipment is provided and health care and social service professionals are available to deal with health issues, provide counselling, and facilitate access to detoxification and treatment programs. Supervision is provided by health professionals trained in low-risk injection techniques and overdose intervention."11 The drugs are acquired elsewhere, and they are located in areas of concentrated and highly visible drug scenes. Such services have existed for many years in many countries, and there are over 90 sites operating in countries such as Australia, Germany, Luxembourg, the Netherlands, Norway, Spain and Switzerland.12 Clients of these sites have complex histories of trauma, mental illness and drug use, and live at the margins of society, unreached by traditional health and social services. Supervised consumption sites are developed as low threshold services for hard-to-reach populations which are experiencing unacceptable levels of deaths and diseases. Existing outreach and treatment programs are insufficient to meet the needs of this population, and these sites are a point of entry into health and social services. Insite, the first supervised injection site in North America, operates in Vancouver's downtown east side as part of the 'four pillars' drug strategy: prevention, treatment, harm reduction, and enforcement.13 14 In 2012, Insite had an average of 1028 visits per day. There were 497 overdose incidents with no fatalities and 3418 clinical treatment interventions. Insite staff made 4564 referrals for further health care, housing and social supports, and the vast majority was for detox and addiction treatment.15 Insite has been one of the most researched public health interventions to date.16 Research was conducted by the BC Centre for Excellence on HIV/AIDS, funded partially by Health Canada, and there are over 30 publications in leading peer-reviewed scientific and medical journals.17 18The evidence shows that there has been: * A reduction in the overall rate of needle sharing in the area;19 * A reduction in deaths due to overdose in the area, with no overdose deaths in the facility;20 21 * Increased access to addiction counseling and increased enrolment in detox programs;22 23 * Opportunities for HIV prevention through education, and increased links between patients and HIV treatment and services;24 * Improvements in measures of public order including reduced public drug injections and publicly discarded syringes;25 and * No increase in levels of drug dealing or other drug related crime in the area in which the facility is located. 26 * Cost savings to health and social systems, reducing risks of infectious diseases, intervening early when there are issues, and reducing the need for emergency care.27 28 Reports from other countries show similar results.29 30 However, "research evidence, even if it meets rigorous academic standards, might be insufficient to sway opinions among those who hold a firm view of addiction as a moral failure."31 Assertions that supervised consumption sites will not reduce disease transmission, exacerbate crime, encourage drug use, have destructive effects on local businesses and residents are not based on evidence. Physicians believe that medical decisions must be based on evidence, not ideology or public opinion, and the evidence shows that supervised injection reduces the spread of infectious diseases, decreases the incidence of overdose and death and increases access to much needed services, without increasing problems with public safety. Significantly, the Court accepted the evidence that "Insite has saved lives and improved health without increasing the incidence of drug use and crime in the surrounding area."32 It also stated that Insite is supported by the Vancouver police, the city and provincial governments. Supervised consumption rooms aim to address problems of specific, high-risk populations of people who use drugs, particularly those who consume in public and other high risk situations. They seek to meet the needs of those who use drugs, but also of the communities that are struggling with a crisis situation. The CMA has the following concerns with Bill C-2: 1. Bill C-2 does not strike a balance between the public health and public safety goals of the CDSA. As written, Bill C-2 disregards the strong evidence of important positive impacts on public health and public safety and giving undue emphasis on public opinion, which might not be fully informed or experienced. Although public opinion might initially be against the introduction of such facilities, public acceptance of supervised consumption sites is considerably high in most of the locations where they have been established, in both Vancouver sites (Insite and the Dr Peter Centre) and in European countries. "Health problems have been reduced, and law and order have been improved. Communities, neighbourhoods and local authorities are usually involved in the good functioning of the facilities through cooperation and communication."33 The Supreme Court states that there has been "no discernible negative impact on the public safety and health objectives of Canada during its [Insite's] eight years of operation." 2. Bill C-2 contradicts the spirit and intent of the unanimous decision of the 2011 Supreme Court of Canada regarding Insite which states that "the potential denial of health services and the correlative increase in the risk of death and disease to injection drug users outweigh any benefit that might be derived from maintaining an absolute prohibition on possession of illegal drugs".34 Bill C-2 does not acknowledge the extensive evidence that exists regarding supervised consumption sites both internationally and in Canada, as discussed previously. Passing Bill C-2 in its current form could potentially prevent the renewal of the exemption to Section 56 of the CDSA for Insite. A likely consequence will be further costly litigation. 3. Bill C-2 would impose multiple and significant barriers that providers of health services to obtain an exemption to section 56 of the CDSA. From five criteria in the Supreme Court decision concerning Insite, Bill C-2 lists 27 requirements (Section 56(1)(3)), which include demographic and scientific data, letters of opinions from representatives of local police and local and provincial governments, information about proposed staff, descriptions of planned procedures and reports from community consultations. Such evidence could require extensive resources and funding by local public health units and community agencies. Some of the data required may only be available in the context of a research project. The data is not only influenced by the existence or not of a supervised consumption site, but by many other factors, such as poverty, enforcement resources and others. Community opinion of supervised consumption sites can also change to be significantly positive after experiencing months of its operation. Finally, Bill C-2 does not address how the Minister is to weigh the information submitted, to guarantee impartiality, or even if he or she must consider an application. Even after meeting all those requirements, the Minister has the sole discretion to decide whether a site can open, and the preamble states that exemptions will only be granted in "exceptional circumstances". 4. Bill C-2 did not involve consultation with provincial and territorial ministries of health, community agencies and professional associations, such as the CMA. Public health authorities and particularly health professionals, who work with people with addictions on a daily basis, recognize the dire need for complementary approaches to substance use that address different needs. The exemption to section 56 is for medical purposes, and public health agencies have the competency to determine when there is a need. It is the CMA's ultimate position that Bill C-2, the Respect for Communities Act must be withdrawn, and that it be replaced with legislation that recognizes the unequivocal evidence of benefits of supervised consumption sites, that was accepted by the Supreme Court. Legislation would enhance access to health services, which include prevention, harm reduction and treatment services in communities where the evidence has shown they would benefit from such health services. * "Supervised consumption site" is the term used in Bill C-2, section 56.1, and defined as "a location specified in the terms and conditions of an exemption, granted by the Minister under subsection (2) for a medical purpose, that allows any person or class of persons described in the exemption to engage in certain activities in relation to an illicit substance within a supervised and controlled environment." The Supreme Court of Canada and other documents use terms such as "supervised injection site" "supervised injection services", "drug consumption rooms" or "safer injection site". In the literature, supervised consumption sites could also include supervised inhalation services. 1 Bill C-2: An Act to amend the Controlled Drugs and Substances Act. 2nd Session, 41st Parliament. Retrieved from: http://www.parl.gc.ca/HousePublications/Publication.aspx?Language=E&Mode=1&DocId=6256959&File=4 2 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. Retrieved from: http://scc-csc.lexum.com/scc-csc/scc-csc/en/item/7960/index.do 3 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. supra. p.192-3 4 Department of Justice (2013) National Anti-Drug Strategy Evaluation. Retrieved from: http://www.justice.gc.ca/eng/rp-pr/cp-pm/eval/rep-rap/12/nas-sna/p1.html#sec23 5 Day, Brian (2008) "Ottawa's bad prescription on addiction." Toronto Star, Sunday June 8, 2008. Retrieved from: http://www.thestar.com/comment/article/438967 6 Canadian Centre on Substance Abuse (2008) Harm reduction: what's in a name? Retrieved from: http://www.ccsa.ca/Resource%20Library/ccsa0115302008e.pdf 7 National Alcohol Strategy Working Group (2007) Reducing Alcohol-Related Harm in Canada: toward a culture of moderation. Recommendations for a National Alcohol Strategy. Retrieved from: http://ccsa.ca/Resource%20Library/ccsa-023876-2007.pdf 8 International Harm Reduction Association (2010) Harm Reduction: A position statement from the International Harm Reduction Association. IHRA Briefing. Retrieved from: http://www.ihra.net/files/2010/08/10/Briefing_What_is_HR_English.pdf 9 Canadian Medical Association (2010) Factum of the Intervener. Supreme Court of Canada (Appeal from the British Columbia Court of Appeal) between the Attorney General of Canada and Minister of Health for Canada and PHS Community Services Society, Dean Edward Wilson and Shelly Tomic, Vancouver Area Network of Drug Users. Retrieved from: https://www.cma.ca/Assets/assets-library/document/en/advocacy/CMA-Factum_filed14April2011.pdf 10 Canadian Centre on Substance Abuse (2008) Harm reduction: what's in a name? Retrieved from: http://www.ccsa.ca/Resource%20Library/ccsa0115302008e.pdf 11 Canadian Centre on Substance Abuse (2008) Harm reduction: what's in a name? Retrieved from: http://www.ccsa.ca/Resource%20Library/ccsa0115302008e.pdf 12 Schatz, E. & Nougier, M. (2012) Drug consumption rooms: evidence and practice. International Drug Policy Consortium Briefing Paper. Retrieved from: http://www.drugsandalcohol.ie/17898/1/IDPC-Briefing-Paper_Drug-consumption-rooms.pdf 13 City of Vancouver Four Pillars Drug Strategy (2008) Limiting the harms of drug use. Retrieved from: http://vancouver.ca/fourpillars/harmReduction/limitHarmDrugUse.htm 14 Vancouver Coastal Health. Supervised Injection Site (N.D.) Services. Accessed September 19, 2014 at: http://supervisedinjection.vch.ca/services/services 15 Vancouver Coastal Health. Supervised Injection Site (N.D.). Accessed September 19, 2014 at: http://supervisedinjection.vch.ca/research/supporting_research/user_statistics 16 Urban Health Research Initiative (2010). Insight into Insite. Retrieved from: http://www.cfenet.ubc.ca/sites/default/files/uploads/publications/insight_into_insite.pdf 17 Health Canada. Vancouver's Insite service and other supervised injection sites: what has been learned from Research? Final Report of the Expert Advisory Committee. Ottawa: Health Canada, 2008. Prepared for the Hon. Tony Clement, Minister of Health, Government of Canada. Retrieved from: http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php 18 Wood, E. et al. (2006) Summary of findings from the evaluation of a pilot medically supervised safer injecting facility. Canadian Medical Association J, 175(11): 1399-1404. 19 Kerr, T. et al. (2005) Safer injection facility use and syringe sharing in injection drug users. The Lancet 366: 316-18. 20 Milloy M.J., Kerr, T., Tyndall, M., Montaner, J., & Wood E. (2008) Estimated drug overdose deaths averted by North America's first medically-supervised safer injection facility. PLoS ONE 3(10):e3351. 21 Marshall B. D. L., Milloy, M.-J., Wood, E., Montaner, J. S. G., & Kerr, T. (2011). Reduction in overdose mortality after the opening of North America's first medically supervised safer injecting facility: A retrospective population-based study. Lancet. Published online April 18, 2011. doi: 10.1016/S0140-6736(10)62353-7. 22 Wood, E. et al. (2007) Rate of detoxification service use and its impact among a cohort of supervised injecting facility users. Addiction 102: 916-919. 23 Tyndall, M.W. et al. (2005) Attendance, drug use patterns, and referrals made from North America's first supervised injection facility. Drug and Alcohol Dependence. 24 Tyndall, M.W. et al. (2006) HIV seroprevalence among participants at a medically supervised injection facility in Vancouver Canada: Implications for prevention, care and treatment. Harm Reduction J 3:36. 25 Wood, E. et al. (2004) "Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users." Canadian Medical Association J 171(7): 731-34. 26 Health Canada. Vancouver's Insite service and other supervised injection sites: what has been learned from Research? Final Report of the Expert Advisory Committee. Ottawa: Health Canada, 2008. Prepared for the Hon. Tony Clement, Minister of Health, Government of Canada. Retrieved from: http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php 27 Andresen, M.A. & Boyd, N. (2010) A cost-benefit and cost-effectiveness analysis of Vancouver's supervised injection facility. Int.J.DrugPolicy 21(1): 70-76. 28 Pinkerton, S.D. (2010) Is Vancouver Canada's supervised injection facility cost-saving? Addiction 105(8): 1429-36. 29 Schatz, E. & Nougier, M. (2012) Drug consumption rooms: evidence and practice. International Drug Policy Consortium Briefing Paper. 30 Hedrich, D. (2004) European report on drug consumption rooms. Report prepared for the European Monitoring Centre on Drugs and Drug Addiction. 31 Watson, T.M. et al. (2012) Police Perceptions of Supervised Consumption Sites (SCSs): A Qualitative Study. Substance Use & Misuse, 47:364-374. 32 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. supra. p. 136 33 Schatz, E. & Nougier, M. (2012) Drug consumption rooms: evidence and practice. International Drug Policy Consortium Briefing Paper. (p.20) 34 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. supra (p.188).
