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Building a Comprehensive Post-Market Surveillance System : Canadian Medical Association Response to Health Canada’s Discussion Paper “Designing a Mandatory System for Reporting Serious Adverse Reactions”

https://policybase.cma.ca/en/permalink/policy1951
Last Reviewed
2012-03-03
Date
2005-07-28
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2012-03-03
Date
2005-07-28
Topics
Health systems, system funding and performance
Text
Building a Comprehensive Post-Market Surveillance System Canadian Medical Association Response to Health Canada’s Discussion Paper “Designing a Mandatory System for Reporting Serious Adverse Reactions” Submitted to Health Canada July 28, 2005 Overview The CMA believes that all stakeholders should work together to improve adverse drug reaction (ADR) reporting, in the interests of improving patients’ safety and health. However, we believe that activity in pursuit of this end must be based on two fundamental premises: a) Reporting is only one part of a comprehensive post-market surveillance system. In order to effectively monitor the safety of Canada’s drug supply, this system should include: * a simple, comprehensive and user-friendly reporting process; * rigorous analysis of reports to identify significant threats to drug safety; * a communications system that produces useful information, distributed to health care providers and the public in a timely, easily understood manner. There is no point in enacting a mandatory reporting requirement until all of these elements are in place. We wonder why mandatory reporting has been singled out for discussion when a holistic approach to reforming Canada’s drug safety system is called for. b) Health care providers should be encouraged to participate willingly and voluntarily in the reporting process. To be successful, Canada’s post-market surveillance system will depend on the active participation of physicians and other health professionals. Experience with health system quality and safety improvement efforts over the past several years has demonstrated that meaningful acceptance is most effectively obtained when those involved are willing participants. If you build a comprehensive, efficient and effective post-market surveillance system, physicians will participate actively in it. Forcing them to participate before the system has been built will result in alienation, frustration and failure. Comments on Discussion Paper a) Is Mandatory Reporting Necessary? This is a fundamental question and the discussion paper does not satisfactorily address it. There are two reasons why we question the necessity for imposing an ADR reporting requirement on health professionals. First, as awareness of the drug-safety system’s importance has increased, the number of ADR reports has increased along with it - more than 10% in 2004, as the discussion paper notes - without a mandatory reporting requirement. Given this trend, it is highly probable that time, education, adequate resources and increasing familiarity with the surveillance system will raise reporting rates to the desired level (however defined) without mandatory reporting. Second, as the discussion paper points out, there is no evidence that mandatory reporting has been effective in other jurisdictions where it has been implemented. The paper offers no clear explanation for this lack of success. More importantly, it does not indicate how Health Canada plans to ensure that mandatory reporting will succeed in this country when it has proven ineffective elsewhere. A primary principle of any system change is that we should not repeat the mistakes of others. Before launching a program whose success has not been proven, other viable, and possibly more effective, alternatives should be examined. b) Addressing known barriers to reporting The CMA acknowledges that ADRs are under-reported, in Canada and worldwide. The discussion paper identifies a number of barriers to reporting, and its list mirrors the observations and experiences of our own members. We believe most of these barriers can, and should, be overcome. We also agree that it is necessary to raise health professionals’ awareness of the importance of, and process for, ADR reporting. But we question the curious assertion that “Mandatory reporting could raise awareness of the value of reporting simply by virtue of the public debate.” Surely there are more positive ways to raise awareness than publicly speculating about the punitive consequences of non-compliance. We suggest that instead, Health Canada work with physicians and other health professionals to address the existing barriers to reporting. Specifically, we recommend that Health Canada implement: * a well-funded and targeted awareness-raising campaign focused on provider education and positive messaging, * a user-friendly reporting system, including appropriate forms, efficient processes and adequate fees. These measures are within Health Canada’s purview in the existing policy and legislative environment. We believe they would increase reporting without the need for coercive measures. At a minimum, positive system improvements should be tried first before considering a mandatory-reporting requirement. With regard to specific questions posed in the discussion paper: Question 1: Health professionals should be explicitly protected from any liability as a result of reporting an adverse drug reaction. This should be the case regardless of whether reporting is voluntary or mandatory. Question 2: Professionals should be compensated for all meaningful work including the completion of forms and any follow-up required as a result of the information they have provided. We would be happy to expand further on this issue on request. Question 3: Issues of confidentiality should be covered in legislation. The CMA has developed an extensive and authoritative body of knowledge on privacy issues in health care, which we would be pleased to share with Health Canada. c) Improved report quality We agree that increasing the quality and richness of ADR reports is as important as increasing their number. Perhaps it is even more important, since high-quality reports allow for high-quality analysis. Mandatory reporting will not improve the quality of ADR reports; it will simply increase their quantity. It may even compromise the system’s efficiency and effectiveness by increasing the volume of clinically insignificant reports. Experience elsewhere has taught us that true quality cannot be legislated or imposed; any attempt to do so would be pointless. If ADR reports included the information listed in Table 4, this would improve their usefulness and the effectiveness of the overall surveillance process. However, it is unrealistic to expect all reports to contain this level of information. The treating physician may not be able to provide all of it, especially if he or she is not the patient’s regular primary care provider. Some of this information, particularly about outcomes, may not be available at the time of the reporting, and gathering it would require follow-up by Health Canada. Health Canada should consider measures other than mandatory reporting to improve the quality of ADR reports. The CMA suggests that consideration be given to: * Improving follow-up capacity. We agree that it should be made easier for Health Canada officials to contact reporters and request details on follow-up or outcomes. This should be considered as part of a comprehensive initiative to improve Health Canada’s capacity to analyze ADR reports. * Establishing a sentinel system. Another option for increasing high-quality reports would be to establish a “sentinel” group of practicing physicians who would contract to report all ADRs in detail. These physicians, because of their contractual obligation, would be committed to assiduous reporting. Sentinel systems could be established concurrently with efforts to increase voluntary ADR reporting by the broader health professional community. In addition to the current information provided, consideration should be given to including on reporting forms the option to allow Health Canada officials to act on information the physician provides; for example, in the reporting of sexually transmitted diseases physicians provide certain information and have the option to request that public health officials undertake follow-up and contact tracing. d) Minimize administrative burden We agree that Health Canada should give consideration to making the ADR reporting system user-friendly, non-complex and easy to integrate into the patient-care work stream. These reforms can and should be implemented regardless of whether a mandatory requirement is in place. They do not need mandatory reporting to make them work; in fact, they are more likely to encourage ADR reporting than any form of coercive legislation. Rather than making a mandatory reporting requirement “fit” with the traditional patient-care framework, we invite Health Canada to work with us to increase health professionals’ capacity to report ADRs voluntarily. We are already working with Health Canada to improve physicians’ access to drug safety material. Health Canada’s ADR reporting form can now be downloaded from the cma.ca web site, which also posts the latest drug alerts from Health Canada and from the Food and Drug Administration in the U.S. We have developed an on-line course in partnership with Health Canada, to teach physicians when and how to make ADR reports. We hope to build on this collaboration, with the goal of making it possible for physicians to report ADRs online via cma.ca. This will permit them to fit reporting more conveniently into their daily workflow. (Note: the “MedEffects” Web portal now being developed at Health Canada does not fit well into the workflow and therefore will not make reporting easier for health professionals.) In the future, we hope that ADR reporting can be built directly into the Electronic Medical Record (EMR). We think this will be a critical element in the bi-directional communicating that ADR reporting requires. It will also enable rapid integration of advisories into the EMR so that they can be available to physicians at the time they are writing a prescription. Before electronic ADR reporting can work, a standard for electronic data should be in place (at present it is not) and Health Canada should develop the capacity to accept data electronically. Health Canada’s discussion paper makes reference to cost-benefit analysis. We recommend that you take great care not to over-emphasize cost-benefit when it comes to enhancing patient safety. Meaningful improvements in the post-market surveillance system will be costly whatever solution Health Canada eventually embraces, and it is impossible to measure financially the value of safety. What is an acceptable cost for one life saved? e) Minimize Over-Reporting The discussion paper acknowledges that not all adverse reactions need be reported. We strongly agree that one of the dangers of mandatory reporting is its potential to overwhelm the system with an unmanageable flood of reports. There is no reason to require reports of minor side effects that are already known to be associated with given drugs. We agree that the reactions Health Canada most needs to know about are those which are severe and/or unexpected. If Health Canada insists on implementing a mandatory reporting system, it should be limited to these reactions (possibly with the corollary that well known serious ADRs would not need to be reported). However, the operating definitions may need clarification, and we recommend that Health Canada consult with health professionals and others on operational guidelines for defining “serious adverse reaction.” Health Canada’s desire to encourage reports on drugs approved within the last 5 years is understandable (though some drugs may be on the market for longer than this before their true risks are known). In practice, however, many physicians do not know which drugs these are, and seeking out this information may impose a heavy administrative burden. As we move toward an EMR-based reporting system, a tag on the Drug Identification Number to tell when the drug was approved will allow physicians to identify which medications require special vigilance. Appropriate reporting could be encouraged, and over-reporting discouraged, by clear guidelines as to what should be reported as well as appropriate compensation for reporting. f) Match Assessment Capacities In our opinion, this is one of the most important sections in the document. What happens once the reports have been received is crucial if we want to identify a serious drug risk as quickly as possible. Under the current system, one of the most significant barriers to physicians’ reporting is lack of confidence that anything meaningful will be done with their reports. Enhancements to the analysis function must be made concurrently with efforts to increase ADR reporting. ADR reports are only cyber-bytes or stacks of paper unless we can learn from them. This requires rigorous data analysis that can sort “signal from noise” – in other words, sift through thousands of reports, find the ones that indicate unusual events, investigate their cause, and isolate those that indicate a serious public health risk. This requires substantial resources, including an adequate number of staff with the expertise and sensitivity required for this demanding task. Unless Health Canada has this capacity, increasing the number of reports will only add to the backlog in analysts’ in-boxes. The CMA recommends that Health Canada allocate sufficient resources to enable it to effectively analyze and respond to ADR reports and other post-market surveillance information. g) Respect privacy Privacy of both patient and physician information is a significant concern. Physicians’ ethical obligation to maintain patient confidentially is central to the patient-physician relationship and must be protected. We acknowledge that issues of privacy and confidentiality must be resolved when designing an ADR reporting system, particularly as we work toward electronic communication of drug surveillance data and its incorporation into an EMR. For example, regulations should explicitly state that ADR reports are to be used only for the purpose for which they were submitted, i.e. for post-market drug surveillance. In addition, Health Canada should ensure that any privacy provisions it develops meet the legislative test outlined in Section 3.6 of CMA’s Health Information Privacy Code (Attachment I). Health Canada can be assured that physicians take their privacy obligations seriously. The CMA has been a strong and pro-active player in debate on this issue, and our Privacy Code lays the groundwork on which we believe any privacy policies involving ADR reporting should be based. h) Compliance through sanctions Physicians are motivated to report ADRs by their concern for public health and their patients’ well-being. In addition, they are guided by the CMA Code of Ethics and governed by regulatory authorities in every province. A clear ethical and professional obligation already exists to report anything that poses a serious threat to patient safety. If physicians do not comply with this obligation, sanctions are available to the provincial regulatory authorities. In fact, the most serious threat for physicians is loss of standing with the professional regulatory authority, not the courts or any external judicial system. It would be superfluous to add a second level of regulation or scrutiny when remedies already exist. The discussion paper presents few alternatives to the existing self-regulatory system. As the paper itself acknowledges, it is unrealistic to impose sanctions based on failure to report an ADR, since it is not always easy to determine whether an adverse effect is attributable to a health product. But the only suggested alternatives - requiring physicians to demonstrate knowledge, or to have the required reporting forms in their office - seem intrusive, crude and unreasonable; they are also meaningless since they have no direct relation to a physician’s failure to report. If Health Canada is considering a large outlay of taxpayers’ dollars for post-market surveillance, we suggest they target those funds to education and awareness raising, and to enhancing the system’s ability to generate and communicate meaningful signal data, rather than to enforcing a mandatory reporting system based on weak compliance measures, with no evidence of its effectiveness in other jurisdictions. Physicians who are in serious breach of their ethical and legal responsibility to report are subject to sanctions by provincial regulatory authorities. Most provincial colleges have policies or guidelines regarding timely reporting and appropriate enforcement mechanisms. Medicine’s tradition of self-regulation has served it well, and we recommend that Health Canada respect and support existing regulatory authorities as they maintain the standards for appropriate professional behaviour. As we have said before - the preferred quality improvement tools to enhance performance and encourage compliance are education and positive reinforcement, not legislation and the threat of sanctions. Conclusion In its discussion paper Health Canada has invited stakeholders to provide their input on how best to develop a mandatory system for reporting ADRs. The Canadian Medical Association believes that the best way to do this is not to develop one at all. Instead, we believe stakeholders should concentrate on building a sustainable, robust and effective post-market surveillance system which: * encourages and facilitates voluntary reporting, by designing a simple and efficient process that can be incorporated into a physician’s daily workflow; * effectively uses reporting data to identify major public health risks; * communicates drug safety information to providers and the public in a timely, meaningful and practical way. The CMA is committed to working, in partnership with Health Canada and other stakeholders, toward the ultimate goal of a responsive, efficient and effective post-market drug surveillance system. This is part of our long-standing commitment to optimizing Canadians’ safety and health, and achieving our vision of a healthy population and a vibrant medical profession.
