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CMA's Presentation to the House of Commons Standing Committee on Finance: Pre-budget Consultations 2010-2011

https://policybase.cma.ca/en/permalink/policy10018

Date
2010-10-27
Topics
Health systems, system funding and performance
Health human resources
  1 document  
Policy Type
Parliamentary submission
Date
2010-10-27
Topics
Health systems, system funding and performance
Health human resources
Text
The CMA brief contains seven recommendations to address pressing needs in the health care system. Before I get to those, I'd like to highlight why, from my perspective, our health care system is in need of the federal government's attention. Yesterday, at the Ottawa Hospital, where I am Chief of Staff: * Our occupancy was 100 per cent. * 30 patients who came to the emergency department were admitted to the hospital, but we had beds for only four of them. * 10 are still waiting on gurneys in examining rooms within the emergency department. * Six patients were admitted to wards and are receiving care in hallways. * Three surgeries were cancelled - bringing the number of cancellations this year to 480. * But while all this was happening, we had 158 patients waiting for a bed in a long-term-care facility. Equally, a few blocks from here and in communities across the country, the health status of our poorest and most vulnerable populations is comparable to countries that have a fraction of our GDP - despite very significant investments in their health. This is just my perspective. Health care providers of all types experience the failings of our system on a daily basis. We as a country can do better and Canadians deserve better value for their money. Canada's physicians are calling for transformative change to build a health care system based on the principles of accessibility, high quality, cost effectiveness, accountability and sustainability. Through new efficiencies, better integration and sound stewardship, governments can reposition health care as an economic driver, an agent of productivity and a competitive advantage for Canada in today's global marketplace. The Health Accord expires in March 2014, and we strongly urge that the federal government begin discussions now with the provinces and territories on how to transform our health care system so that it meets patients' needs and is sustainable into the future. Canadians themselves also need to be part of the conversation. To help position the system for this transformative change, the CMA brief identifies a number of issues that the federal government should address in the short term: First, our system needs investments in health human resources to retain and recruit more doctors and nurses. Although we welcome measures in the last budget to increase the number of residency positions, we urge the government to fulfill the balance of its election promise by further investing in residencies, and to invest in programs to repatriate Canadian-trained physicians living abroad. Second, we need to bolster our public health e-infrastructure so that it can provide efficient, quality care that responds more effectively to pandemics. We recommend increased investment: * to improve data collection and analysis between local public health authorities and primary care practices, * for local health emergency preparedness, and * for the creation of a pan-Canadian strategy for responding to potential health crises. Third, issues related to our aging population also call for action. As continuing care moves from hospitals into the home, the community, or long-term care facilities, the financial burden shifts from governments to individuals. We recommend that the federal government study options for pre-funding long-term care - including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance - to help Canadians prepare for their future home care and long-term care needs. And, as much of the burden of continuing care for seniors also falls on informal, unpaid caregivers, the CMA recommends that pilot studies be undertaken to explore tax credit and/or direct compensation for informal caregivers for their work, and to expand programs for informal caregivers that provide guaranteed access to respite services in emergency situations. Finally, the government should increase RRSP limits and explore opportunities to provide pension vehicles for self-employed Canadians. Mr. Chair, a fuller set of recommendations is contained in our report -- Health Care Transformation in Canada: Change that Works. Care that Lasts. These include universal access to prescription drugs; greater use of health information technology; and the immediate construction of long-term care facilities. We urge the Committee to consider both our short-term recommendations - and our longer term vision for transforming Canada's health care system. I look forward to your questions. Thank you.

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CMA's Presentation to the House of Commons Standing Committee on Health : H1N1 Preparedness and Response

https://policybase.cma.ca/en/permalink/policy9699

Date
2009-10-05
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2009-10-05
Topics
Population health/ health equity/ public health
Text
Good afternoon Madame Chair. The Canadian Medical Association is pleased to address the committee as part of its ongoing study of H1N1 planning and response. In the broad context of pandemic planning, the CMA has focused on developing information and education tools on cma.ca to ensure Canada's doctors are equipped to provide the best possible care to patients. We have also engaged in discussions with the Assembly of First Nations to address workforce shortages in First Nations and Inuit communities during a pandemic. Despite the work of governments and others, there remains much to do. To provide optimal patient care, individual physicians - primary care providers and specialists alike - require: * Regular updates on the status of H1N1 in their community; * Timely and easy access to diagnostic and treatment recommendations with clear messages tailored to their service level; * Rapid responses to questions; and * Adequate supplies of key resources such as masks, medications, diagnostic kits and vaccines. The CMA commends federal, provincial and territorial governments for creating the Canadian Pandemic Influenza Plan for the Health Care Sector. The CMA was pleased to provide feedback on elements of the plan and we are participating on the anti-viral and clinical care task groups. There are three issues that still must be addressed: First, the communications gap between public health officials and front-line providers; Second, the lack of adequate resources on the front lines; and finally, variability that exists across the country. The Communications Gap Physicians must be involved in the planning stages and must receive consistent, timely and practical plain-language information. They should not have to seek information out from various websites or other sources, or through the media. This communications gap also includes a gap between information and action. For example, we are told to keep at least a six-foot distance between an infected patient and other patients and staff. This will not be possible in a doctor's waiting room, nor will disinfecting examining and waiting rooms in-between each patient. Adequate resources Patient volumes may increase dramatically and there are serious concerns about how to manage supplies if an office is overwhelmed. There is also considerable concern over whether we can keep enough health care professionals healthy to care for patients, and whether we have enough respirators and specialty equipment to treat patients. Intensive-care units of hospitals can also expect to be severely strained as a second-wave pandemic hits. This speaks to a general lack of surge capacity within the system. Also, pandemic planning for ICUs and other hospital units must include protocols to determine which patients can benefit most when there are not enough respirators and personnel to provide the required care for all who need it. Beyond the need for more supplies, however, there is also the concern that there are only so many hours in a day. Doctors will always strive to provide care for those who need it, but if treating H1N1 cases takes all of our time, who will be available to care for patients with other conditions? Variability across the country CMA has consulted with provincial and territorial medical associations and their level of involvement in government planning as well as the general state of preparedness varies greatly. There is also marked inconsistency province-to-province around immunization schedules. We need a clear statement of recommendation to clear up this variability. In summary, there remains a great deal of uncertainty among physicians about: the vaccine, the supply of antivirals, the role of assessment centres and mass immunization clinics, delegated acts, and physicians' medico-legal obligations and protections. The bottom line is that there is still more work to do at all levels before front-line clinicians feel well prepared with information, tools and strategies they need. The CMA was pleased to meet with Dr. Butler-Jones to discuss our concerns last week and will continue to work closely with Public Health Agency of Canada to identify gaps and to prepare user-friendly information for clinicians. Thank you and I welcome any questions.