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Bill C-12: An Act to prevent the introduction and spread of communicable disease : CMA’s Submission to the House of Commons Standing Committee on Health

https://policybase.cma.ca/en/permalink/policy1948
Last Reviewed
2012-03-03
Date
2004-11-23
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2012-03-03
Date
2004-11-23
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) appreciates the opportunity to appear before the House of Commons Standing Committee on Health to provide our observations concerning Bill C-12, an Act to prevent the introduction and spread of communicable disease, which will repeal and replace the current Quarantine Act. Since our founding in 1867, the CMA has had a long tradition in the field of public health and infectious diseases. For example, in 1885 we worked with the federal government to prevent an outbreak of cholera in Canada, while in 1891 we began a long campaign to encourage governments to deal with tuberculosis. And fast forward to 2003 and SARS, CMA worked along with many levels of government to deal with this public health crisis. While the CMA is particularly interested in how the proposed legislation will impact the practices of our more than 58,000 members across the country, we have reviewed this legislation through the lens of what is in the best interest of patients and the public. 1) Comprehensive Approach to Public Health Our comments call for and are embedded in the broader context of a comprehensive approach to public health. They are also based on previous recommendations CMA has made to the federal government including: a) Response to the Health Protection Legislative Renewal initiative carried out by Health Canada (2004). In this submission, CMA identified the Quarantine Act as a piece of legislation the CMA believed merited urgent updating; b) Review of the World Health Organizations’ draft revised International Health Regulations (IHR), (2004); c) Submission to the Naylor Advisory Committee on SARS and Public Health (2003); d) Submission to the Senate Standing Committee on Social Affairs, Science and Technology during its study of public health issues (2003); and e) Pre-budget submission to the House of Commons Standing Committee on Finance following September 11, 2001. These submissions are all available on request, or at www.cma.ca. The CMA is pleased that Parliament has identified revision of the Quarantine Act as a priority. The Act is more than a century old and the medical community and others have long called for it to be updated. Bill C-12 is an excellent start to modernizing the previous Act; however, we believe the proposed legislation does not go far enough in remedying its deficiencies. In this submission we present eight key recommendations for your consideration, along with questions about particulars in the implementation process, which we suggest Parliament address in subsequent review of the Act and its regulations. 2) Recommendations for Consideration in Review of Bill C-12 Recommendation 1: The Act should be part of a larger, comprehensive Emergency Health Measures Plan. In our brief to the Naylor Advisory Committee, CMA recommended the enactment of a comprehensive Emergency Health Measures Act, administered by the Chief Public Health Officer of Canada. This Act would consolidate and enhance existing legislation, allowing for a more rapid national response to health emergencies, in cooperation with the provinces and territories, based on a graduated, systematic approach. We also recommended that the Emergency Health Measures Act be part of a strong commitment, by all levels of government, to a public health strategy that also included a 5-year capacity enhancement program, development of research and surveillance capability; and funding for a communications initiative to improve technical capacity for real-time communication with front-line health providers during public health emergencies. Recommendation 2: The Chief Public Health Officer of Canada must have authority to enforce the Act The proposed legislation designates the Minister of Health as the person with ultimate responsibility for enforcing the Act; it grants the Minister sweeping powers including the power to overrule a health official’s quarantine. As medical professionals we believe that public health decisions should be made primarily on the basis of the best available medical and scientific evidence, and should be independent to the greatest extent possible of other considerations. Therefore we believe that responsibility for the implementation of the Act should rest with the Public Health Agency of Canada, and with the Chief Public Health Officer of Canada, not with the Minister of Health. In the provinces and territories, Medical Officers of Health do not require approvals from their Ministers to exercise their functions as health professionals; the same should hold true at the federal level. We understand that responsibility has been placed with the Minister of Health due to a lack of existing legislation setting out the mandate, roles, responsibilities and powers of the recently created Public Health Agency of Canada, and the newly appointed Chief Public Health Officer of Canada. We are also aware that enabling legislation is currently being prepared; we urge that this legislation be enacted as soon as possible. On enactment of this enabling legislation, the powers now vested in the Minister should be ceded to the Chief Public Health Officer. Locating responsibility for administration of the Act within the Public Health Agency of Canada will also combine enforcement with other needed functions of surveillance, monitoring and linkage with international monitoring agencies. As we stressed in our previous recommendation, these must all be part of a comprehensive Canadian emergency response strategy. Recommendation 3: The Act must address interprovincial as well as international traffic. We are happy that the provisions of Bill C-12 apply to goods and travellers leaving as well as entering Canada. This was a deficiency identified in the previous Quarantine Act. However, the Act must also expressly address goods and travellers crossing provincial or territorial boundaries. Currently, there is tremendous variation in public health system capacity among provinces and territories and, more particularly, among municipalities and local authorities. Inconsistencies in provincial approaches to public health matters have resulted in significant weaknesses in the “emergency shield” between and across provinces. Unless the potential consequences of these disparities are remedied through federal legislation they must, as a priority, be remedied through federal/provincial/territorial agreements. The role of the Public Health Agency of Canada in facilitating, equalizing and monitoring the management of public health emergencies nationwide must be enshrined in the legislation that establishes the Agency. CMA also hopes that the development of a pan-Canadian Public Health Network, acknowledged in the 2004 Throne Speech, will facilitate the nationwide collaboration essential for adequate and appropriate response to health emergencies. The CMA supports those provisions in Bill C-12 that give the Minister (preferably the Chief Public Health Officer of Canada) the power to establish quarantine centres anywhere in the country. In times of threat to national health security, such bold leadership would be both warranted and expected. Recommendation 4: “Public Health Emergency” must be adequately defined. Bill C-12 contains no definition of “public health emergency” or “public health emergency of international concern.” We believe these should be defined.1 Bill C-12 includes a schedule of specific communicable diseases to which its provisions would apply. We are concerned that this Schedule may limit Canada’s capacity to respond to emergencies. The next public health emergency may be a disease we have not heard of yet; or it may be a bio-terrorist attack, or a chemical or nuclear event. The Act must enable Canada to respond to new and emerging, as well as existing, threats to health. The World Health Organizations’ draft International Health Regulations (IHR) has proposed a set of criteria for assessing emergencies; these include: * Is the event serious? * Is the event unexpected? * Is there a significant risk of international spread? The CMA urges the Canadian government to consider a hybrid approach incorporating both known disease states and criteria such as the ones used by the IHR, for assessing new diseases or other public health emergencies. Recommendation 5: The Act, or its regulations, must clarify the roles, responsibilities and training requirements of emergency response personnel. Some provisions of Bill C-12 have raised questions in our minds about the scope of practice of personnel involved in disease screening, and we would appreciate clarification on these points. For example: Screening officers, the first point of contact for travelers entering or leaving Canada, are customs officers and others designated by the Minister. Their primary role under Section 14 of the Act is to use “non-invasive” screening technology to detect travelers entering and exiting Canada with communicable disease vectors, etc. According to Section 15 (3) screening officers, who are not health professionals, will have the power to “order any reasonable measure to prevent spread of a communicable disease”. Of what might these “reasonable measures” consist? Quarantine officers, by definition in Section 5(2) are medical practitioners or other health professionals or anyone else in this “class of persons”. Since the quarantine officer’s job description includes physical assessment of travellers to determine whether they should be detained – a function that requires the expertise of a health professional - we would appreciate clarification of the phrase “in this class”. Similarly, under Section 26, the quarantine officer has the power to order the traveler “to comply with treatment”. Which officer—screening/quarantine or medical—might actually prescribe the course of treatment? This function must be specifically delegated to medical officers. Bill C-12 gives authorities the powers to restrict personal movement and temporarily impound or seize property. The CMA believes that the government should also provide adequate resources and powers to allow for tracking down apparently well people who cross borders and are subsequently diagnosed with infectious diseases. The Act or its regulations should also address factors that hinder deployment of qualified health professionals, such as portability of licensure and coverage for malpractice and disability insurance. CMA has previously called for the establishment of a Canadian Public Health Emergency Response Service that would maintain a “reserve” of public health professionals who could be deployed to areas of need during times of crisis, and which would co-ordinate the logistics of the issues above mentioned. This would improve the capacity of health professionals to be deployed quickly in times of health emergency, to locations where they are most needed. Finally, CMA suggests that the Act or its regulations provide greater detail on training requirements for screening officers, to guarantee that they are appropriately trained. Recommendation 6: Privacy and confidentiality must be respected and safeguarded. Bill C-12 grants quarantine officers and the Minister some sweeping powers to arrest and detain people without warrants, including people who have refused to comply with testing. Though on rare occasions such measures may be required to protect the public, it is recognized that potential for their abuse may exist. In addition, Bill C-12 raises questions about the degree to which personal health information might be exposed to scrutiny. We note that Section 51 authorizes a quarantine officer to “order any person to provide any information or record…the officer might reasonably require.” This provision could include patient medical records in a doctor’s office, particularly if the Bill guarantees travellers the right to request a “second opinion” which we assume could be obtained from any practicing physician in Canada. Similarly, Sections 55 and 56 appear to give the Minister authority to “collect medical information in order to carry out the purposes of this Act” and to “disclose personal information obtained under the Act” to a host of entities. The CMA believes that the power to obtain and disclose information should be explicitly constrained and circumstances under which this power could be exercised must be outlined in the Act. Recommendation 7: The role of physicians and other health care workers must be respected. The health professional sector is on the front lines of response to health emergencies, as they were during the SARS outbreak. Therefore as a first principle the new Act should recognize the importance of health professionals having the power, subject to appropriate constraints, to make vital decisions in response to health emergencies. This is a legitimate delegation of power, because of the competencies of health professionals. During the SARS outbreak of 2003, physicians and other health care providers were not only partners in containing infection; many became ill or died as well. Since health care workers expose themselves to infection as they respond to health emergencies, protocols should ensure that care and attention is paid to their safety, through measures such as ensuring ready availability of proper masks The Act or regulations should address precautions required to protect quarantine officers and other health care workers from transmission of disease or the effects of becoming ill. For example, it should address compensation for quarantine officers who lose work because they become infected in the course of their duty. We would be remiss in our review of this act if we did not pursue with this Committee the issue of compensation and indemnification programs for physicians and trainees requiring quarantine because of exposure to a communicable disease while providing medical service, or who are required to close their offices for other public health reasons, or who cannot practice in hospitals because of closure of hospitals for public health reasons. Indeed, delegates to our annual general council meeting called on the CMA to do so. A number of these physicians were caught in such situations during the turmoil of the SARS outbreak. Recommendation 8: Decision-making should be evidence-based. At times, public perception and political considerations may widely influence the assessment and management of risk. While this is probably unavoidable, CMA believes that public policy should be founded first and foremost on the highest possible quality of scientific evidence. The Act should provide the requisite mechanisms to ensure that reviews of risk are independent and unbiased. We acknowledge, however, that this principle should not be rigidly applied; “we’re waiting for the evidence” must not be used as an excuse for inaction when action is urgently required. 3) Additional Comments In addition to the above recommendations, additional concerns remain regarding implementation of the Act. In particular we note that many crucial components, such as how physical examinations are to be carried out (section 62(1), medical practitioner’s review process (section 62(d), and the protection of personal information (62(g) are left to regulations. These regulations must be developed as soon as possible. We understand that the current Act constitutes “Phase I” of a longer-term strategy to enhance Canada’s capacity to respond to public health emergencies. Though we believe that the Quarantine Act merits attention at this time, we also believe that it should be looked at with a longer-term view. For instance, as we have already recommended, it should be incorporated into the broader legislative renewal of public health in Canada, with a view to enhancing this country’s ability to respond swiftly and effectively to public health emergencies, locally and nationwide. Above all, Canada must ensure a sustained and substantial commitment of resources to its public health emergency response program. Without this, the best-written laws will be inadequate. The Canadian Medical Association commends the Government of Canada for bringing this bill forward, and looks forward to working with the Government, and the Public Health Agency of Canada, to help keep Canadians safe in the event of a public health emergency. End Notes 1 A public health emergency has been defined by the US Model State Emergency Powers Act (http://www.publichealthlaw.net accessed July 7, 2003) as an occurrence or imminent threat of an illness or health condition of a temporary nature that is believed to be caused by: * the appearance of a novel or previously controlled or eradicated infectious agent or biological toxin; * a bioterrorist event; * a natural disaster * a chemical event or accidental release; or * a nuclear event or accident and that poses a high probability of any of the following harms: * a large number of deaths in the affected population; * a large number of serious or long-term disabilities in the affected population; or * widespread exposure to an infectious or toxic agent that poses a significant risk of substantial future harm to a large number of people in the affected population.
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Bill C-17 An Act to amend the Food and Drugs Act

https://policybase.cma.ca/en/permalink/policy11196
Date
2014-06-11
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2014-06-11
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association (CMA) is pleased to present this brief to the House of Commons Standing Committee on Health for consideration as part of its study of Bill C-17, Protecting Canadians from Unsafe Drugs Act, which proposes amendments to the Food and Drugs Act. The CMA has over 80,000 physician-members. 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. Prescription medication has a very important role as part of a high-quality, patient-centred and cost-effective health care system. Prescription medication can prevent serious disease, reduce the need for hospital stays, replace surgical treatment and improve a patient's capacity to function productively in the community. As such, the CMA has developed a substantial body of policy on pharmaceutical issues, including on the post-approval surveillance of prescription medication. Over the last several years, the CMA has prepared several briefs and reports on pharmaceutical medication and prescribing-related issues.1 It is a priority to physicians that all Canadians have access to medically-necessary drugs that are safe, effective, affordable, appropriately prescribed and administered, as part of a comprehensive, patient-centered health care and treatment plan. The CMA supports a robust legislative framework and unbiased, evidence-based system for the oversight of pharmaceutical products. As outlined below, the CMA has identified opportunities to strengthen elements of Bill C-17 toward this end. 1) Clarify ministerial authority and responsibility The current legislative limit to the health minister's authorities is troubling. The CMA, along with many other stakeholders, has long called for an expansion of ministerial authorities related to the pharmaceutical legislative framework, including both pre- and post-approval, in support of patient safety. The CMA supports the underlying intent to expand the authority of the health minister to require the submission of information, modify the label or replace the package, to order a recall or relocation of a product. However, the CMA has two concerns regarding the limitations to this expanded authority (section 3, proposed new FDA sections 21.1, 21.2 and 21.3): * Firstly, that the threshold for the new authorities in section 3 (new proposed section 21.1, 21.2, and 21.3 of the FDA) may be too high. The term "serious risk of injury to health" will be the standard for these new ministerial powers and may limit the authority of the minister to take action when the concern may be serious, but not necessarily permanently debilitating or life threatening. * Secondly, that the minister is not required to take any of the actions proposed in Bill C-17 even if the threshold is met (these sections specify that the minister "may" take the specified action, rather than the minister "shall"). While seemingly minor, the difference between "may" and "shall" is the difference between having the authority to take action and being responsible to take this action. This difference is critical to a robust legislative framework for patient safety. Recommendation 1 In order to clarify the health minister's authority to take appropriate measures to protect patient safety, the CMA recommends that the standard "a serious risk of injury to human health" in section 3 proposed new FDA section 21.1 and "serious or imminent risk of injury to health" in section 3 proposed new FDA section 21.3 be amended to ensure an appropriate threshold that does not constrain ministerial authority. Recommendation 2: To ensure that the health minister has the clear responsibility to take appropriate measures to protect patient safety, the CMA recommends that the word "may" is replaced with "shall" in section 3, proposed new FDA sections 21.1, 21.2 and 21.3. 2) Oversight of natural health products The extensive use of natural health products, such as vitamins and herbal medicines, is partially due to a belief that such products are "natural" and thus low risk. Increasingly, it has become clear that these products can have adverse effects, including drug interactions. However, relatively little is known about the adverse effects associated with natural health products due to its limited legislative and regulatory requirements, including reporting. To ensure that patient safety risks associated with natural health products are addressed, these products should be included in the new patient safety legislation, as proposed in the previous iteration of this legislation in 2008, Bill C-51 An act respecting foods, therapeutic products and cosmetics. The CMA encourages the Health Committee to include natural health products within the scope of Bill C-17, as a first step toward ensuring that natural health products are subject to the same regulatory requirements and oversight as are prescription and over-the-counter pharmaceuticals in order to promote patient safety. Recommendation 3: The ministerial authorities and measures proposed in Bill C-17 should be extended to include natural health products and, as such, CMA recommends that the definition of "therapeutic product" in section 2(3), be amended to include natural health products. 