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The Canadian Medical Association's brief to the Standing Committee on Finance concerning the 2007 budget

https://policybase.cma.ca/en/permalink/policy8566
Last Reviewed
2019-03-03
Date
2006-09-27
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2006-09-27
Topics
Health systems, system funding and performance
Text
Making Canadians healthy and wealthy In the face of an increasingly competitive global economy, Canada must create incentives for its citizens and businesses to invest so that greater investment will increase productivity and our standard of living. The first place to invest is in the health of the workforce. The CMA recognizes the benefits of aligning tax policy with health policy in order to create the right incentives for citizens to realize their potential. Global competitiveness is about getting Canada beyond commodities The latest Canadian economic outlook is mixed. Our economy is forecast to grow by 3 per cent in 2007 which is the fastest growing economy among the G7 countries, according to the International Monetary Fund's semi-annual World Economic Outlook. While this may seem impressive, this growth is fuelled by commodity prices. "The Canadian economy continues to perform robustly, benefiting from...the boom in global commodity prices,'' the IMF said. In fact this is one of the key concerns included in the latest outlook from TD Economics, namely that, "Weakening U.S. demand will lead to a pullback in commodity prices, including a drop in the price of oil to $50 US a barrel in 2007"1. What can the federal government do to mitigate these bumps in the global economy? Investing in "specialized factors" is the key to global competitiveness Canada's place in a competitive world cannot be sustained by commodities or what the godfather of competitive advantage theory, world-renowned Harvard Professor Michael Porter, calls "non-key" factors. Instead, Porter suggests that sustainable competitive advantage is based on "specialized factors" such as skilled labour, capital and infrastructure. These specialized factors are created, not inherited. Moreover, Porter makes the important distinction that the crafting of "social" policies must make them reinforcing to the true sources of sustainable prosperity.2 The demand for highly skilled labour forces does not fluctuate as commodity prices do. This submission follows Porter's line of thinking in suggesting that Canada should build on these specialized factors, emphasizing the health of our skilled labour force, enhancing the skills of our health care providers and making key investment in our electronic health infrastructure. Why the CMA is addressing Canada's place in competitive world The 63,000 members of the Canadian Medical Association are best known for taking care of Canadians - 32.3 million of them - individually and collectively. Through prevention, treatment and research, physicians are also vital in supporting business by ensuring that our work force is as healthy as can be. But our members are also an important economic force in their own right as they own and operate over 30,000 small businesses employing 142,000 people across the country. 3 What's more, small businesses, like the ones physicians run, invest in research and development proportionally on a far larger scale than big corporations. 4 In addition to the clinical services they provide, physicians are vitally engaged in advancing medical knowledge through teaching and research, leading to greater innovation. Health as an investment -"the greatest benefit to mankind" According to distinguished Yale economist, William Nordhaus, "The medical revolution over the last century appears to qualify, at least from an economic point of view, for Samuel Johnson's accolade as "the greatest benefit to mankind." 5 People demand and spend more money on health because it is useful. The goal of a competitive economy is to produce more wealth. The wealthier our citizens become, the more health care they demand. In other words health care is in economic terms a "superior good". Short, medium and long-run incentives for increased productivity The pursuit of productivity to ensure Canada's competitiveness in the world is not and cannot be a short-term goal. Productivity is apolitical. Setting the foundation for productivity requires dedication to long-term goals in education, physical infrastructure and health. However, there are recommendations that can create immediate incentives for citizens and businesses to kick start more productive activity sooner than later. Executive Summary The CMA's pre-budget submission presents the facts on how investments in citizens, businesses and health infrastructure make our economy more competitive. Improvements in the quality of care, and especially timely access to care, enable the Canadian labour force to increase its performance and fully reach its potential. Our submission is also sensitive to the constraints facing the federal government and so we have considered the return on investment for these recommendations. The CMA recognizes the benefits of aligning tax policy with health policy in order to create the right incentives for citizens to realize their potential. Accordingly, our proposals include tax incentives for healthy living and a recommendation to encourage savings for long-term health care. The time horizon for our 10 recommendations ranges from short-term wins such as getting Canadian doctors working in the U.S. back to Canada sooner than later to turning the tide of rising obesity in Canada. We hope that the Standing Committee on Finance considers these short-term returns on investment as well as the longer returns on investment. A Greek proverb said it best, "A society grows great when old men plant trees whose shade they know they shall never sit in". This can be a great legacy of the Committee. On behalf of the members of the Canadian Medical Association, I wish you all the best in your deliberations. Recommendations for Committee consideration Medicine for a More Competitive Canadian Economy6 -10 recommendations with investment estimates A. CITIZENS - healthy living Recommendation 1: That the government consider the use of taxes on sales of high-calorie, nutrient-poor foods as part of an overall strategy of using tax incentives and disincentives to help promote healthy eating in Canada. Recommendation 2: That the government assess the feasibility of an individual, tax-sheltered, long-term health care savings plan. B. BUSINESS - healthy workforce Recommendation 3: That the government advances the remaining $1-billion from the 2004 First Ministers Accord that was originally intended to augment the Wait Times Reduction Fund (2010-2014) to support the establishment of a Patient Wait Times Guarantee and deliver on the speech from the throne commitment. Recommendation 4: That the federal government provide the Canadian Institute for Health Information with additional funding for the purpose of enhancing its information gathering efforts for measuring, monitoring and managing waiting lists and extending the development and collection of health human resource data to additional health professions. Recommendation 5: That the government launch a direct advertising campaign in the United States to encourage expatriate Canadian physicians and other health professionals to return to practice in Canada. Investment: A one-time investment of $10-million. Recommendation 6: That the government provide a rebate to physicians for the GST/HST on costs relating to health care services provided by a medical practitioner and reimbursed by a province or provincial health plan. Investment: $52.7-million per year or 0.2 % of total $31.5- billion GST revenues. C. INFRASTRUCTURE - healthy systems Recommendation 7: That the government follow through on the recommendation by the Federal Advisor on Wait Times to provide Canada Health Infoway with an additional $2.4-billion to secure an interoperable pan-Canadian electronic medical record with a targeted investment toward physician office automation. Investment: $2.4-billion over 5 years. Recommendation 8: That the government establish a Public Health Infrastructure Renewal Fund ($350-million annually) to build partnerships between federal, provincial and municipal governments, build capacity at the local level, and advance pandemic planning. Recommendation 9: That the government recommit to the $100-million per year for immunization programs under the National Immunization Strategy. Recommendation 10: That the government Increase the base budget of the Canadian Institutes of Health Research to enhance research efforts in the area of population health and public health, as well as significantly accelerate the pace of knowledge transfer. Investment: $600-million over 3 years. Introduction It is well known that Canada's place in a competitive world cannot be sustained by commodities or what the godfather of competitive advantage theory, Michael Porter calls "non-key" factors. Instead Porter suggests that sustainable competitive advantage is based on "specialized factors" such as skilled labour, capital and infrastructure. These specialized factors are created, not inherited. Moreover, Porter makes the important distinction that the crafting of "social" policies must make them reinforcing to the true sources of sustainable prosperity.7 The demand for highly skilled labour forces does not fluctuate as commodity prices do. This submission follows that line of thinking in suggesting that Canada should build on these specialized factors, emphasizing the health of our skilled labour force, enhancing the skills of our health care providers as well as making key investment in our health infrastructure - electronic and otherwise. Outline: healthy citizens, businesses, infrastructure and affordable government The Canadian Medical Association (CMA) brief submitted to the Standing Committee on Finance will make 10 recommendations on how the federal government can make our economy more competitive by investing in three priorities: health, health care and health infrastructure. The brief will address these topics, aligning them with support for our (A) citizens, (B) businesses and (C) infrastructure. The CMA also recognizes that the federal government does not have unlimited resources and suggests actions to be taken in order to ensure that these recommendations are both affordable and sustainable. Accordingly, we will also provide a "balance sheet" of investments, return on investments, as well as revenue raising possibilities that could help create incentives for healthy living and, in turn, a more competitive economy. A. Citizens - healthy living Canadians must become fitter and healthier. Almost 60% of all Canadian adults and 26% of our children and adolescents are overweight or obese. 8 Dr. Ruth Collins-Nakai, the immediate past-president of the CMA and a cardiac-care specialist, recently said ""I have a very real fear we are killing our children with kindness by setting them up for a lifetime of inactivity and poor health,". Canada should follow the lead of European countries, which have recently recommended a minimum of 90 minutes a day of moderate activity for children. Kicking a soccer ball or riding a skateboard for 15 to 30 minutes two or three times a week is not good enough, she said. Obesity costs Canada $9.6 billion per year. 9 These costs continue to climb. The federal government must use every policy lever possible at its disposal in order to empower Canadians to make healthy choices, help to reduce the incidence of obesity and encourage exercise as well as a proper diet. Obesity and absenteeism affect the bottom line Obesity not only hurts our citizens it is also a drag on Canadian competitiveness. There is a direct correlation between increasing weights and increasing absenteeism. The costs associated with employee absenteeism are staggering. Employee illness and disability cost employers over $16-billion each year.10 For instance, the average rate of absence due to illness or disability for full-time Canadian workers was 9.2 days in 2004, a 26% increase over the last 8 years, according to Statistics Canada's latest labour force survey. While there is a growing awareness of the costs due to obesity are well known. The programs and incentives in place now are clearly not working as the incidence of obesity continues to grow. The benefits of turning the tide of obesity are also clear. In his remarks to the CMA in August 2006, Minister Tony Clement made the following statement: "And you know and I know that health promotion, disease and injury prevention not only contribute to better health outcomes, they help reduce wait times as well." The experts agree, "The economic drive towards eating more and exercising less represents a failure of the free market that governments must act to reverse it."11 Recommendation 1: That the government consider the use of taxes on sales of high-calorie, nutrient-poor foods as part of an overall strategy of using tax incentives and disincentives to help promote healthy eating in Canada. Tax-sheltered savings for long-term care - aligning tax policy and health policy Canada is entering an unprecedented period of accelerated population aging that will see the share of seniors aged 65 and over increase from 13% in 2005 to 23% in 2031. At the same time, the cost of privately funded health services such as drugs and long-term care are projected to increase at double-digit rates as new technologies are developed and as governments continue to reduce coverage for non-Medicare services in order to curb fiscal pressures12. Since seniors tend to use the health system more intensively than non-seniors, the rising cost of privately funded health services will have a disproportionately high impact on seniors. Canadians are not well equipped to deal with this new reality. Private long-term care insurance exists in Canada, but is relatively on the Canadian scene and has not achieved a high degree of market penetration. New savings vehicles may be needed to help seniors offset the growing costs of privately funded health services. One approach would be extend the very successful model of RRSPs to enable individuals save for their long-term care needs via a tax-sheltered savings plan. Recommendation 2: That the government assess the feasibility of an individual tax-sheltered long-term health care savings plan. B. Business - healthy workforce In spite of the fact that health as an economic investment has proven returns, governments have been letting up in their support of their citizens' health. The impact is felt not only in terms of poorer health but it also affects businesses through increased absenteeism, as well as governments through lower tax revenues. According to the Center for Spatial Economics, "...the cumulative economic cost of waiting for treatment across Ontario, Saskatchewan, Alberta and BC in 2006 is estimated to be just over $1.8-billion. This reduction in economic activity lowers federal government revenues by $300-million." 13 The total costs to the federal government are even higher if all 10 provinces were included. The estimate is based on four of the five priority areas identified in the 2004 First Ministers Health Accord: total joint replacement surgery, cataract surgery, coronary artery bypass graft, and MRI scans. If you wonder what all this has to do with Canadian business, ask yourself how many person/hours employers lose due to illness? How much productive time is lost due to the stress of an employee forced to help an elderly parent who cannot find a doctor? This challenging situation is going to get worse, as the population ages, and as our health professionals age and retire. Supporting the Patient Wait Time Guarantee The establishment of pan-Canadian wait time benchmarks and a Patient Wait Times Guarantee are key to reducing wait times and improving access to health services. The 2004 First Ministers' health care agreement set aside $5.5-billion for the Wait Time Reduction Fund, of which $1-billion is scheduled to flow to provinces between 2010 and 2014. To assist provinces with the implementation of the wait time guarantee while remaining within the financial parameters of the health care agreement, the federal government could advance the remaining $1-billion and flow these funds to provinces immediately. Recommendation 3: That the government advances the remaining $1-billion from the 2004 First Ministers Accord that was originally intended to augment the Wait Times Reduction Fund (2010-2014) to support the establishment of a Patient Wait Times Guarantee and deliver on the speech from the throne commitment. Making investments count and counting our investments It would be irresponsible for government to make investments if the results were not being measured. As management guru Tom Peters suggests, "What you do not measure, you cannot control." And, "What gets measured gets done." As billion dollar federal funding of health care reaches new heights, the value of measuring these investment increases. That is where the Canadian Institute for Health Information (CIHI) comes in. CIHI has been involved in developing wait time indicators and tracking Canada's progress on wait times. It is essential that we have an arm's length body responsible for collecting data on wait times as part of Canada's effort to improve timely access to care for Canadians. CIHI has also played an active role in health human resource data collection and research. Their financial support for the 2004 National Physician Survey resulted in a one-of-a-kind research file with input from over 20,000 Canadian physicians. Recommendation 4: That the federal government provide the Canadian Institute for Health Information with additional funding for the purpose of enhancing its information gathering efforts for measuring, monitoring and managing waiting lists and extending the development and collection of health human resource data to additional health professions. Direct advertising in the U.S. to bolster health human resources deficit The primary barrier affecting timely access to quality health care is the shortage of health care professionals. Canada currently ranks 26th in the OECD in terms of physicians per capita, at 2.1 MDs per 1,000 people. More than three million Canadians do not have a family physician. This situation will get worse as the population ages and as our health professionals age and retire. Fortunately, another short-term source of health professionals exists that Canada should pursue. Thousands of health care professionals are currently working in the United States including approximately 9,000 Canadian trained physicians. We know that many of the physicians who do come back to Canada are of relatively young age meaning that they have significant practice life left. While a minority of these physicians do come back on their own, many more can be repatriated in the short-term through a relatively small but focussed effort by the federal government led by a secretariat within Health Canada. Recommendation 5: That the government launch a direct advertising campaign in the United States to encourage expatriate Canadian physicians and other health professionals to return to practice in Canada. Investment: A one-time investment of $10-million. Re-investing the GST for 30,000 small businesses The continued application of the GST on physician practices is an unfair tax on health. Because physicians cannot recapture the GST paid on goods and services for their practices in the same way most other businesses can, the GST distorts resource allocation for the provision of medical care. As a result, physicians end up investing less than they otherwise could on goods and services that could improve patient care and enhance health care productivity such as information management and information technology systems. The introduction of the GST was never intended to fall onto the human and physical capital used to produce goods and services. The GST is a value-added tax on consumption that was put into place to remove the distorting impact that the federal manufacturers sales tax was having on business decisions. However, the GST was applied to physician practices in a way that does exactly the opposite. The federal government must rectify the situation once and for all. Based on estimates by KPMG, physicians have paid $1.1-billion in GST related to their medical