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Elder Abuse and Disability Hearing: CMA's Presentation to the Parliamentary Committee on Palliative and Compassionate Care

https://policybase.cma.ca/en/permalink/policy10060

Date
2010-10-25
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2010-10-25
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) wishes to commend the multi-party group of Members of Parliament who have come together to form the Parliamentary Committee on Palliative and Compassionate Care. The challenge we face today in caring for our aging population is only going to get greater. Statistics Canada has projected a rapid increase in the proportion of seniors in the population. The first wave of the baby boom generation turns 65 next year. By 2031, seniors will account for roughly one-quarter of the population, nearly double the 13.9% observed in 2009.1 Canadians are clearly concerned about their ability to cope with future health care expenses, either their own or those of their parents. Respondents to the CMA's 2010 Annual National Report Card on Health Care survey anticipate a range of implications associated with our aging population: * 29% reported that they will likely alter their retirement plans (e.g., work longer) to help pay for their own future costs or those of their parents; * Almost one in five (19%) anticipates moving their parents into their own home and supporting them financially; and * One in six (16%) anticipates paying for their parents to live in a nursing home.2 The CMA believes that the federal government could play a key role in allaying Canadians' concerns about the future by leading negotiations with the provinces and territories and taking direct action on extending access along the continuum of care. These actions should focus on three priority areas: * Increasing access by all Canadians to affordable prescription drugs; * Supporting informal caregivers; and * Increasing access to palliative care at the end of life. If nothing is done to extend Medicare to cover more of the continuum of care, it will erode over time as a national program. When the Canada Health Act (CHA) was passed in 1984, physician and hospital services represented 57% of total health spending; this had declined to 42% as of 2009.3 While there is significant public spending beyond CHA-covered services (more than 25% of total spending) for programs such as seniors' drug coverage and home care, these programs are not subject to the CHA principles and coverage across the provinces and territories varies significantly. Access to Prescription Drugs The federal government missed an excellent opportunity to modernize Medicare in July 2004 when Premiers called on it to upload responsibility for drug programs. The Premiers stated that "a national pharmaceutical program should immediately be established. The federal government should assume full financial responsibility for a comprehensive drug plan for all Canadians, and be accountable for the outcomes."4 The federal government did not give this offer even fleeting consideration. Instead, the September 2004 10-Year Plan to Strengthen Health Care contained a watered-down version of the First Ministers' 2003 commitment to ensure that all Canadians would have reasonable access to catastrophic drug coverage by the end of 2005/06. The 2004 Accord reduced this commitment to the development of costing options for pharmaceutical coverage, as part of a nine-point National Pharmaceuticals Strategy (NPS).5 Costing options were included in the 2006 progress report of the NPS but they included estimates of the cost of catastrophic coverage wildly exceeding those of Romanow and Kirby, ranging from $6.6 billion to $10.3 billion.6 Nothing further has been heard about the NPS since stakeholder consultations were held in fall 2007. As recently as September 2008, the provinces and territories (PTs) were still interested in federal participation in pharmaceuticals. In the communiqué from their annual meeting, the PT health Ministers called for a three-point funding formula to support a national standard of pharmacare coverage, including: * PT flexibility and autonomy in program design; * Prescription drug costs not to exceed 5% of net income; and * Federal and PT governments to cost share 50/50, estimated at $2.52 billion each in 2006.7 Again there was no reaction from the federal government. Since then the PT governments have appeared to be giving up hope of federal participation in access to pharmaceuticals. At their June 2009 meeting, the western Premiers announced they would develop a joint western purchasing plan for pharmaceuticals,8 and more recently at the August 2010 meeting of the Council of the Federation, Premiers agreed to establish a pan-Canadian purchasing alliance for common drugs, medical supplies and equipment.9 Health Ministers reaffirmed this commitment at their September 2010 meeting.10 One can speculate that had the federal government taken up the Premiers' offer in 2004, many aspects of the NPS would be in place by now. Meanwhile, access to prescription drugs presents a hardship for many Canadians. In the CMA's 2009 National Report Card survey, nearly one in six (14%) reported they had either delayed or stopped buying some prescription drugs. This ranged from more than one in five (22%) with annual incomes of less than $30,000 to just over one in 20 (7%) of those with incomes greater than $90,000.11 The wide geographic disparity in out-of-pocket drug expenditures is shown in the table below, which is compiled from Statistics Canada's 2009 Survey of Household Spending. Table 1 shows the percentage of households spending more than 3% and 5% of after-tax income on prescription drugs, by province, in the year prior to the survey. [Note - see PDF for correct display of table information] % of Households Spending Greater than 3% and 5% of After-tax Income on Prescription Drugs, Canada and Provinces, 2008 Geography >3% >5% Canada 7.6 3.0 Newfoundland and Labrador 11.6 5.4E Prince Edward Island 13.3 5.8E Nova Scotia 8.9 3.8 New Brunswick 9.1 4.1E Quebec 11.6 3.3 Ontario 4.7 2.2E Manitoba 12.0 5.2 Saskatchewan 11.5 5.9 Alberta 4.6E 2.2E British Columbia 7.5 3.6 E - Use with caution - high coefficient of variation Source: Statistics Canada, CANSIM Table 109-5012 Under both thresholds there is a more than two-fold variation across provinces in the incidence of catastrophic drug expenditures. At the 5% threshold the range is from 2.2% of households in Ontario and Alberta to 5.8% in PEI and 5.9% in Saskatchewan. With the growing availability of more expensive drugs, this variation is only likely to be exacerbated in the years ahead. Recommendation 1 The federal government should negotiate a cost-shared program of comprehensive prescription drug coverage with the provincial/territorial governments. This program should be administered through provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. Such a program should include the following elements: * A mandate for all Canadians to have either private or public coverage for prescription drugs; * Uniform income-based ceiling (between public and private plans across provinces/territories) on out-of-pocket expenditures on drug plan premiums and/or prescription drugs (e.g., 5% of after-tax income); * Federal/provincial/territorial cost-sharing of prescription drug expenditures above a household income ceiling, subject to capping the total federal and/or provincial/territorial contributions either by adjusting the federal/provincial/territorial sharing of reimbursement or by scaling the household income ceiling or both; * Group insurance plans and administrators of employee benefit plans to pool risk above a threshold linked to group size; and * A continued strong role for private supplementary insurance plans and public drug plans on a level playing field (i.e., premiums and co-payments to cover plan costs). In negotiating this plan, consideration should be given to the following: * Establishing a program for access to expensive drugs for rare diseases where those drugs have been demonstrated to be effective; * Assessing the options for risk pooling to cover the inclusion of expensive drugs in public and private drug plan formularies; * Provision of adequate financial compensation to the provincial and territorial governments that have developed, implemented and funded their own public prescription drug insurance plans; and * Provision of comprehensive coverage of prescription drugs and immunization for all children in Canada. Supporting Informal Caregivers As the population ages, the incidence of diseases associated with dementia is projected to increase dramatically. A 2010 study commissioned by the Alzheimer Society of Canada has reported that the 2008 level of an estimated 103,728 new dementia cases is expected to more than double to 257,811 per year by 2038. Over this period, the demand for informal caregiving will skyrocket. In 2008, the Alzheimer Society reports, the opportunity cost of unpaid care giving was estimated at almost $5 billion. By 2038 this cost is expected to increase by 11-fold, to reach $56 billion, as the overall prevalence of dementia will have risen to 1.1 million people, representing 2.8% of the Canadian population.12 The burden of informal care giving extends beyond the costs related to dementia. Statistics Canada's 2007 General Social Survey has documented the extent to which Canadians are providing unpaid assistance to family, friends or other persons with a long-term health condition or physical limitation. Nationwide, 1.4 million adults aged 45 or over living in the community were receiving care in 2007. Of this number almost one in two (46.9%) were receiving both paid and unpaid care, almost three in 10 (27.4%) were receiving unpaid care only, and just under one in five (18.8%) were receiving paid care only. This underscores the importance of the informal sector. In terms of who was providing this care, an estimated four million Canadians were providing care, of whom one million were aged 65 or over, while almost two million (1.8) were in the prime working age range of 45 to 54. The provision of unpaid care represents a significant time commitment. The caregivers who reported helping with at least one activity spent an average 11.6 hours in a typical week doing so. Those providing care reported significant personal consequences. One