3) Comprehensive post-market surveillance and response system The CMA has advocated for significant improvements to Health Canada's post-market surveillance and response system in light of significant shortcomings. A) Increasing accountability and public transparency Robust accountability and transparency are important elements in the legislative framework governing the post-market surveillance and response system. The 2011 report of the Office of the Auditor General of Canada (OAG) highlighted significant concerns regarding this system, not least of which being Health Canada's failure to meet its own benchmarks in reviewing and responding to pharmaceutical safety issues. While there was no assessment of the benchmarks themselves, as is typical with an audit, the OAG report highlighted a number of issues with Health Canada's approach to measuring its performance against its benchmarks. Following the publication of the OAG audit report, Health Canada's 2013-14 Main Estimates and Report of Plans and Priorities2 shows cuts in both budget and staff allocation for health products (which includes drug oversight). The 2011 OAG report states that "Canada's small population reduces the likelihood of serious, rare adverse drug reactions being identified in this country; therefore, the capacity to search and analyze foreign reports electronically would contribute to more comprehensive safety monitoring."3 Of note, the audit found that Health Canada "does not take timely action in its regulatory activities" (...). "In particular, the Department is slow to assess potential safety issues. It can take more than two years to complete an assessment of potential safety issues and to provide Canadians with new safety information."4 Despite Health Canada's March 2013 update on its efforts to address the OAG recommendations5 the status of the improvements to the reporting tools, timeliness of information or quality of information provided to practitioners and patients remains unclear. The preceding paragraphs capture a number of issues pertaining to the post-approval surveillance and response system; it is imperative that Health Canada not only address these issues, but that Health Canada has adequate resources to do so. This is paramount prior to any consideration of expanding the input of reporting data. Recommendation 4: The CMA recommends that Bill C-17 be amended to require Health Canada undertake public consultations in establishing its performance benchmarks related to adverse drug reaction reporting, analysis and response communication. Recommendation 5: The CMA recommends that Bill C-17 be amended to establish a new public reporting requirement of its performance in meeting its performance benchmarks. B) Improving the reporting and communication system The CMA cautions against the advancement of new legislative authority with respect to mandatory reporting of serious adverse drug reactions prior to the improvement of the system and model currently in place. Information gathering does not in itself constitute post-market surveillance. In our opinion, the most important element of the process is the monitoring and analysis that occurs once an adverse drug reaction report has been received. Monitoring capacity requires rigorous data analysis and, to be useful in preventing further adverse events, it must be timely. As well, it should also provide information about a drug's efficacy and effectiveness. When new information is uncovered about a prescription drug, it is important that health professionals are made aware of it as quickly and efficiently as possible. Therefore, post-approval surveillance requires a system for communicating timely, reliable and objective information in a manner that allows them to incorporate it into their everyday practice. Ideally, this communication would report not the safety problem alone but also its implications for their patients and practice: for example, whether some patients are particularly at risk, or whether therapeutic alternatives are available. Such feedback will encourage further reporting. In order to improve patient safety, the CMA recommends that Health Canada's establish a model that includes: * Making it easier for physicians and other health professionals to report adverse drug reactions by making the reporting system user-friendly and easy to incorporate into a practitioner's busy schedule. Currently the existing system imposes an unnecessary administrative burden that comes at the expense of time dedicated to patient care. * Making the reporting process even more efficient by incorporating it directly into the Electronic Health Record systems. Health Canada has improved the process by introducing online reporting, which may have contributed to the significant increase in the number of reports over the past 10 years, but being able to connect patient information with drugs they are taking, reporting of adverse drug reactions and safety information would improve care on the front line. * Augmenting spontaneous reports with information gathered through other, more systematic means. These could include formal post-market studies of specific drugs, or recruitment of "sentinel" groups of health care providers who would contract to report adverse drug reactions in detail, and who would be committed to assiduous reporting. * Linking to international post-approval surveillance systems, thus increasing the body of data at researchers' disposal, as well as the capacity for meaningful analysis. Health Canada should take a leadership role in ensuring that the public has access to appropriate information on drugs and drug safety, engaging civil society at the appropriate phases of the process. In providing this information, Health Canada should consider the management and communication of risk, and take into account the diversity of Canada's population. Access to accurate, unbiased information allows people to make decisions regarding their own health. In addition to ensuring a comprehensive model is in place, it is essential that there be more clarity in Bill C-17 regarding what constitutes a "prescribed health care institution". There are very different changes to the system that would need to be in place should it refer to tertiary care hospitals, community hospitals, clinics or doctors in family practice. Bill C-17 must not place an unnecessary administrative burden, which would ultimately fall on health professionals. Further, it is unclear whether a cost assessment of the proposed new requirements for health care institutions with respect to provincial/territorial resources has been undertaken. Only those health care institutions that are best positioned to improve the quantity and quality of reporting should be required to report. Another term that requires clarification in the legislation is "serious adverse drug reaction". It should be clear whether it means adverse drug reactions that require visits to emergency departments or hospitalization, or whether there are other criteria to define it. Recommendation 6: The CMA recommends that Bill C-17 be amended to require that Health Canada implement comprehensive post-surveillance monitoring and reporting model that includes: * Accessible, comprehensive and user-friendly reporting tools that are clinically relevant and linked to electronic health records; * Rigorous and timely analysis of reports for the early identification and response to emerging drug safety threats; and * Communication of timely, user-friendly and clinically-relevant information to health care practitioners and the public. Recommendation 7: The CMA recommends amendment of Bill C-17 section 5, proposed new FDA section 21.8, to require that an assessment by the minister for reporting regulations be undertaken following a prescribed period after this new model is established; that this assessment precede the coming into force of expanded mandatory reporting. Recommendation 8: The CMA recommends that essential terminology be defined in Bill C-17, including (a) "serious adverse drug reaction" and (b) "health care institution". Canada's physicians are prepared to work with governments, health professionals and the public in strengthening Canada's post-approval surveillance system, to ensure that the prescription drugs Canadians receive are safe and effective. 1 Canadian Medical Association (2005) Building a Comprehensive Post-Market Surveillance System. CMA's Response to Health Canada's Discussion Paper 'Designing a Mandatory System for Reporting Serious Adverse Reactions'. CMA. Retrieved from: http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Submissions/2005/English/Mandatory_Response.pdf Canadian Medical Association (2014) Federal levers to address unintended consequences of prescription pharmaceuticals and support public health, quality care, and patient safety. CMA Submission to the Senate Committee on Social Affairs, Science and Technology. CMA. Retrieved from: http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Submissions/2014/SOCI_BriefEnglish-Final.pdf Canadian Medical Association (2008) Post-Market Surveillance of Pharmaceutical Products. CMA Submission to the House of Commons Standing Committee on Health. CMA. Retrieved from: https://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Submissions/2008/brief-drug-en-08.pdf Canadian Medical Association (2012) Prescription Drugs: Clinical Trials and Approval. CMA Presentation to the Senate Standing Committee on Social Affairs, Science and Technology. CMA. Retrieved from: https://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Submissions/2012/Senate-ClinicalTrials_en.pdf Canadian Medical Association (2012) Prescription Pharmaceuticals in Canada: The Post-Approval Monitoring of Prescription Pharmaceuticals. CMA Submission to the Senate Committee on Social Affairs, Science and Technology. CMA. Retrieved from: http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Submissions/2012/Senate-Pharmaceuticals-Oct2012_en.pdf Canadian Medical Association (2014) Review of Controlled Drugs and Substances Act. Submission to Health Canada in response to the consultation on the Controlled Drugs and Substances Act and its regulations. CMA. Retrieved from: http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Submissions/2014/CMA_SubmissiontoHealthCanada-CDSA_Modernization.pdf Canadian Medical Association (2013) The need for a national strategy to address abuse and misuse of prescription drugs in Canada. CMA Submission to the House of Commons Standing Committee on Health. CMA. Retrieved from: http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Submissions/2013/Prescription-Drug-Abuse_en.pdf 2 Health Canada (2013) 2013-14 Report on Plans and Priorities. Government of Canada. http://www.hc-sc.gc.ca/ahc-asc/alt_formats/pdf/performance/estim-previs/plans-prior/2013-2014/report-rapport-eng.pdf (pg 30) 3 Office of the Auditor General of Canada (2011) Chapter 4 Regulating Pharmaceutical Drugs - Health Canada. 2011 Fall Report of the Auditor General of Canada. Government of Canada. Retrieved from: http://www.oag-bvg.gc.ca/internet/docs/parl_oag_201111_04_e.pdf (pg 21) 4 Office of the Auditor General of Canada (2011) Chapter 4 Regulating Pharmaceutical Drugs - Health Canada. 2011 Fall Report of the Auditor General of Canada. Government of Canada. Retrieved from: http://www.oag-bvg.gc.ca/internet/docs/parl_oag_201111_04_e.pdf (pg 2) 5 Health Canada (2013) Update and response to OAG recommendations for the regulation of pharmaceutical drugs in Fall 2011. Government of Canada. Retrieved from: http://www.hc-sc.gc.ca/ahc-asc/pubs/hpfb-dgpsa/oag-bvg-eng.php
Documents
Less detail

Bill C-45: The Cannabis Act

https://policybase.cma.ca/en/permalink/policy13723
Date
2017-08-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2017-08-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The CMA is pleased to provide this submission to the House of Commons Standing Committee on Health on Bill C-45, the Cannabis Act. The CMA has long-standing concerns about the health risks associated with consuming cannabis,i particularly in its smoked form.1,2 Children and youth are especially at risk for cannabis-related harms, given their brains are undergoing rapid and extensive development. i The term cannabis is used, as in Bill C-45: that is, referring to the cannabis plant or any substance or mixture that contains any part of the plant. ii The plant contains at least 750 chemicals, of which there are over 100 different cannabinoids. Madras BK. Update of cannabis and its medical use. Agenda item 6.2. 37th Meeting of the Expert Committee on 1 Canadian Medical Association. Health risks and harms associated with the use of marijuana. CMA submission to the House of Commons Standing Committee on Health. Ottawa: The Association; 27 May 2014. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/Brief-Marijuana-Health_Committee_May27-2014-FINAL.pdf (accessed 2017 Jul 27). 2 Canadian Medical Association. A public health perspective on cannabis and other illegal drugs. CMA submission to the Special Senate Committee on Illegal Drugs. Ottawa: The Association; 11 Mar 2002. Available: http://policybase.cma.ca/dbtw-wpd/BriefPDF/BR2002-08.pdf (accessed 2017 Jul 27). 3 Canadian Medical Association. Bill C-2 An Act to Amend the Controlled Drugs and Substances Act (Respect for Communities Act). CMA submission to the House of Commons Standing Committee on Public Safety and National Security. Ottawa: The Association; 28 Oct 2014. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/CMA_Brief_C-2_Respect%C3%A9-for_Communities_Act-English.pdf (accessed 2017 Jul 27). 4 Harm Reduction International. What is harm reduction? A position statement from Harm Reduction International. London, UK: Harm Reduction International; 2017. Available: www.hri.global/what-is-harm-reduction (accessed 2017 Jul 27). 5 Riley D, O’Hare P. Harm reduction: history, definition and practice. In: Inciardi JA, Harrison LD, editors. Harm reduction: national and international perspectives. Thousand Oaks, CA: Sage Publications; 2000. 6 Fischer B, Russel C, Sabioni P, et al. Lower-risk cannabis use guidelines: a comprehensive update of evidence and recommendations. Am J Public Health 2017;107(8):e1–e12. 7 Canadian Medical Association. Legalization, regulation and restriction of access to marijuana. CMA submission to the Government of Canada – Task Force on Cannabis Legalization and Regulation. Ottawa: The Association; 2016 Aug 29. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/2016-aug-29-cma-submission-legalization-and-regulation-of-marijuana-e.pdf (accessed 2017 Jul 27). 8 Government of Canada. Canadian Tobacco, Alcohol and Drugs Survey (CTADS): 2015 summary. Ottawa: Government of Canada; 2017. Available: www.canada.ca/en/health-canada/services/canadian-tobacco-alcohol-drugs-survey/2015-summary.html (accessed 2017 Jul 27). 9 Health Canada. Canadian Alcohol and Drug Use Monitoring Survey (CADUMS): summary of results for 2012. Ottawa: Health Canada; 2014. Available: www.canada.ca/en/health-canada/services/health-concerns/drug-prevention-treatment/drug-alcohol-use-statistics/canadian-alcohol-drug-use-monitoring-survey-summary-results-2012.html (accessed 2017 Jul 27). 10 World Health Organization. The health and social effects of nonmedical cannabis use. Geneva: World Health Organization; 2016. Available: http://apps.who.int/iris/bitstream/10665/251056/1/9789241510240-eng.pdf?ua=1 (accessed 2017 Jul 27). 11 Task Force on Cannabis Legalization and Regulation. A framework for the legalization and regulation of cannabis in Canada: final report. Ottawa: Health Canada; 2016. 12 Government of Canada. Legislative background: an Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts (Bill C-45). Ottawa: Government of Canada; 2017. 13 An Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts, Bill C-45, First Reading 2017 Apr 13. 14 Crean RD, Crane NA, Mason BJ. An evidence based review of acute and long-term effects of cannabis use on executive cognitive functions. J Addict Med 2011;5(1):1–8. The CMA’s approach to cannabis is grounded in broad public health policy. It includes promotion of health and prevention of drug dependence and addiction; access to assessment, counselling and treatment services; and a harm reduction perspective. The CMA believes that harm reduction encompasses policies, goals, strategies and programs directed at decreasing adverse health, social and economic consequences of drug use for the individual, the community and the society while allowing the user to continue to use drugs, not precluding abstinence.3,4 Specifically, the CMA recommends a multi-faceted cannabis public health strategy that prioritizes impactful and realistic goals before, and certainly no later than, any legalization of cannabis.5 We propose that the first goal should be to develop educational interventions for children, teenagers and young adults. Other goals relate to data collection; monitoring and surveillance; ensuring a proportionate balance between enforcement harms and the direct and indirect harms caused by cannabis use; and research. There is an ongoing need for research into the medicinal and harmful effects of cannabis use. As noted by the Lower-Risk Cannabis Use Guidelines, 6 there is limited evidence on such subjects as synthetic cannabinoids; practices like “deep inhalation” to increase the psychoactive effects of cannabis; and the combination of risky behaviours, like early-onset and frequent use, associated with experiencing acute or chronic health problems.6 Since 2002, the CMA has taken a public health perspective regarding cannabis and other illegal drugs. More recently, the CMA endorsed the Lower-Risk Cannabis Use Guidelines, and we submitted 22 recommendations to the Task Force on Cannabis Legalization and Regulation (“the Task Force”).7 Overview According to the recent Canadian Tobacco, Alcohol and Drugs Survey, cannabis is the most used illicit drug in Canada.8 In particular, 25%–30% of adolescents or youth report past-year cannabis use.9 This concerns the CMA. The increasing rate of high usage, despite the fact that non-medical use of cannabis is illegal, coupled with cannabis’ increased potency (from 2% in 1980 to 20% in 2015 in the United States),10 the complexity and versatility of the cannabis plant,ii the variable quality of the end product, and variations in the frequency, age of initiation Drug Dependence, Department of Essential Medicines and Health Products, World Health Organization; 2015. Available: www.who.int/medicines/access/controlled-substances/6_2_cannabis_update.pdf (accessed 2017 Jul 27). and method of use make it difficult to study the full health impacts and produce replicable, reliable scientific results. The CMA submits, therefore, that any legalization of cannabis for non-medical use must be guided by a comprehensive cannabis public health strategy and include a strong legal-regulatory framework emphasizing harm reduction principles. Given that the Task Force employed a minimizing of harms approach11 and given how the proposed legislation aligns with the Task Force’s recommendations,12 the bill addresses several aspects of a legal-regulatory framework “to provide legal access to cannabis and to control and regulate its production, distribution and sale.”13 This work provides the starting point for creating a national cannabis public health strategy. The CMA has long called for a comprehensive drug strategy that addresses addiction, prevention, treatment, enforcement and harm reduction.3 There are, however, key public health initiatives that the Canadian government has not adequately addressed and should be implemented before, or no later than, the implementation of legislation. One such initiative is education. Education is required to develop awareness among Canadians of the health, social and economic harms of cannabis use especially in young people. Supporting a Legal-Regulatory Framework that Advances Public Health and Protection of Children and Youth From a health perspective, allowing any use of cannabis by people under 25 years of age, and certainly those under 21 years of age, is challenging for physicians given the effects on the developing brain.1,3,14 The neurotoxic effect of cannabis, especially with persistent use, on the adolescent brain is more severe than on the adult brain.15,16 15 Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proc Natl Acad Sci USA 2012;109(40):E2657–64 16 Crépault JF, Rehm J, Fischer B. The cannabis policy framework by the Centre for Addiction and Mental Health: a proposal for a public health approach to cannabis policy in Canada. Int J Drug Policy 2016;34:1–4. 17 Pope HG Jr, Gruber AJ, Hudson JI, et al. Early-onset cannabis use and cognitive deficits: What is the nature of the association? Drug Alcohol Depend 2003;69(3):303–310. 18 Gruber SA, Sagar KA, Dahlgren MK, et al. Age of onset of marijuana use and executive function. Psychol Addict Behav 2011;26(3):496–506. 19 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): The National Academies Press; 2017. 20 Canadian Cancer Society. 2017 federal pre-budget submission. Canadian Cancer Society submission to the Standing Committee on Finance. 2014 Aug. Available: www.ourcommons.ca/Content/Committee/421/FINA/Brief/BR8398102/br-external/CanadianCancerSociety-e.pdf (accessed 2017 Jul 27). 21 Health Canada. Backgrounder: legalizing and strictly regulating cannabis: the facts. Ottawa: Health Canada; 2017. Available: www.canada.ca/en/health-canada/news/2017/04/backgrounder_legalizingandstrictlyregulatingcannabisthefacts.html (accessed 2017 Jul 27) 22 Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet 2009;374(9698):1383–91. 23 Statistics Canada. Canadian Community Health Survey: Mental Health, 2012. The Daily. 2013 Sep 18. Statistics Canada cat. No. 11-001-X. Available: www.statcan.gc.ca/daily-quotidien/130918/dq130918a-eng.htm (accessed 2017 Jul 27). 24 Miech RA, Johnston LD, O’Malley PM, Bachman JG, Schulenberg, JE. Monitoring the future national survey results on drug use, 1975–2010. Vol 1: Secondary students. Ann Arbor: Institute for Social Research, University of Michigan; 2011. 25 Spithoff S, Kahan M. Cannabis and Canadian youth: evidence, not ideology. Can Fam Physician 2014;60(9):785–7. 26 Health Canada. Strong foundation, renewed focus: an overview of Canada’s Federal Tobacco Control Strategy 2012–2017. Ottawa: Health Canada; 2012. Available: www.canada.ca/content/dam/canada/health-canada/migration/healthy-canadians/publications/healthy-living-vie-saine/tobacco-strategy-2012-2017-strategie-tabagisme/alt/tobacco-strategy-2012-2017-strategie-tabagisme-eng.pdf (accessed 2017 Jul 27). 