practice since 1991. This is $1.1-billion that could have been invested in better technology to increase care and productivity. Recommendation 6: That the government provide a rebate to physicians for the GST/HST on costs relating to health care services provided by a medical practitioner and reimbursed by a province or provincial health plan. Investment: $52.7-million per year or 0.2 % of total $31.5-billion GST revenues. C. Infrastructure -healthy system Recovery of health information technology investments is almost immediate A Booz, Allen, Hamilton study on the Canadian health care system estimates that the benefits of an EHR could provide annual system-wide savings of $6.1 billion, due to a reduction in duplicate testing, transcription savings, fewer chart pulls and filing time, reduction in office supplies and reduced expenditures due to fewer adverse drug reactions. The study went on to state that the benefits to health care outcomes would equal or surpass these annual savings. Evidence shows that the sooner we have a pan-Canadian EHR in place, the sooner the quality of, and access to health care will improve.14 Mobilizing physicians to operationalize a pan-Canadian Electronic Health Record The physician community can play a pivotal role in helping the federal governments make a connected health care system a realizable goal in the years to come. Through a multi-stakeholder process encompassing the entire health care team, the CMA will work toward achieving cooperation and buy-in. This will require a true partnership between provincial medical associations, provincial and territorial governments and Canada Health Infoway (CHI). The CMA is urging the federal government to allocate an additional investment of $2.4-billion to Canada Health Infoway over the next five years15 to build the necessary information technology infostructure to address wait times16 as well as support improved care delivery. Both the Federal Wait Times Report and Booz Allen Study concur that this requires automating all community points of care - i.e., getting individual physician offices equipped with electronic medical records (EMRs). This is a necessary, key element to the success of the EHR agenda in Canada and recent assessments place the investment required at $1.9-billion of the $ 2.4-billion. CHI has proven to be an effective vehicle for IT investment in Canadian health care. For example, as a result of CHI initiatives, unit costs for Digital Imaging have been reduced significantly and are already saving the health care system up to 60-million dollars. In fact as a result of joint procurements and negotiated preferred pricing arrangements through existing procurement efforts with jurisdictional partners the estimated current cost avoidance is between $135-million to $145-million. Moreover, in the area of a Public Health Surveillance IT solution, a pan Canadian approach to CHI investments with jurisdictional partners has lead to benefits for users, the vendor and Canadians. The negotiation of a pan-Canadian licence enables any jurisdiction to execute a specific licence agreement with the vendor and spawn as many copies as they need to meet their requirements. The vendor still owns the IP and is free to market the solution internationally - clearly a win/win for both industry and the jurisdictions. Recommendation 7: That the government follow through on the recommendation by the Federal Advisor on Wait Times to provide Canada Health Infoway with an additional $2.4-billion to secure an interoperable pan-Canadian electronic medical record with a targeted investment toward physician office automation. Investment: $2.4-billion over 5 years. Establishing a Public Health Infrastructure Renewal Fund The CMA remains concerned about the state of Canada's public health system. Public health, including the professionals providing public health services, constitutes our front line against a wide range of threats to the health of Canadians. While there is much talk about the arrival of possible pandemics, Canada's public health system must be ready to take on a broad range of public health issues. The CMA has been supportive of the Naylor report which provides a blue print for action and reinvestment in the public health system for the 21st century. While this will take several years to achieve, there are some immediate steps that can be taken which will lessen the burden of disease on Canadians and our health care system. These steps include establishing a Public Health Partnership Program with provincial and territorial governments to build capacity at the local level and to advance pandemic planning. In addition, we call on the government to continue its funding of immunization programs under its National Immunization Strategy. Public health must be funded consistently in order to reap the full benefit of the initial investment. Investments in public health will produce healthier Canadians and a more productivity workforce for the Canadian economy. But this takes time. By the same token, neglect of the public health system will cost lives and hit the Canadian economy hard. Recommendation 8: That the government establish a Public Health Infrastructure Renewal Fund ($350-million annually) to build partnerships between federal, provincial and municipal governments, build capacity at the local level, and advance pandemic planning. Supporting the National Immunization Strategy Dr. Ian Gemmell, Co-Chair of the Canadian Coalition for Immunization Awareness and Promotion, has said, "Vaccines provide the most effective, longest-lasting method of preventing infectious diseases in all ages." strongly urge that immunization programs be supported. Healthy citizens are productive citizens and strong immunization programs across the country pay for themselves over time. Recommendation 9: That the Federal Government recommit to the $100-million per year for immunization programs under the National Immunization Strategy. Making medical research investments count - supporting knowledge transfer The Canada Institutes of Health Research (CIHR) was created to be Canada's premier health research funding agency. One of the most successful aspects of the CIHR is its promotion of inter-disciplinary research across the four pillars of biomedical, clinical, health systems and services as well as population health. This has made Canada a world leader in new ways of conducting health research. However, with its current level of funding, Canada is significantly lagging other industrialized countries in its commitment to health research. Knowledge transfer is one of the areas where additional resources would be most usefully invested. Knowledge Translation (KT) is a prominent and innovative feature of the CIHR mandate. Successful knowledge translation significantly increases and accelerates the benefits flowing to Canadians from their investments in health research. Through the CIHR, Canada has the opportunity to establish itself as an innovative and authoritative contributor to health-related knowledge translation. Population and public health research is another area where increased funding commitments would yield long-term dividends. Recommendation 10: That the government Increase the base budget of the Canadian Institutes of Health Research to enhance research efforts in the area of population health and public health, as well as significantly accelerate the pace of knowledge transfer. Investment: $600-million over 3 years. Conclusion The CMA recognizes the benefits of aligning tax policy with health policy in order to create the right incentives for citizens to realize their potential. Accordingly our proposals include tax incentives for healthy living as well as a recommendation to encourage savings for long-term health care. The time horizon for our 10 recommendations ranges from short-term wins such as getting Canadian doctors working in the U.S. back to Canada sooner than later to turning the tide of rising obesity in Canada. We hope that the Standing Committee on Finance considers these short-term returns on investment as well as the longer returns on investment. A Greek proverb said it best, "A society grows great when old men plant trees whose shade they know they shall never sit in". This can be a great legacy of the Committee. On behalf of the members of the Canadian Medical Association, I wish you all the best in your deliberations. Appendix 1 - Recommendations for Committee consideration 10 point plan with estimated investments and revenues Appendix 2 - The Information Technology Agenda in the Canadian Health Care Sector * The Health Council of Canada, the Presidents and CEOs from the Academic Healthcare Organizations and the federal advisor on wait times all agree on the need to accelerate the building out of the information technology infostructure for the healthcare sector * All these groups amongst others argue that there are large gains to be made on improving healthcare delivery and achieving efficiencies in operating the health care system * Automating health care delivery in Canada will lead to a more efficient healthcare system and will build industry capacity to compete in the international market place * A $10-billion investment is estimated to result in a return on investment (ROI) exceeding investment dollars by an 8:1 margin, and a net savings of $39.8-billion over a 20-year period. It is estimated that a net positive cash flow would occur in Year Seven of implementation, and an investment breakeven by Year 11, resulting in an annual net benefit of $6.1-billion.17 * Part of this investment is to automate the over 35,000 physicians who have a clinic in a community setting * It is estimated that $1.9-billion is needed to accomplish this task which when complete will facilitate better management of wait times, improved patient safety, helping to address in part the human resource shortage for providers as well as make a contribution to improved First Nation health. * Our recommendation is that the Federal government provide a further direct investment of $1-billion into Canada Health Infoway (CHI) that is targeted to the automation of physician offices. This funding would pay for 50% of the costs to automate a physician's clinic. * The funds would be allocated to provinces and medical associations through CHI once an agreement has been developed. A jointly developed program would ensure complementarity with a provincial health IT strategy and a program that has been designed by physicians such that it does the most to improve health care delivery * Physicians would be asked to pay the other 50% and through tax policy they would be able to claim a deduction for capital information technology acquisitions * This arrangement mirrors current programs funded by CHI on a 75%-25% cost sharing model with provinces but with physicians picking up approximately 25% of the costs Appendix 3 Can taxation curb obesity? A recent article in the New Scientiest.com1 asks, Can taxation curb obesity? "The economic drive towards eating more and exercising less represents a failure of the free market that governments must act to reverse."18 "We have market failure in obesity, because we have social costs greater than the private costs," according to Lynee Pezullo director of the economic advisory group Access Economics. "The government also bears the health costs, and people don't take into account costs they bear themselves. If people had to pay for their own dialysis they might bear these things in mind a bit more." When two-thirds of the population of countries like Australia or the US are obese or overweight, you can't handle the problem with simple solutions like education," Barry Popkin of the University of North Carolina, Chapel Hill. A Yale University professor is generating support for a "twinkie tax"1 on high-calorie foods like french fries. This tax works In California in 1988, Proposition 99 increased the state tax by 25 cents per cigarette pack and allocated a minimum of 20% of revenue to fund anti-tobacco education. From 1988 to 1993, the state saw tobacco use decline by 27%, three times better than the U.S. average.1 CMA is not alone in supporting a junk food tax In December, 2003, the World Health Organization proposed that nations consider taxing junk foods to encourage people to make healthier food choices. According to the WHO report, "Several countries use fiscal measures to promote availability of and access to certain foods; others use taxes to increase or decrease consumption of food; and some use public funds and subsidies to promote access among poor communities to recreational and sporting facilities." The American Medical Association is planning to demand the government to levy heavy tax on the America's soft drinks industry. Currently, 18 U.S. states have some form of "snack" food tax in place and five states have proposed policy and legislative recommendations. The economic costs of obesity are estimated at $238-billion annually, and rising. Along the same lines, the former Surgeon General, C. Everett Koop, believes that after smoking, "obesity is now the number one cause of death in [the U.S.]...we're not doing the same kind of things with obesity that we have done with smoking and alcohol as far as government programs are concerned ... It's got to be like smoking, a constant drum beat." 1 "U.S. Slowdown Underway Canada in for a Bumpy Ride" See www. td.com/economics/ (accessed Sept. 19, 2006) 2www.worldbank.org/mdf/mdf1/advantge.htm (accessed Sept. 19, 2006) 3 Source: Statistics Canada, Business Register 2005. 4 Source: Statistics Canada, Industrial Research and Development -2004 intentions, No. 88-202-XIB, January 2005. 5 Nordhaus notes that over the 1990-1995 period the value of improved health or health income grew at between 2.2 and 3.0 per cent per year in the United States, compared to only 2.1 per cent for consumption. See The Health of Nations: The Contribution of Improved Health to Living Standards William D. Nordhaus, Yale University www.laskerfoundation.org/reports/pdf/economic.pdf (accessed Sept. 18, 2006) 6 See Appendix 1 for 3-year investment details as well as short, medium and long-term returns on investment 7 www.worldbank.org/mdf/mdf1/advantge.htm Accessed September 20, 2006. 8 Source: ww2.heartandstroke.ca/Page.asp?PageID=1366&ArticleID=4321&Src=blank&From=SubCategory Accessed August 14, 2006. 9 P.Katzmarzyk, I. Janssen "The Economic costs associated with physical inactivity and obesity in Canada: An Update" Can J Applied Physiology 2004 Apr; 29(2):90-115. www.phe.queensu.ca/epi/ABSTRACTS/abst81.htm Accessed August 14, 2006. 10 Staying@Work 2002/2003 Building on Disability Management, Watson Wyatt Worldwide www.watsonwyatt.com/canada-english/pubs/stayingatwork/ Accessed July 31, 2006. 11 Swinburn, et al. International Journal of Pediatric Obesity (vol 1, p 133) (accessed Sept. 19, 2006) 12 Canada's Public Health Care System Through to 2020, the Conference Board of Canada, November 2003. 13 The Economic Cost of Wait Times in Canada, by the Center for Spatial Economics, June 2006. www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/CMA_This_Week/BCMA-CMA-waittimes.pdf 14 Booz, Allan, Hamilton Study, Pan-Canadian Electronic Health Record, Canada's Health Infoway's 10-Year Investment Strategy, March 2005-09-06 15 See Appendix 1 and Appendix 2 for more investment details and background. 16 Final Report of the Federal Advisor on Wait Times, June 2006, Dr. Brian Postl 17 Booz Allen Hamilton Study, Pan-Canadian Electronic Health Record, Canada Health Infoway's 10-Year Investment Strategy, March 2005 18 Can taxation curb obesity? See www.newscientist.com/article/dn9787-can-taxation-curb-obesity.html (accessed September 20, 2006.) Medicine for a more competitive Canadian economy
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CMA Letter to the Senate Committee on Legal and Constitutional Affairs regarding Bill C-2, An Act to amend the Criminal Code and to make consequential amendments to other Acts

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

https://policybase.cma.ca/en/permalink/policy9135
Last Reviewed
2020-02-29
Date
2008-05-27
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2008-05-27
Topics
Health systems, system funding and performance
Text
The CMA appreciates the opportunity to present to the Standing Committee on Health today. My presentation will focus on: 1. Wait Times 2. Health Human Resources; and 3. Patient Focused Care Wait Times In regard to the issue of wait times, I would echo the two main points of my colleagues from the Wait Time Alliance: * First, while progress is being made on wait times, that progress is limited and not consistent across the country; and second, * Health workforce and infrastructure capacity shortages remain the primary barriers to effectively addressing wait times. Wait times don't only exact a heavy human toll - they also carry severe economic costs. A CMA-commissioned report released earlier this year found that the economic cost of having patients wait longer than medically recommended was $14.8 billion in 2007. That stunning total was for just four of the five procedures identified as priorities in the 10-year plan - joint replacement, diagnostic imagining and cataract and bypass surgery - and it was only for one year. Over a million Canadians continue to suffer on wait lists because of deficiencies in our system. This is unacceptable. We need to "break the back" of wait times for the sake of our patients and for the economic health of Canada. This will require: * More federal leadership, not less; * A revolutionary change in the "focus" of our health care system; and * Substantial investments. Health Human Resources The 10-Year Plan to Strengthen Health Care acknowledged the need to increase the supply of health care professionals in Canada. However, not enough progress has been made. Canada is 26,000 doctors short of the average of developed countries, and we now rank a lowly 24th among OECD countries in doctors per population. A poll released today by the CMA found that Canada's doctor shortage ranked second only to the economy as a top public issue. In this same poll, 91% of Canadians say having a plan to address the doctor shortage will influence their vote in the next federal election. Federal political parties who ignore this issue in the next election could pay a price at the polls. In the 10-year plan to strengthen health care, $1-billion was set aside for the last four years (2010-2014) of the agreement. We can't afford to wait that long. This funding should be immediately fast-tracked to focus on the three priority areas in the CMA's "More Doctors. More Care" Campaign: * One, expanding health professional education and training capacity; * Two, ensuring self sufficiency in health human resources by investing in long-term health human resource planning; and. * Three, investing in health information technology to make our health care system more responsive and efficient. In terms of IT, we should be ashamed that we only spend a third of the OECD average on IT in our hospitals. Canada's poor record in avoidable adverse effects is, in part, due to our system's inability to share available information in a timely manner. Patient Focused Care Many countries have systems that provide universal care, have no wait lists and cost the same or less to run as our system does. Wait lists can and must be eliminated in Canada. The momentum to do just that depends simply on making the system work for patients, not on forcing patients to work the system. We must reposition patients to the centre of our health-care system, which requires that we move beyond block funding or global budgets for health institutions. We need a system where funds follow the patient - patient-focused funding. Block funding blocks access. Patient-focused funding will increase productivity, lead to greater efficiencies and reduce wait lists. A patient will become a value to an institution, not a cost. Canada remains the last country in the developed world to fund hospitals with block funding. In England, patient-focused funding helped eliminate wait lists in less than four years. Conclusion So, my question to the Committee is why do we wait? Why do we continue to keep patients on wait lists when research shows it costs a lot less to cut wait times then it does to have them? Why do we not make the necessary reforms and investments to provide Canadians with timely access to quality care? Thank you.
