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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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CMA’s Response to CRA’s Questions, Public consultation on the Disability Tax Credit Promoters Restrictions Act regulations

https://policybase.cma.ca/en/permalink/policy14027

Date
2015-05-15
Topics
Health systems, system funding and performance
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Date
2015-05-15
Topics
Health systems, system funding and performance
Physician practice/ compensation/ forms
Text
The Canadian Medical Association (CMA) is pleased to provide the information below in response to questions by the Canada Revenue Agency (CRA) for consideration as part of the development of regulations following the enactment of the Disability Tax Credit Promoters Restriction Act. This information is in follow up to CMA’s submission to the CRA dated December 19, 2014, attached for reference. As explained in the CMA’s submission attached, the CMA strongly encourages the CRA to include an exemption for “a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment” from the reporting requirements in the forthcoming regulations enabled by the Disability Tax Credit Promoters Restriction Act. This exemption is necessary to ensure CRA does not impose duplicative regulatory oversight of the medical profession, specific to the provision of this uninsured service. As fully explained in the CMA’s brief, this exemption would not introduce a potential “loophole”. Issue 1: Organizations Responsible for Physician Regulatory Oversight The statutory authority for the regulatory oversight of physicians rests with the provincial and territorial medical regulatory colleges. As explained on page 4 of the CMA’s submission, medical regulatory colleges have statutory, comprehensive regulatory authority of physicians; this authority captures: medical licensure, governing standards of practice, professional oversight, and disciplinary proceedings. Included in this authority is broad regulatory oversight for fees that physicians may charge for uninsured services, which would capture the fee charged for the Disability Tax Credit form. The Federation of Medical Regulatory Authorities of Canada (FMRAC) is the umbrella organization representing provincial and territorial medical regulatory authorities in Canada and can address how best to contact individual regulatory colleges.1 Issue 2: CMA’s Code of Ethics In addition to policies, guidance and oversight by provincial and territorial regulatory colleges, charging a fee associated with the delivery of an uninsured service, in this case a fee associated with completing the form associated with the Disability Tax Credit, is captured by Section 16 of the CMA’s Code of Ethics. Section 16 states: “In determining professional fees to patients for non-insured services, consider both the nature of the service provided and the ability of the patient to pay, and be prepared to discuss the fee with the patient.”2 Issue 3: Fee Structure for Uninsured Services As the CRA does not provide remuneration to physicians for the completion of the Disability Tax Credit form, the delivery of this service by physicians is an uninsured service. As an uninsured service there is no set fee level. While provincial and territorial medical associations Canadian Medical Association 3 May 15, 2015 may provide guidance to physicians within their jurisdiction on uninsured services, which may be referenced in policies by regulatory colleges, this guidance does not constitute a set fee schedule. As captured in the CMA’s Code of Ethics referenced above, physicians may consider patient-specific and other factors in determining a fee for the delivery of an uninsured service. The CMA encourages CRA to review relevant policies and guidance of individual provincial and territorial regulatory colleges for a comprehensive understanding of the oversight of uninsured services. Closing Once again, the CMA appreciates the opportunity to provide further information to support the development of regulations to enable the new authorities of the Disability Tax Credit Promoters Restriction Act and to ensure that CRA does not impose redundant and duplicative regulatory oversight of the medical profession. 1 FMRAC’s Executive Director is Dr. Fleur-Ange Lefebvre and can be reached at falefebvre@fmrac.ca 2 CMA’s Code of Ethics may be accessed here: https://www.cma.ca/Assets/assetslibrary/ document/en/advocacy/policyresearch/ CMA_Policy_Code_of_ethics_of_the_Canadian_Medical_Association_Update_2004_PD04-06-e.pdf

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Registered retirement savings plans : Presentation to the House of Commons Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy1996

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

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Response of the Canadian Medical Association to the Canada Revenue Agency Draft GST/HST Policy Statement* (GST/HST Notices - Notice 286)