27 Controlled Drugs and Substances Act, SC 1996, c 19, s 9. Further, neurological studies have shown that adolescent-onset cannabis use produces greater deficits in executive functioning and verbal IQ and greater impairment of learning and memory than adult-onset use.17,18 This underscores the importance of protecting the brain during development. Since current scientific evidence indicates that brain development is not completed until about 25 years of age,19 this would be the ideal minimum age for legal cannabis use. Youth and young adults are among the highest users of cannabis in Canada. Despite non-medical use of cannabis being illegal in Canada since 1923, usage has increased over the past few decades. The CMA recognizes that a blanket prohibition of possession for teenagers and young adults would not reflect current reality or a harm reduction approach.3 Harm reduction is not one of polarities rather it is about ensuring the quality and integrity of human life and acknowledging where the individual is at within his/her community and society at large.5 The possibility that a young person might incur a lifelong criminal record for periodic use or possession of small amounts of cannabis for personal use means that the long-term social and economic harms of cannabis use can be disproportionate to the drug’s physiological harm. The Canadian government has recognized this disproportionality for over 15 years. Since 2001, there have been two parliamentary committee reportsiii and two billsiv introduced to decriminalize possession of small amounts of cannabis (30 g). It was recommended that small amounts of cannabis possession be a “ticketable” offence rather than a criminal one. iii House of Commons Special Committee on the Non-Medical Use of Drugs (2001) and the Senate Special Committee on Illegal Drugs (2002). iv An Act to amend the Contraventions Act and the Controlled Drugs and Substances Act (Bill C-38), which later was reintroduced as Bill C-10 in 2003. v For example, the Substance Use and Addictions Program (SUAP), a federal contributions program, is delivered by Health Canada to strengthen responses to drug and substance use issues in Canada. See Government of Canada. Substance Use and Addictions Program. Ottawa: Health Canada; 2017. Available: www.canada.ca/en/services/health/campaigns/canadian-drugs-substances-strategy/funding/substance-abuse-addictions-program.html (accessed 2017 Jul 27). Given all of the above, the CMA recommends that the age of legalization should be 21 years of age and that the quantities and the potency of cannabis be more restricted to those under age 25. Supporting a Comprehensive Cannabis Public Health Strategy with a Strong, Effective Education Component The CMA recognizes that Bill C-45 repeals the prohibition against simple possession while increasing penalties against the distribution and sale of cannabis to young people, but this is not enough to support a harm reduction approach. We note that the Federal Tobacco Control Strategy, with its $38 million budget, is intended to help reduce smoking rates and change Canadians’ perceptions toward tobacco.20 Similarly, there are extensive education programs concerning the dangers of alcohol, particularly for young people.v The government of Canada has proposed a modest commitment of $9.6 million to a public awareness campaign to inform Canadians, especially youth, of the risks of cannabis consumption, and to surveillance activities.21 A harm reduction strategy should include a hierarchy of goals with an immediate focus on groups with pressing needs. The CMA submits that young people should be targeted first with education. The lifetime risk of dependence to cannabis is estimated at 9%, increasing to almost 17% in those who initiate use in adolescence.22 In 2012, about 1.3% of people aged 15 years and over met the criteria for cannabis abuse or dependence — double the rate for any other drug — because of the high prevalence of cannabis use.23 The strategy should include the development of educational interventions, including skills-based training programs, social marketing interventions and mass media campaigns. Education should focus not only on cannabis’ general risks but also on its special risks for the young and its harmful effects on them. This is critical given that for many, the perception is that (i) legalization of possession for both adults and young people translates into normalization of use and (ii) government control over the source of cannabis for sale translates into safety of use. Complicating this has been the fear-mongering messaging associated with illegal drugs. The evidence shows that fewer adolescents today believe that cannabis use has any serious health risks24 and that enforcement policies have not been a deterrent.25 Having an appropriate education strategy rolled out before legalization of possession would reduce the numbers of uninformed young recreational users. It would also provide time to engage in meaningful research on the impact of the drug on youth. Such strategies have been successful in the past; for example, the long-termvi Federal Tobacco Control Strategy has been credited with helping reduce smoking rates to an all-time low in Canada.26 vi The Federal Tobacco Control Strategy was initiated in 2001 for 10 years and renewed in 2012 for another five years. The Lower-Risk Cannabis Use Guidelines were developed as a “science-based information tool for cannabis users to modify their use toward reducing at least some of the health risks.”6 The CMA urges the government to support the widespread dissemination of this tool and incorporation of its messages into educational efforts. Other strategies must include plain packaging and labelling with health information and health warnings. Supporting a One-System Approach. Alternatively, a Review of Legislation in Five Years The CMA believes that once the act is in force, there will be little need for two systems (i.e., one for medical and one for non-medical cannabis use). Cannabis will be available for those who wish to use it for medicinal purposes, either with or without medical authorization (some people may self-medicate with cannabis to alleviate symptoms but may be reluctant to raise the issue with their family physician for fear of being stigmatized), and for those who wish to use it for other purposes. The medical profession does not need to continue to be involved as a gatekeeper once cannabis is legal for all, especially given that cannabis has not undergone Health Canada’s usual pharmaceutical regulatory approval process. The Task Force’s discussion reflects the tension it heard between those who advocated for one system and those who did not. One concern raised by patients was about the stigma attached to entering retail outlets selling non-medical cannabis. The CMA submits that this concern would be alleviated if the federal government continued the online purchase and mail order system that is currently in place. Given that there is a lack of consensus and insufficient data to calculate how much of the demand for cannabis will be associated with medical authorization, the Task Force recommended that two systems be established, with an obligation to review — specifically, a program evaluation of the medical access framework in five years.11 If there are two systems, then in the alternative, the CMA recommends a review of the legislation within five years. This would allow time to ensure that the provisions of the act are meeting their intended purposes, as determined by research on the efficacy of educational efforts and other research. Five-year legislative reviews have been previously employed, especially where legislation must balance individual choice with protecting public health and public safety.vii For example, like Bill C-45, the purpose of the Controlled Drugs and Substances Act is to protect public health and public safety.27 Its review within five years is viewed as allowing for a thorough, evidence-based analysis to ensure that the provisions and operations of the act are meeting their intended purpose(s).viii Furthermore, a harm reduction approach lends itself to systematic evaluation of the approach’s short- and long-term impact on the reduction of harms.5 vii Several federal acts contain review provisions. Some examples include the Controlled Drugs and Substances Act, SC b1996, c 19, s 9 (five-year review); the Preclearance Act, SC 1999, c 20, s 39 (five-year review); the National Defence Act, RSC 1985, c N-5, s 273.601(1) (seven-year review); the Public Servants Disclosure Protection Act, SC 2005, c 46, s 54 (five-year review); and the Red Tape Reduction Act, SC 2015, c 12 (five-year review). viii The 2012 amendments to the Controlled Drugs and Substances Act were adopted from Bill S-10, which died on order papers in March 2011. The Senate Standing Committee on Legal and Constitutional Affairs reviewed Bill S-10 and recommended that the review period should be extended from two to five years as two years is not sufficient to allow for a comprehensive review. See Debates of the Senate, 40th Parliament, 3rd Session, No 147:66 (2010 Nov 17) at 1550; see also Senate Standing Committee on Legal and Constitutional Affairs, Eleventh Report: Bill S-10, An Act to Amend the Controlled Drugs and Substances Act and to Make Related and Consequential Amendments to Other Acts, with Amendments (2010 Nov 4). The CMA, therefore, submits that if a two-system approach is implemented when the legislation is enacted, the legislation should be amended to include the requirement for evaluation within five years of enactment. Criteria for evaluation may include the number of users in the medical system and the number of physicians authorizing medical cannabis use. The CMA would expect to be involved in the determination of such criteria and evaluation process. Conclusion Support has risen steadily in Canada and internationally for the removal of criminal sanctions for simple cannabis possession, as well as for the legalization and regulation of cannabis’ production, distribution and sale. The CMA has long-standing concerns about the health risks associated with consuming cannabis, especially by children and youth in its smoked form. Weighing societal trends against the health effects of cannabis, the CMA supports a broad legal-regulatory framework as part of a comprehensive and properly sequenced public health approach of harm reduction. Recommendations 1. The CMA recommends that the legalization age be amended to 21 years of age, to better protect the most vulnerable population, youth, from the developmental neurological harms associated with cannabis use. 2. The CMA recommends that a comprehensive cannabis public health strategy with a strong, effective health education component be implemented before, and no later than, the enactment of any legislation legalizing cannabis. 3a. The CMA recommends that there be only one regime for medical and non-medical use of cannabis, with provisions for the medical needs of those who would not be able to acquire cannabis in a legal manner (e.g., those below the minimum age). 3b. Alternatively, the CMA recommends that the legislation be amended to include a clause to review the legislation, including a review of having two regimes, within five years.
Documents
Less detail

Bill C-45: The Cannabis Act

https://policybase.cma.ca/en/permalink/policy13861
Date
2018-04-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2018-04-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The CMA is pleased to provide this submission to the Senate Standing Committee, Social Affairs, Science &Technology on Bill C-45, the Cannabis Act. The CMA has long-standing concerns about the health risks associated with consuming cannabis,i particularly in its smoked form.1,2 Children and youth are especially at risk for cannabis-related harms, given their brains are undergoing rapid and extensive development. The CMA's approach to cannabis is grounded in broad public health policy. It includes promotion of health and prevention of drug dependence and addiction; access to assessment, counselling and treatment services; and a harm reduction perspective. The CMA believes that harm reduction encompasses policies, goals, strategies and programs directed at decreasing adverse health, social and economic consequences of drug use for the individual, the community and the society while allowing the user to continue to use drugs, not precluding abstinence.3,4 Specifically, the CMA recommends a multi-faceted cannabis public health strategy that prioritizes impactful and realistic goals before, and certainly no later than, any legalization of cannabis.5 We propose that the first goal should be to develop educational interventions for children, teenagers and young adults. Other goals relate to data collection; monitoring and surveillance; ensuring a proportionate balance between enforcement harms and the direct and indirect harms caused by cannabis use; and research. There is an ongoing need for research into the medicinal and harmful effects of cannabis use. As noted by the Lower-Risk Cannabis Use Guidelines, 6 there is limited evidence on such subjects as synthetic cannabinoids; practices like "deep inhalation" to increase the psychoactive effects of cannabis; and the combination of risky behaviours, like early-onset and frequent use, associated with experiencing acute or chronic health problems.6 Since 2002, the CMA has taken a public health perspective regarding cannabis and other illegal drugs. More recently, the CMA endorsed the Lower-Risk Cannabis Use Guidelines, and we submitted 22 recommendations to the Task Force on Cannabis Legalization and Regulation ("the Task Force").7 Overview According to the recent Canadian Tobacco, Alcohol and Drugs Survey, cannabis is the most used illicit drug in Canada.8 In particular, 25%-30% of adolescents or youth report past-year cannabis use.9 This concerns the CMA. The increasing rate of high usage, despite the fact that non-medical use of cannabis is illegal, coupled with cannabis' increased potency (from 2% in 1980 to 20% in 2015 in the United States),10 the complexity and versatility of the cannabis plant,ii the variable quality of the end product, and variations in the frequency, age of initiation and method of use make it difficult to study the full health impacts and produce replicable, reliable scientific results. The CMA submits, therefore, that any legalization of cannabis for non-medical use must be guided by a comprehensive cannabis public health strategy and include a strong legal-regulatory framework emphasizing harm reduction principles. Given that the Task Force employed a minimizing of harms approach11 and given how the proposed legislation aligns with the Task Force's recommendations,12 the bill addresses several aspects of a legal-regulatory framework "to provide legal access to cannabis and to control and regulate its production, distribution and sale."13 This work provides the starting point for creating a national cannabis public health strategy. The CMA has long called for a comprehensive drug strategy that addresses addiction, prevention, treatment, enforcement and harm reduction.3 There are, however, key public health initiatives that the Canadian government has not adequately addressed and should be implemented before, or no later than, the implementation of legislation. One such initiative is education. Education is required to develop awareness among Canadians of the health, social and economic harms of cannabis use especially in young people. Supporting a Legal-Regulatory Framework that Advances Public Health and Protection of Children and Youth From a health perspective, allowing any use of cannabis by people under 25 years of age, and certainly those under 21 years of age, is challenging for physicians given the effects on the developing brain.1,3,14 The neurotoxic effect of cannabis, especially with persistent use, on the adolescent brain is more severe than on the adult brain.15,16 Further, neurological studies have shown that adolescent-onset cannabis use produces greater deficits in executive functioning and verbal IQ and greater impairment of learning and memory than adult-onset use.17,18 This underscores the importance of protecting the brain during development. Since current scientific evidence indicates that brain development is not completed until about 25 years of age,19 this would be the ideal minimum age for legal cannabis use. Youth and young adults are among the highest users of cannabis in Canada. Despite non-medical use of cannabis being illegal in Canada since 1923, usage has increased over the past few decades. The CMA recognizes that a blanket prohibition of possession for teenagers and young adults would not reflect current reality or a harm reduction approach.3 Harm reduction is not one of polarities rather it is about ensuring the quality and integrity of human life and acknowledging where the individual is at within his/her community and society at large.5 The possibility that a young person might incur a lifelong criminal record for periodic use or possession of small amounts of cannabis for personal use means that the long-term social and economic harms of cannabis use can be disproportionate to the drug's physiological harm. The Canadian government has recognized this disproportionality for over 15 years. Since 2001, there have been two parliamentary committee reportsiii and two billsiv introduced to decriminalize possession of small amounts of cannabis (30 g). It was recommended that small amounts of cannabis possession be a "ticketable" offence rather than a criminal one. Given all of the above, the CMA recommends that the age of legalization should be 21 years of age and that the quantities and the potency of cannabis be more restricted to those under age 25. Supporting a Comprehensive Cannabis Public Health Strategy with a Strong, Effective Education Component The CMA recognizes that Bill C-45 repeals the prohibition against simple possession while increasing penalties against the distribution and sale of cannabis to young people, but this is not enough to support a harm reduction approach. We note that the Federal Tobacco Control Strategy, with its $38 million budget, is intended to help reduce smoking rates and change Canadians' perceptions toward tobacco.20 Similarly, there are extensive education programs concerning the dangers of alcohol, particularly for young people.v The government of Canada has proposed a modest commitment of $9.6 million to a public awareness campaign to inform Canadians, especially youth, of the risks of cannabis consumption, and to surveillance activities.21 A harm reduction strategy should include a hierarchy of goals with an immediate focus on groups with pressing needs. The CMA submits that young people should be targeted first with education. The lifetime risk of dependence to cannabis is estimated at 9%, increasing to almost 17% in those who initiate use in adolescence.22 In 2012, about 1.3% of people aged 15 years and over met the criteria for cannabis abuse or dependence - double the rate for any other drug - because of the high prevalence of cannabis use.23 The strategy should include the development of educational interventions, including skills-based training programs, social marketing interventions and mass media campaigns. Education should focus not only on cannabis' general risks but also on its special risks for the young and its harmful effects on them. This is critical given that for many, the perception is that (i) legalization of possession for both adults and young people translates into normalization of use and (ii) government control over the source of cannabis for sale translates into safety of use. Complicating this has been the fear-mongering messaging associated with illegal drugs. The evidence shows that fewer adolescents today believe that cannabis use has any serious health risks24 and that enforcement policies have not been a deterrent.25 Having an appropriate education strategy rolled out before legalization of possession would reduce the numbers of uninformed young recreational users. It would also provide time to engage in meaningful research on the impact of the drug on youth. Such strategies have been successful in the past; for example, the long-termvi Federal Tobacco Control Strategy has been credited with helping reduce smoking rates to an all-time low in Canada.26 The Lower-Risk Cannabis Use Guidelines were developed as a "science-based information tool for cannabis users to modify their use toward reducing at least some of the health risks."6 The CMA urges the government to support the widespread dissemination of this tool and incorporation of its messages into educational efforts. Other strategies must include plain packaging and labelling with health information and health warnings. Supporting a One-System Approach. Alternatively, a Review of Legislation in Five Years The CMA believes that once the act is in force, there will be little need for two systems (i.e., one for medical and one for non-medical cannabis use). Cannabis will be available for those who wish to use it for medicinal purposes, either with or without medical authorization (some people may self-medicate with cannabis to alleviate symptoms but may be reluctant to raise the issue with their family physician for fear of being stigmatized), and for those who wish to use it for other purposes. The medical profession does not need to continue to be involved as a gatekeeper once cannabis is legal for all, especially given that cannabis has not undergone Health Canada's usual pharmaceutical regulatory approval process. The Task Force's discussion reflects the tension it heard between those who advocated for one system and those who did not. One concern raised by patients was about the stigma attached to entering retail outlets selling non-medical cannabis. The CMA submits that this concern would be alleviated if the federal government continued the online purchase and mail order system that is currently in place. Given that there is a lack of consensus and insufficient data to calculate how much of the demand for cannabis will be associated with medical authorization, the Task Force recommended that two systems be established, with an obligation to review - specifically, a program evaluation of the medical access framework in five years.11 If there are two systems, then in the alternative, the CMA recommends a review of the legislation within five years. This would allow time to ensure that the provisions of the act are meeting their intended purposes, as determined by research on the efficacy of educational efforts and other research. Five-year legislative reviews have been previously employed, especially where legislation must balance individual choice with protecting public health and public safety.vii For example, like Bill C-45, the purpose of the Controlled Drugs and Substances Act is to protect public health and public safety.27 Its review within five years is viewed as allowing for a thorough, evidence-based analysis to ensure that the provisions and operations of the act are meeting their intended purpose(s).viii Furthermore, a harm reduction approach lends itself to systematic evaluation of the approach's short- and long-term impact on the reduction of harms.5 The CMA, therefore, submits that if a two-system approach is implemented when the legislation is enacted, the legislation should be amended to include the requirement for evaluation within five years of enactment. Criteria for evaluation may include the number of users in the medical system and the number of physicians authorizing medical cannabis use. The CMA would expect to be involved in the determination of such criteria and evaluation process. Conclusion Support has risen steadily in Canada and internationally for the removal of criminal sanctions for simple cannabis possession, as well as for the legalization and regulation of cannabis' production, distribution and sale. The CMA has long-standing concerns about the health risks associated with consuming cannabis, especially by children and youth in its smoked form. Weighing societal trends against the health effects of cannabis, the CMA supports a broad legal-regulatory framework as part of a comprehensive and properly sequenced public health approach of harm reduction. Recommendations 1. The CMA recommends that the legalization age be amended to 21 years of age, to better protect the most vulnerable population, youth, from the developmental neurological harms associated with cannabis use. 2. The CMA recommends that a comprehensive cannabis public health strategy with a strong, effective health education component be implemented before, and no later than, the enactment of any legislation legalizing cannabis. 