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CMA's letter to Mr. James Rajotte, MP Chair, Standing Committee on Industry, Science and Technology: Review of the service sector in Canada

https://policybase.cma.ca/en/permalink/policy9114
Last Reviewed
2020-02-29
Date
2008-02-23
Topics
Health human resources
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2008-02-23
Topics
Health human resources
Health systems, system funding and performance
Text
On behalf of the Canadian Medical Association (CMA), I want to thank you for the opportunity to provide the following information to the House of Commons Standing Committee on Industry, Science and Technology during its review of the service sector in Canada. The committee's study of the strengths and challenges facing this sector, overall employment percentage, overall average of salaries across the sector its impact on Canada's overall economy and the role of the Government of Canada in strengthening this sector comes at an opportune time. CANADA'S HEALTH SERVICES SECTOR Canada's health services sector is facing a critical shortage of physicians and other health care professionals and the CMA and our over 67,000 physician members are pleased to have the opportunity to present practical solutions within the jurisdiction of the federal government - working collaboratively with provincial/territorial governments and other health system stakeholders. Health care delivery in Canada is a $160 billion industry, representing over 10% of our country's gross domestic product (GDP).1 The 30,120 physicians' offices across Canada make important contributions to our economy. In 2003, the latest year for which data are available, offices of physicians employed 142,000 Canadians and contributed $11.6 billion to the Canadian economy.2 This represents almost 39 per cent of all Health Service Delivery establishments, and almost 11% of all HSD employees. As a standard measure of economic productivity, physician offices report the highest levels of GDP per employee within the Health Service Delivery sector. On this measure, they are approximately twice as productive as other components of Health Service Delivery. THE CHALLENGE There are simply not enough physicians to continue providing the quality health care that Canadians expect and deserve. Here are the facts: - Almost 5 million Canadians do not have access to a family physician; - By 2018 an additional 4.5 million Canadians could be without a doctor; - Canada ranks 24th in Organisation for Economic Co-operation and Development (OECD) nations in terms of physicians-per-population ratio. Canada would need 26,000 more doctors right now to meet the OECD average; - Canada spends only a third of the OECD average on information technology (IT) and diagnostic equipment in our hospitals; and - Canada has the highest hospital occupancy rate of all OECD countries and among the highest waits for access to specialty care services. The lack of physicians and other health care providers has resulted in restricted access to health care services and the growth of wait times for necessary medical procedures. In January 2008, CMA released new research by the Centre for Spatial Economics that proved that, in addition to the human health cost, waiting for care results in dramatic and excessive costs to our economy. Researchers addressed just four priority areas targeted in the 2004 First Ministers Health Accord. They used government and other data to determine how many Canadians were waiting longer than the maximum medical consensus established by the Wait Time Alliance. Selected for analysis were: joint replacement, cataract surgery, heart bypass grafts, and MRI scans. Costs, as calculated for all provinces varied from $2,900 to over $26,000 per patient. The cumulative cost of waiting in 2007, for treatment in just 4 areas, was $14.8 billion. This reduced economic activity lowered government revenues in 2007 by $4.4 billion. That is equivalent to over 1/3rd of the total Ontario health budget. The reduction in economic activity included the impact of the patient's inability to work while waiting, and direct losses from decreased production of goods and services, reduced income, and lowered discretionary spending. It is important to note that the figure of 14.8 billion dollars is based only on patients that exceed designated maximum waiting times in just 4 clinical areas. In the example of hip replacements, the research only factored in costs for waits that exceed 6 months. Of those waiting longer than the maximum recommended time, average waits were 1 year for hip and knee replacement surgery, 7 months for cataract surgery, and twice maximum for heart bypass surgery. Those who didn't make the MRI target waited an average of 12 weeks. Reduced economic activity included informal caregiver costs. These costs are generated when caregivers reduce work hours to care for family members on wait lists, or attend appointments with family members. Patients languishing on wait lists also incur additional costs for drug and other treatments that timely care would eliminate. Estimates in this study are extremely conservative. They address only the wait time to treatment after a specialist's consultation and recommendation. And exclude the growing, and significant costs of waiting to see the GP or specialist. They do not include anyone who is not working. They do not include the costs, short and long term, of the deterioration that occurs while waiting. THE SOLUTIONS To solve Canada's doctor shortage, the CMA believes governments must: - Adopt a long-term policy of self-sufficiency to provide Canadians with the health care professionals they need when and where they need them; - Establish a dedicated health human resource renewal fund to educate, retain and enhance the lives of health care professionals; and - Invest in health technology, infrastructure and innovation to make our health care system more responsive and efficient. SELF-SUFFICIENCY Over the past decade, there have been increasing concerns that Canada is not producing an adequate number of health providers to meet the growing demand for health services - now and into the future. These concerns have been consistently registered by physicians, nurses, pharmacists, technicians, in addition to other groups that represent other providers and the institutional and heath facilities community. Furthermore, the policy challenges related to health human resources (HHR) have been identified in several seminal reports - including the Royal Commission on the Future of Health Care in Canada, the Standing Senate Committee on Social Affairs, Science & Technology, and the Health Council of Canada.3 A growing number of health providers are looking to retire over the next decade (or leave the health system all together) relative to the number of trainees who are entering the health system, and at a time where a growing number of Canadians will be turning to the health system for diagnosis and treatment. Over 6% of physicians who responded to the National Physician Survey 20074 said they plan to retire from clinical practice and 1% plan to permanently leave practice for other reasons in the next 2 years. The effect of these changes could mean that, as the baby boom generation gets older, over 4,000 physicians will cease their medical practice within the next 2 years, making it even more difficult for Canadians to find a family physician. At the same time, the HHR challenges facing Canada's health care system are not unique to our country - over the next decade all western developed countries can expect intensified global competition for talent when it comes to health providers.5 While there are, no doubt, other provider groups who are also concerned about the future supply of health providers, there is a growing national consensus that, in addition to the primary role that the provinces and territories play in supporting the training of health providers across the country, there is a significant, catalytic and strong complementary role for the federal government in the area of health human resources. CMA, like many health care organizations, is of the view that there is a legitimate role for the federal government to strengthen its working relationship with the provinces and territories, and health providers through the creation of a time-limited, issue-specific and strategically-targeted fund to accelerate training capacity in the health system. The World Medical Association's ethical guidelines for international recruitment of physicians16 (2003), fully supported by the CMA, recommend that every country "should do its utmost to educate an adequate number of physicians, taking into account its needs and resources. A country should not rely on immigration from other countries to meet its need for physicians."7 However, in reality Canada continues to rely heavily on recruitment of internationally educated health professionals. Approximately one-third of the increase in physician supply each year is due to International Medical Graduates (IMGs) who are either recruited directly to practice or who have taken significant postgraduate medical training in Canada. In nursing, the number of internationally educated nurses applying for licensure is increasing rapidly, almost tripling from 1999 to 2003. Previous recommendations of the CMA to the House of Commons included improved medium- to longer-term supply projection models; sufficient opportunities for Canadians to train for health professional careers in Canada; and integration of international graduates, who are permanent residents or citizens of Canada, into practice. The CMA recognizes that professionals are working in an increasingly global world in terms of the exchange of scientific information, mutual recognition of qualifications between countries and the movement of people. The greatest barrier to enhancing Canada's ability to become more self-sufficient, in terms of physician resources, is the capacity of our medical schools. Despite recent increases in enrolment, Canada continues to turn away approximately 3 equally qualified students for every 1 that is accepted into an undergraduate medical program. This has resulted in over 1500 Canadian students, with the financial means to do so, who are training in medical schools outside of Canada. INTERNATIONAL MEDICAL GRADUATES In the larger context, Canada's current fertility rate is not sufficient to support self-sufficiency in general in relation to any professions. And, while self-sufficiency in the production of physicians is a desirable goal, it is also important to promote the international exchange of teaching and research, particularly in an increasingly global society. In this regard, IMGs should be considered as a planning component for a sustainable Canadian physician workforce. Historically IMGs have entered the practice of medicine through a variety of routes, which most typically include a recognized period of post-MD training in Canada. CMA's best estimate is that there are about 400 IMGs newly licensed to practice in Canada each year who have not completed postgraduate training in Canada. In addition, there are another 300 or so who are exiting Canadian postgraduate training programs and heading into practice. In fact, for the past few years, the College of Physicians and Surgeons of Ontario has licensed more IMGs than new Ontario medical graduates. In recent years, there have been an increasing number of opportunities for IMGs already living in Canada to achieve the required credentials for licensure. The number of ministry-funded IMG postgraduate residents has more than tripled in the past seven years from 294 to 1065 trainees. In 2007, there were almost 1500 IMGs who were qualified to compete in the Canadian Resident Matching Service (CaRMS) match. By the end of the second round, close to 300 had matched and about 60 were placed through other provincial programs. Recommendation The federal government should make a clear policy commitment to increasing self-sufficiency in the education and training of health professionals in Canada that would incorporate the following. - Short term - increase number of community preceptors to train Canadian graduates and assess internationally educated health professionals already living in Canada. Recognition of the time and value of community teaching is needed. - Medium term - support increased capacity for academic health science centres and other institutions that train health professionals. - Long term - creation of new academic health science centres to increase capacity for self-sufficiency. REPATRIATING CANADIAN DOCTORS WORKING ABROAD It is known that there are thousands of Canadian-trained health professionals practising in the United States and abroad. Between 1991 and 2004, almost 8,000 physicians left Canada (although some 4,000 returned for a net loss of 4,000).8 Of this number, roughly 80% went to the US.9 During the 1990s, approximately 27,000 nurses migrated from Canada to the US.1011 A more recent indicator of nursing outmigration is that in 2006, 943 Canadian-trained Registered Nurses and Licensed Practical Nurses wrote the US licensing board examination for the first time.12 Data for other health professional disciplines are not readily available. In 2007, with the assistance of the American Medical Association, the Canadian Medical Association (CMA) surveyed all (n=5,156) Canadian-trained physicians practicing in the US who were age 55 or under, with regard to the likelihood of their return to Canada and the importance of various factors that might be incentives to return. A 32% response rate was achieved with a single mailing with no follow-up - this is considered exceptionally high. While only 13% of respondents indicated that they were likely or very likely to return to Canada, a further 25% were neutral in their opinion. What is more telling is that more than one-half of respondents indicated that they would be willing to be contacted by CMA to explore practice opportunities and provided their contact information for this purpose. When asked about a range of potential incentives to return to Canada, 57% agreed that a relocation allowance would be somewhat or very important.13 It must be stressed, however, that it is clear from the results that a number of factors would need to be taken into consideration, such as practice opportunities. This would also be true of other disciplines; in the case of nursing, nurses will only come back for full-time jobs and healthy work environments.14 Nonetheless, expatriate Canadian medical graduates should be good candidates for recruitment on the basis of the greater likelihood that they will meet Canadian standards for full medical licensure, and it is expected that this would also apply to nursing and other disciplines. As well, significant progress has been made in restoring and adding capacity to our medical schools but, to achieve self-sufficiency, much more needs to be done. For example, we must try and repatriate Canadian medical students and doctors who are studying and working abroad. There are currently some 1500 Canadian medical students and residents training abroad, we must act now, before things get worse. During that past few years there have been efforts to enhance national coordination in the health human resources arena. One area of national focus has been the integration of International Medical Graduates, since extended to nursing and other disciplines. There have been several initiatives undertaken in this area such as the establishment of the Canadian Information Centre for International Medical Graduates15 which provides a clearinghouse of information and links to provincial/territorial jurisdictions. Relocation grants, from $10,000 up to $20,000 could be offered to Canadian-trained physicians practising in the US. It is suggested that advertising be concentrated in and around US cities where Canada maintains a consulate/office (in states with a significant concentration with recruitment candidates) and in major national and selected state health professional journals. The cost of a repatriation secretariat is estimated at $162,500 per year. Assuming that 1,500 health professionals are recruited back over the 3-year period, the total cost would range from $21.5 million to $36.5 million. This would further translate to a per recruit cost that ranges from $14,325 to $24,325. Even at the high end of the range this would be cost-effective as compared to the total cost of training a practice-entry level graduate of any licensed health professional discipline in Canada. Recommendation In light of the foregoing, the CMA has recommended that the federal government should establish a Health Professional Repatriation Program in the amount of $30 million over 3 years that would include the following: - secretariat within Health Canada that would include a clearinghouse function on issues associated with returning to Canada such as licensure, citizenship and taxation; - An advertising campaign in the US to encourage health professionals practicing south of the border to return home; and - A program of one-time relocation grants for health professionals returning to active practice in Canada. NATIONAL HEALTH HUMAN RESOURCES INFRASTRUCTURE FUND The implementation of Medicare in Canada in the 1960s required a major investment in the capacity to train more health professionals. The 1966 Health Resources Fund Act played a key role in enabling a significant expansion in training capacity across the provinces for a range of health professionals. Forty years later, Canada faces growing shortages across most health disciplines. Clearly another giant step up is required in the human and physical infrastructure needed to train health professionals if Canadians are to have timely access to care. During the years of fiscal famine of the 1990s, health professional enrolment was either reduced (e.g., 10% in the case of medicine) or flat-lined. While there have been increases since 2000, we are about to face the double impact of both an aging population as the first of the baby boomers reach 65 in 2011 and aging health professions. For example, more than 1 out of 3 physicians (35%) are aged 55 or older. As mentioned, as many as 4,000 physicians are expected to retire in the next 2 years. If we are going to have sufficient numbers of health providers to meet the needs of the next few decades, it is imperative to expand the human and physician infrastructure capacity of our health professional education and training system. The federal investments in health human resources over 2003-2005 of some $200 million have been welcome, but fall far short of what is needed. It is proposed that the federal government implement a National Health Human Resources Infrastructure Fund in the amount of $1 billion over 5 years that would be made available to the provinces/territories on an equal per capita basis, and awarded through a competitive process that would include federal/ provincial/territorial representation with consultation/engagement of health professional organizations. The fund would address the following elements: 1. The direct costs of training providers and developing leaders (e.g., cost of recruiting and supporting more community- based teachers/preceptors). 2. The indirect or infrastructure costs associated with the educational enterprise (e.g., physical plant [housekeeping, maintenance]; support for departments [information systems, library resources, occupational health, etc.]; education offices, and the materials and equipment necessary for clinical practice and practical training. 