in three reported spending less time on social activities (33.7%) or incurring extra expenses (32.7%), almost one in five cancelled holiday plans (18.7%) or spent less time with their spouse (18.7%), and more than one in 10 (13.7%) reported that their health had suffered. The 2.5 million informal caregivers who were in the paid labour force were likely to report that caregiving had had a significant impact on their jobs. Almost one in four (24.3%) reported missing full days of work and one in six (15.5%) reported reducing hours of work. Compared to the total population, informal caregivers were more likely to report stress in their lives. Almost three in 10 (27.9%) reported their level of stress on most days to be either quite a bit or extremely stressful compared to fewer than one in four (23.2%) of the total population.13 As the demand for informal care grows, it seems unlikely that the burden of informal caregiving will be sustainable without additional support. The federal government took the positive step in 2004/05 of introducing Employment Insurance (EI) Compassionate Care Benefits for people who are away from work temporarily to provide care or support to a family member who is gravely ill and at risk of dying within 26 weeks.14 So far, however, this program has had limited uptake. In 2007/08, 5,706 new claims were paid.15 This pales in comparison to the 235,217 deaths that year (although not all of these would be candidates for this type of care).16 Recommendation 2 The federal government should implement measures within its jurisdiction, such as the use of tax credits, to support informal caregivers. Increasing Access to Palliative Care at the End of Life The Senate of Canada, and Senator Sharon Carstairs in particular, have provided exemplary leadership over the last 15 years in highlighting both the progress and the persistent variability across Canada in access to quality end-of-life care. The Senator's 2005 report Still Not There noted that only an estimated 15% of Canadians have access to hospice palliative care and that for children the figure drops even further to just over 3%.17 The 2005 report repeated the 1995 call for a national strategy for palliative and end-of-life care. To date, palliative care in Canada has primarily centred on services for those dying with cancer. However, cancer accounts for less than one-third (30%) of deaths in Canada. Diseases at the end of life, such as dementia and multiple chronic conditions, are expected to become much more prevalent in the years ahead. The demand for quality end-of-life care is certain to increase as the baby boom generation ages. There will be an estimated 40% more deaths a year by 2020. While the proportion of Canadians dying in hospital has been decreasing over the past decade, many more Canadians would undoubtedly prefer to have the option of hospice palliative care at the end of their lives than current capacity will permit. In the 2004 Health Accord, First Ministers built on their 2003 Accord by agreeing to provide first dollar coverage for certain home care services by 2006, including end-of-life care for case management, nursing, palliative-specific pharmaceuticals and personal care at the end of life. Seven years later we have no comprehensive picture of the availability of end-of-life care across Canada. The Health Council of Canada's last detailed reporting on the implementation of the 2003 Accord was in 2006. At that time, the only province to report comprehensive end-of-life care was British Columbia.18 For most other jurisdictions, end-of-life care was discussed under "next steps." Since then, the Health Council has ceased comprehensive reporting on the Accord. In the 2007 National Physician Survey, doctors across Canada were asked to rate the accessibility of the range of services for their patients. Just one in three (32%) rated access to palliative care services as either excellent or very good.19 In 2006, the Canadian Hospice Palliative Care Association and the Canadian Home Care Association jointly issued a 35-point "gold standard" for palliative home care, covering the areas of case management, nursing care, pharmaceuticals and personal care, which they commended to governments.20 In its April 2009 report, the Special Senate Committee on Aging recommended a federally funded national partnership with provinces, territories and community organizations to promote integrated, quality end-of-life care for all Canadians, the application of gold standards in palliative home care to veterans, First Nations and Inuit, and federal inmates, and renewed research funding for palliative care.21 In 2010, the Quality End-of-Life Care Coalition of Canada (QELCC), of which the CMA is a member, released its Blueprint for Action 2010 to 2020. The four priorities are: * Ensure all Canadians have access to high-quality hospice palliative end-of-life care; * Provide more support for family caregivers; * Improve the quality and consistency of hospice palliative end-of-life care in Canada; and * Encourage Canadians to discuss and plan for end-of-life.22 This blueprint embodies the sound ideas that have emerged over the past decade. In June 2010, Senator Carstairs released her latest report Raising the Bar, which, while acknowledging some of the achievements that have been made in palliative care, repeats her previous calls for a national role and active engagement of the federal government.23 A wide range of stakeholders either have, or should have, a significant stake in the issue of palliative care. They include patients and the organizations that advocate on their behalf, caregivers (both formal and informal), the institutional and community health sectors, and the employer/business community. Recommendation 3 The CMA urges the federal government to collaborate with the provincial and territorial governments to convene a national conference in 2011 to assess the state of palliative care in Canada. Notes 1 Statistics Canada. Population projections for Canada, provinces and territories 2009 to 2036. Catalogue no. 91-520-X. Ottawa. Minister of Industry, 2010. 2 Canadian Medical Association. 10th Annual National Report Card on Health Care, August, 2010. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/2010/report_card/2010-National-Report-Card_en.pdf. Accessed 09/28/10. 3 Canadian Institute for Health Information. National health expenditure trends 1975 to 2009. Ottawa, 2009. 4 Canadian Intergovernmental Conference Secretariat. Premiers' action plan for better health care: resolving issues in the spirit of true federation. July 30, 2004. http://www.scics.gc.ca/cinfo04/850098004_e.html. Accessed 09/28/10. 5 Canadian Intergovernmental Conference Secretariat. A 10-year plan to strengthen health care. http://www.scics.gc.ca/cinfo04/800042005_e.pdf. Accessed 09/28/10. 6 Health Canada. National Pharmaceuticals Strategy Progress Report. June 2006. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2006-nps-snpp/2006-nps-snpp-eng.pdf. Accessed 09/28/10. 7 Canadian Intergovernmental Conference Secretariat. Annual Conference of Provincial-Territorial Ministers of Health. September 4, 2008. http://www.scics.gc.ca/cinfo08/860556005_e.html. Accessed 09/28/10. 8 Canadian Intergovernmental Conference Secretariat. Premiers taking action on pharmaceuticals. June 18, 2009. http://www.scics.gc.ca/cinfo09/850114004_e.html. Accessed 09/28/10. 9 Council of the Federation. Premiers protecting Canada's health care systems. http://www.councilofthefederation.ca/pdfs/PremiersProtectingCanadasHealthCareSystem.pdf. Accessed 09/28/10. 10 Canadian Intergovernmental Conference Secretariat. P/T health Ministers work together to advance common issues. September 13, 2010. http://www.scics.gc.ca/cinfo10/860578004_e.html. Accessed 09/28/10. 11 Canadian Medical Association. 9th Annual National Report Card on Health Care. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/2009/report_card/Report-Card_en.pdf. Accessed 09/28/10. 12Alzheimer Society of Canada. Rising tide: the impact of dementia on Canadian society. http://www.alzheimer.ca/docs/RisingTide/Rising%20Tide_Full%20Report_Eng_FINAL_Secured%20version.pdf. Accessed 09/28/10. 13 Statistics Canada. 2007 General Social Survey: Care tables. Catalogue no. 89-633-X. Ottawa, Minister of Industry, 2009. 14Human Resources and Skills Development Canada. Information for health care professionals: EI Compassionate Care. http://www.rhdcc-hrsdc.gc.ca/eng/publications_resources/health_care/ei_ccb.shtml. Accessed 09/28/10. 15 Human Resources and Skills Development Canada. Table 2.12 Compassionate care benefits. http://www.hrsdc.gc.ca/eng/employment/ei/reports/eimar_2009/annex/annex2_12.shtml. Accessed 09/28/10. 16 Statistics Canada. Deaths 2007. The Daily, Tuesday, February 23, 2010. 17 Carstairs S. Still not there. Quality end-of-life care: a status report. http://sen.parl.gc.ca/scarstairs/PalliativeCare/Still%20Not%20There%20June%202005.pdf. Accessed 09/24/09. 18 Health Council of Canada. Jursdictional tables on health care renewal. Companion document to Health care renewal in Canada Measuring up? Annual report to Canadians 2006. Toronto, ON, 2007 19 College of Family Physicians of Canada. Canadian Medical Association. Royal College of Physicians and Surgeons of Canada. National Physician Survey 2007. Q25a. Please rate the accessibility of the following for your patients. http://www.nationalphysiciansurvey.ca/nps/2007_Survey/Results/ENG/National/pdf/Q25/Q25aALL.only_NON.CORE.only.pdf. Accessed 09/28/10. 20 Canadian Hospice Palliative Care Association. Canadian Home Care Association. The pan-Canadian gold standard for palliative home care. http://www.chpca.net/resource_doc_library/pan-cdn_gold_standards/Gold_Standards_Palliative_Home_Care.pdf. Accessed 09/28/10. 21 Special Senate Committee on Aging. Final report: Canada's aging population: Seizing the opportunity. April 2009. http://www.parl.gc.ca/40/2/parlbus/commbus/senate/com-e/agei-e/rep-e/AgingFinalReport-e.pdf. Accessed 09/28/10. 22 Quality End -of-life Coalition of Canada. Blueprint for action 2010 to 2020. http://www.chpca.net/qelccc/information_and_resources/Blueprint_for_Action_2010_to_2020_April_2010.pdf. Accessed 09/28/10. 23Carstairs S. Raising the bar: a roadmap for the future of palliative care in Canada. June 2010. http://sen.parl.gc.ca/scarstairs/PalliativeCare/Raising%20the%20Bar%20June%202010%20(2).pdf. Accessed 09/29/10.