3a. The CMA recommends that there be only one regime for medical and non-medical use of cannabis, with provisions for the medical needs of those who would not be able to acquire cannabis in a legal manner (e.g., those below the minimum age). 3b. Alternatively, the CMA recommends that the legislation be amended to include a clause to review the legislation, including a review of having two regimes, within five years. i The term cannabis is used as in Bill C-45: that is, referring to the cannabis plant or any substance or mixture that contains any part of the plant. ii The plant contains at least 750 chemicals, of which there are over 100 different cannabinoids. Madras BK. Update of cannabis and its medical use. Agenda item 6.2. 37th Meeting of the Expert Committee on Drug Dependence, Department of Essential Medicines and Health Products, World Health Organization; 2015. Available: www.who.int/medicines/access/controlled-substances/6_2_cannabis_update.pdf (accessed 2017 Jul 27). iii House of Commons Special Committee on the Non-Medical Use of Drugs (2001) and the Senate Special Committee on Illegal Drugs (2002). iv An Act to amend the Contraventions Act and the Controlled Drugs and Substances Act (Bill C-38), which later was reintroduced as Bill C-10 in 2003. v For example, the Substance Use and Addictions Program (SUAP), a federal contributions program, is delivered by Health Canada to strengthen responses to drug and substance use issues in Canada. See Government of Canada. Substance Use and Addictions Program. Ottawa: Health Canada; 2017. Available: www.canada.ca/en/services/health/campaigns/canadian-drugs-substances-strategy/funding/substance-abuse-addictions-program.html (accessed 2017 Jul 27). vi The Federal Tobacco Control Strategy was initiated in 2001 for 10 years and renewed in 2012 for another five years. vii Several federal acts contain review provisions. Some examples include the Controlled Drugs and Substances Act, SC b1996, c 19, s 9 (five-year review); the Preclearance Act, SC 1999, c 20, s 39 (five-year review); the National Defence Act, RSC 1985, c N-5, s 273.601(1) (seven-year review); the Public Servants Disclosure Protection Act, SC 2005, c 46, s 54 (five-year review); and the Red Tape Reduction Act, SC 2015, c 12 (five-year review). viii The 2012 amendments to the Controlled Drugs and Substances Act were adopted from Bill S-10, which died on order papers in March 2011. The Senate Standing Committee on Legal and Constitutional Affairs reviewed Bill S-10 and recommended that the review period should be extended from two to five years as two years is not sufficient to allow for a comprehensive review. See Debates of the Senate, 40th Parliament, 3rd Session, No 147:66 (2010 Nov 17) at 1550; see also Senate Standing Committee on Legal and Constitutional Affairs, Eleventh Report: Bill S-10, An Act to Amend the Controlled Drugs and Substances Act and to Make Related and Consequential Amendments to Other Acts, with Amendments (2010 Nov 4). 1 Canadian Medical Association. Health risks and harms associated with the use of marijuana. CMA submission to the House of Commons Standing Committee on Health. Ottawa: The Association; 27 May 2014. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/Brief-Marijuana-Health_Committee_May27-2014-FINAL.pdf (accessed 2017 Jul 27). 2 Canadian Medical Association. A public health perspective on cannabis and other illegal drugs. CMA submission to the Special Senate Committee on Illegal Drugs. Ottawa: The Association; 11 Mar 2002. Available: http://policybase.cma.ca/dbtw-wpd/BriefPDF/BR2002-08.pdf (accessed 2017 Jul 27). 3 Canadian Medical Association. Bill C-2 An Act to Amend the Controlled Drugs and Substances Act (Respect for Communities Act). CMA submission to the House of Commons Standing Committee on Public Safety and National Security. Ottawa: The Association; 28 Oct 2014. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/CMA_Brief_C-2_Respect%C3%A9-for_Communities_Act-English.pdf (accessed 2017 Jul 27). 4 Harm Reduction International. What is harm reduction? A position statement from Harm Reduction International. London, UK: Harm Reduction International; 2017. Available: www.hri.global/what-is-harm-reduction (accessed 2017 Jul 27). 5 Riley D, O'Hare P. Harm reduction: history, definition and practice. In: Inciardi JA, Harrison LD, editors. Harm reduction: national and international perspectives. Thousand Oaks, CA: Sage Publications; 2000. 6 Fischer B, Russel C, Sabioni P, et al. Lower-risk cannabis use guidelines: a comprehensive update of evidence and recommendations. Am J Public Health 2017;107(8):e1-e12. 7 Canadian Medical Association. Legalization, regulation and restriction of access to marijuana. CMA submission to the Government of Canada - Task Force on Cannabis Legalization and Regulation. Ottawa: The Association; 2016 Aug 29. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/2016-aug-29-cma-submission-legalization-and-regulation-of-marijuana-e.pdf (accessed 2017 Jul 27). 8 Government of Canada. Canadian Tobacco, Alcohol and Drugs Survey (CTADS): 2015 summary. Ottawa: Government of Canada; 2017. Available: www.canada.ca/en/health-canada/services/canadian-tobacco-alcohol-drugs-survey/2015-summary.html (accessed 2017 Jul 27). 9 Health Canada. Canadian Alcohol and Drug Use Monitoring Survey (CADUMS): summary of results for 2012. Ottawa: Health Canada; 2014. Available: www.canada.ca/en/health-canada/services/health-concerns/drug-prevention-treatment/drug-alcohol-use-statistics/canadian-alcohol-drug-use-monitoring-survey-summary-results-2012.html (accessed 2017 Jul 27). 10 World Health Organization. The health and social effects of nonmedical cannabis use. Geneva: World Health Organization; 2016. Available: http://apps.who.int/iris/bitstream/10665/251056/1/9789241510240-eng.pdf?ua=1 (accessed 2017 Jul 27). 11 Task Force on Cannabis Legalization and Regulation. A framework for the legalization and regulation of cannabis in Canada: final report. Ottawa: Health Canada; 2016. 12 Government of Canada. Legislative background: an Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts (Bill C-45). Ottawa: Government of Canada; 2017. 13 An Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts, Bill C-45, First Reading 2017 Apr 13. 14 Crean RD, Crane NA, Mason BJ. An evidence based review of acute and long-term effects of cannabis use on executive cognitive functions. J Addict Med 2011;5(1):1-8. 15 Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proc Natl Acad Sci USA 2012;109(40):E2657-64 16 Crépault JF, Rehm J, Fischer B. The cannabis policy framework by the Centre for Addiction and Mental Health: a proposal for a public health approach to cannabis policy in Canada. Int J Drug Policy 2016;34:1-4. 17 Pope HG Jr, Gruber AJ, Hudson JI, et al. Early-onset cannabis use and cognitive deficits: What is the nature of the association? Drug Alcohol Depend 2003;69(3):303-310. 18 Gruber SA, Sagar KA, Dahlgren MK, et al. Age of onset of marijuana use and executive function. Psychol Addict Behav 2011;26(3):496-506. 19 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): The National Academies Press; 2017. 20 Canadian Cancer Society. 2017 federal pre-budget submission. Canadian Cancer Society submission to the Standing Committee on Finance. 2014 Aug. Available: www.ourcommons.ca/Content/Committee/421/FINA/Brief/BR8398102/br-external/CanadianCancerSociety-e.pdf (accessed 2017 Jul 27). 21 Health Canada. Backgrounder: legalizing and strictly regulating cannabis: the facts. Ottawa: Health Canada; 2017. Available: www.canada.ca/en/health-canada/news/2017/04/backgrounder_legalizingandstrictlyregulatingcannabisthefacts.html (accessed 2017 Jul 27) 22 Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet 2009;374(9698):1383-91. 23 Statistics Canada. Canadian Community Health Survey: Mental Health, 2012. The Daily. 2013 Sep 18. Statistics Canada cat. No. 11-001-X. Available: www.statcan.gc.ca/daily-quotidien/130918/dq130918a-eng.htm (accessed 2017 Jul 27). 24 Miech RA, Johnston LD, O'Malley PM, Bachman JG, Schulenberg, JE. Monitoring the future national survey results on drug use, 1975-2010. Vol 1: Secondary students. Ann Arbor: Institute for Social Research, University of Michigan; 2011. 25 Spithoff S, Kahan M. Cannabis and Canadian youth: evidence, not ideology. Can Fam Physician 2014;60(9):785-7. 26 Health Canada. Strong foundation, renewed focus: an overview of Canada's Federal Tobacco Control Strategy 2012-2017. Ottawa: Health Canada; 2012. Available: www.canada.ca/content/dam/canada/health-canada/migration/healthy-canadians/publications/healthy-living-vie-saine/tobacco-strategy-2012-2017-strategie-tabagisme/alt/tobacco-strategy-2012-2017-strategie-tabagisme-eng.pdf (accessed 2017 Jul 27). 27 Controlled Drugs and Substances Act, SC 1996, c 19, s 9.
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Bill C-422 An Act respecting a National Lyme Disease Strategy

https://policybase.cma.ca/en/permalink/policy11140
Date
2014-06-02
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2014-06-02
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
The Canadian Medical Association is pleased to present this submission to the House of Commons Standing Committee on Health regarding Bill C-422, National Lyme disease strategy. The Canadian Medical Association (CMA) is the national organization representing over 80,000 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. Lyme disease is a growing problem in Canada. According to the Public Health Agency of Canada (PHAC) there were 315 cases of Lyme disease reported in Canada in 2012 -two and one-half times more cases than the 128 reported in 2009, the year that it became a reportable disease. In the Ottawa area, cases have increased almost 8 fold from 6 in 2009 to 47 in 2013. The PHAC surveillance indicates that established populations of blacklegged ticks are spreading their geographic scope, and are increasing in number, in much of southern Canada. In 2013 the US Center for Disease Control and Prevention released new estimates of Lyme disease that was 10 times higher than the previous yearly reported number of 30,000 reported cases.1 This highlights the difficulty in establishing the true burden of illness from Lyme disease. Why this matters to Canada's physicians The Canadian Medical Association supports the implementation of a national strategy that can address the breath of public health and medical issues surrounding the spread of Lyme disease in Canada. As with any new infectious disease threat, Canada needs to ensure that we are prepared to address the impact of Lyme disease on Canadians. CMA's policy on climate change and human health notes that changes in the range of some infectious disease vectors such as blacklegged ticks, are a possible consequence of climate change in Canada. Research has suggested that the tick vector of Lyme disease has been expanding into southeastern Canada which can lead to increased disease risk for those living in areas with tick populations.2 In this policy, CMA recommends that the federal government report diseases that emerge in relation to global climate change, and participate in field investigations, as with outbreaks of infectious diseases like Lyme disease, and develop and expand surveillance systems to include diseases caused by global climate change. The World Medical Association Declaration of Delhi on Health and Climate Change urges colleges and universities to develop locally appropriate continuing medical and public health education on the clinical signs, diagnosis and treatment of new diseases that are introduced into communities as a result of climate change. Diagnosis of Lyme disease can be difficult, as signs and symptoms can be non-specific and found in other conditions. 3 If Lyme disease is not recognized during the early stages, patients may suffer seriously debilitating disease, which may be more difficult to treat.4 Given the increasing incidence of Lyme disease in Canada, continuing education for health care and public health professionals and a national standard of care would improve identification, treatment and management of Lyme disease. Greater awareness of where blacklegged ticks are endemic in Canada, as well as information on the disease and prevention measures, can help Canadians protect themselves from infection. Recommendation The CMA supports a national Lyme disease strategy which includes the federal, provincial and territorial governments and the medical and patient communities. This strategy must address concerns around research, surveillance, diagnosis, treatment and management of the disease and public health prevention measures will advance our current knowledge base, and improve the care and treatment of those suffering from Lyme disease. Conclusion Once again, CMA is pleased to provide this brief to the Standing Committee on Health as part of its study on this important issue. Canada's physicians recognize the importance of monitoring all emerging infectious diseases in Canada. In addition, Canada's physicians recognize the importance of developing strategies to treat, manage, and prevent Lyme disease in Canada. 1 CDC provides estimate of Americans diagnosed with Lyme disease each year, media release August 19, 2013 Accessed at http://www.cdc.gov/media/releases/2013/p0819-lyme-disease.html on Feb 21, 2014. 2 Ogden, N., L. Lindsay, and P. Leighton. 2013. Predicting the rate of invasion of the agent of Lyme disease Borrelia burgdorferi. Journal of Applied Ecology. April, 2013. 50(2):510-518. 3 Mayo Clinic, accessed at http://www.mayoclinic.org/diseases-conditions/lyme-disease/basics/tests-diagnosis/con-20019701 on Feb 21, 2014. 4 Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006;43: 1089-134.
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Brief to the House of Commons Standing Committee on Finance 1995 Pre-Budget Consultation

https://policybase.cma.ca/en/permalink/policy1994
Last Reviewed
2019-03-03
Date
1994-11-18
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
1994-11-18
Topics
Health systems, system funding and performance
Text
I. PURPOSE While Canada is undergoing significant social, political and economic change, the Canadian Medical Association (CMA) remains committed to the delivery of high quality health care and to safeguarding the national integrity of the health system. However, given the need for the federal government to gain control over our deficit and national debt, it seems clear that putting Canada's fiscal house in order remains a high priority. In this regard, CMA appreciates the invitation to submit its views on the 1995 pre-budget consultations that are underway. One overriding objective of the brief is to provide the Committee with a better understanding of the current pressures on physicians across Canada that have arisen as a direct result of past government decisions in this area. It is our firmly-held position that the health care system in general, and the medical profession in particular, have paid more than their fair share in terms of contributing to debt management. This brief focusses on five somewhat distinct areas of concern to Canadian physicians: (1) federal health transfers to the provinces; (2) taxable health benefits; (3) the goods and services tax (GST); (4) Registered Retirement Savings Plan (RRSP) contributions, and (5) the Lifetime Capital Gains Exemption (LCGE) for Small Businesses. In each case, the brief contains specific recommendations as to what the government should do, and more importantly what the government should not do, to balance its short-term deficit reduction targets against longer-term Canadian values. To summarize, good health policy and prudent economic policy go hand-in-hand provided the principles of fairness and good management practices are observed. If change is to come within an overall policy framework that is strategic, coordinated and fair and which preserves (or augments) the integrity of Canada's health care system, it behooves us to avoid short-term, stop-gap initiatives. As the government's 1994 Throne Speech put it "...the agenda of the government is based on an integrated approach to economic, social, environmental and foreign policy". Accordingly, in establishing an appropriate fiscal framework for health, change must take place within the context of a longer-term integrated view. II. BACKGROUND...."Medicare Is A Shared Value" Canada's system of universal health insurance is still one of the best in the world. Experts from around the world travel many thousands of miles to study and, in some cases, emulate our system. For most Canadians, medicare is a highly cherished, integral component of our social fabric. While Medicare's popularity has not diminished over the past 30 years, it is sometimes taken for granted in these difficult economic times. Recent public opinion surveys indicate that 84% of Canadians (with the highest response in Quebec) see medicare as a defining characteristic of being Canadian. Furthermore, 84% of Canadians are of the opinion that the system provides high quality care. 1 At the same time, however, 65% of Canadians are concerned about continued accessibility to a full range of publicly-financed benefits. According to the same poll, 83% of Canadians see current financing of the system as being "unsustainable" over the longer-term 2 and they are right. As much loved as the Canadian medicare system is, there is a large and growing consensus that we need to make changes. This brief is not about maintaining the status quo. Rather, it is about managing the changes required in the long-term best interests of all Canadians and of the physicians who are ultimately responsible for serving those interests, subject to the fiscal realities confronting government. III. CONSIDERATIONS CMA acknowledges that there is a pressing need, now more than ever, for the federal government to balance a number of competing social and economic policy challenges. In a time when deficit reduction measures are required, all segments of society are being asked to do more with the same or less. Health care is no exception, having done so for quite some time. At the same time, we must re-evaluate the variety of services provided or paid for by government. Deficit Management, but at what Costs? As of 1993/94, Canada's net public debt stood at $508.2 billion, or $17,484 for every Canadian. Combined with the debts of the provinces and territories, our national debt is in excess of $700 billion. Not to understate the case, currently one-third of each revenue dollar the government collects is allocated to debt service payments on the federal debt. 3 CMA believes enough is enough: we must not pass this burden on to future generations of Canadians. The federal government has managed to run operating surpluses for five of the past seven years. 4 While this is necessary it is no longer sufficient to meet our fiscal challenges. Maintaining the status quo would mean that debt service payments would further crowd out government expenditures at an accelerated rate. While the government's first priority should be to get us "out of hock", there is an equally- compelling need to respect the longstanding and fundamental principle of fairness/equity that help define Canadian society. One step toward meeting these twin objectives is to consider all possible methods of repatriating that portion of the national debt held by the international lending community. Some experts have argued that Canada, as a country, can no longer afford to have "massive leakages" in interest payments to individuals/countries abroad. 5 In so doing, we would also repatriate our ability as a sovereign nation to set and maintain social policy objectives. This involves guarding against the persistent "tyranny of the deficit" and the influence that international bond rating agencies can exert on the economy. Facts and Fallacies about Health Spending In reviewing expenditures in the public sector, some would suggest that health and health care spending are "out of control". This is a myth. While it is true that Canada spends 10.0% (1993) of Gross Domestic Product (GDP) on health care (second highest among OECD countries), the reality is that the public sector share of total health care expenditures has fallen from 76.4% in 1975 to approximately 71.9% in 1993 6 (falling to the lowest third of OECD countries). This process of reducing real public sector expenditures, in the absence of a well-coordinated and planned framework, has not always been in the best interests of health and health care. Specifically, federal offloading in terms of unilateral reductions in health cash transfers to the provinces have been followed by: * the elimination of entire programs, such as dental insurance programs for children and universal drug insurance programs; * hospital closures (e.g., 52 hospitals in Saskatchewan); * massive regionalization of health programs and the attendant disempowerment of community hospital boards; * the reduction of total bed capacity by as much as 20% in some provinces; * the reduction in medical school enrolment by 10% and a planned 10% reduction in post-MD residency slots; * global medical care expenditure caps in virtually every province in Canada; * individual physician income thresholds in at least five provinces; * a moratorium on interprovincial mobility of physicians; * legislative overrides of duly-negotiated contracts for health care providers; * widespread restrictions on the operation of high technology equipment; and * the de facto "expropriation" of physician business practices without compensation (e.g., Saskatchewan pathologists). These repercussions also serve to underline the fact that change is the only constant in the health care system. Many physicians across the country have expressed concerns that such changes or "threats" to our health care system are already beginning to have serious consequences for individual patients in terms of access to needed medical facilities. If the national integrity of medicare is to survive, federal fiscal policy changes must be assessed within a larger and longer-term framework; one that respects the need for innovation and professionalism in the health care system. Physicians as Responsible Professionals Some mistakenly argue that physician expenditures are responsible for the increasing costs to the health care system. The reality is that physician expenditures as a proportion of total health care expenditures in Canada have declined from 15.7% in 1975 to 15.1 in 1991. 