3. Resources that improve the country's overall data management capacity when it comes to health human resources, and in particular, facilitate the ability to model and forecast health human resource requirements in the face of the changing demand for health services. Clearly it would be necessary to develop guidelines around the types of expenditures that would be eligible as was done for the 1966 Health Resources Fund, and more recently for the Medical Equipment Fund II. CMA Recommendation The federal government should establish a National Health Human Resources 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 - resources that improve Canada's data collection and management capacity in the area of health human resources. HEALTH INNOVATION More than 85% of the health care delivered in Canada occurs within the community. This is the most under-invested segment of the health care delivery system in terms of information technology. Dr. Brian Postl in his June 2006 wait-time report16 to the federal government noted health information technology is essential in improving wait times. He quantified the investment needed at $2.4 billion with the largest portion of this investment ($1.9 billion) targeted to automating physician offices, which are located at the front line of care in community settings and are key to managing and resolving the wait time issue in Canada. Why invest in physician office automation? Because it will lead to improved productivity from the provider community through more efficient resource usage and through improved coordination in the delivery of care; it will enable labour mobility of health care workers through portability of records; it will support the wait time agenda by improving the flow of timely information; it will build an electronic infrastructure platform to enhance patient care and health research and will provide a direct financing vehicle for the federal government to influence and shape the health care sector. The federal government has made similar types of infrastructure investment. The CFI Program was established to fund research infrastructure, which consists of the state-of-the-art equipment, buildings, laboratories and databases required to conduct research. Investing in EMR infrastructure will lead to the creation of state of the art clinical environments across Canada, electronic data base of health information and the foundational underpinnings of a health information network to support enhanced population health and health research. Under this scenario the federal contribution would provide a direct benefit to physicians without any need for provincial or territorial involvement. Second, the federal government could use existing government machinery to manage the program. Third, the federal contribution to infrastructure would only flow after a physician has introduced an EMR into his/her clinic ensuring that the funding is directly tied to building the EMR infrastructure platform. The recent National Physician Survey notes that some progress is being made across the country to automate community clinics. However without incentives the adoption trend will be incremental and extend over a further 20-year time frame. Financial incentives can shorten the timelines since it addresses one of the main adoption barriers physicians identify.17 Diffusion theory18 of new technologies into any sector of the economy demonstrates that without appropriate incentives it will take approximately 25 years the technology to reach the saturation point of integration. It is estimated that a financial incentive can shorten this timeline by 15 years. Recommendation The federal government, over a 5-year time frame, should provide a full tax credit to any physician who takes the steps to automate his or her clinical office. The tax credit would only apply to 1-time costs to establish a state of the art clinical environment. It is estimated, on average, 1-time costs would be $22,000. Total costs of the program if fully subscribed would amount to $880 million. CONCLUSION The health services sector makes significant contributions to the Canadian economy, both in terms of direct stimulus and by keeping Canadians healthy and productive. However, Canada's health services sector is facing a critical shortage of physicians and other health care professionals. By: - Adopting a long-term policy of self-sufficiency to provide Canadians with the health care professionals they need when and where they need them; - Establishing a dedicated health human resource renewal fund to educate, retain and enhance the lives of health care professionals; - Investing in health technology, infrastructure and innovation to make our health care system more responsive and efficient; the federal government, in partnership with provincial/territorial governments and other health system stakeholders can strengthen this sector. A strong health services sector means healthy Canadians and a vibrant Canadian economy. Again, on behalf of the Canadian Medical Association, Canada's doctors appreciate the opportunity to provide information to the Committee. Sincerely, Brian Day, MD President, Canadian Medical Association 1 National Health Expenditure Trends, 1975-2007. Canadian Institute for Health Information. 2007 2 Source: Business Register (STC 2003) and TIM (Informetrica Limited) 3 The Royal Commission on the Future of Health Care in Canada, November 2002. Senate Standing Committee on Social Affairs, Science & Technology, October 2002. The Health Council of Canada "Modernizing the Management of Health Human Resources in Canada: Identifying Areas for Accelerated Change: November 2005. 4 The National Physician Survey is a major ongoing research project conducted by the College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and Surgeons of Canada that gathers the opinions of all physicians, 2nd year medical residents and medical students from across the country. It is the largest census survey of its kind and is an important barometer of where the country's present and future doctors are on a wide range of critical issues. 5 The Economist, The Battle for BrainPower - A Survey of Talent, October 7, 2006. 7 World Medical Association. The World Medical Association Statement on Ethical Guidelines for the International Recruitment of Physicians. Geneva: The World Medical Association; 2003. Available: www.wma.net/e/policy/e14.htm 8 Canadian Institute for Health Information. 2. Canadian Institute for Health Information. 10 Zaho J, Drew D, Murray T. Barin drain and brain gain: the migration of knowledge workers from and to Canada. Education Quarterly Review 2000;6(3):8-35. 12 Little L, Canadian Nurses Association, personal communication, January 8, 2008. 13 Buske L. Analysis of the survey of Canadian graduates practicing in the United States. October 2007. http://www.cma.ca/multimedia/CMA/Content_Images/Policy_Advocacy/Policy_Research/US_survey_ver_4.pdf. Accessed 02/04/08. 14 Little L, Canadian Nurses Association, personal communication, January 28, 2008. 15 www.img-canada.ca 16 Postl, B. Final Report of the Federal Advisor on Wait Times. Ottawa: Minister of Health Canada, Health Council of Canada; 2005. 17 Canadian Medical Association/Canada Infoway. Physician Technology Usage and Attitudes Survey. Ottawa: CMA/CanadaInfoway; 2005. Available: www.cma.ca/index.cfm/ci_id/49044/la_id/1.htm (accessed 8 Jan 2008). 18 Bower, Anthony. The Diffusion and Value of Healthcare Information Technology. Santa Monica (CA): RAND Corporation; 2005
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Improving access to world-class health care by accelerating health information technology investments: CMA's 2009 pre-budget brief to the Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy9399
Last Reviewed
2020-02-29
Date
2008-08-15
Topics
Health human resources
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2008-08-15
Topics
Health human resources
Health systems, system funding and performance
Text
By many measures Canada's health care system is underperforming. One symptom of this weak performance are exceedingly long wait times that have an impact on care and cost patients, the system and governments money1. There are a number of responses to this poor performance including increasing the supply of health human resources2. Another response is to maximize the resources we have on the front lines and work smarter through information technology. This productivity approach is aligned with the assumptions set out in the federal government's Advantage Canada strategy. This strategy involves principally a 'knowledge advantage' and an 'infrastructure advantage'. Consequently, the Canadian Medical Association (CMA) is recommending that the federal government make a strategic "strings attached" $570-million investment to create an interconnected health information technology network3 through a Health Information System Transition Fund and time-limited accelerated IT tax incentives. This investment aims to integrate all Canadian patient health care records, an effort that will take time. However, there are foundations upon which to build thanks to federal government investments - most recently in providing $400 million for wait-time related health information systems. But for these investments to bear fruit further connectivity and integration is vital. In other words, our current system is like having an ATM card that only works at the bank's head office. We believe that additional investments must concentrate on connecting patient records in physician offices with hospitals and medical laboratories. Physicians also believe in accountability, and suggest investments should not be made unless the clinical community confirms a high level of system integration. The CMA recommends that the federal government should invest $570 million over five years in an interconnected pan-Canadian health information system that includes: => A $225 million, 5-year Health Information System Transition Fund aimed at change management training and support to convert 26-million patient records in 36,000 physician offices and community care facilities into interoperable electronic records across Canada. => $305 million for a 3-year time-limited and accelerated Capital Cost Allowance for software and hardware costs related to health information technologies that connect patient records from physician offices to laboratories and hospitals. => $10 million to sponsor a cross-country education campaign to inform Canadians of the health and system benefits of e-health connectivityi. => $2 million annually for Canada Research Chairs to promote and demonstrate the value of interconnectivity in health information between the faculties of Medicine, Management and Engineering. The federal government must also encourage provinces to increase their support of these initiatives and work to reduce the barriers to health information system interfacing, by ensuring patient record systems use similar codes in labs, hospitals and physician offices. Federal government guidance, encouragement and cooperation with the provinces is integral to making these connectivity investments a success. It is time that the federal government helped finish the job of health information system connectivity. A health information network will improve patient outcomes, system efficiency, increase accountability and save billions of dollars. 1. Why advance e-health interconnectivity now? Our health system e-performance is poor Both national and international studies confirm that Canada lags behind nearly every major industrial country when it comes to health information technology (Figure 8). The impact of this underinvestment is longer wait times, poorer quality, and a severe lack of financial accountability especially of federal dollars. Investments in connectivity are needed now because Canada's health care system compares poorly in both value and efficiency compared to other countries. The Conference Board of Canadaii, the OECDiii, the World Health Organizationiv, the Commonwealth Fundv, and the Frontier Centre for Public Policy all rate Canada's health care system poorly in terms of "value for money" as well as efficiency. Benchmarking health information connectivity-where we stand, where we must go According to the 2007 National Physician Survey, just 30% of physicians have an electronic interface with a medical laboratory or diagnostic imaging facility, while fewer than 5% have such an interface with a pharmacy/pharmacistvi. Imagine if just 30% of Canadian banks had ATMs throughout the country? This is a difference of not only convenience, but quality and cost savings. In comparison, Denmark and New Zealand have near 100% use of electronic medical records (EMRs) in ambulatory care. According to Dr. Allan Brookstonevii an EMR expert, "If most physicians in a health region or geographic area implemented an EMR system, the incentive for a local hospital or region to connect to those physicians would be significantly enhanced". In an emergency situation right now in Canada it is easier to access critical financial information than critical health information. This reality is not a matter of technology but the lack of will to put it in place. 2. Why the federal government should be interested in e-health interconnectivity. -Health information technology connectivity yields returns on investment: 8:1 International strategy and technology consulting firm Booz Allen Hamilton found that viii the benefits of an interconnected Electronic Health Record (EHR) in Canada could provide annual system-wide savings of $6.1 billion. These savings would come from reduced duplicate testing, transcription savings, fewer chart pulls and filing time, reductions in office supplies and reduced expenditures due to fewer adverse drug reactions. The study went on to state that the benefits to health care outcomes would equal or surpass these annual savings, thus providing a possible combined annual savings of $12.2 billion. In addition, a comprehensive literature reviewix comparing health IT productivity gains to similar industries in the U.S. concludes that effective EMR implementation and networking could eventually save more than $81 billion annually by improving health care efficiency and safety. Similarly, health information technology-enabled prevention and management of chronic disease could eventually double those savings while increasing health and other social benefits. Assuming that the Canadian health system is one-tenth the size of US system, savings would range from $8 to $16 billion annually. Connected health information technology - increasing performance and accountability A fundamental question the Standing Committee on Finance may ask is where $22 billion (growing at 6 % annually) in federal health care transfers to the provinces is going and what are the results of this support? Right now, we do not know exactly. Health care in Canada represents 10% of our economy ($160 billion annually and growing at 6% per year) and is larger than the total agricultural sector. The question Canadians are asking is not whether tax dollars should be spent on health care, but whether the money being spent is worth the services receivedx. Moreover, in health care, there are legitimate questions as to whether improvements to date have justified the associated costs. The public institutions and organizations that deliver health care in Canada could deliver more value than they do at present. With a national health information (management) system in place they could work to reduce variations in the quality of service and in the way services are used across the system. However at a national level, we do not have an accounting systemxi in place to uniformly measure quality across the country. 3. Who: Canadians - our patients - want and need e-health interconnectivity. Health information technology is critical to managing wait times Quality of care is an important concern for Canadians, but first they must be able to get the care they need. But waiting for health care is the principal concern for Canadiansxii. Excessive wait times result in mental anguish for patients and their families and also cost the Canadian economy billions of dollars each year. In 2007 a study commissioned by the CMAxiii conservatively calculated that excessive wait times in just four procedures (joint replacements, cataract surgery, coronary artery bypass grafts and MRIs) cost the economy over $14 billion in lost output and government revenues. It is important to note that beyond these hospital procedures there is potential to reduce wait times and cost in physician offices through information technology. This is why we have suggested accelerating the capital cost allowance tax for EMR related software and hardware purchases and that they go to community care and physician offices where most patient visits occur every day. Figure 1 below shows that in Ontario for example, just 3,000 out of an average of 247,000 patient visits per day or 1.2% of the total are made in hospitals. That is why this submission is aimed at (the circle area in the chart) increasing connectivity and tying investments to the 99% of the places where patients visit most. Figure 1 Patient visits per day in Ontario, Source: Canada Health Infoway Most of the emphasis on connectivity in Canadian health care to date has not focused on the point of care -even though the number of patient interactions with hospitals is greatly exceeded by the number of visits to physicians' officesxiv. Thus patient-physician office interactions outnumber patient-hospital interactions by a ratio of 18 to 1. It is also important that patients understand the value of electronic health records, which is why we are recommending a $10 million cross-country educational campaign to impact the demand side of this critical health and industrial equation. 4. Why physicians are involved in e-health interconnectivity The physician community can play a pivotal role in helping the federal governments make a connected health care system a realizable goal in the years to come. Through a multi-stakeholder process encompassing the entire health care team, the CMA will work toward achieving cooperation and buy-in. This will require a true partnership between provincial medical associations, provincial and territorial governments and Canada Health Infoway (CHI). Accelerating Advantage Canada through health information technologies The CMA's pre-budget submission, related to health system connectivity, incorporates the five tenets of Advantage Canadaxv. This submission principally addresses the infrastructure and knowledge advantages that are involved in investing in an interconnected network that is useless unless the 'knowledge' advantage to provide stewardship of the Electronic Health Record through our physicians' is in place. That is why we recommend that the federal government help support research, development and knowledge transfer at our major universities in health information technology by supporting 10 Canada Research Chairs in the faculties of Medicine, Management and Engineering. In addition, a pan-Canadian health information technology network will provide the kind of infrastructure that supports labour mobility where for example a migrant worker from Atlantic Canada can access his health records in Fort McMurray Alberta. 