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"More Doctors. More Care:" A Promise Yet Unfulfilled - The Canadian Medical Association's brief to the House of Commons Standing Committee on Health concerning health human resources

https://policybase.cma.ca/en/permalink/policy9438

Date
2009-04-28
Topics
Health systems, system funding and performance
Health human resources
  1 document  
Policy Type
Parliamentary submission
Date
2009-04-28
Topics
Health systems, system funding and performance
Health human resources
Text
The Canadian Medical Association (CMA) brief submitted to the House of Commons Standing Committee on Health makes 12 practical recommendations within the jurisdiction of the federal government for investing in the capacity needed to expand and retain our practising physician population. These recommendations are a clarion call for pan-Canadian planning and innovative thinking to meet an ever-increasing demand for physician services from the Canadian public. CMA's research on Health Care Transformation has shown that a commitment to ensuring an adequate supply of health human resources (HHR) is a common trait shared by high-performing European health systems. The last federal election campaign saw most political parties pledge to urgently address HHR shortages. Now is the time to keep those election commitments. A. Capacity Cuts to medical school enrolment in the 1990s contributed to Canada's significant shortage of physicians. Growing demand for physician services, the aging of the physician population and changing practice styles among younger physicians are further compounding the problem. Seriously addressing HHR shortages is crucial to transforming Canada's health care system into one that is truly patient focused. Canada should strive for self-sufficiency in physician supply and do more to repatriate Canadians studying and practising medicine abroad. The CMA supports bringing into practice qualified international medical graduates (IMGs) already in Canada. IMGs should be assessed according to the same evaluation standards as Canadian graduates and more should be done to reduce the backlog in assessing IMGs. With recent increases to medical school enrolment, more support must also be given for the capital infrastructure and faculty required to ensure the highest standard of medical education. B. Retention Competition for physicians is an issue with both international and inter-provincial/territorial facets. The revised Agreement on Internal Trade (AIT) and bilateral agreements will ease the movement of health professionals across jurisdictions, but may exacerbate retention difficulties in underserviced areas. Canada should be active in retaining and repatriating our health care professionals, particularly since the predicted physician shortage in the United States may result in a return to the physician out-migration seen in the 1990s. C. Innovation Canada must do more to encourage innovation within our health care system. Collaborative care - including care delivered with the assistance of Physician Assistants (PAs) - and advances in information technology hold the promise of helping create a more efficient health care system that provides higher quality care. Introduction Canada has suffered from a significant physician shortage since the mid-1990s. Nationally, we rank 26th of 30 Organisation for Economic Co-operation and Development (OECD) member countries in physician-to-population ratio. We would need 20,000 new physicians just to meet the OECD average. Figure 1: Physicians per 1000 population (including residents) Source: OECD 2008 Health Data; CMA Physician Resources Evaluation Template During the 2008 federal election campaign, four of the five parties represented in the House of Commons recognized the urgency of this situation and promised measures that would address HHR shortages. Following through on these promises is critical if we are to transform Canada's health care system into one that truly puts the needs of patients first. Research conducted for CMA's Health Care Transformation initiative demonstrates that European countries whose health care systems outperform our own all share a strong commitment to HHR, as demonstrated by their higher physician-to-population rankings. A. Capacity First-year medical school enrolment was already in decline when health ministers imposed a further 10% cut resulting in a low of 1,577 places in 1997. While there have been substantial increases since then, it took a decade to rebound. In 2007, first-year enrolment stood at 2,569 - 63% higher than a decade earlier. If we had left our domestic production unchanged, we would have almost 1,300 more physicians than we have today. Canada remains well behind other industrialized countries in the education and training of physicians. In 2005, Canada graduated 5.8 physicians per 100,000 population, 40% below the 9.6 average for the OECD. Currently, between 4 and 5 million Canadians do not have a family physician. Over one-third of all Canadian physicians are over the age of 55. Many will either retire soon or reduce their practice workload. Most are not accepting new patients. Ironically, advances in medicine and lifestyle that are helping Canadians live better and longer also mean increased demand for health care professionals. An aging population with high expectations of the health care system is increasing pressure on health care providers to ensure they maintain a high quality of life through their elder years. A growing culture of 'health consumerism,' facilitated by the Internet has resulted in a very knowledgeable patient population that expects top quality care delivered in a timely manner by the appropriate health professional. Advances in medical diagnostics and technology, new and evolving diseases and increasingly complex protocols and guidelines for medical care all increase the demand for physician services. Declining mortality rates for patients with diseases such as cancer have increased treatment of what have become 'chronic' diseases. In a collaborative care setting, physicians often take responsibility for the most complex patients. There is evidence of a cultural change among physicians to place greater importance on their home life by working less. This trend may have a positive effect on the health of the profession but it means Canada will need more physicians to provide the same volume of services. Greater coordination among jurisdictions is needed to facilitate HHR planning on a national scale. Canada's doctors and other health professions are ready to assist policy-makers in their planning and coordination to better meet the health care needs of Canadians. During the 2008 federal election campaign, most political parties recognized the urgency of addressing HHR shortages. The Conservative Party, specifically, promised to fund 50 new residency positions to increase supply of physicians in areas of priority need. Recommendation 1: The federal government should fulfill its promise to fund 50 new residency positions at a cost of $10 million per year for four years. Support for IMGs The CMA fully supports bringing into practice qualified IMGs already in Canada. Canada has historically benefited from a steady flow of IMGs to our country. In fact, close to one quarter of all physicians in Canada and over 50% of doctors in Saskatchewan are IMGs. Many areas in Canada would have no physicians if not for the contribution of these practitioners. While IMGs are a boon to Canada, actively recruiting from developing countries is not an acceptable solution to our physician shortage. Canada must strive for greater self-sufficiency in the education and training of physicians. In fact, self-sufficiency is a key principle of the government's Advisory Committee on Health Delivery and Human Resources' Framework for Collaborative Pan-Canadian Health Human Resources Planning. CMA supports online assessment tools and websites that provide information to foreign-trained physicians so they know what standards they must meet once they arrive in Canada. In 2006, over 1700 people used the online assessment tool established by the Medical Council of Canada (MCC). CMA also supports applying the same evaluation standards to international graduates as it does to graduates of Canadian medical schools. Despite a four-fold increase in the number of IMGs in ministry-funded postgraduate training programs over the last decade, there is still a backlog of IMGs awaiting entry into these programs. About 1300 IMGs applied for a postgraduate training position last year but only 350 (27%) were successful. CMA recommends that funding be made available to provinces for use in mentoring IMGs towards licensure. This could lower costs for the IMGs, pay the community preceptors, cover operational costs and defray other expenses. It is estimated that up to 1500 Canadians are studying medicine abroad. Two-thirds of these IMGs want to come home to complete their postgraduate training. Canada turns away four good applicants for every student accepted into medical school. Increased training opportunities for all groups of IMGs will ensure that Canada fully utilizes the skills and knowledge of its citizens who have studied medicine. Recommendation 2: The federal government should make $5 million (over five years), available to provinces/territories to address the backlog of IMGs through community preceptorship programs that mentor and assess IMGs for integration into the physician community. Recommendation 3: The federal government should take concrete steps to ensure Canada becomes self-sufficient when it comes to the supply of health care professionals. Recommendation 4: The federal government should continue to fund information tools such as the IMG-Canada website to better inform offshore physicians. Infrastructure and faculty Canada's teaching centres have had to absorb increases in operational and infrastructure costs to accommodate increased enrolment. This includes instructors, space, overhead and supplies. While it appears that the number of faculty members has kept pace with