https://policybase.cma.ca/en/permalink/policy11479

Date
2015-02-23
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Date
2015-02-23
Topics
Physician practice/ compensation/ forms
Text
*Draft GST/HST Policy Statement - Qualifying Health Care Supplies and the Application of Section 1.2 of Part II of Schedule V to the Excise Tax Act to the Supply of Medical Examinations, Reports and Certificates (GST/HST Notices - Notice 286, October 2014) The Canadian Medical Association (CMA) is the national voice of Canadian physicians. Founded in 1867, CMA's mission is to help physicians care for patients. 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. Introduction The 2013 Federal Budget introduced amendments to the Excise Tax Act that extend the application of the Goods and Services Tax/Harmonized Sales Tax (GST/HST) to supplies of reports, examinations and other property or services that are not made for the purpose of the protection, maintenance or restoration of the health of a person or for palliative care: new sections were added to the Excise Tax Act introducing additional conditions that must be met before uninsured health care services will be exempted from the GST/HST. These amendments are retroactive to March 22, 2013, for most provinces (exception: April 1, 2013, for Prince Edward Island). In response, the Canadian Medical Association (CMA) detailed the concerns of its members in a formal letter to the Canada Revenue Agency (CRA) and requested that the CRA conduct a consultation with stakeholders. On October 31, 2014, the CRA released a draft GST/HST policy statement, Qualifying Health Care Supplies and the Application of Section 1.2 of Part II of Schedule V to the Excise Tax Act to the Supply of Medical Examinations, Reports and Certificates, herein referred to as the draft policy. The CRA notes that these "amendments clarify that [the] GST/HST applies to supplies of reports, examinations and other property or services that are not made for the purpose of the protection, maintenance or restoration of the health of a person or for palliative care." The CMA has consulted with all provincial and territorial medical associations on this matter and is pleased to provide its comments with respect to the draft policy. This document is intended to (1) highlight CMA's concerns with respect to the draft policy and (2) provide recommendations to improve it. Overall comments Although the draft policy is intended to clarify CRA's position with respect to the meaning of the term "qualifying health care supply" (QHCS), it provides insufficient guidance with respect to the CRA's view on (1) the meaning of the different elements of a QHCS, (2) the factors to be considered when determining if a supply is a QHCS and/or (3) the documentation required to support a physician's conclusions regarding the nature of his/her supplies. The CMA is concerned that this ambiguity will ultimately lead to confusion for patients and clinicians alike. Moreover, the CMA has identified the following high-level concerns with the draft policy: * Changes in the draft policy are retroactive to March 22, 2013, for most provinces (exception: April 1, 2013, for Prince Edward Island). There is a prolonged gap between the coming into force date (budget date) and the date on which CRA issued guidance on the new tax rules. * The draft policy places the responsibility for determining the purpose of a supply on the practitioner. The policy needs to provide additional guidance to practitioners on how to determine the purpose of a particular supply. * The CRA must ensure that the audit process respects patient-physician confidentiality. The draft policy should indicate the record-keeping/reporting requirements a physician should consider. The scope of the policy is also limited in some other ways. The policy does not address the implications for a physician of making a taxable supply, such as (1) how to apply the coming into force rule, (2) when to register for the GST/HST and (3) which rate of GST/HST to apply. New purpose test The CMA believes that physicians will find it problematic to apply the new purpose test in certain situations. This is because the purpose test is subjective and needs to be applied on a case-by-case, patient-by-patient basis. As a result, different individuals may reach different conclusions, depending on their expertise (i.e., physicians vs. CRA auditors). Furthermore, the draft policy does not provide comments on the meaning of terms such as "for the purpose of" or the terms "maintaining health," "preventing disease" and "treating ... illness, disorder or disability." Moreover, the draft policy does not mention the first order supply principle or specify CRA's view on whose health must be maintained or whose disease, injury, illness, disorder or disability must be addressed. Must it be the recipient of the supply, the person to whom the services are rendered, or may it be another person? The answers to these questions are determined based on the particular scenario. The draft policy places the responsibility for determining the purpose of a supply on the practitioner. However, the draft policy does not provide guidance on how to determine the purpose of a particular supply. Furthermore, it is conceivable that the purpose of a supply could change either during an initial visit (i.e., if an illness is identified) or over time (as a result of changing medical opinions on certain procedures). Moreover, the draft policy does not recognize and consider that the diagnostic procedures performed by a practitioner when examining a patient are the same whether or not the practitioner is being paid by or providing a report to a third party. It also does not recognize and consider that even though the practitioner may be reporting to a third party, he/she is also discussing his/her recommendations for treatment with the patient. Recommendations 1. Expand on the meaning of "for the purpose of," as follows: * Discuss the first order supply principle and how it would apply to the purpose test in this circumstance (e.g., is the purpose the immediate reason for the supply or does one have to consider the eventual or ultimate goal?). * Provide a list of factors that practitioners should consider when they are determining the purpose of the supply (see Appendix 1 for other CRA policy statements that include such lists). * Discuss the impact of an additional purpose arising during the course of an examination. 2. Clarify the meaning of the following terms: * maintaining health * preventing disease * treating, relieving or remediating an injury, illness, disorder or disability 3. Recognize and consider that the diagnostic procedures used by a practitioner when examining a patient are the same whether or not the practitioner is being paid or providing a report to a third party (e.g., insurance company, court) and that even though the practitioner may be reporting to a third party, the practitioner is also discussing their recommendations for treatment with the patient. The draft policy should address and explore this issue. 