5. How to speed-up health information technology connectivity -a green tax incentive approach Thus far the strategy applied to health information connectivity in Canada has been focused on a top-down approach that has produced limited success. That is why the CMA is suggesting that the federal government accelerate the Capital Cost Allowance (CCA) on EMR-related software and hardware equipment over the next three years - an early-bird special or incentive. The CMA does not pretend to be tax policy experts however we do appreciate the federal governments' recent increase in the CCA rates for software and hardware. Our recommendation would mean changing the current software CCA (Class 12xvi) from 100% over two years to 100% in the first year specifically for EMR related investments. And for EMR hardware (Class 50xvii) accelerate the CCA to 100% in the first year from the current 55% rate for a limited time only of three years. These accelerated CCA rate proposals are also consistent with the governments' environmentally friendly CCA initiative as EMRs would save tonnes of paper for years. Mixed results for Canada Health Infoway => Health Information System Transition Fund The CMA lauds the federal government's 2008 Budget for making a $400-million investment in Canada Health Infoway (CHI) to support early movement toward patient wait time guarantees through the development of health information systems and electronic health records. At the same time the physician community believes that CHI has had mixed results, especially when it comes to digitizing and integrating patient records at the places where most patients contact the health care system: physician offices, laboratories and emergency rooms. However, we believe with targeted, conditional policies CHI can be an effective vehicle to accelerate the transition of current health centre paper practices into electronic operations through a time limited five-years Health Information Transition Fund. We also believe that federal transition funds should be matched at a fifty-fifty rate by the provinces. Although this may not be easy, there are other non-monetary policy levers (e.g. regulatory) that the federal government could and should use to persuade the provinces of the value of investing in electronic health record system integration. This is particularly true since the provinces will yield most of the return on the investment. It is imperative that the current health information technology gap be closed and be set at levels for similar service-intensive industries (see Figure 2 in the Appendix 1). That is why; beyond the figures outlined in this submission, the CMA recommends continued federal health information technology support for the next 10 years. Conclusion - Big investments. but big payoffs too As the Health Council of Canada stated in their 2008 annual reportxviii, "Change is underway, but too slowly". The OECD, WHO, The Commonwealth Fund and the Conference Board of Canada's research all strongly suggest that Canada lags behind the rest of the industrialized world in terms of health information technology investments and system integration. The investments made so far may seem large but they will be wasted if a second effort in connecting the entire system is not made now. It is time that the federal government finishes the job of health information system connectivity at the point of care. A Pan-Canadian network of health information will improve patient outcomes, health system efficiency and dramatically increase system accountability. The Health Council of Canada also said that, "These [health information technology] are big investments but the payoff is big too". Accordingly we suggest that over the next five years the following investments will improve the running of Medicare as well as the Canadian economy. The CMA recommends that the federal government should invest $570 million over five years in an interconnected pan-Canadian health information system that includes: => A $225 million, 5-year Health Information System Transition Fund aimed at change management training and support involved in converting 26 million patient records in 36,000 physician offices and community care facilities into interoperable electronic records across Canada. => $305 million for a 3-year time limited accelerated Capital Cost Allowance for EMR software and hardware costs related to health information technologies that connect patient records from physician offices to laboratories and hospitals. => $10 million to sponsor a cross-country education campaign to inform Canadians of the health and system benefits of e-health connectivityxix. => $2 million annually for Canada Research Chairs promoting the value of interconnectivity in health information between the faculties of Medicine, Management and Engineering. References 1The cumulative economic cost of waiting for treatment across just 4 priority areas in 2007 was an estimated $14.8 billion. This reduction in economic activity lowered federal and provincial government revenues in 2007 by a combined $4.4 billion. See:www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/pdf/2008/EconomicReport.pdf 2 Almost 5-million Canadians do not have a family physician. Canada would need 26,000 more doctors to meet the OECD average of physicians per population. Physicians spend more time on paperwork and less with patients than they did 20 years ago. See: "More Doctors. More Care.": www.moredoctors.ca/take_action/ 3 Please see Table l in Appendix 1 for full investment horizon details. i Patient perspective on electronic medical record. Meldgaard M; International Society of Technology Assessment in Health Care. Meeting (19th : 2003 : Canmore, Alta.). Annu Meet Int Soc Technol Assess Health Care Int Soc Technol Assess Health Care Meet. 2003; 19: abstract no. 148. CONCLUSIONS: Patient confidence and perceived quality of care is influenced by a well informed forward-looking staff as can be obtained in settings where EPR is successfully implemented. Patient satisfaction and the functional level of EPR implementation are interdependent. ii A Report Card on Canada see: http://sso.conferenceboard.ca/HCP/overview/health-overview.aspx iii Organization for Economic Co-operation and Development [OECD] (2007). OECD Health Data 2007. Version 07/18/2007. CD-ROM. Paris: OECD. iv World Health Organization [WHO] (2007). World Health Statistics 2007. see: http://www.who. v 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 vi See Tables Q39 and Q40a in the 2007 National Physician Survey at:www.nationalphysiciansurvey.ca/nps/ vii Dr. Alan Brookstone is a family physician in Richmond, BC and the founder of CanadianEMR. The quote was taken from: Online resource enables MDs to rate EMRs. See: www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Future_Practice/English/2007/November/Online-e.pdf The CanadianEMR Physician Resource Directory provides access to a province specific searchable list of vendors of products and services to support the EMR-based practice. http://www.canadianemr.ca/ viii Booz, Allan, Hamilton Study, Pan-Canadian Electronic Health Record, Canada's Health Infoway's 10-Year Investment Strategy, March 2005-09-06. ix Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs Richard Hillestad, James Bigelow, Anthony Bower, Federico Girosi, Robin Meili, Richard Scoville and Roger Taylor, Health Affairs, 24, no. 5 (2005): 1103-1117. x In November 2008 the Auditor General of Canada will present it's performance audit on, "Reporting on Health Indicators-Health Canada" to Parliament. See: www.oag-bvg.gc.ca/internet/English/oag-bvg_e_29401.html xi There has been heavy emphasis is being placed on "accountability" and "performance measurement," endorsed by the Romanow Commission (Commission on the Future of Healthcare in Canada 2002), the Kirby Committee (Standing Senate Committee on Social Affairs, Science and Technology 2002), and the First Ministers' accord (First Ministers 2004). See Raisa Deber Why Did the World Health Organization Rate Canada's Health System as 30th? Some Thoughts on League Tables. Some Thoughts on League Tables xii The results of an Ipsos Reid poll (January 2008) finds that eight in ten (78%) Canadians believe that hospital and other health care wait times cost Canada money because people who are waiting for treatment are less productive and miss work. This is compared to just two in ten (19%) who think that wait times save Canada money because governments don't have to put as many resources into healthcare. xiii The economic cost of wait times in Canada, January 2008. This study was commissioned by the Canadian Medical Association (CMA) to analyze the economic costs of wait times in Canada's medical system. The CMA's membership includes more than 67,000 physicians, medical residents and medical students. It plays a key role by representing the interests of these members and their patients on the national stage. Located in Ottawa, the CMA has roots across the country through its close ties to its 12 provincial and territorial divisions. See: www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/pdf/2008/EconomicReport.pdf xiv Sources: Physician visits - CIHI - Physicians in Canada: Fee-for-Service Utilization 2005-2006. Table 1-21. Hospital contacts - CIHI - Trends in Acute Inpatient Hospitalizations and Day surgery Visits in Canada 1995-1996 to 2005-2006 and CIHI -National Ambulatory Care Reporting System - Visit Disposition by Triage Level for All Emergency Visits - 2005-2006. xvAdvantage Canada builds on Canada's strengths and seeks to gain a global competitive advantage in five areas: 1. Tax Advantage-Reducing taxes for all Canadians and establishing the lowest tax rate on new business investment in the G7. 2. Fiscal Advantage-Eliminating Canada's total government net debt in less than a generation. 3. Entrepreneurial Advantage-Reducing unnecessary regulation and red tape and increasing competition in the Canadian marketplace. 4. Knowledge Advantage-Creating the best-educated, most-skilled and most flexible workforce in the world. 5. Infrastructure Advantage-Building the modern infrastructure we need. xvi Software: CLASS 12 , (100 per cent) Property not included in any other class that is.... (o) computer software acquired after May 25, 1976, but not including systems software or property acquired after August 8, 1989 and before 1993 that is described in paragraph (s). xvii Hardware: CLASS 45 , (45 per cent) Property acquired after March 22, 2004 (other than property acquired before 2005 in respect of which an election is made under subsection 1101(5q)) that is general-purpose electronic data processing equipment and systems software for that equipment, including ancillary data processing equipment. Draft Regulation (a) electronic process control or monitor equipment; (b) electronic communications control equipment; (c) systems software for equipment referred to in paragraph (a) or (b); or (d) data handling equipment (other than data handling equipment that is ancillary to general-purpose electronic data processing equipment). Class 50 (55 per cent) Property acquired after March 18, 2007 that is general-purpose electronic data processing equipment and systems software for that equipment, including ancillary data processing equipment, but not including property that is principally or is used principally as (a) electronic process control or monitor equipment; (b) electronic communications control equipment; (c) systems software for equipment referred to in paragraph (a) or (b); or (d) data handling equipment (other than data handling equipment that is ancillary to general-purpose electronic data processing equipment). xviii Health Council of Canada, Rekindling Reform: Health Care Renewal in Canada, 2003 - 2008, June 2008 (page 23). See: www.healthcouncilcanada.ca/docs/rpts/2008/HCC%205YRPLAN%20(WEB)_FA.pdf Appendix 1 (Table does not display correctly -- See PDF) Table 1 -Health Interconnectivity investments over five years. Figure 2 -Major Canadian health centers are well below industry IT investment standard
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International Medical Graduates : Notes for an address by Dr. Albert J. Schumacher, President, Canadian Medical Association : Presentation to the Standing Committee on Citizenship and Immigration

https://policybase.cma.ca/en/permalink/policy2006
Last Reviewed
2012-03-03
Date
2005-02-17
Topics
Health human resources
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2012-03-03
Date
2005-02-17
Topics
Health human resources
Text
Good afternoon, I am Dr. Albert Schumacher, President of the Canadian Medical Association (CMA) and a family physician from Windsor, Ontario. With me today is Dr. Todd Watkins, Director, Office of Professional Services at CMA and also a family physician. It is estimated that some 4.5 million Canadians have had trouble finding a family doctor, while more than 3 million Canadians do not have regular access to one. Long waiting lists for consultations and specialized diagnostic and therapeutic procedures suggest there is a shortage of specialists. Including time spent on call, Canada’s physicians worked an average of 70 to 80 hours a week. Of the 21,000 physicians surveyed in the recently released National Physicians’ Survey, over a quarter said they plan to reduce their work week within the next two years. 60% of family doctors either limit the number of new patients they see or have closed their practices. At the same time, the average age of physicians in Canada is 48 years with 32% 55 years of age or older. Almost 4000 physicians may retire in the next two years. There is a “perfect storm” brewing in terms of health human resource in Canada. The message I hope to leave with you today is that the valuable participation of International Medical Graduates (IMGs) in our medical workforce must be part of a coordinated pan-Canadian plan that strives to address the double imperatives of immigration policies that are fair and policies that in the short, medium and longer term will ensure greater self-sufficiency in the education and training of physicians in Canada. Today I am going to focus on three things: Number one: clarify some of the myths about IMGs in Canada; Number two: stress the need for greater capacity in Canada’s medical education and training infrastructure; and Lastly: emphasize the importance of a national standard for licensure. Myths There are a few myths that abound about IMGs in Canada. If you were to believe some of what you read or hear in the media you might gather that it is next to impossible for international medical graduates to enter the practice of medicine in Canada. Nothing could be further from the truth. As of last month, almost one quarter of the physicians working in our health care system received their medical degree in a country other than Canada. This proportion has declined by only 2% since the 1960s. Estimates peg the number of IMGs arriving in Canada with pre-arranged employment licensed to practice each year at 400. Quite simply, our health care system could not function without the critical contributions of qualified international medical graduates (IMGs). Also, many IMGs access the postgraduate training system in Canada. As of December 2004 there were 316 IMGs who were either Canadian citizens or permanent residents in their first year of postgraduate residency training – this represents 15% of the total number of first-year trainees. In the past few years only a few provinces have greatly expanded opportunities for assessing the clinical skills of IMGs and providing supplementary training and practice opportunities. Just two weekends ago some 550 IMG’s participated in the Ontario Provincial IMG Clinical Assessment which was offered at four medical schools across the province. This will lead to some 200 IMGs being licensed to practice in Ontario. Other provinces have similar programs. I would note that the initiatives of the federal government announced by the Honourable Hedy Fry in March 2004 have been very helpful in communicating information about and raising awareness of the requirements to practice medicine in Canada. Some $3 million announced at that time was provided to assist provinces and territories in assessing IMGs and will add at least 100 internationally trained physicians into the system. I am optimistic that her continued collaborative efforts with the medical community will result in positive changes. So, has Canada closed its borders to IMGs? Hardly. Can more be done to achieve fairness? Absolutely. Capacity I can not stress strongly enough the need to increase the capacity of Canada’s undergraduate medical education and postgraduate training system. There are some who think that the fastest and least expensive way of meeting our medical workforce requirements is to simply recruit medical graduates from other countries. In the short term this is a major part of the fix. It is, however, no substitute for a “made in Canada” solution for the long term. As a long-term policy it fails to recognize the fact that the countries from which we poach these IMGs can ill afford to lose them. We are simply not pulling our weight as a country in educating and training future physicians. As my predecessor, Dr. Sunil Patel told his Committee last April, in 2002 there were roughly 6.5 first year medical school places per 100,000 population in Canada – just over one-half of the UK’s rate of 12.2 per 100,000. The CMA has recommended a 2007 target of 2500 first year medical positions and at the moment we are tracking toward 2300. Over reliance on IMGs also fails to appreciate the critical role played by Canada’s academic health science centres. These institutions have a three-fold mission of teaching, research and the provision of a great deal of patient care and these three components are inextricably linked. Expanded capacity will work to the benefit of both Canadians aspiring to attain a medical education and IMGs. For example, in 2004 of the 657 IMGs entering second iteration of the residency match, just 87 or 13% were successful. We need to expand capacity not only within academic health sciences centres themselves, but we need to recruit and support clinical teachers out in the community. This is crucial, especially for the IMG assessment programs now being rolled out. But most importantly, an enhanced education and training infrastructure will help meet the future health needs of Canadians. The goal that had been identified in the 2004 First Minister’s Agreement, specified $250 million a year beginning in 2009-10 through 2013-14 “primarily for health human resources” training and hiring. However, Bill C-39, which was recently tabled to implement provisions of the 10-year plan by creating the Wait Times Reduction Fund, falls short of what Canadians deserve and expect. Specifically, it stipulates theses dollars may be used for multiple purposes. This failure to recognize the critical shortage of health care professionals by dedicating specific dollars to the issue now could mean the promised investments may never be made to enhance health human resources. The temptation will be to continue to rely on “beggar thy neighbour” policies. However, Canada can and must do better to pull its own weight. Importance of a National Standard As the national organization representing Canada’s physicians we have a direct interest in working with government to ensure Canadians have access to health care when they need it. The CMA has a role in medical and health education in the accreditation of undergraduate medical education and the accreditation of the training programs of some 15 health disciplines. However, the CMA is not a regulator. We do not grant credentials or license physicians. Regulation of medicine falls under the purview of the provincial and territorial colleges of physicians and credentials are granted by the College of Family Physicians of Canada, the Royal College of Physicians and Surgeons of Canada and the College des Médecins du Quebec. If medicine has a lesson to offer other professions and occupations it is in the value of having a national standard. While health is the constitutional responsibility of the provinces and territories, medicine has been able to realize a national standard for portable eligibility for licensure across Canada. Beginning in 1992 the basis for licensure in all provinces/territories except Quebec has been the successful completion of the two-part Qualifying Examination of the Medical Council of Canada plus certification by either the College of Family Physicians of Canada or the Royal College of Physicians and Surgeons of Canada. The procedures in place in Quebec are very similar. To be sure there can be interpretation around the application of the standard, but without a doubt it has provided a significant degree of transparency and uniformity about what is required to practice medicine in Canada. This not only promotes a concordance between the programs offered by our 16 (soon to be 17) medical schools but also provides a basis for the assessment of international programs. On this latter point, the Institute for International Medical Education has a database that contains information on more than 1,800 medical schools in 165 countries around the world. Conclusion During pre-budget hearings last fall, I submitted to the Standing Committee on Finance our plan to address health human resources shortages. As was the case then, IMGs are a critical part of the CMA plan. A plan that has as its core the belief that Canada must adopt a policy of increased self-sufficiency in the production of physicians in Canada. This involves: * increased opportunities for Canadians to pursue medical education in Canada; * enhanced opportunities for practising physicians to return for additional training; * strategies to retain physicians in practice and in Canada; and * increased opportunities for IMGs who are permanent residents or citizens of Canada to access post-MD training leading to licensure/certification and the practice of medicine in Canada. This set of imperatives needs to be balanced against a need for fairness. Fairness to ensure those who need to obtain further medical training are able to do so. And, fairness to young Canadians who deserve a chance to pursue a career in medicine. I appreciate the opportunity of entering into a dialogue with members of the Committee and look forward to your questions. Thank you.