7 Furthermore, physician expenditures constitute a declining share of GDP. Given the recent round of unilateral reductions in medical care spending in many jurisdictions, this percentage share will continue to drop significantly as more recent data become available. As health care resources have become increasingly constrained, physicians have taken on added responsibilities at the macro, meso and micro levels to better manage our health resources. * At the "macro" level, within the provinces and territories, the medical profession has been engaged in formalized consultation structures known as "Joint Management Committees" or "Administrative Councils" with government and other stakeholders to ensure value for money within a diminishing "real" globe of publicly-available resources for health care. * At the "meso" or institutional level, physicians are working hand-in-hand with health care administrators and other community stakeholders to "rationalize" services so as to provide the best value for money in all areas. In addition, to give a greater voice for choice and improve overall accountabilities in the system, physicians are providing formal input to governments that are looking to regionalize health system operations. * At the "micro" or clinical level, physicians have been taking the lead in developing and disseminating clinical practice guidelines (CPGs) to ensure that the care provided is both appropriate and cost-effective. More can and is being done, in collaboration with government, to ensure responsible use of the taxpayer's dollar while meeting the needs of individual patients. At all levels, physicians will continue to involve themselves as capable and responsible professionals. As the health policy agenda continues its rapid pace, physicians and the organizations that represent them should be viewed as "agents" for, rather than "objects" of, change. Good Health Policy Means Good Economic Policy Agencies such as the World Economic Forum, 8 tell us that our system of financing health care is one of Canada's greatest assets in competing in the new world economic order. We should heed this advice, as the Prime Minister recently observed. Compared to the United States, this economic advantage takes the form of 30 percent lower health spending (measured as a percent of GDP or in per capita expenditures) while providing for universal medical benefits and high quality care. In terms of our European trading partners, the fact that health insurance programs are financed primarily through consolidated revenues (rather than employment-based taxes), also confers a unit cost advantage to Canadian exporters. In this sense, good health policy and good economic policy should be mutually reinforcing. Aside from the complementary nature of the relationship between health and the economy, this fundamental concept also suggests that we need to take a longer-term, more integrated and more strategic approach to managing our collective debt and debt-servicing challenges. The federal government can no longer simply shift its financial obligations onto the backs of lower levels of government or individual Canadians without consultation or advance notice. We need to re-evaluate the full range of government- provided or -funded services. Again, however, if federal fiscal reductions are to take place, the principles of fairness and equity must begin to guide the development of sustainable economic and health policies. While there are no doubt trade-offs that can and must be made, if the price of getting our fiscal house in order is losing a national treasure - i.e., our health care system, it is a price too high to be paid. To summarize, we have set out a series of principles that should serve to guide the Committee in its decision-making, they are: * take the longer-term view; * adopt a system-wide, integrated approach for fiscal management; * strive for a strategic approach that mutually reinforces health and economic policies; and * strengthen the fundamental foundation of fairness and equity. These four principles form the building blocks of the remainder of CMA's submission. IV. ISSUES Canada is at a social, political and economic crossroad. The challenge to this Committee and to this Government is to balance short-term fiscal pressures against the longer-term need to re-position Canada to take advantage of economic opportunity while preserving that which is of fundamental importance to Canadian society as a whole. As the Committee looks to striking the right balance, there are five specific areas of concern that the CMA wishes to bring to your attention on behalf of the Canadian medical profession. The Temptation to Reduce Federal Health Transfers CMA commends this Government for exempting EPF health transfers from the extended freeze that was applied to other provincial transfer programs in its spring 1994 budget. We would have been surprised had this Government done anything else, given that medicare is the "Liberal legacy" of the 1960s and given the Liberal Party's consistent opposition to the previous government's "policy by stealth" (i.e., Bill C-69; Bill C-96). The fact is that medicare's contribution to getting our "fiscal house in order" is already large and continues to grow. In specific terms, the Committee will know that over the 1986/87 to 1995/96 fiscal period, it is estimated that $42.108 billion will have been removed via reductions in Established Program Financing for health and post-secondary education. For health alone, over $30 billion will have been removed from the system by fiscal year 1995/96. 9 Even with a resumption of GNP minus three percent growth formula in per capita EPF entitlements for health, beginning next spring, reduced cash contributions to medicare programs will continue to contribute to the attainment of the government's fiscal targets. Given the unprecedented health reforms taking place across the country, Canadians and the health care system can ill afford another federal fiscal shock. The system is already balkanizing, with poorer regions not being able to fiscally sustain some basic health care benefits. Any further acceleration in the rate of reduction in federal cash transfers will all but assure the demise of the national integrity of medicare programs. Moreover, any further reductions in federal health-related cash transfers will: (1) significantly hamper or stall the work of the newly-created National Health Forum; (2) further reduce the capacity for enforcement of national health principles under federal law; (3) exacerbate health-related problems of dealing with child poverty and problems of reducing health inequalities by socio-economic class; and (4) increase other areas of federal direct program expenditures in the context of renewed efforts to provincial program "uploading" (e.g., Canada Pension Plan Disability Program). A propos of health and economy going hand-in hand, it is useful to remind ourselves of the importance of maintaining the comparability of health benefits across Canada in terms of promoting regional development, shared opportunity and efficient resource allocation. Poor regions of this country are already finding it difficult to compete for scarce new business investment capital. The implications of competing from a more uneven playing field in terms of being able to offer only "bare bones" publicly-financed health benefits will further widen the gap between the "have" and "have not" provinces. It is for these reasons that the CMA joins with other national health organizations 10 in recommending the following: 1. THAT THE FEDERAL GOVERNMENT AVOID FURTHER CUTS TO THE EPF HEALTH TRANSFER AND LOCK IN THE CASH PORTION; 2. THAT THE FEDERAL GOVERNMENT NEGOTIATE A STABLE FIVE-YEAR FUNDING ARRANGEMENT WITH THE PROVINCES/TERRITORIES; 3. THAT THE FEDERAL GOVERNMENT MUST ENSURE THAT ACCOUNTABILITY OF THE HEALTH TRANSFER BE SEPARATE AND EXPLICIT. Taxable Health Benefits Canadians have already been dealt one blow with the increasing de-insurance of health care services (e.g., reduction of out-of-country benefits to an unfair and dangerous level, elimination or reduction in drug benefit programs). In the context of funding those services that remain public benefits, only the cruellest government would strike yet another blow to individual Canadians and to Canadian business by taxing the very benefits that taxes were raised to pay. If implemented, this proposal would be tantamount to nothing less than double taxation. Fairness and equity would suggest that the government should be doing more, not less at the legislative and regulatory levels to promote the availability of private health insurance benefits in areas increasingly vacated by government cutbacks. This is why CMA makes the following recommendation: 4. THAT THE CURRENT FEDERAL GOVERNMENT POLICY WITH RESPECT TO NON-TAXABLE HEALTH BENEFITS BE MAINTAINED; Goods and Services Tax (GST) When the GST was introduced in 1991, preoccupation with implementation issues resulted in a number of fundamental injustices at the micro level. One such injustice was dealt to the medical profession. Physicians, like other Canadians, expect to pay their fair share of taxes. We do not however, accept what essentially amounts to double taxation. Physicians in practice in Canada are in the unique, unenviable and unfair position of being forced to absorb all the GST on business inputs. Unlike all other professions, physicians are precluded from being able to pass on the tax to consumers (with provincial health insurance plans as payment in full) or from claiming input tax credits (ITCs) since insured medical services are deemed to be "tax exempt". Unlike other professions, physicians cannot claim input credits for the imputed taxes associated with providing needed medical care. In fact, all of the following health professionals are capable of recouping from patients the GST paid on inputs because their revenues are not restricted by government: dentists; optometrists; chiropractors; physiotherapists; chiropodists; osteopaths; audiologists; speech therapists; occupational therapists and psychologists. Physicians are still angrily awaiting remedial steps to correct this injustice. To be clear, CMA is not asking for preferential treatment for Canadian physicians. What we want is the same fair and equitable treatment from the federal government accorded to other self-employed professional groups. Like physicians, other professions are purchasing inputs and paying GST; but unlike physicians, they are able to recoup the GST. Given this oversight in the legislation and regulations, physicians have already been asked to pay (over and above the GST paid by other professional groups) a cumulative total of $250 million since its introduction of the tax in 1991. The magnitude of this tax paid is not in dispute (as a result of a study prepared by KPMG). While the direct effects of the GST are significant and measurable, the indirect effects are even more significant though less measurable. It is estimated that the 55,000 physicians in Canada employ up to 100,000 Canadians. Given the disproportionate effects of the GST on the medical profession as employers, the employment dampening could be at least as high as 1,000 full-time jobs lost. In addition, the tax-induced distorting effects in terms of efficient resource allocation in the health care system cannot be measured, but are thought to be significant. A goal of health reform in many parts of the country is to move care services out of institutions and into the community. Current federal GST policy, by taxing supplies in a clinical practice setting but not in a hospital setting, acts to discourage this shift in emphasis. No other issue in recent years has raised the ire of individual practitioners as much as the imposition of this most unfair and inequitable tax on business inputs. Understanding that the Minister of Finance is in the process of consulting with the provinces as to the nature of a replacement tax for the GST, we are confident that this oversight will be remedied. In the interests of fundamental fairness/equity and allocative efficiency, CMA respectfully recommends the following: 5. THAT THE COMMITTEE WORK TO ENSURE THAT CANADIAN PHYSICIANS, AS SMALL BUSINESSES, PAY NO MORE THAN OTHER PROFESSIONS UNDER ANY REPLACEMENT TAX FOR THE GST; 6. THAT ALL TAXES ON BUSINESS EXPENSES BE FAIRLY AND FULLY REMOVED UNDER ANY REPLACEMENT TAX FOR THE GST; 7. THAT IF ANY REMEDIAL STEPS ARE TAKEN TO ENSURE NO TAXES ARE LEVIED ON BUSINESS INPUTS, THESE BE APPLIED UNIFORMLY ACROSS ALL EXEMPT SERVICES. Registered Retirement Savings Plan (RRSP) Canadian physicians, while receiving a large proportion of their professional earnings from the public sector (94%), do not benefit as self-employed individuals from defined benefit plans or from publicly-financed pension benefits that accrue to employed professionals. They, like other self-employed individuals, must plan and fund their own retirement. Fairness/equity once again demands that there be symmetry between money-purchase (MP) and defined-benefit (DB) retirement plans. This is all the more important for physicians because of their compressed period of lifetime earnings in relation to other groups. This Committee will have heard various calls for either reducing the annual contribution limit or taxing assets within RRSPs. Such arguments are both specious and patently unfair. Both propositions potentially involve double taxation. Experts both within and outside government argue, quite correctly, that the current policy be maintained, and that equity between employees and the self-employed before the taxman be assured. It is for these reasons, that CMA has led an unprecedented alliance for the preservation of retirement savings, and recommends the following: 8. THAT THE FEDERAL GOVERNMENT CONSIDER THE TOTAL COST OF THE RETIREMENT SAVINGS SYSTEM BEFORE MAKING ANY CHANGES TO THE INCOME TAX ACT; 9. THAT THE EQUITY ESTABLISHED DURING PENSION REFORM NOT BE DISTURBED BY DISCRIMINATORY CHANGES AND THAT ANY FUNDAMENTAL CHANGES TO THE SYSTEM INVOLVE A PROCESS OF INFORMED AND THOUGHTFUL INQUIRY AND DEBATE; 10. THAT THE FEDERAL GOVERNMENT FOSTER ECONOMIC DEVELOPMENT BY TREATING RRSP CONTRIBUTIONS AS ASSETS RATHER THAN LIABILITIES AND BY EXPLORING THE REGULATORY CHANGES NECESSARY TO ENSURE INCREASED ACCESS TO SUCH FUNDS BY SMALL AND MEDIUM-SIZED BUSINESSES. Lifetime Capital Gains Exemption (LCGE) for Small Businesses Most Canadian physicians are independent, self-employed practitioners. As such, they have the ability if they are incorporated to claim the LCGE when they sell their practices. Over time, several provinces have accorded physicians the right to incorporate (e.g., Prince Edward Island, New Brunswick, Alberta, British Columbia, and the Yukon Territory), in other jurisdictions, physician incorporation is under active review (e.g., Nova Scotia, Quebec, Ontario and the Northwest Territories). While physicians have benefited from incorporation on a limited basis, this issue takes on added importance when one considers the "national" move towards incorporation allowing a greater number of eligible physicians to claim the LCGE. Recent health reforms have also underscored the importance of maintaining the current policy. Previously, physicians were free to move their practices from one location to another to meet the changing health needs of Canadians. Over the past two years, provincial governments have moved to restrict inter-provincial mobility of physicians and indeed mobility within any given province or territory. These "barriers" not only restrict the number of new entrants into the system in addition to those who wish to move to other areas of the country, but also can be thought of as increasing the capitalized value of established practices. Indeed, with the advent of regional physician resource plans across Canada, the cost of establishing a new practice can be expected to continue to grow at an unprecedented rate. So while some physicians have yet to claim the LCGE, it is reasonable to think that they will some time in the future. As the health needs of Canadians change, and as people move, medical care services will have to respond accordingly. The elimination of the LCGE, by significantly increasing the purchase price of a new medical practice, unnecessarily and unfairly raises additional economic barriers to shifting practices in response to changing community health needs. CMA therefore recommends: 11. THAT THE FEDERAL GOVERNMENT MAINTAIN THE CURRENT POLICY FOR THE LIFETIME CAPITAL GAINS EXEMPTION FOR SMALL BUSINESSES. V. TRADE-OFFS To summarize: in broad terms the health care sector has already paid its fair (and to a larger extent unfair) share. Everyone who has appeared before this Committee will argue that cuts should not occur in their backyard. They can't all be right! The government of Canada must decide where its priorities lie over the longer-term. Deficit reduction targets can no longer be met by simply chipping away at the full range of federally-sponsored programs. The national integrity of national health insurance programs, given their importance to Canada's economic, social and political future must be on the short list of safeguarded social programs. If further reductions in federal health transfers are deemed appropriate, the Committee should be prepared to publicly acknowledge that the principles of universality or comprehensiveness (i.e., the choice between covering everyone versus everything) will have to be fundamentally re-examined. Given the degree of support for the universality principle, if the federal government is serious about further reducing its direct or indirect contributions to health, then it must reconsider the range of core benefits that will be made available to Canadians. In fact, we may now have reached the point where we need to get back to basics; reminding ourselves of the original medicare promise, which was to protect Canadians from the spectre of personal bankruptcy associated with large and unexpected health care bills. Not to pay the day-to-day ("grocery") bill of health care. The recently-announced National Health Forum, chaired by the Prime Minister, will provide an important opportunity to assess the breadth and depth of publicly-financed health care. The contribution of medicine to the health of Canadians and to the economy is just too important to be traded off. Physicians are still feeling the "aftershocks" of recent federal fiscal decisions. They have also had to absorb sharp unilateral reductions at the provincial level. The provinces of Nova Scotia, Prince Edward Island and Alberta - to name only three - have disproportionately singled out the medical profession on a net earnings basis in decreasing health funding. Taken together, these fiscal forces could trigger an unprecedented exodus of physicians from Canada. As governments move to restrict the ability of physicians to provide needed medical care, CMA is increasingly concerned about the growing number of physicians who are being actively recruited by the United States, and those who feel they have no alternative but to leave the country. At a macro level, we as a society, must recognize that we are in a North American labour market, and as such, each physician heading south represents both a short-term pain and long-term pain. VI. SUMMARY OF RECOMMENDATIONS The CMA offers the following recommendations to the Committee in its deliberations: 1. THAT THE FEDERAL GOVERNMENT AVOID FURTHER CUTS TO THE EPF HEALTH TRANSFER AND LOCK IN THE CASH PORTION; 2. THAT THE FEDERAL GOVERNMENT NEGOTIATE A STABLE FIVE-YEAR FUNDING ARRANGEMENT WITH THE PROVINCES/TERRITORIES; 3. THAT THE FEDERAL GOVERNMENT MUST ENSURE THAT ACCOUNTABILITY OF THE HEALTH TRANSFER BE SEPARATE AND EXPLICIT. 4. THAT THE CURRENT FEDERAL GOVERNMENT POLICY WITH RESPECT TO NON-TAXABLE HEALTH BENEFITS BE MAINTAINED; 5. THAT THE COMMITTEE WORK TO ENSURE THAT CANADIAN PHYSICIANS, AS SMALL BUSINESSES, PAY NO MORE THAN OTHER PROFESSIONS UNDER ANY REPLACEMENT TAX FOR THE GST; 6. THAT ALL TAXES ON BUSINESS EXPENSES BE FAIRLY AND FULLY REMOVED UNDER ANY REPLACEMENT TAX FOR THE GST; 7. THAT IF ANY REMEDIAL STEPS ARE TAKEN TO ENSURE NO TAXES ARE LEVIED ON BUSINESS INPUTS, THESE BE APPLIED UNIFORMLY ACROSS ALL EXEMPT SERVICES. 8. THAT THE FEDERAL GOVERNMENT CONSIDER THE TOTAL COST OF THE RETIREMENT SAVINGS SYSTEM BEFORE MAKING ANY CHANGES TO THE INCOME TAX ACT; 9. THAT THE EQUITY ESTABLISHED DURING PENSION REFORM NOT BE DISTURBED BY DISCRIMINATORY CHANGES AND THAT ANY FUNDAMENTAL CHANGES TO THE SYSTEM INVOLVE A PROCESS OF INFORMED AND THOUGHTFUL INQUIRY AND DEBATE; 10. THAT THE FEDERAL GOVERNMENT FOSTER ECONOMIC DEVELOPMENT BY TREATING RRSP CONTRIBUTIONS AS ASSETS RATHER THAN LIABILITIES AND BY EXPLORING THE REGULATORY CHANGES NECESSARY TO ENSURE INCREASED ACCESS TO SUCH FUNDS BY SMALL AND MEDIUM-SIZED BUSINESSES. 11. THAT THE FEDERAL GOVERNMENT MAINTAIN THE CURRENT POLICY FOR THE LIFETIME CAPITAL GAINS EXEMPTION FOR SMALL BUSINESSES. _______________ 1 The Angus Reid Group, The Reid Report. Vol. 8, No. 7, July/August, 1993 and Vol. 8, No. 8, September, 1993. 2 Ibid. 3 Agenda: Jobs and Growth: Creating A Healthy Fiscal Climate (The Economic and Fiscal Climate), Department of Finance, October 1994. 4 Economic and Fiscal Reference Tables, Department of Finance, September 1994; Annual Financial Report of the Government of Canada, Fiscal Year, 1993/94. 5 Valaskakis K.: The Debt Monster, Montreal Gazette, November 5, 1994. 6 National Health Expenditures in Canada, 1975-1993. Health Canada. 7 Ibid. 8 World Economic Forum 1991: The World Competitiveness report 1990, Institut pour l'étude des méthodes de direction de l'entreprise, Lausanne, Switzerland. 9 Thomson A 1991: Federal Support for Health Care: A Background Paper. Health Action Lobby, Ottawa, June 1991. 10 See the 1995/96 Pre-Budget Submission to the Standing Committee on Finance by the Health Action Lobby (HEAL), November 15, 1994.