the increased number of medical students, part-time faculty now make up a much larger proportion of the total than 10 years ago. i In addition to the traditional academic centres, much of the training of doctors now occurs in a community environment. Mentoring is provided by physicians who may have less experience or resources than do those in the larger centres. Those who teach often experience lost productivity in their practice and receive little or no remuneration. This deficiency must be addressed to achieve a sustainable educational workforce. Recommendation 5: The federal government should implement a Health Human Resources Infrastructure Fund in the amount of $1 billion over 5 years to expand health professional education and training capacity by providing funding to support the: * Direct costs of training providers; * Indirect or infrastructure costs associated with the educational enterprise; and * Resources that improve Canada's data collection and management capacity in the area of health human resources. B. Retention of Canadian Physicians Competition for physicians is both an international and an inter-jurisdictional challenge. The new Agreement on Internal Trade within Canada and numerous bilateral agreements will no doubt ease the movement of health professionals. This may exacerbate the already difficult task of retaining physicians in underserviced areas. On the positive side, it is hoped this will facilitate the movement of physicians who provide short-term relief for physicians needing time off for continued professional development and vacation (i.e., locum tenens). Repatriation As the political situation and health care plans evolve south of our border, Canada should remain active in the quest to retain the health professionals we have educated and trained and make it easier for those who have emigrated to return to practice in Canada. The Conservative Party committed in the 2008 election campaign to create a repatriation fund for Canadian physicians practising abroad. The federal government should keep this important commitment. Migration to the United States peaked in the late 1990s when Canada lost between 600 and 700 physicians per year. While some physicians returned to Canada each year, our net losses for this period were over 400 per year. Today we are enjoying small net gains each year but this may not last given the predicted shortages in the U.S. of between 80,000 and 100,000 physicians in the years ahead. We can expect U.S. recruiters to ramp up activities in Canada in the near future. Recommendation 6: The federal government should fulfill its election promise to establish a fund of $5 million per year over four years to help Canadian physicians living abroad who wish to relocate to Canada. It is thought this initiative could bring back as many as 300 Canadian physicians over four years. Recommendation 7: The federal government should establish a Health Professional Repatriation Program in the amount of $30 million over 3 years that would include the following: * A secretariat within Health Canada that would include a clearinghouse function on issues associated with health care workers returning to practise in Canada. * An ad campaign in the United States. * A program of one-time relocation grants for returning health professionals. Physician Health and Well Being Ultimately, we hope that healthier physicians will create a more vibrant profession. Hopefully these healthier physicians will in turn create a more healthful professional environment that will support their ability to provide patient care of the highest quality. Through programs and conferences, the CMA has contributed to growing efforts to reduce the stigma surrounding physician ill-health and to support a new, healthier culture for the profession. Given the myriad other issues that contribute to our doctor shortage, it is clear that Canada cannot afford to lose a single physician to ill health. Our research shows that the most stressful aspect of the medical profession is being on call after hours. Physicians average 50 hours a week in the usual settings of office, hospital or clinic but then 70% are on call for another 30 hours per week. In small communities, physicians are often on call all the time. A quarter of all physicians face some form of mental health challenge that makes their work difficult. This is higher than the 1 in 5 Canadians that will face a mental illness over their lifetime.ii The ongoing pressures experienced by overworked physicians can result in stress related disorders and burn-out and are frequently a precursor to more significant physical and mental health problems. If not addressed early, these conditions can lead to physicians taking prolonged periods of time off work, changing their practice patterns or leaving the practice of medicine altogether. Prevention programs are the key to assisting physicians before they are at significant risk. The CMA visited such a program in Norway which has been shown to significantly reduce burn-out and reduce the subsequent time-off work related to stressiii. A program to enhance physician resiliency and prevent stress related disorders, based on the Norway model, could be expanded to include services for all health professionals. The potential impact would be improved provider health and morale, reduced sick days and fewer long-term leaves. Recommendation 8: The federal government should invest in research directed at assessing the quality of work life among health workers through an interprofessional survey at a cost of $1.5 million. Recommendation 9: The federal government should explore the feasibility of developing a 'made in Canada' Resiliency Program for Health Professionals that would include the development of a feasibility study, including a business case, and a pilot curriculum, at a cost of $500,000. C. Innovation While Canada must do more to increase both our supply and retention of HHR, we must also encourage innovation within our health care system to make better use of our existing health resources. Collaborative models of interprofessional care and advances in information technology hold the promise of helping create a more efficient health care system that provides higher quality care. Physician Assistants Increasingly physicians are working in interprofessional teams that may include professions that are relatively new to Canada's health workforce such as physician assistants (PAs). The CMA accredits PA curricula and has held two conferences to promote the use of PAs in all levels of care. Recommendation 10: The federal government should fund a study to evaluate the impact of physician assistants on access to health care and to determine their cost effectiveness relative to other providers at cost of $150,000. Technology to Support Health Care Delivery Information technology will continue to create a more efficient and effective health care system. It will lead to more patient safety, more Canadians finding a physician, better care, cost avoidance such as eliminating duplicate tests and the establishment of collaborative interprofessional health care teams. Canada's adoption of electronic medical records lags behind other OECD countries. We only spend a third of the OECD average on information technology in our hospitals. The adoption of EMRs in community settings (primary care, home care and long-term care facilities) also trails most other countries (Figure 2iv). This is not due to any general resistance by providers, but rather a combination of: a lack of evidence on how best to use electronic records to improve care delivery; a need to improve the return on investment for physicians by providing value-added solutions such as greater connectivity to lab results, drug data and colleagues; the time it takes to implement a new electronic record capability and a lack of funds to acquire new technology. Recent investments in Canada Health Infoway (CHI) will help address some of these issues but it is estimated that for Canada to have a fully automated health care delivery system we need to invest $ 10 to $12 billionv. An overall investment of $2 billion is required to fully IT enable the community-based health care delivery sector. While Budget 2009 provided $500 million to CHI for EMRs, more is still required. Recommendation 11: The federal government should provide a further investment of $500 million for new technology to fully enable all points of care in the community settings and an enhanced change management program to speed up EMR adoption. Recommendation 12: The federal government should create a $10-million fund to establish an applied research program for the next five years that will provide evidence on how best to integrate information technology into the health care delivery system. D. Conclusion Canada's doctors believe that we can build a health care system where all Canadians can get timely access to quality health care services regardless of their ability to pay. Developing a comprehensive HHR strategy that assures an adequate supply of all health care providers, including physicians, is a pillar of achieving timely access to high quality care. Building such a system requires that we shift our attitude and move to implement new strategies, new ideas and new thinking. That new thinking must begin with a commitment to act now to address Canada's physician shortage. A promise made must be a promise fulfilled. References i Canada's Health Care Providers 2007, Ottawa: CIHI, 2007 ii Frank E. Canadian physicians healthy - national survey finds. A report from the 2008 International Conference on Physician Health. London, UK Nov 2008. iii Isaksson Ro, K et al. Counselling for burnout in Norwegian doctors : One year cohort study. BMJ. November 2008. Vol 337, 1146-9. iv * Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions, access test results, access hospital records; computer for reminders, Rx alerts, prompt test results; easy to list diagnosis; medications, patients due for care. v Vision 2015 - Advancing Canada's Next Generation of Healthcare, Canada Health Infoway, 2008