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Letter - CMA’s 2006 Pre-Budget Submission to the Minister of Finance

https://policybase.cma.ca/en/permalink/policy2031
Last Reviewed
2013-03-02
Date
2006-04-19
Topics
Health human resources
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2013-03-02
Date
2006-04-19
Topics
Health human resources
Health systems, system funding and performance
Text
On behalf of the Canadian Medical Association (CMA), I am pleased to present you with our pre-budget submission for your government's consideration. The CMA appreciates the opportunity to provide input into this government's first budget and to identify strategic investment opportunities for the long term health of Canadians. While Canada's health system faces many challenges, we believe that immediate action by the federal government in four key areas will offer both short term and long term benefits. They are: (1) the establishment of a Canada Health Access Strategy to support a patient wait-times guarantee; (2) a proposed Visa position buyback program and a repatriation program to immediately address shortfalls in health human resources; (3) a strengthening of Canada's public health infrastructure; and (4) a remedy for GST-induced distortions in the health care system.We believe these proposals fit well with the government's stated priorities. While information on each of these recommendations is attached for your information and consideration, I would like to provide you with an overview of each. 1. CANADA HEALTH ACCESS STRATEGY The CMA has been advocating for the implementation of maximum wait time thresholds or care guarantees for a number of years and is pleased that the government has included this as one of its top five priorities. As a first step, the CMA worked with six other specialty societies as part of the Wait Times Alliance (WTA) to develop a set of pan-Canadian wait-time benchmarks or performance goals released last August. We believe this work served as a catalyst for the provincial and territorial governments to move some way toward meeting their commitment in announcing pan-Canadian wait-time benchmarks last December. We must continue to work with governments and the academic community to improve access to medical care beyond the five priority health issues identified in the First Ministers' 2004 10-year health care plan. The second step in implementing patient wait-time guarantees is the issue of honouring the commitment and providing for patient recourse. As a member of the WTA, the CMA strongly supports accelerating the timetable to reduce wait times nationwide. However, the federal government needs to do its part to assist provinces in advancing the timetable by stepping up the flow of funds earmarked for the last four years of the accord. Our proposed Canada Health Access Strategy is comprised of three components directed at making this happen: supporting provinces to expand capacity and to handle surges in demand; supporting the creation of regional and/or national referral networks; and establishing a Canada Health Access Fund for a "safety valve" to help Canadians access care elsewhere when necessary. Details on how this Strategy would work are attached. The point is that this Strategy is necessary to assure Canadians that they get the care they need when they need it. Recommendation 1. The federal government advance the remaining $1 billion from the 2004 First Ministers Accord that was originally intended to augment the Wait Times Reduction Fund (2010-2014) to support a Canada Health Access Strategy by: (a) expanding provincial surge capacity : $500 million to be flowed immediately to provinces on a per capita basis in return for agreement to accelerate the timetable for bringing down wait times, as was promised in the recent federal election campaign; (b) improving national coordination of wait time management: $250 million to support creation of regional and/or national referral networks, a more coordinated approach to health human resource planning, expansion of information technology solutions to wait time management and facilitation of out-of-country referrals; and (c) establishing a Canada Health Access Fund: $250 million initial investment in an alternative patient recourse system or "safety valve" when and if clinically-indicated maximum wait time benchmarks as agreed to by provinces/territories last December are exceeded. Addressing Shortfalls in Health Human Resources As identified by Minister Clement in a recent speech at the "Taming of the Queue III" wait-time conference, addressing shortages in health human resources is a key element of any strategy for reducing lengthy wait-times. Unfortunately, we face serious physician shortages, starting with family physicians. The bad news is that it can take several years to educate and train the necessary professionals. The good news is that there are some strategies that can be undertaken to address the situation in the short term. 2. VISA POSITION BUYBACK FUND One such strategy is our Visa Position Buyback proposal that would eliminate the backlog of 1,200 qualified international medical graduates (IMGs) over the next five to seven years. Currently, these qualified IMGs, who are either Canadian citizens or landed immigrants, are unable to access the necessary residency training. One existing source for training capacity exists with the positions purchased by foreign governments for visa trainees. We estimate that there are over 900 current visa trainees at all rank levels. By implementing the Visa Position Buyback program, the government is able to take an immediate step that will produce tangible results as soon as a two to four years from now. This initiative would be part of a longer term plan to fully address the shortages in health human resources and help the government meet its commitment to implement a properly functioning patient wait-time guarantee. Recommendation 2a. The federal government allocate $381.6 million toward the training of up to 1,200 IMGs through to practice over the 2007/08 to 2015/16 period. Funding would be made available in two installments: an immediate investment of $240 million and the remaining $140 million subject to a satisfactory progress report at the end of five years. Repatriate Health Professionals Working in the United States Fortunately, another short-term source of health professionals exists that Canada should pursue. Thousands of health care professionals are currently working in the United States including approximately 9,000 Canadian trained physicians. We know that many of the physicians who do come back to Canada are of relatively young age meaning that they have significant practice life left. While a minority of these physicians do come back on their own, many more can be repatriated in the short-term through a relatively small but focussed effort by the federal government led by a secretariat within Health Canada. Recommendation 2b. The federal government should establish a secretariat within Health Canada that would provide funding to national professional associations to conduct targeted campaigns to encourage the repatriation of Canadian health professionals working in the United States, and act as a clearinghouse on issues associated with returning to Canada (e.g., citizenship, taxation, etc.). 3. PUBLIC HEALTH INFRASTRUCTURE RENEWAL The CMA remains concerned about the state of Canada's public health system. Public health, including the professionals providing public health services, constitutes our front line against a wide range of threats to the health of Canadians. While there is much talk about the arrival of possible pandemics, Canada's public health system must be ready to take on a broad range of public health issues. The CMA has been supportive of the Naylor report which provides a blue print for action and reinvestment in the public health system for the 21st century. While this will take several years to achieve, there are some immediate steps that can be taken which will lessen the burden of disease on Canadians and our health care system. These steps include establishing a Public Health Partnership Program with provincial and territorial governments to build capacity at the local level and to advance pandemic planning. In addition, we call on the government to continue its funding of immunization programs under its National Immunization Strategy. Recommendation 3a. The federal government should establish a Public Health Infrastructure Renewal Fund in the amount of $350 million annually to establish a Public Health Partnership Program with the provincial/territorial governments for the purposes of building capacity at the local level and advancing pandemic planning. In addition, the $100 million per year for immunization programs under the National Immunization Strategy should be continued. 4. A REMEDY FOR GST-RELATED DISTORTIONS IN THE HEALTH SYSTEM The CMA and many other national health organizations are concerned about the increasing, unintended and negative consequences the GST is having on health care. For example, the 83% rebate originally provided for under the so-called "MUSH" formula is no longer tax neutral and is acting as a deterrent in some cases toward increased use of ambulatory care services such as day surgeries. Over the past 15 years the physicians of Canada have faced a large and growing unfair tax burden due to the GST. Since physicians' services are tax exempt under the law, physicians are unable to either claim input tax credits or pass on the tax because of the prohibition under the Canada Health Act of billing patients directly. This puts physicians in a unique and patently unfair catch 22 that now amounts to over $65 million per year, which further acts as a deterrent to repatriating or retaining Canadian physicians. Recommendation: 4a. That the federal government, in the course of reducing the GST from 7% to 5% further to its campaign commitments, remove the large and growing deterrent effects of the GST on the efficient and effective delivery of health care in Canada. In summary, the CMA is providing you with recommendations on strategic investments to help your government honour its commitment to timely access to care and to improve the health of Canadians. Our recommendations are financially reasonable, making good use of Canadians' tax dollars. We look forward to meeting with you on April 19 to discuss our proposals with you. Sincerely, Ruth L. Collins-Nakai, MD, MBA, FRCPC, MACC President c.c. The Honourable Tony Clement, Health Minister
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Letter to the International Joint Commission on the 2004 Progress Report addressing air quality

https://policybase.cma.ca/en/permalink/policy1952
Last Reviewed
2012-03-03
Date
2005-02-11
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2012-03-03
Date
2005-02-11
Topics
Population health/ health equity/ public health
Text
On behalf of Canada’s physicians, the Canadian Medical Association (CMA) would like to take this opportunity to provide comments to the International Joint Commission on the 2004 Progress Report addressing air quality. The Association, first founded in 1867, currently represents more than 59,000 physicians across the country. Our mission includes advocating for the highest standard of health and care for all Canadians and we are committed to activities that will result in healthy public policy which support health and the environment. The environment, as a determinant of health, is a major concern for the general public as well as health care providers. Air pollution affects the health of all Canadians, but particularly children, the elderly and those with respiratory and cardiac conditions. Poor air quality can provoke devastating health effects. Every day physicians come face to face with the reality of an unhealthy environment and its effects on our patients. The impact can be seen in terms of increased frequency of symptoms, medication use, physician visits, emergency room visits, hospitalizations and premature deaths. Canadians and Americans breathe the same air, drink the same water, and share a common responsibility to provide future generations with a healthy environment. This is why the Canada-U.S. agreement to address and resolve environmental issues is so important. The U.S.-Canada Air Quality Agreement established a formal and flexible method of addressing trans-boundary air pollution and laid the groundwork for cooperation between the United States and Canada on very important air quality issues. Under the Air Quality Agreement of 1991, both countries have made progress in coordinating and implementing their acid rain control programs and have focused activities on ground level ozone since 2000. The improvements, as described in the 2004 Progress Report are commendable. But while many of the parties’ emission reduction commitments are on-track, dangerous air pollution continues to blow both ways across our borders. This suggests that the measures included in this agreement are not sufficient to ensure that Canadians have clean air to breathe. In fact, we believe that future evaluations should describe air quality improvement as the outcome of interest, in addition to cataloguing emission reduction initiatives, as is done in the 2004 Progress Report. The 2004 Progress Report, prepared by Environment Canada and the United States Environmental Protection Agency, is the seventh biennial report compiled under the 1991 United States-Canada Air Quality Agreement. Ground level ozone, a primary component of smog, directly contributes to air quality and health. The commitment to reduce ground level ozone under the 2000 Agreement has the potential to improve air quality and the quality of life of literally millions of people. As indicated in the Progress Report 2004, Canada is “on track to implement all of its commitments for vehicles, engines and fuels” in order to reduce ground level ozone. However, the stationary emissions of NOx remain above target levels. An aggressive strategy to reduce NOx and VOC to lessen smog, and the adverse health impact on Canadians and Americans is urgently required. Smog and climate change are not distinct problems. In fact, a large proportion of the smog pollutants that cause serious cardiac and respiratory problems in Canada are emitted from the same tailpipes and industrial smokestacks as the greenhouse gases, which the Kyoto agreement aims to reduce. Canada’s commitment to the Kyoto Accord provides an opportunity to significantly reduce smog and achieve cleaner air for all Canadians to breathe. The purchasing of emission credits from foreign countries to make up for a shortfall in the reductions of greenhouse-gas emissions Canada agreed to in the Kyoto accord is clearly short-term thinking that does not address the long term goals outlined in the accord. Climate change measures under the Accord will yield additional benefits through improved local and regional air quality. But more can and needs to be done. Canada must bring air pollution down to safe levels and to cut greenhouse gas emissions to halt climate change. For these reasons, CMA recommended that the Prime Minister commit to choosing a climate change strategy that satisfies Canada’s international commitments while maximizing the clean air co-benefits and smog–reduction potential of any greenhouse gas reduction initiatives. Canada’s physicians are concerned about the pollutants that are affecting the health of Canadians, and believe that there should be appropriate mechanisms to warn those who are vulnerable and at risk, so that they can act to protect themselves from contaminants in the air, water, or food. We have called on the government of Canada to establish a national Air Quality Index so that real-time air quality information and predictive forecasting is made available to all Canadians. Health-based reporting about pollutants is a way to allow Canadians to partner in their own health protection, while such pollutants are being addressed by policies aimed at producing cleaner air. Environment Canada and Health Canada have long been developing a health-based Air Quality Index, which would incorporate the most recent health science and make air quality forecasts and current ambient conditions available across the nation. We contend this is a key initiative and we urge this work be expedited. CMA reaffirms our support for the Kyoto protocol and in the best interest of Canadians, urges the government to establish a national Air Quality Index. There is a fundamental role for governments in preventing and controlling smog and poor air quality through healthy public policy and regulations. There remains much work to be done. CMA’s vision of a healthy population for Canada underpins our commitment to advocate for clean air. I would like to thank you and the IJC for your continued commitment to improving air quality for Canadians and Americans. It is through efforts like this, that our mutual goal for a clean, healthy and safe environment may be realized. We look forward to your next report demonstrating even further gains in achieving high air quality. Yours truly, Albert J. Schumacher, MD President AJS/jns
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Mental Health, Mental Illness & Addiction : CMA Submission to the Standing Committee on Social affairs, Science and Technology

https://policybase.cma.ca/en/permalink/policy1950
Last Reviewed
2012-03-03
Date
2005-04-20
Topics
Population health/ health equity/ public health
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2012-03-03
Date
2005-04-20
Topics
Population health/ health equity/ public health
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association (CMA) welcomes the opportunity to provide input to the Standing Senate Committee on Social Affairs, Science and Technology’s study of mental health, mental illness and addiction in Canada. The Committee is to be commended for their commitment to the examination of the state of mental health services and addiction treatment in Canada. The Interim Report Mental Health, Mental Illness and Addiction: Overview of Policies and Programs in Canada is a most comprehensive and thorough study. It highlights and reinforces the myriad of players, programs and services as well as the scope and breadth of concerns related to mental health/mental illness care. The Issues and Options paper cogently outlines all the major issues facing mental health, mental illness and addiction care today and provides a platform to stimulate an important public debate on the direction that should be taken to address mental health reform in Canada. The CMA was pleased to appear before the Committee during its deliberations in March of 2004 to speak to the issues facing mental health and mental illness care and put forward recommendations for action by the federal government. The CMA recommended: * developing legislative or regulatory amendments to ensure that psychiatric hospitals are subject to the five program criteria and the conditions of the Canada Health Act, * adjusting the Canada Health Transfer to provide net new federal cash for these additional insured services, * re-establishing an adequately resourced federal unit focussed on mental health, mental illness and addiction, * reviewing federal policies and programs to ensure that mental illness is on par, in terms of benefits, with other chronic diseases and disabilities, * mounting a national public awareness strategy to address the stigma associated with mental illness and addiction. The physicians of Canada continue to support these recommendations. While the Committee has asked for input on a number of important issues in its Issues and Options paper, CMA will focus on the role of the federal government in three areas: * national leadership and intergovernmental collaboration, * accessibility, * accountability. We understand that the Canadian Psychiatric Association, the College of Family Physicians of Canada and the Canadian Paediatric Society will, in their submissions to the Standing Committee, address specific issues of concern to the medical profession in the areas of primary care, child and adolescent mental health and mental illness services, and psychiatric care. The CMA supports the positions of these national specialty organizations. THE ROLE OF THE FEDERAL GOVERNMENT The economic burden of mental health problems is estimated, at a minimum, at $14.4 billion annually. 