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Budget 2009: Economic Stimulus through Targeted Investments in Health Infrastructure - Brief to the Minister of Finance's Roundtable

https://policybase.cma.ca/en/permalink/policy9401
Date
2009-01-12
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2009-01-12
Topics
Health systems, system funding and performance
Text
With economic growth having slowed, Budget 2009 provides an historic opportunity to invest in initiatives that will stimulate the Canadian economy in the short term while also strengthening it in the long term. With the federal government now considering several areas for potential fiscal stimulus, the Canadian Medical Association (CMA) views infrastructure spending as the government's best option. In order to provide much-needed immediate economic stimulus and a responsible, long-term strategy to achieve economic stability, the CMA recommends the federal government invest $2.4 billion in health infrastructure upgrade initiatives to be carried out over the next two years. These initiatives fall into three priority areas: 1) Accelerating existing or "construction-ready" capital projects in health care facilities. The CMA recommends a federal investment of $1.5 billion over two years to accelerate existing hospital and health facility construction projects. While investments in physical infrastructure are required across the continuum of care, a focus on hospital construction - specifically on construction-ready projects already approved at the provincial level - will allow funds to flow more quickly and thus provide a more immediate economic stimulus. Federal investment in hospital and health facility construction will create 16,500 jobs over two years and 11,000 jobs in 2009 alone. These projects may be financed through existing public-private partnerships (P3s). With targeted and strategic federal investment, health facility capital projects would also stimulate further investment in the form of private-sector financing of these capital projects. 2) Accelerating implementation of electronic medical records. Health system information technology is an area where infrastructure investments are needed and would provide significant return on investment through immediate economic stimulus and improved health system efficiency in the medium and long term. CMA recommends that the federal government make a strategic "strings attached" $225-million investment in an Electronic Medical Record Patient Transition Fund that could be managed by the Canada Health Infoway. 3) Modernizing information systems in small- and medium-sized health care facilities. A federal investment of $700 million over two years to upgrade information system hardware and software in small- and medium-sized hospitals could be implemented within the next eight quarters and begin to create 7,700 jobs and rapidly improve health care efficiency. These health infrastructure investments would create 27,000 new jobs over the next two years: 1. 16,500 jobs for existing hospital building projects that are "construction ready"; 2. 4,950 jobs for electronic medical records (EMR) implementation for community-based health care offices; 3. 7,700 jobs for hospital information systems in small- and medium-sized hospitals. Introduction In these challenging economic times, the federal government is to be commended for casting a wide net in search of effective and immediate measures to stimulate Canada's economy. Of course, Canadians must also be assured that we will not be mortgaging our future by doing so. In order to both provide much-needed immediate economic stimulus and a responsible, long-term strategy to achieve economic stability, the CMA recommends that the federal government invest $2.4 billion in health infrastructure upgrade initiatives to be carried out over the next two years. These investments would stimulate further provincial/territorial and private-sector investment. To be clear: these recommendations are in the context of a fiscal stimulus plan and do not encompass CMA's entire long-term vision for high-quality and patient-focused health care. The CMA initiatives fall into three priority areas: 1) Accelerating existing or "construction-ready" capital projects in health care facilities; 2) Accelerating implementation of electronic medical records; 3) Modernizing information systems in small- and medium-sized health care facilities. A critical factor in these recommendations is the fact that the federal government already has in place funding mechanisms to deliver stimulus funds rapidly in all three areas. Canada Health Infoway is such an established vehicle for the EMR initiative and the upgrading of hospital information systems. The Canada Foundation for Innovation or an expanded "Building Canada" program are initiatives that have organizations in place to administer the investments in hospital construction projects. Additionally, these initiatives are flexible in both size and duration. Most economists agree that increasing infrastructure spending generally will boost the economy by creating jobs. In no sector is this more true than health care. Infrastructure investments, will lead to higher employment and more spending on products and services, and generate higher overall demand.i (See Appendix A for investment and job creation quarterly forecasts 2009/2010ii). The Business Register of Statistics Canada reports there were 75,615 establishments in the health service delivery (HSD) industry in 2003, employing 1.3 million people. That year, they accounted for 3.3% of all Canadian business establishments and 7.6% of total employment. In 2003, the GDP of the HSD industry was larger than wholesale trade, retail trade, and the upstream oil and gas mining industry, and almost as large as the construction sector. Physicians' offices (30,120 establishments) accounted for almost 39% of all HSD establishments and employed 142,000 people, or almost 11% of all HSD employees. By targeting investment in the three areas outlined above, the government will respond to Canadians' desire for a strengthened health care system, support Canada's competitive advantage and create 27,000 jobs in the next two years (Figure 1). 1. Accelerating Health Facility Construction Projects The CMA recommends that the federal government invest $1.5 billion over two years to accelerate hospital and/or health facility projects that are "construction ready". In 2001 the CMA identified inadequate investment in buildings, machinery and equipment and in scientific, professional and medical devices as major hurdles to timely access to health care services. While spending has increased in health care since then, governments have placed a lower priority on capital investment when allocating financial resources for health care. The CMA recommends a federal investment of $1.5 billion over two years to accelerate existing hospital and health facility construction projects. This does not capture all the capital requirements in the health system in the medium- and long-term. While investments in physical infrastructure are required across the continuum of care, a focus on hospital construction - specifically on construction-ready projects - will allow funds to flow more quickly and thus provide a more immediate stimulus to the economy. Federal investment in hospital and health facility construction will create 16,500 jobs over a two-year period and 11,000 jobs in 2009 alone. These projects may be financed through existing public-private partnerships (P3s). With targeted and strategic federal investment, health facility capital projects can also stimulate further investment in the form of private-sector financing of capital projects. Across Canada hospitals are seeking to develop innovative approaches to financing capital infrastructure. The CMA agrees with other organizations such as the Canadian Healthcare Association about the need to explore the concept of entering into public-private partnerships to address capital infrastructure needs as an alternative to relying on government funding. Joint ventures and hospital bonds are but two examples of P3 financing. As these types of partnerships are pursued, the CMA recommends that governments establish uniform requirements and regulations to ensure the transparency of the tendering process and adequate measuring of quality of care and cost-effectiveness in both public and private settings.iii The federal government has long showed great leadership in partnering to build Canada's health care system - the Hospital Construction Grants Program of 1948 and the Health Resources Fund Act of 1966. Today our country and our health care system need a new vision for replacing aging physical infrastructure. 2. Electronic Medical Records - Accelerating Coverage for 26 Million Patients CMA recommends that the federal government invest $225 million over two years to accelerate the implementation of an interoperable electronic medical record across Canada. International studies confirm that Canada lags behind nearly every major industrial country when it comes to the adoption of health information technology (Figure 8). The Conference Board of Canadaiv, the Organization for Economic Co-operation and Development (OECD)v, the World Health Organizationvi, the Commonwealth Fundvii, and the Frontier Centre for Public Policy all rate Canada's health care system poorly in terms of value for money and efficiency. The impact of this underinvestment is longer wait times, poorer quality, greater health system costs and a severe lack of financial accountability - especially when it comes to federal dollars. Health system information technology is an area where infrastructure investments are needed and would provide significant return on investment through immediate economic stimulus and improved health system efficiency in the medium- and long-term. CMA recommends that the federal government make a strategic, "strings attached,"1 $225-million investment in an Electronic Medical Record Patient Transition Fund that could be managed by the Canada Health Infoway.2 The fund would finance EMR capital equipment acquisition and EMR change management and transition support, specifically the conversion of 26 million patient records in 30,000 physician offices. This federal investment would be matched by provincial-territorial funds and would thus provide a total of $450 million in economic stimulus and create 5000 new jobs over two years. While public funds would kick-start this initiative, they would stimulate considerable private sector activity in the provision of EMR capabilities across Canada. Assuming the current trend prevails, the ongoing management of the data holdings would be outsourced to private sector companies based on application service provider arrangements. Moreover, these investments are consistent with the Building Canada plan's focus on broadband and connectivity, and with Advantage Canada's goals of creating a knowledge advantage and an infrastructure advantage. Beyond providing immediate stimulus to the Canadian economy, a fully realized EMR system will improve patient outcomes, system efficiency and accountability and save billions of dollars annually. Technology consulting firm Booz Allen Hamilton found that the benefits of an interconnected Electronic Health Record (EHR) in Canada could provide annual system-wide savings of $6.1 billion.viii These savings would come from reduced duplicate testing, transcription savings, fewer chart pulls and less filing time, reductions in office supplies and reduced expenditures due to fewer adverse drug reactions. The study also found that the benefits to health care outcomes would equal or surpass these annual savings, thus providing a possible combined annual savings of $12.2 billion. By reducing wait times, an interoperable EMR will contribute to saving the Canadian economy billions of dollars each year. A study commissioned by the CMA conservatively calculated that excessive wait times involving just four procedures (joint replacements, cataract surgery, coronary artery bypass grafts and MRIs) cost the economy over $14 billion in 2007 due to lost output and government revenues.ix The Electronic Medical Record Patient Transition Fund focuses on community care and the physician offices where most patient visits occur. Most of the emphasis on connectivity in Canadian health care to date has not focused on the point of care, even though the number of patient interactions with hospitals is greatly exceeded by the number of visits to physicians' offices.x Thus, patient-physician office interactions outnumber patient-hospital interactions by a ratio of 18 to 1. In Ontario (Figure 2), just 3,000 of an average of 247,000 patient visits per day, or 1.2%, are made in hospitals. Figure 2 Patient visits per day in Ontario (Canada Health Infoway) 3. Modernizing Hospital Information Systems The federal government should invest $700 million over two years to modernize information systems in small- and medium-sized hospitals. Aging information systems in small hospitals (fewer than 100 beds) and medium-sized hospitals (100 to 300 beds) create considerable inefficiency in patient care and administration. While larger hospitals have upgraded their information systems, hundreds of smaller facilities have information systems that are at least 10 years old. This means that patients are often forced to provide their personal and health information many times: when checking in to the emergency department, then when having a diagnostic test performed, and again when being admitted to hospital. Each step creates room for error and needlessly wastes the time of health care staff and patients. In addition, these discrete systems may not be networked, a situation that risks compromising patient care. A federal investment of $700 million over two years to upgrade information system hardware and software in small- and medium-sized hospitals could be implemented within the next eight quarters and begin to create 7,700 jobs and rapidly improve health care efficiency. The $700 million investment is based on a recent conservative estimate for outfitting hospitals across the country (see Appendix B). There are at least 70 medium-sized Canadian hospitals requiring major system upgrades immediately at a cost of $15 million per hospital. The distribution of these hospitals would help spread out the fiscal stimulus regionally and mitigate against potential labour shortages. The $700-million recommendation assumes that the majority of hospital information system investments (64%) would need to be focused on the hardware and professional services related to implementing the new systems, with the rest focused on system software. It is important to note that these investments would help support related Canadian software, hardware and professional services firms over the next 24 months and beyond. More importantly, the hospital information system sector is a multibillion dollar global industry. A fiscal stimulus investment in this sector now would help Canadian firms to capitalize on a golden opportunity to export these goods and services, which are increasingly in high demand.xi It is also important that patients be involved in evaluating these systems in order to improve care and system efficiencies. As Roger Martin, Dean of the Rotman School of Business noted: "We can dramatically improve the production of globally competitive health care product and services firms, but only if we work to significantly improve the demand side (patients) of our innovation equation."xii This is in line with the CMA's call for patient-focused funding. Conclusion That these are extraordinary economic times is beyond question, but the CMA contends that it is precisely during such times that opportunities often present themselves. We think the federal government must continue to examine and leverage all available policy levers at its disposal, including studying how the tax system could be used to support renewal within the health care sector. The tax system's level of support for people facing high out-of-pocket expenses remains a particularly pressing question. Currently, the medical expenses tax credit provides limited relief to those whose expenses exceed $1,637, or 3% of net income. The 3% threshold was established before medicare was introduced. Does it still make sense in 2009? Are there ways to enhance this provision to reduce financial disincentives facing many Canadians when they have to pay for health services? The CMA encourages the federal government to undertake a comprehensive review of these and other tax questions pertaining to health. By itself, tax policy will not solve all the challenges facing Canada's health care system, but the CMA believes that the tax system can play a key role in helping the system adapt to changing circumstances, thereby complementing the other two components of our renewal strategy. Similarly, the government must remember that almost five million Canadians do not have a family physician and that Canada needs 26,000 more doctors to meet the OECD average of physicians per population. The federal government wisely recognized the urgency of this situation when it committed to several targeted and affordable measures to begin to address the doctor shortage. It should follow through on its election commitment to take first steps towards addressing the shortage, including contributing $10 million per year over four years to provinces to allow them to fund 50 new residencies per year in Canada's major teaching hospitals, and $5 million per year over four years to help Canadian physicians living abroad who wish to relocate to Canada. These initiatives would begin to increase the supply and retention of physicians in areas of priority need, and could bring back as many as 300 Canadian physicians over four years. Today, the federal government is focused on instituting specific, strategic and immediate economic stimulus measures, and rightfully so. However, we must not let the urgent crowd out the important in terms of building a sustainable health care system that provides timely access to quality health care services for all Canadians. Appendix A. Investment and job creation profile estimates 2009-10 B. Projected Costs to Implement / Upgrade Hospital Information Systems3 Assumptions 1. Total number of hospitals in Canada = 734 a. % small hospitals (< 100 beds) = 69% b. % medium hospitals (< 300 beds) = 18% 2. Components in hospital information systems a. Finance & Administration b. Admission, Discharge, Transfer (ADT) System c. Patient Information System d. Radiology Information System e. Laboratory Information System f. Pharmacy Information System g. Coding & Abstracting System 3. Cost to implement complete HIS for medium size hospital = $15 million a. Ratio of software to hardware and professional services - 1:1.8 b. Software = $5,357,143 c. Hardware & Professional Services = $9,642,857 4. Small hospitals (i.e. < 25 beds) would not have the resources to manage a full HIS a. Cluster implementations among 8 hospitals b. Number of clusters = 33 (total # of hospitals = 270) 5. Small hospitals would have greater requirement for full implementation of HIS a. % of hospitals requiring full implementations = 50% b. Number of hospitals (exclusive of clusters in #4) = 117 c. Total number including clusters in # 4 requiring full implementation = 91 d. Cost to implement full HIS - 60% of medium hospital implementation = $9 million 6. Medium sized hospitals with systems > 10 years old would require full implementation a. % of hospitals requiring full HIS implementation = 30% b. Number of hospitals= 40 7. Major system upgrades are estimated at 40% of cost of a full HIS a. Cost to complete system upgrade = $6 million b. % small hospitals (# of beds between 25 - 99) requiring upgrade = 30% c. Number of hospitals = 70 d. % of medium hospitals requiring upgrade = 30% e. Number of hospitals = 40 Investment Needed 1. Investment required for small hospitals - full implementation $ 9,000,000 x 91 = $ 819,000,000 2. Investment required for small hospitals - system upgrade $ 6,000,000 x 70 = $ 420,000,000 3. Investment required for medium hospitals - full implementation $ 15,000,000 x 40 = $ 600,000,000 4. Investment required for medium hospitals - system upgrades $ 6,000,000 x 40 = $ 240,000,000 5. Total investment for HIS for small and medium size hospitals $ 2,079,000,000 References 1 The conditions of this health information investment should include: * Fifty-fifty FPT cost sharing; * Involvement of the clinical community in the input and oversight of the program; * Use of consistent standards. 2 See Table l in Appendix A for full investment horizon details. 3 Prepared for the Canadian Medical Association by Branham Group December 2008 see: http://www.branhamgroup.com/company.php i Will Stimulus Help Employment in a 21st Century Economy? Wall Street Journal, Dec. 5, 2008. ii These estimates were derived using the principle of an employment multiplier and adapted using the methodology applied by Informetrica for an infrastructure study they prepared for the Federation of Canadian Municipalities (05/08). iii Improving performance measurement, quality assurance and accountability in the public-private interface - CMA Policy Statement, It's still about access! Medicare Plus, July 2007 iv A Report Card on Canada see: http://sso.conferenceboard.ca/HCP/overview/health-overview.aspx v Organization for Economic Co-operation and Development [OECD] (2007). OECD Health Data 2007. Version 07/18/2007. CD-ROM. Paris: OECD. vi World Health Organization [WHO] (2007). World Health Statistics 2007. see: http://www.who.int. vii Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care May 15, 2007 (updated May 16, 2007)
Volume 59 Authors: Karen Davis, Ph.D., Cathy Schoen, M.S., Stephen C. Schoenbaum, M.D., M.P.H., Michelle M. Doty, Ph.D., M.P.H., Alyssa L. Holmgren, M.P.A., Jennifer L. Kriss, and Katherine K. Shea Editor(s):Deborah Lorber see: www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678 viii Booz, Allan, Hamilton. Canada Health Infoway's 10-Year Investment Strategy: pan-Canadian electronic health record, March 2005-09-06. ix The economic cost of wait times in Canada, January 2008. This study was commissioned by the Canadian Medical Association to analyze the economic costs of wait times in Canada's medical system. The CMA's membership includes more than 67,000 physicians, medical residents and medical students. It plays a key role by representing the interests of these members and their patients on the national stage. Located in Ottawa, the CMA has roots across the country through its close ties to its 12 provincial and territorial divisions. See: www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/pdf/2008/EconomicReport.pdf x Sources: Physician visits - CIHI - Physicians in Canada: Fee-for-Service Utilization 2005-2006. Table 1-21. Hospital contacts - CIHI - Trends in Acute Inpatient Hospitalizations and Day surgery Visits in Canada 1995-1996 to 2005-2006 and CIHI -National Ambulatory Care Reporting System - Visit Disposition by Triage Level for All Emergency Visits - 2005-2006. xi Canada boasts a sophisticated network of providers, many globally-recognized hospitals, and a number of major centres for health research. We spend aggressively in global terms on health research, which is supported nationally by the Canadian Institutes of Health Research (CIHR). But against this backdrop lies a mystery: why do so few Canadian health care firms sell their products and services in the international market? Only nine sell as much as $100 million of any product or service to customers outside the country, with total sector sales outside Canada of less than $5 billion. This sector total compares unfavourably with the foreign sales of individual firms such as Bombardier at $22 billion, and Magna International at $14 billion; overseas health-care sales are even dominated by the export of sawn logs, at $9 billion. see: http://www.rotman.utoronto.ca/rogermartin/Canadianhealthcaremystery.pdf (accessed January 7, 2009) From: Roger, Martin, The Canadian Health Care Mystery: Where Are the Exports? Rotman magazine (Winter 2006). xii Ibid.