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Presentation to The Standing Committee on the Status of Women

https://policybase.cma.ca/en/permalink/policy10020

Date
2010-04-19
Topics
Health human resources
  1 document  
Policy Type
Parliamentary submission
Date
2010-04-19
Topics
Health human resources
Text
Good afternoon. As was said in my introduction, my name is Anne Doig and like the chair, I am a family physician. I practice as a "full service" family physician, which means that I provide care in hospital as well as in my office, including obstetrical services. I have practiced in Saskatoon for almost 32 years. It is my pleasure to be here today. As President of the Canadian Medical Association, I represent all physicians, but today, I am proud to represent women participating in what is now a traditional occupation for them, that is, medicine. Joining me today is Dr. Mamta Gautam, a specialist and champion of physician health and well-being. For 20 years, she worked as a psychiatrist treating physicians exclusively in her private practice in Ottawa, and has been hailed as "the Doctor's Doctor." The Association of Universities and Colleges of Canada has reported full-time university enrolment increased by more than 190,000, or 31%, between 2000 and 2006 and now stands at record levels. Full-time male enrolment has passed 350,000 students and full-time female enrolment has passed 460,000. Women account for two-thirds of full-time enrolment growth since 1971, a surge driven by the rapid increase in women's participation in the professions, including medicine. As it stands now, the males outnumber females among practicing physicians by 67%-33%. While there are still more men than women in practice, the percentage of female first-year residents in 2008 was 57%. This is a reversal of the percentage when I graduated, and an increase from 44% fifteen years ago. This means that a significant majority of physicians close to the beginning of their medical careers, are women. Not surprisingly, given those figures, there are many medical disciplines where the proportion of females is much higher than it was even just a few years ago. For instance, in general surgery - long held to be a bastion of male physicians - females comprised 18% of the 1993 first year residents compared to 40% in 2008. Just over half of first-year family medicine residents in 1993 were female compared to 64% today. However, women medical graduates still tend to choose to pursue residency training in family medicine, pediatrics, and obstetrics/gynecology in greater proportions than their male counterparts. As has always been the case, males continue to have a stronger preference for surgery - 23% compared to 11% of females - although that gap is narrowing. So, the overall numbers of women physicians are increasing as are the percentages of those going into what one might call non-traditional specialties, albeit at a slower rate. The so-called feminization of medicine brings with it several other issues and I will touch on two major ones. First, work-life balance. The rise in the number of women physicians is bringing a positive shift in the way physicians practice and the hours that they keep. Very few of today's young physicians - male or female - are willing to work the long hours that physicians of previous generations did. That said, data from the 2007 National Physician Survey, which included responses from over 18,000 physicians across the country, show that, on average, male doctors still work nearly 54 hours per week, while female doctors work 48 - although many work more than that. These figures do not include time on call, nor time spent on child care or other family responsibilities. Many members of the Committee can empathize with this level of commitment. In contrast, the European Union Work Time Directive has said that the maximum work week must be 48 hours. If Canada were to try to apply that directive to physicians our health care system would grind to a halt. The number of physicians opting to be paid by a means other than pure fee-for-service has dramatically increased. FFS rewards the doctor financially for seeing more patients. Female physicians typically spend more time in each patient encounter, a trait that is valued by patients but not rewarded by FFS remuneration. The second issue is stress. In spite of their increasing numbers, women in medicine still report higher rates of incidents of intimidation, sexual harassment and abuse than their male colleagues. As well, many female physicians continue to assume primary responsibility for home and family commitments in addition to their practice workload, thus compounding their stress levels. Female physicians are more likely to work flexible hours; flexibility in work schedules has been the method by which female physicians balance their professional and personal lives. Yet, as they take on more and strive to be more flexible that in itself creates more stress as they battle to be "all things to all people". The CMA identified the need to address and mitigate the unique demands on women physicians in its 1998 policy on Physician Health and Well-Being. I have brought copies to be shared with you today. As I mentioned at the start, I am joined today by Dr. Gautam who has considerable expertise in the stressors faced by physicians - and women physicians in particular - and in managing them. We will be happy to discuss the participation of women in medicine and to answer questions that you may have. Thank you.

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Transforming Health Care, Securing Canada's Competitive Advantage: The Canadian Medical Association's brief to the Standing Committee on Finance's pre-budget consultation