1 Mental illness and addiction affects one in five Canadians during their lifetime. According to a 2003 Canadian Community Health Survey, 2.6 million Canadians over the age of 15 reported symptoms consistent with mental illness during the past year. Mental illness impacts people in the prime of their life. Estimates from 1998 indicates that 24% of all deaths among those aged 15-24 and 16% of all deaths among those aged 25- 44 are from suicide 2. In contrast, the 2003 outbreak of Severe Acute Respiratory Syndrome (SARS) that tragically, resulted in 483 cases and 44 deaths with an estimated economic impact in the Greater Toronto Area of 2 billion dollars served as the ‘wake-up call’ that galvanized the federal government into paying attention to public health in Canada. In the aftermath of SARS, the federal government appointed a Minister of State for Public Health, established the Public Health Agency of Canada and selected a Chief Public Health Officer for Canada. Nine hundred and sixty five million dollars has been invested by the federal government in public health in the two federal budgets following SARS and a new spirit of federal-provincial-territorial cooperation on public health issues has been spawned. The evidence of the enormous burden that mental illness and addiction places on Canadian society has been a clarion call to many concerned stakeholder organizations across the country to mobilize and search for solutions. It is astounding that the federal government has not heard the call. And it is hard to imagine just what more could constitute a ‘wake-up call’ for mental health care. In fact the federal government falls woefully short of fulfilling its responsibilities to the people of Canada. The Interim report of the Committee correctly outlines the state of fragmentation and gaps in services to those specific populations under direct federal jurisdiction. It also notes the ‘apparent ambivalence’ over the years by the federal government about the place of mental health services within publicly funded health care. This ambivalent approach also spills over to the broad national policies and programs of the federal government that can impact those suffering from mental illness, addiction or poor mental health. The federal government has systematically excluded mental health services since the earliest days of Medicare. Mental illness has been treated like a second class disease with little dedicated federal funding, and with programs and services not subject to national criteria or conditions as are set out in the Canada Health Act. In fact, the federal government could be seen as moving in reverse with the downgrading of mental health resources within Health Canada through the 1980s and 1990s. Leadership The CMA firmly believes that strong federal leadership is required to address the sometimes invisible epidemic of mental health problems and addiction in Canada.The government must lead by example and begin by ‘cleaning up its own backyard’ in terms of its direct role as service provider to those Canadians under its jurisdiction. It should take a ‘whole of government’ approach that recognizes the interplay of health services, education, housing, income, community and the justice system on mental health and mental illness care. Further, the federal government has a responsibility to ensure that there is equitable access to necessary services and supports across the county. This will require a strong degree of cooperation and collaboration among provinces and territories and the federal government. The federal, provincial and territorial governments must come together to develop a national action plan on mental health, mental illness and addiction modeled on the framework developed by the Canadian Alliance on Mental Illness and Mental Health in 2000. The CMA has noted the options put forward to elevate mental health, mental illness and addiction in government priorities: A Canada Mental Health Act or a Minister of State for mental health, mental illness and addiction. We continue to believe that an adequately resourced, dedicated federal centre focussed on mental health, mental illness and addiction must be established within Health Canada. This will ensure that mental health, mental illness and addiction are not seen as separate from the health care system but an integral component of acute care, chronic care and public health services. A centre with dedicated funding and leadership at the Associate Deputy Minister level is required to signal the intent of the government to seriously address mental health, mental illness and addiction in terms of both its direct and indirect roles. This centre must also have the authority to coordinate across all federal departments and lead F/P/T collaborations on mental health, mental illness and addiction. The responsibility of the provinces and territories for the delivery of services for mental illness and addiction within their jurisdictions is unquestioned. But, as CMA has noted in relation to the acute care and public health systems, we have a concern with the disparity of these services across the country. We believe that the federal government must take a lead role, working with the provinces and territories, in establishing mental health goals, standards for service delivery, disseminating best practices, coordinating surveillance and research, undertaking human resource planning and reducing stigma. It is unfortunate that the Council of Deputy Ministers of Health withdrew its support of the F/P/T Advisory Network on Mental Health in 1990. The lack of a credible and resourced F/P/T forum for information sharing, planning and policy formation has impeded inter-provincial cooperation and collaboration for over a decade. F/P/T collaboration is essential to ensure adequacy of services in all parts of the country and end the piecemeal approach to mental illness and addiction. It would also encourage pan Canadian research and knowledge transfer. The CMA therefore recommends: 1. That the federal government create and adequately resource a Centre for Mental Health within Health Canada led by an Associate Deputy Minister with a mandate to initiate and coordinate activity across all federal departments to address the federal government’s responsibilities to specific populations under its direct jurisdiction, to oversee national policies and programs that impact on mental health, mental illness and addiction and to support intergovernmental collaboration. 2. That the federal government re-establish and adequately resource the F/P/T Advisory Network on Mental Health with a broader mandate to encompass mental health, mental illness and addiction. 3. That the federal government work with the provinces, territories and the Canadian Alliance on Mental Illness and Mental Health to establish a Pan Canadian Mental Health, Mental Illness and Addiction Network to develop a national mental health strategy, mental health goals and action plan; and serve as a forum for inter-provincial cooperation and collaboration on mental health, mental illness and addiction. Accessibility Accessibility leads the way as the number one concern regarding the health care system for patients and their families. This concern is in no way lessened when we look at access to mental health and addiction services and programs. The CMA has long identified accessibility as an essential issue that must be addressed to improve the health care system. In recent years, public concern over timely access has been growing. Recent polling for the CMA has shown that a significant majority of Canadians have suffered increased pain and anxiety while waiting for health care services. 3 The same polling clearly demonstrated that the vast majority of Canadians attributed long waits for health care services to a lack of available health providers and infrastructure. More recently, another opinion poll found that Canadians gave the health care system an overall grade of “C” in terms of their confidence that the system will provide the same level and quality of service to future generations. 4 The 2003 Hospital Waiting Lists in Canada report released by the Fraser Institute included a psychiatry waiting list survey which revealed that wait times from referral by a GP ranges from a Canadian average of 8.5 weeks to 20 weeks in New Brunswick. Patients then face a further delay as they wait for appropriate treatment after they have been seen by the specialist. This wait can be anywhere from 4 weeks to 19 weeks depending on the treatment or program. 5 The 2004 National Physician Survey, a collaboration between the CMA, the Royal College of Physicians and Surgeons of Canada, and the College of Family Physicians of Canada, found that 65.6% of physicians rated accessibility to psychiatrists as fair or poor. 6 These statistics do not reflect those patients that do not make it on to lengthy waiting lists where access is effectively denied. In September 2004 the CMA released a national plan of action to address issues of accessibility, availability and sustainability across the health system 7 . Better Access Better Health lays out a number of recommendations designed to ensure that access exists at times of need, and to improve system capacity and the sustainability of the system. While Better Access Better Health speaks to the health care system writ large, the provision of mental health services and addiction treatment clearly falls under this umbrella. Specific recommendations detailed in the plan of action for pan-Canadian wait-time benchmarks, a health human resource reinvestment fund, expanding the continuum of care and an increase in federal “core’ funding commitments would all have a positive impact on the accessibility of mental health and addiction services. The review of mental health policies and programs in select countries (Report 2 of the Interim Report) is striking for the similarity of problems facing mental health care. In each of the four countries studied there is concern for the adequacy of resources as well as recognition of the need to coordinate and integrate service delivery. The CMA agrees with the Committee’s commentary that: “The means for achieving these objectives that stands out from our survey of four countries is to set actionable targets that engage the entire mental health community, and to establish measurable criteria for the ongoing monitoring of reform efforts. Comprehensive human resource planning in the mental health field, as well as adequate funding for research and its dissemination are also suggested as key elements of a national strategy to foster mental health and treat mental illness.” CMA strongly supports setting national standards and targets with regard to mental health services and addiction treatment, but it must be understood that standards and targets can not be established until we have a clear and accurate picture of the current situation in Canada. Pan-Canadian research is needed to determine the availability of services across the country. Surveillance of mental illness risk factors, outcomes and services is essential to guide appropriate development and delivery of programs. Research is also needed to determine ways of integrating the delivery of mental health services between institutional and community settings. The Health Transition Fund supported 24 projects between 1997 and 2001 that made a substantial contribution toward a practical knowledge base in mental health policy and practice. The 2000 Primary Health Care Transition Fund is also supporting projects in the mental health field. For those projects that are due to be completed in 2006, they should be encouraged to put in place a prospective evaluation framework to determine the feasibility and scalability of collaborative care initiatives. As noted in Better Access Better Health availability is first and foremost about the people who provide quality care and about the tools and infrastructure they need to provide it. The shortage of family practitioners, specialists, nurses, psychologists and other health care providers within the publicly funded health care system is certainly an impediment to timely access to care. A health human resources strategy for mental health, mental illness and addiction is a first step in finding a solution to the chronic shortage of health professionals. The CMA therefore recommends: 4. That the federal government, through the Institute of Neurosciences, Mental Health and Addiction, undertake a program of surveillance and research to determine actual availability of services for mental health, mental illness and addiction across the country. 5. That the federal government in consultation with provincial and territorial governments, health care providers and patients/clients establish national standards and targets for access to services. 6. That the Institute of Neurosciences, Mental Health and Addiction and the Institute of Health Services and Policy Research within Canadian Institutes of Health Research establish a joint competition for research on ways of integrating the delivery of mental health services between institutions and community settings. 7. That the federal government undertake an evaluation of those Health Transition Fund and Primary Health Care Transition Fund projects in the mental health, mental illness and addiction field to determine the feasibility and scalability of collaborative care initiatives. 8. That the federal government work with the provinces and territories to develop a health human resource strategy for the field of mental health, mental illness and addiction. Accountability In its presentation to the Committee in March of 2004, CMA recommended that the federal government make the legislative and/or regulatory amendments necessary to ensure that psychiatric hospital services are subject to the criteria and conditions of the Canada Health Act. This would accomplish two objectives. It would signal the federal government’s serious intent to address the historical imbalance in the treatment of mental health and illness care while at the same time increase the accountability of these institutions and services to the values espoused in the Canada Health Act. This would be a very positive step, but we must also develop accountability mechanisms that can measure the quality and effectiveness of the mental health services provided. Since 2000, First Ministers and their governments have committed to reporting on numerous comparable indicators on health status, health outcomes and quality of services. In September 2002, all 14 jurisdictions including the federal government, released reports covering some 67 comparable indicators. In November 2004, these governments released their second report covering 18 indicators with a focus on health system performance including primary health care and homecare. Unfortunately, mental illness--despite its magnitude--has received little attention in these reports. Of the now 70 indicators that have been developed, only 2 directly address mental illness (potential years of life lost due to suicide and prevalence of depression). Furthermore, no performance indicators related to mental health outcomes or wait times for mental health services have been included in these reports. This is one more example of the oversight of mental illness related issues and the vicious circle that exists since few indicators makes it difficult to present the case for greater attention. The lack of information on availability of services, wait times and health outcomes for mental health services compromises governments’ ability to establish a funding framework to allocate funding equitably. Research that will reveal gaps in service delivery, and the establishment of targets should allow governments to better calculate sustainable funding levels needed to build capacity in the mental health, mental illness and addiction fields. As important as it is to ensure that mental health and addiction services within the health system are available, accessible and adequately resourced we must not lose sight of the fact that to effectively address mental health, mental illness and addiction issues services from a broad range of government sectors are required. Therefore the proposed Associate Deputy Minister for Mental Health must be accountable to ensure collaboration across sectors within the federal government. As in public health in general, a clarification of the roles and responsibilities of the various levels and sectors of government and health providers involved in the provision of mental health, mental illness and addiction services would allow for greater accountability. The CMA therefore recommends: 9. That performance indicators for mental health services and support, based on the work of the F/P/T Advisory Network on Mental Health, are incorporated in the federal, provincial and territorial reporting of comparable indicators on health status, health outcomes and quality of services called for in the 2003 First Ministers’ Accord on Health Care Renewal. 10. The federal, provincial and territorial governments establish resource targets based on national standards for access to services and minimum wait times to determine and commit to sustainable funding levels. 11. That the Health Council of Canada report on the performance of the mental health, mental illness and addiction system. CONCLUSION The CMA welcomes the spotlight that the Committee has shone on the mental health, mental illness and addiction system in Canada and has been pleased to provide input on behalf of the physicians of Canada. The neglect of those impacted by mental illness and addiction must not be allowed to continue. It is unconscionable that millions of Canadians do not have access to the programs, treatments or supports that would ease their suffering. The federal government must recognize its responsibility towards these Canadians, embrace its leadership role and ensure that the mental health, mental illness and addiction system is placed on an equal footing within the health care system in Canada. Physicians are an integral part of the mental health, mental illness and addiction field. We are eager to work with governments and other concerned stakeholders to bring to fruition a national mental health strategy with mental health goals and an associated action plan that can effectively address the concerns of today and prepare the mental health, mental illness and addiction system for the future. CMA recommendations on Mental Health, Mental Illness and Addiction 1. That the federal government create and adequately resource a Centre for Mental Health within Health Canada led by an Associate Deputy Minister with a mandate to initiate and coordinate activity across all federal departments to address the federal government’s responsibilities to specific populations under its direct jurisdiction, to oversee national policies and programs that impact on mental health, mental illness and addiction, and to support intergovernmental collaboration. 2. That the federal government re-establish and adequately resource the F/P/T Advisory Network on Mental Health with a broader mandate to encompass mental health, mental illness and addiction. 3. That the federal government work with the provinces, territories and the Canadian Alliance on Mental Illness and Mental Health to establish a Pan Canadian Mental Health, Mental Illness and Addiction Network to develop a national mental health strategy, mental health goals and action plan; and serve as a forum for inter-provincial cooperation and collaboration on mental health, mental illness and addiction. 4. That the federal government, through the Institute of Neurosciences, Mental Health and Addiction, undertake a program of surveillance and research to determine actual availability of services for mental health, mental illness and addiction across the country. 5. That the federal government in consultation with provincial and territorial governments, health care providers and patients/clients establish national standards and targets for access to services. 6. That the Institute of Neurosciences, Mental Health and Addiction and the Institute of Health Services and Policy Research within Canadian Institutes of Health Research establish a joint competition for research on ways of integrating the delivery of mental health services between institutions and community settings. 7. That the federal government undertakes an evaluation of those Health Transition Fund and Primary Health Care Transition Fund projects in the mental health, mental illness and addiction field to determine the feasibility and scalability of collaborative care initiatives. 8. That the federal government works with the provinces and territories to develop a health human resource strategy for the field of mental health, mental illness and addiction. 9. That performance indicators for mental health services and support, based on the work of the F/P/T Advisory Network on Mental Health, are incorporated in the federal, provincial and territorial reporting of comparable indicators on health status, health outcomes and quality of services called for in the 2003 First Ministers’ Accord on Health Care Renewal. 10. The federal, provincial and territorial governments establish resource targets based on national standards for access to services and minimum wait times to determine and commit to sustainable funding levels. 11. That the Health Council of Canada report on the performance of the mental health, mental illness and addiction system. 1 Stephens T and Joubert N, The Economic Burden of Mental Health Problems in Canada, Chronic Disease in Canada, 2001:22 (1) 18-23. 2 Health Canada. A Report on Mental Illnesses in Canada. Ottawa, Canada 2002. 3 Health Care Access and Canadians, Ipsos-Reid for the CMA, 2004. 4 2004 National Report Card on the Sustainability of Health Care, Ipsos-Reid for the CMA, 2004. 5 Hospital Waiting Lists in Canada (13th edition), Critical Issues Bulletin, The Fraser Institute, October 2003. 6 National Physician Survey, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, College of Family Physicians of Canada, 2004, (http://www.cfpc.ca/nps/English/home.asp), accessed April 6, 2005. 7 Better Access Better Health: Accessible, Available and Sustainable Health Care For Patients, CMA September 2004 , attached as Appendix I.
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