4. Provide examples of documentation that could be used to support a practitioner's decision, taking into account the need to maintain the confidentiality of patient records. Assisting (other than financially) an individual in coping with an injury illness, disorder or disability Without further guidance, the meaning of "assisting (other than financially) an individual in coping with an injury illness, disorder or disability" is subjective. Practitioners may disagree on whether or not a particular supply meets the definition. The current policy provides insufficient guidance on how to determine if a report is for financial assistance or for coping with an injury, illness, disorder or disability. For example, reports to employers could be for either purpose. Recommendations 5. Provide greater clarity with respect to the concept of "assisting (other than financially) an individual in coping with an injury illness, disorder or disability." 6. Provide comments on the meaning of the following terms: * financial assistance * injury, illness, disorder or disability 7. Provide factors to guide practitioners in determining when a report to a third party is for financial assistance or for another purpose. 8. Provide examples of documentation that would be sufficient to demonstrate to the CRA the validity of the practitioner's conclusion that a supply is a QHCS. Single- versus multiple-supply analysis The draft policy states: "In cases where a supply is made for more than one purpose, all of these purposes would be considered when determining if the supply is a qualifying health care supply. If one of the purposes for the supply meets the definition of 'qualifying health care supply' then the supply would be a qualifying health care supply. However, it should be noted that supplies are generally made for a single purpose. In cases where a health care service, such as an examination or assessment, is supplied together with a report or certificate it is necessary to determine if the supplier has made a single or multiple supplies." The addition of the single versus multiple supply analysis adds significant complexity to the process of determining whether a supply is a QHCS. If a service is considered by the CRA as constituting multiple supplies, each with a different tax treatment, the practitioner will have to apportion the fees between the supplies for tax application purposes. It is not practical for a clinician to analyze whether a particular patient visit is a single supply or whether it constitutes multiple supplies. This responsibility would be an onerous burden for practitioners. Recommendations 9. The draft policy should take the view that, in general, there is a single supply. 10. The draft policy should clearly indicate that the health care purpose is determinative and takes precedence over any other purpose. If a supply has multiple purposes, and one of the purposes is a qualifying health care supply, then the supply will be classified as a QHCS and thus exempt from GST/HST. 11. Provide practical examples of situations in which a practitioner could be making multiple supplies. 12. Provide a list of factors specific to the QHCS to help practitioners determine whether a supply constitutes a single supply or multiple supplies. Examples The draft policy includes 23 examples that each set out the CRA's view on whether or not a particular supply or combination of supplies qualifies as a QHCS and is therefore exempt. All of the examples involve a single supply; there are no scenarios involving multiple supplies. Furthermore, although the examples provide the CRA's decision on whether or not the supply in question constitutes a QHCS, they do not discuss the various factors/elements that the CRA would consider in reaching that decision. For example, examples 3, 4 and 5 all involve an examination of a patient and a report or document that a patient provides to an employer or potential employer. The draft policy does not clearly explain why the supplies in examples 4 and 5 are QHCS but the supply in example 3 is not. Moreover, in some cases, the examples provided by the CRA do not reflect all of the aspects of the scenario in question. For example, in Alberta, a driver's medical examination (and completion of the associated form) is an insured service after the age of 75 years, but example 10 makes the blanket statement that completion of such a form is not a QHCS. Another example is that in some cases there is a subtle distinction between sick notes and short-term disability forms, for time missed because of illness. Recommendations 13. If both single- and multiple-supply concepts are included in the final version of the policy, examples with multiple supplies should also be included. 14. For each example, clarify in the rationale section how the tax status was determined in each example. 15. Include a linkage to the factors discussed in the draft policy statement suggested above in making its determination of the tax status of the supply. 16. The CRA should maintain a repository and distribute a list of additional examples not included in this iteration of the policy (e.g., annual executive medical examinations, applications for Disability Tax Credit). 17. The policy could include comments on GST/HST registration, collection and reporting requirements, the association rules and the small supplier threshold as well as possible eligibility for recoveries of GST/HST by way of rebate or input tax credits (ITC) and ITC allocation requirements. Conclusion The CMA appreciates the opportunity to comment on the draft policy as part of CRA's consultation process. To ensure that clinicians can implement the new requirements with minimal impact on their patients and their practice, additional clarity is required with respect to the meaning of the various elements in the definition of a QHCS, the factors to be considered when determining if a supply is a QHCS, and the documentation required to support a physician's conclusions regarding the nature of his/her supplies. The CMA would welcome the opportunity to comment on future iterations of this policy. Appendix 1 Examples of GST/HST policy statements that include a list of factors to assist the reader in determining whether a particular set of facts meets the CRA's policy: * P - 244: Partnerships - Application of subsection 272.1(1) of the Excise Tax Act. * P - 238: Application of the GST/HST to Payments Made Between Parties Within a Medical Practice Organization * P - 228: Primary Place of Residence * P - 208R: Meaning of Permanent Establishment * P - 276R: Application of Profit Test to Carrying on a Business * P - 167R: Meaning of the First Part of the Definition of Business * P - 164: Rent-to-own Agreements * P - 111R: The Meaning of Sale with Respect to Real Property * P - 104: Supply of Land for Recreational Units Such as Mini-homes, Park Model Trailers, and Travel Trailers * P - 090 Remote Work Site * P - 077R2 - Single and Multiple Supplies * P - 051R2: Carrying on Business in Canada

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