https://policybase.cma.ca/en/permalink/policy9585

Date
2009-08-14
Topics
Health systems, system funding and performance
Health human resources
  1 document  
Policy Type
Parliamentary submission
Date
2009-08-14
Topics
Health systems, system funding and performance
Health human resources
Text
As signs of economic recovery begin to emerge, both in Canada and globally, the Canadian Medical Association is pleased to put forward three recommendations that will initiate a needed transformation of our health care system so that it is truly patient focused and sustainable. Additionally, these measures will create 17,000 jobs and solidify Canada's health care competitive advantage. Although related to the health care sector, these recommendations are within the context of ensuring a prosperous, and sustainable economic, social and environmental future for Canada in the short, medium and long-term. Each of these three recommendations also takes into account the finance committee's questions: 1. What federal tax and program spending measures are needed to ensure prosperity and a sustainable future for Canadians from an economic, social and/or environmental perspective? 2. What federal stimulus measures have been effective and how might relatively ineffective measures be changed to ensure that they have the intended effects? CMA research demonstrates that it is possible to maintain a universally accessible health care system without long waits for care. In 2007 alone, waiting for care in just four clinical areas cost the Canadian economy $14.8 billion. In particular, two areas require federal attention: 1. ENHANCING PATIENT ACCESS ACROSS THE CONTINUUM OF CARE Continuing care (ie. long-term care and home care) and prescription drug coverage need urgent attention. Many Canadians do not have access to as wide a range of insured care as citizens in other highly industrialized countries. Recommendation 1: The federal government should expand the Building Canada Plan to include 'shovel-ready' health facility construction projects including ambulatory, acute and continuing care facilities. Cost: $1.5 billion over 2 years 2. HELPING PROVIDERS HELP PATIENTS a. Accelerating physician EMR adoption: Both national and international studies confirm that Canada lags behind nearly every major industrialized country when it comes to health information technology. Accelerating physician EMR adoption will reduce wait times, improve quality, and improve financial accountability especially of federal dollars. Budget 2009 proposed $500 million in additional funding to Canada Health Infoway and a temporary, accelerated capital cost allowance for computer hardware. Transfer of these funds to Infoway is imperative. Together, transferring the funding to Infoway and further improving of the capital cost allowance will ensure these initiatives have the intended effects of improving EMR adoption and stimulating the economy. b. Boosting Health Human Resources: Canada does not have enough physicians, nurses, technicians or other health care professionals to provide the care patients need. Addressing HHR shortages is critical to ensuring sustainable, accessible, responsive and high-quality health care. Recommendation 2: The federal government should expand the 2-year time-limited accelerated Capital Cost Allowance for hardware costs related to health information technologies by extending it to five years; removing the 50% half-year rule on related software; and including electronic tools involved in connecting patient records from physician offices to laboratories and hospitals. Cost: $50 million over four years. Recommendation 3: The federal government should fulfill its 2008 election promise, beginning in 2010, of investing $65 million in health human resources over four years to fund 50 new residencies per year; repatriate Canadian physicians living abroad; and launch pilot projects with nursing organizations to promote recruitment and retention. 1. INTRODUCTION - HEALTHY ECONOMICS: THE FOUNDATION OF FUTURE PROSPERITY The CMA believes that by being innovative in its actions Canada can sustain a publicly funded, universal health care system. In fact, doing so provides Canadian industry with a significant competitive advantage in the global marketplace. Despite having one of the richest health care programs in the industrialized world (eighth among 28 Organization for Economic Co-operation and Development [OECD] countries), international benchmarking studies consistently report that the Canadian program is not performing as well as it should. The Euro-Canada Health Consumer Index ranked Canada 30th out of 30 countries in terms of value for money spent on health care in both 2008 and 2009.The CMA's recent review of several European health systems illustrates that a sustainable, patient-centred approach to health care is possible on a system-wide level without compromising founding principles such as universality, and without causing financial difficulty for the country or its citizens. However, getting there will require transformational change to refocus our system. The Canadian Medical Association's 2010 pre-budget submission puts forward three recommendations in the areas of health care infrastructure, health human resources (HHR) and electronic medical records (EMRs).1 These three affordable, strategic initiatives fall within the jurisdiction of the federal government and recognize both the ongoing and promising economic recovery and the current fiscal capacity of the federal government. CMA's recommendations help to chart a course toward a prosperous, and sustainable economic, social and environmental future for Canada in the short, medium and long terms. These proposals will kickstart a transformation of the health care system and create over 17,000 jobs that will ensure a competitive economic foundation for the future. Based on CMA's research, transforming Canada's health care system to better meet the needs of Canadians hinges on five directions for a reorientation of the system: 1. Building a culture of patient-centred care; 2. Incentives for enhancing access and improving quality of care; 3. Enhancing patient access across the continuum of care; 4. Helping providers help patients; 5. Building accountability/responsibility at all levels. While each of the five directions is important to reorienting the system, points 3 and 4 are directly relevant to the Finance Committee's deliberations. 2. ENHANCING PATIENT ACCESS ACROSS THE CONTINUUM OF CARE While all elements of the continuum of care are important, the CMA believes that continuing care (long-term care and home care) and prescription drug coverage need urgent attention. Many Canadians do not have access to as wide a range of insured care as citizens in other highly industrialized countries. In fact, many of these other industrialized countries count access to prescription drugs and home care/long-term care among their basic insured services. a. Continuing care: Augmenting the Building Canada Plan to include health care infrastructure Recommendation 1: The federal government should expand the Building Canadai Plan to include 'shovel-ready' health facility construction projects including ambulatory, acute and continuing care facilities. Cost: $1.5 billion over two years Continuing care in Canada faces three key challenges: capacity and access; informal caregiver support and long-term care funding. At 91%, Canada has the highest hospital occupancy rate in the OECD.ii Roughly 25-30% of hospital acute care beds are occupied by patients who do not require hospital or medical care but rather need 24-hour supervised care. Scarce long-term care facilities and home-care services dictate that patients remain in hospital, delaying hospitals from performing elective surgeries and restricting the movement of other patients from the emergency room to acute care wards. Much of the burden of continuing care falls on informal (unpaid) caregivers who need to be better supported. Statistics Canada reported that in 2007 about 2.7 million Canadians aged 45 and over, or approximately one-fifth of the total in this age group, provided some form of unpaid care to seniors (people 65 years of age or older) who had long-term health problems iiiIt seems unlikely that future requirements for long-term care can be funded on the same "pay-as-you-go" basis as other health expenditures. The seven-year, $33-billion Building Canada Plan announced in Budget 2007 and augmented in Budget 2009, could better support a smart economic recovery and the health needs of Canadians if it were to be expanded to include health facility construction.iv Federal investment in hospital and health facility construction will create 16,500 jobs over a two-year period and 11,000 jobs in 2010 alone. (Appendix: Table 1). Although CMA's $1.5 billion recommendation does not eliminate the entire health-facility infrastructure gap in Canada, estimated at over $20 billionv, it does provide additional stimulus aimed at shovel-ready projects. It also better prepares our health system to deal with the needs of an aging population. Federal government investment in health infrastructure has two important precedents - the first in 1948 (Hospital Construction Grants Program) and the second in 1966 (Health Resources Fund Act). Infrastructure funding should be directed toward projects that deliver long-term value and enhance Canadians' lives. b. Prescription drugs: 3.5 million Canadians underinsured Prescription drugs represent the fastest growing item in the health budget, and the second largest category of health expenditure. More than 3.5 million Canadians have no prescription drug coverage or are underinsured against high prescription drug costs. In 2006 almost one in 10 (8%) of Canadian households spent more than 3% of their after-tax income on prescription drugs; and almost one in 25 (3.8%) spent more than 5%. It is estimated that less than one-half of prescription drug costs were publicly paid for in 2008. Canada must strive for a program of comprehensive pharmaceutical coverage that is universal and effectively pools risks across individuals and public and private plans throughout Canada. 