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Building a Comprehensive Post-Market Surveillance System : Canadian Medical Association Response to Health Canada’s Discussion Paper “Designing a Mandatory System for Reporting Serious Adverse Reactions”

https://policybase.cma.ca/en/permalink/policy1951
Last Reviewed
2012-03-03
Date
2005-07-28
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2012-03-03
Date
2005-07-28
Topics
Health systems, system funding and performance
Text
Building a Comprehensive Post-Market Surveillance System Canadian Medical Association Response to Health Canada’s Discussion Paper “Designing a Mandatory System for Reporting Serious Adverse Reactions” Submitted to Health Canada July 28, 2005 Overview The CMA believes that all stakeholders should work together to improve adverse drug reaction (ADR) reporting, in the interests of improving patients’ safety and health. However, we believe that activity in pursuit of this end must be based on two fundamental premises: a) Reporting is only one part of a comprehensive post-market surveillance system. In order to effectively monitor the safety of Canada’s drug supply, this system should include: * a simple, comprehensive and user-friendly reporting process; * rigorous analysis of reports to identify significant threats to drug safety; * a communications system that produces useful information, distributed to health care providers and the public in a timely, easily understood manner. There is no point in enacting a mandatory reporting requirement until all of these elements are in place. We wonder why mandatory reporting has been singled out for discussion when a holistic approach to reforming Canada’s drug safety system is called for. b) Health care providers should be encouraged to participate willingly and voluntarily in the reporting process. To be successful, Canada’s post-market surveillance system will depend on the active participation of physicians and other health professionals. Experience with health system quality and safety improvement efforts over the past several years has demonstrated that meaningful acceptance is most effectively obtained when those involved are willing participants. If you build a comprehensive, efficient and effective post-market surveillance system, physicians will participate actively in it. Forcing them to participate before the system has been built will result in alienation, frustration and failure. Comments on Discussion Paper a) Is Mandatory Reporting Necessary? This is a fundamental question and the discussion paper does not satisfactorily address it. There are two reasons why we question the necessity for imposing an ADR reporting requirement on health professionals. First, as awareness of the drug-safety system’s importance has increased, the number of ADR reports has increased along with it - more than 10% in 2004, as the discussion paper notes - without a mandatory reporting requirement. Given this trend, it is highly probable that time, education, adequate resources and increasing familiarity with the surveillance system will raise reporting rates to the desired level (however defined) without mandatory reporting. Second, as the discussion paper points out, there is no evidence that mandatory reporting has been effective in other jurisdictions where it has been implemented. The paper offers no clear explanation for this lack of success. More importantly, it does not indicate how Health Canada plans to ensure that mandatory reporting will succeed in this country when it has proven ineffective elsewhere. A primary principle of any system change is that we should not repeat the mistakes of others. Before launching a program whose success has not been proven, other viable, and possibly more effective, alternatives should be examined. b) Addressing known barriers to reporting The CMA acknowledges that ADRs are under-reported, in Canada and worldwide. The discussion paper identifies a number of barriers to reporting, and its list mirrors the observations and experiences of our own members. We believe most of these barriers can, and should, be overcome. We also agree that it is necessary to raise health professionals’ awareness of the importance of, and process for, ADR reporting. But we question the curious assertion that “Mandatory reporting could raise awareness of the value of reporting simply by virtue of the public debate.” Surely there are more positive ways to raise awareness than publicly speculating about the punitive consequences of non-compliance. We suggest that instead, Health Canada work with physicians and other health professionals to address the existing barriers to reporting. Specifically, we recommend that Health Canada implement: * a well-funded and targeted awareness-raising campaign focused on provider education and positive messaging, * a user-friendly reporting system, including appropriate forms, efficient processes and adequate fees. These measures are within Health Canada’s purview in the existing policy and legislative environment. We believe they would increase reporting without the need for coercive measures. At a minimum, positive system improvements should be tried first before considering a mandatory-reporting requirement. With regard to specific questions posed in the discussion paper: Question 1: Health professionals should be explicitly protected from any liability as a result of reporting an adverse drug reaction. This should be the case regardless of whether reporting is voluntary or mandatory. Question 2: Professionals should be compensated for all meaningful work including the completion of forms and any follow-up required as a result of the information they have provided. We would be happy to expand further on this issue on request. Question 3: Issues of confidentiality should be covered in legislation. The CMA has developed an extensive and authoritative body of knowledge on privacy issues in health care, which we would be pleased to share with Health Canada. c) Improved report quality We agree that increasing the quality and richness of ADR reports is as important as increasing their number. Perhaps it is even more important, since high-quality reports allow for high-quality analysis. Mandatory reporting will not improve the quality of ADR reports; it will simply increase their quantity. It may even compromise the system’s efficiency and effectiveness by increasing the volume of clinically insignificant reports. Experience elsewhere has taught us that true quality cannot be legislated or imposed; any attempt to do so would be pointless. If ADR reports included the information listed in Table 4, this would improve their usefulness and the effectiveness of the overall surveillance process. However, it is unrealistic to expect all reports to contain this level of information. The treating physician may not be able to provide all of it, especially if he or she is not the patient’s regular primary care provider. Some of this information, particularly about outcomes, may not be available at the time of the reporting, and gathering it would require follow-up by Health Canada. Health Canada should consider measures other than mandatory reporting to improve the quality of ADR reports. The CMA suggests that consideration be given to: * Improving follow-up capacity. We agree that it should be made easier for Health Canada officials to contact reporters and request details on follow-up or outcomes. This should be considered as part of a comprehensive initiative to improve Health Canada’s capacity to analyze ADR reports. * Establishing a sentinel system. Another option for increasing high-quality reports would be to establish a “sentinel” group of practicing physicians who would contract to report all ADRs in detail. These physicians, because of their contractual obligation, would be committed to assiduous reporting. Sentinel systems could be established concurrently with efforts to increase voluntary ADR reporting by the broader health professional community. In addition to the current information provided, consideration should be given to including on reporting forms the option to allow Health Canada officials to act on information the physician provides; for example, in the reporting of sexually transmitted diseases physicians provide certain information and have the option to request that public health officials undertake follow-up and contact tracing. d) Minimize administrative burden We agree that Health Canada should give consideration to making the ADR reporting system user-friendly, non-complex and easy to integrate into the patient-care work stream. These reforms can and should be implemented regardless of whether a mandatory requirement is in place. They do not need mandatory reporting to make them work; in fact, they are more likely to encourage ADR reporting than any form of coercive legislation. Rather than making a mandatory reporting requirement “fit” with the traditional patient-care framework, we invite Health Canada to work with us to increase health professionals’ capacity to report ADRs voluntarily. We are already working with Health Canada to improve physicians’ access to drug safety material. Health Canada’s ADR reporting form can now be downloaded from the cma.ca web site, which also posts the latest drug alerts from Health Canada and from the Food and Drug Administration in the U.S. We have developed an on-line course in partnership with Health Canada, to teach physicians when and how to make ADR reports. We hope to build on this collaboration, with the goal of making it possible for physicians to report ADRs online via cma.ca. This will permit them to fit reporting more conveniently into their daily workflow. (Note: the “MedEffects” Web portal now being developed at Health Canada does not fit well into the workflow and therefore will not make reporting easier for health professionals.) In the future, we hope that ADR reporting can be built directly into the Electronic Medical Record (EMR). We think this will be a critical element in the bi-directional communicating that ADR reporting requires. It will also enable rapid integration of advisories into the EMR so that they can be available to physicians at the time they are writing a prescription. Before electronic ADR reporting can work, a standard for electronic data should be in place (at present it is not) and Health Canada should develop the capacity to accept data electronically. Health Canada’s discussion paper makes reference to cost-benefit analysis. We recommend that you take great care not to over-emphasize cost-benefit when it comes to enhancing patient safety. Meaningful improvements in the post-market surveillance system will be costly whatever solution Health Canada eventually embraces, and it is impossible to measure financially the value of safety. What is an acceptable cost for one life saved? e) Minimize Over-Reporting The discussion paper acknowledges that not all adverse reactions need be reported. We strongly agree that one of the dangers of mandatory reporting is its potential to overwhelm the system with an unmanageable flood of reports. There is no reason to require reports of minor side effects that are already known to be associated with given drugs. We agree that the reactions Health Canada most needs to know about are those which are severe and/or unexpected. If Health Canada insists on implementing a mandatory reporting system, it should be limited to these reactions (possibly with the corollary that well known serious ADRs would not need to be reported). However, the operating definitions may need clarification, and we recommend that Health Canada consult with health professionals and others on operational guidelines for defining “serious adverse reaction.” Health Canada’s desire to encourage reports on drugs approved within the last 5 years is understandable (though some drugs may be on the market for longer than this before their true risks are known). In practice, however, many physicians do not know which drugs these are, and seeking out this information may impose a heavy administrative burden. As we move toward an EMR-based reporting system, a tag on the Drug Identification Number to tell when the drug was approved will allow physicians to identify which medications require special vigilance. Appropriate reporting could be encouraged, and over-reporting discouraged, by clear guidelines as to what should be reported as well as appropriate compensation for reporting. f) Match Assessment Capacities In our opinion, this is one of the most important sections in the document. What happens once the reports have been received is crucial if we want to identify a serious drug risk as quickly as possible. Under the current system, one of the most significant barriers to physicians’ reporting is lack of confidence that anything meaningful will be done with their reports. Enhancements to the analysis function must be made concurrently with efforts to increase ADR reporting. ADR reports are only cyber-bytes or stacks of paper unless we can learn from them. This requires rigorous data analysis that can sort “signal from noise” – in other words, sift through thousands of reports, find the ones that indicate unusual events, investigate their cause, and isolate those that indicate a serious public health risk. This requires substantial resources, including an adequate number of staff with the expertise and sensitivity required for this demanding task. Unless Health Canada has this capacity, increasing the number of reports will only add to the backlog in analysts’ in-boxes. The CMA recommends that Health Canada allocate sufficient resources to enable it to effectively analyze and respond to ADR reports and other post-market surveillance information. g) Respect privacy Privacy of both patient and physician information is a significant concern. Physicians’ ethical obligation to maintain patient confidentially is central to the patient-physician relationship and must be protected. We acknowledge that issues of privacy and confidentiality must be resolved when designing an ADR reporting system, particularly as we work toward electronic communication of drug surveillance data and its incorporation into an EMR. For example, regulations should explicitly state that ADR reports are to be used only for the purpose for which they were submitted, i.e. for post-market drug surveillance. In addition, Health Canada should ensure that any privacy provisions it develops meet the legislative test outlined in Section 3.6 of CMA’s Health Information Privacy Code (Attachment I). Health Canada can be assured that physicians take their privacy obligations seriously. The CMA has been a strong and pro-active player in debate on this issue, and our Privacy Code lays the groundwork on which we believe any privacy policies involving ADR reporting should be based. h) Compliance through sanctions Physicians are motivated to report ADRs by their concern for public health and their patients’ well-being. In addition, they are guided by the CMA Code of Ethics and governed by regulatory authorities in every province. A clear ethical and professional obligation already exists to report anything that poses a serious threat to patient safety. If physicians do not comply with this obligation, sanctions are available to the provincial regulatory authorities. In fact, the most serious threat for physicians is loss of standing with the professional regulatory authority, not the courts or any external judicial system. It would be superfluous to add a second level of regulation or scrutiny when remedies already exist. The discussion paper presents few alternatives to the existing self-regulatory system. As the paper itself acknowledges, it is unrealistic to impose sanctions based on failure to report an ADR, since it is not always easy to determine whether an adverse effect is attributable to a health product. But the only suggested alternatives - requiring physicians to demonstrate knowledge, or to have the required reporting forms in their office - seem intrusive, crude and unreasonable; they are also meaningless since they have no direct relation to a physician’s failure to report. If Health Canada is considering a large outlay of taxpayers’ dollars for post-market surveillance, we suggest they target those funds to education and awareness raising, and to enhancing the system’s ability to generate and communicate meaningful signal data, rather than to enforcing a mandatory reporting system based on weak compliance measures, with no evidence of its effectiveness in other jurisdictions. Physicians who are in serious breach of their ethical and legal responsibility to report are subject to sanctions by provincial regulatory authorities. Most provincial colleges have policies or guidelines regarding timely reporting and appropriate enforcement mechanisms. Medicine’s tradition of self-regulation has served it well, and we recommend that Health Canada respect and support existing regulatory authorities as they maintain the standards for appropriate professional behaviour. As we have said before - the preferred quality improvement tools to enhance performance and encourage compliance are education and positive reinforcement, not legislation and the threat of sanctions. Conclusion In its discussion paper Health Canada has invited stakeholders to provide their input on how best to develop a mandatory system for reporting ADRs. The Canadian Medical Association believes that the best way to do this is not to develop one at all. Instead, we believe stakeholders should concentrate on building a sustainable, robust and effective post-market surveillance system which: * encourages and facilitates voluntary reporting, by designing a simple and efficient process that can be incorporated into a physician’s daily workflow; * effectively uses reporting data to identify major public health risks; * communicates drug safety information to providers and the public in a timely, meaningful and practical way. The CMA is committed to working, in partnership with Health Canada and other stakeholders, toward the ultimate goal of a responsive, efficient and effective post-market drug surveillance system. This is part of our long-standing commitment to optimizing Canadians’ safety and health, and achieving our vision of a healthy population and a vibrant medical profession.
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