3. HELPING PROVIDERS HELP PATIENTS Canada's health care workforce needs more people and more tools to care for Canadians. a. Accelerating physician EMR adoption Recommendation 2: The federal government should expand the 2-year, time-limited accelerated Capital Cost Allowance for hardware costs related to health information technologies by extending it to 5-years; removing the 50% half-year rule on related software; and including electronic tools involved in connecting patient records from physician offices to laboratories and hospitals. Cost: $50 million over four years. Both national and international studies confirm that Canada lags behind nearly every major industrialized country when it comes to health information technology (see Figure 1 and Figure 22). The impact of this underinvestment is longer wait times, reduced quality, and a severe lack of financial accountability, especially of federal dollars. The Conference Board of Canadavi, the Organization for Economic Co-operation and Development (OECD) vii, the World Health Organizationviii, the Commonwealth Fundix, and the Frontier Centre for Public Policyx all rate Canada's health care system poorly in terms of "value for money" as well as efficiency. The CMA applauds the temporary 100% Capital Cost Allowance (CCA) rate for computer hardware and systems software acquired after January 27, 2009 and before February 1, 2011 that was proposed in Budget 2009. The measure will provide stimulus by helping businesses to increase or accelerate investment in computers. It will also help boost Canada's productivity through the faster adoption of newer technology. However, for this initiative to provide the greatest benefit, the 100% CCA rate should be extended to five years and expanded to include related EMR software. The benefits of EMR investments are clear. International strategy and technology consulting firm Booz Allen Hamilton found the benefits of an interconnected Electronic Health Record (EHR) in Canada could save the health system $6.1 billionxi a year. The CMA's recommendation of delivering incentives through the tax system to adopt EMRs is a bottom-up approach that has gained widespread support. John Halamka, the chief information officer at Harvard Medical School, thinks that reformers need to take a bottom-up approach and listen to both doctors and patients. Studies showxiithat most of the benefits of EMRs flow to the payer. Incentives for hardware, software and as importantly the time that it takes to implement these e-systems must be taken into account and incented. The urgency for e-health is being recognized in the United States and needs to be in Canada. Beyond tax incentives, Budget 2009 also provided Canada Health Infoway (Infoway) with $500 million to support the goal of having 50 % of Canadians with an electronic health record by 2010. As of March 31, 2009, Infoway and its partners had put in place an electronic health record for 17% of the population. Budget 2009 funding will allow Infoway to extend EHRs to 38% of the population by March 31, 2010. xiii This investment will not only enhance the safety, quality and efficiency of the health care system, but will also result in a significant positive contribution to Canada's economy, including the creation of thousands of sustainable, knowledge-based jobs throughout Canadaxiv. Infoway has not yet received this funding and the CMA strongly encourages the federal government to transfer the funds promised in Budget 2009 as soon as possible. b. Boosting Health Human Resources Recommendation 3: The federal government should fulfill its 2008 election promisexv, beginning in 2010, of investing $65 million in health human resources over four years to fund 50 new residencies per year; repatriate Canadian physicians living abroad; and launch pilot projects with nursing organizations to promote recruitment and retention. Canada does not have enough physicians, nurses, technicians or other health care professionals to provide the care patients need. Addressing health workforce shortages is critical to ensuring sustainable, accessible, responsive and high-quality health care across the nation. Canada has suffered from a significant physician shortage since the mid-1990s. Nationally, we rank 26th of 30 OECD member countries in physician-to-population ratio (see Figure 3). The lack of physicians in Canada puts the system under pressure and the impact of this is being felt by patients across the country. Currently, approximately five million Canadians do not have a family physician. In 2008, a study commissioned by the CMA found that the Canadian economy lost $14.8 billion as a result of excessive wait times for just four procedures: joint replacements, MRIs, coronary artery bypass surgery and cataract surgery. As health care reform plans evolve south of our border, Canada should be proactive in order to retain the health professionals we have educated and trained and make it easier for those who have emigrated to return to practice in Canada. In the 2008 federal election, most parties recognized the urgency of HHR shortages and committed to address the situation. The Conservative Party committed to fund additional medical residency positions, create a repatriation fund for Canadian physicians practising abroad and fund nursing recruitment and retention pilot projects. It is thought this repatriation program could bring back as many as 300 Canadian physicians over four years. The federal government should keep this important commitment. Migration to the United States peaked in the late 1990s when Canada lost between 600 and 700 physicians per year. While some physicians returned to Canada each year, our net losses for this period were over 400 per year. Today we are enjoying small net annual gains but this may not last. With predicted shortages in the U.S. of between 80,000 and 100,000 physicians in the years ahead, we can expect U.S. recruiters to ramp up activities in Canada soon. 4. CONCLUSION The emerging economic recovery offers an excellent opportunity for the federal government to create a more patient-focused and sustainable health care system. Enhancing patient access across the continuum of care by bolstering the Building Canada infrastructure plan and helping providers help patients by enhancing EMR tax incentives and addressing health workforce shortages are important first steps in transforming our health care system. Looking ahead, it will be important to continue to honour the financial transfers of the 2004 Health Care Accord, including the annual 6% escalator, through to 2014. Past cuts to health care funding at all levels have had significant negative effects that continue to be felt to this day. Now is the time to begin thinking ahead to the fiscal needs of the health care system in the post-2014 era. Appendix Table 1 [For correct dispaly of table information, see PDF] References 1 A full schedule of the recommended federal investments as well as their job creation potential is included at the end of the document in the Appendix, Table 1. 2 14 functions are: EMR, EMR access, access other doctors, outside office, patient: routine use, electronic ordering tests, prescriptions, access test results, access hospital records, computer for reminders, Rx alerts, prompt test results; easy to list diagnosis, medications, patients due for care. i Building Canada Plan., Announced in Budget 2007, the seven-year, $33-billion Building Canada plan consists of a suite of programs to meet the varying needs of infrastructure projects across Canada. See page 142 of the 2009 Federal Budget. www.budget.gc.ca/2009/pdf/budget-planbugetaire-eng.pdf ii Hospital Occupancy Rates. Organization for Economic Co-operation and Development [OECD] (2008). OECD Health. Data 2007. Version 07/18/2007. CD-ROM. Paris: OECD. iii.Cranswick, Kelly, Donna Dosman. "Eldercare: What we Know Today" Canadian Social Trends.No. 86. Statistics Canada iv Building Canada Plan, Federal Budget 2009 page 142. . www.budget.gc.ca/2009/pdf/budget-planbugetaire-eng.pdf v This estimate is based on survey work in a forthcoming publication commissioned by the Association of Canadian Academic Healthcare Organizations. vi How Canada Performs 2008: A Report Card on Canada, The Conference Board of Canada see: http://sso.conferenceboard.ca/HCP/overview/health-overview.aspx vii Organization for Economic Co-operation and Development [OECD] (2007). OECD Health Data 2007. Version 07/18/2007. CD-ROM. Paris: OECD. viii World Health Organization [WHO] (2007). World Health Statistics 2007. see: http://www.who. ix 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 x Euro-Canada Health Consumer Index 2008, Health Consumer Powerhouse, Frontier Centre for Public Policy, FC Policy Series No. 38 see:www.fcpp.org/pdf/ECHCI2008finalJanuary202008.pdf xi Booz, Allan, Hamilton Study, Pan-Canadian Electronic Health Record, Canada's Health Infoway's 10-Year Investment Strategy, March 2005-09-06. xii Although the savings would accrue to different stakeholders, in the long run they should accrue to payers. If we allocate the savings using the current level of spending from the National Health Accounts (kept by the Centers for Medicare and Medicaid Services), Medicare would receive about $23 billion of the potential savings per year, and private payers would receive $31 billion per year. Thus, both have a strong incentive to encourage the adoption of EMR systems. Providers face limited incentives to purchase EMRs because their investment typically translates into revenue losses for them and health care spending savings for payers. From: Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs, by Richard Hillestad, James Bigelow, Anthony Bower, Federico Girosi, Robin Meili, Richard Scoville and Roger Taylor, Health Affairs, 24, no. 5 (2005): 1103-1117 http://content.healthaffairs.org/cgi/content/full/24/5/1103#R14 xiii Corporate Business Plan 2009/2010, Canada Health Infoway, "Anticipated Progress to March 31, 2010" page 7 see:www2.infoway-inforoute.ca/Documents/bp/Business_Plan_2009-2010_en.pdf xiv Federal Budget 2009 page 152. see: www.budget.gc.ca/2009/pdf/budget-planbugetaire-eng.pdf xv Health Care Certainty for Canadian Families, the Conservative Party of Canada, backgrounder 10/08/08. See: http://www.conservative.ca/?section_id=1091&section_copy_id=107023&language_id=0

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