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Budget 2009: Economic Stimulus through Targeted Investments in Health Infrastructure - Brief to the Minister of Finance's Roundtable

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

https://policybase.cma.ca/en/permalink/policy1951
Last Reviewed
2012-03-03
Date
2005-07-28
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2012-03-03
Date
2005-07-28
Topics
Health systems, system funding and performance
Text
Building a Comprehensive Post-Market Surveillance System Canadian Medical Association Response to Health Canada’s Discussion Paper “Designing a Mandatory System for Reporting Serious Adverse Reactions” Submitted to Health Canada July 28, 2005 Overview The CMA believes that all stakeholders should work together to improve adverse drug reaction (ADR) reporting, in the interests of improving patients’ safety and health. However, we believe that activity in pursuit of this end must be based on two fundamental premises: a) Reporting is only one part of a comprehensive post-market surveillance system. In order to effectively monitor the safety of Canada’s drug supply, this system should include: * a simple, comprehensive and user-friendly reporting process; * rigorous analysis of reports to identify significant threats to drug safety; * a communications system that produces useful information, distributed to health care providers and the public in a timely, easily understood manner. There is no point in enacting a mandatory reporting requirement until all of these elements are in place. We wonder why mandatory reporting has been singled out for discussion when a holistic approach to reforming Canada’s drug safety system is called for. b) Health care providers should be encouraged to participate willingly and voluntarily in the reporting process. To be successful, Canada’s post-market surveillance system will depend on the active participation of physicians and other health professionals. Experience with health system quality and safety improvement efforts over the past several years has demonstrated that meaningful acceptance is most effectively obtained when those involved are willing participants. If you build a comprehensive, efficient and effective post-market surveillance system, physicians will participate actively in it. Forcing them to participate before the system has been built will result in alienation, frustration and failure. Comments on Discussion Paper a) Is Mandatory Reporting Necessary? This is a fundamental question and the discussion paper does not satisfactorily address it. There are two reasons why we question the necessity for imposing an ADR reporting requirement on health professionals. First, as awareness of the drug-safety system’s importance has increased, the number of ADR reports has increased along with it - more than 10% in 2004, as the discussion paper notes - without a mandatory reporting requirement. Given this trend, it is highly probable that time, education, adequate resources and increasing familiarity with the surveillance system will raise reporting rates to the desired level (however defined) without mandatory reporting. Second, as the discussion paper points out, there is no evidence that mandatory reporting has been effective in other jurisdictions where it has been implemented. The paper offers no clear explanation for this lack of success. More importantly, it does not indicate how Health Canada plans to ensure that mandatory reporting will succeed in this country when it has proven ineffective elsewhere. A primary principle of any system change is that we should not repeat the mistakes of others. Before launching a program whose success has not been proven, other viable, and possibly more effective, alternatives should be examined. b) Addressing known barriers to reporting The CMA acknowledges that ADRs are under-reported, in Canada and worldwide. The discussion paper identifies a number of barriers to reporting, and its list mirrors the observations and experiences of our own members. We believe most of these barriers can, and should, be overcome. We also agree that it is necessary to raise health professionals’ awareness of the importance of, and process for, ADR reporting. But we question the curious assertion that “Mandatory reporting could raise awareness of the value of reporting simply by virtue of the public debate.” Surely there are more positive ways to raise awareness than publicly speculating about the punitive consequences of non-compliance. We suggest that instead, Health Canada work with physicians and other health professionals to address the existing barriers to reporting. Specifically, we recommend that Health Canada implement: * a well-funded and targeted awareness-raising campaign focused on provider education and positive messaging, * a user-friendly reporting system, including appropriate forms, efficient processes and adequate fees. These measures are within Health Canada’s purview in the existing policy and legislative environment. We believe they would increase reporting without the need for coercive measures. At a minimum, positive system improvements should be tried first before considering a mandatory-reporting requirement. With regard to specific questions posed in the discussion paper: Question 1: Health professionals should be explicitly protected from any liability as a result of reporting an adverse drug reaction. This should be the case regardless of whether reporting is voluntary or mandatory. Question 2: Professionals should be compensated for all meaningful work including the completion of forms and any follow-up required as a result of the information they have provided. We would be happy to expand further on this issue on request. Question 3: Issues of confidentiality should be covered in legislation. The CMA has developed an extensive and authoritative body of knowledge on privacy issues in health care, which we would be pleased to share with Health Canada. c) Improved report quality We agree that increasing the quality and richness of ADR reports is as important as increasing their number. Perhaps it is even more important, since high-quality reports allow for high-quality analysis. Mandatory reporting will not improve the quality of ADR reports; it will simply increase their quantity. It may even compromise the system’s efficiency and effectiveness by increasing the volume of clinically insignificant reports. Experience elsewhere has taught us that true quality cannot be legislated or imposed; any attempt to do so would be pointless. If ADR reports included the information listed in Table 4, this would improve their usefulness and the effectiveness of the overall surveillance process. However, it is unrealistic to expect all reports to contain this level of information. The treating physician may not be able to provide all of it, especially if he or she is not the patient’s regular primary care provider. Some of this information, particularly about outcomes, may not be available at the time of the reporting, and gathering it would require follow-up by Health Canada. Health Canada should consider measures other than mandatory reporting to improve the quality of ADR reports. The CMA suggests that consideration be given to: * Improving follow-up capacity. We agree that it should be made easier for Health Canada officials to contact reporters and request details on follow-up or outcomes. This should be considered as part of a comprehensive initiative to improve Health Canada’s capacity to analyze ADR reports. * Establishing a sentinel system. Another option for increasing high-quality reports would be to establish a “sentinel” group of practicing physicians who would contract to report all ADRs in detail. These physicians, because of their contractual obligation, would be committed to assiduous reporting. Sentinel systems could be established concurrently with efforts to increase voluntary ADR reporting by the broader health professional community. In addition to the current information provided, consideration should be given to including on reporting forms the option to allow Health Canada officials to act on information the physician provides; for example, in the reporting of sexually transmitted diseases physicians provide certain information and have the option to request that public health officials undertake follow-up and contact tracing. d) Minimize administrative burden We agree that Health Canada should give consideration to making the ADR reporting system user-friendly, non-complex and easy to integrate into the patient-care work stream. These reforms can and should be implemented regardless of whether a mandatory requirement is in place. They do not need mandatory reporting to make them work; in fact, they are more likely to encourage ADR reporting than any form of coercive legislation. Rather than making a mandatory reporting requirement “fit” with the traditional patient-care framework, we invite Health Canada to work with us to increase health professionals’ capacity to report ADRs voluntarily. We are already working with Health Canada to improve physicians’ access to drug safety material. Health Canada’s ADR reporting form can now be downloaded from the cma.ca web site, which also posts the latest drug alerts from Health Canada and from the Food and Drug Administration in the U.S. We have developed an on-line course in partnership with Health Canada, to teach physicians when and how to make ADR reports. We hope to build on this collaboration, with the goal of making it possible for physicians to report ADRs online via cma.ca. This will permit them to fit reporting more conveniently into their daily workflow. (Note: the “MedEffects” Web portal now being developed at Health Canada does not fit well into the workflow and therefore will not make reporting easier for health professionals.) In the future, we hope that ADR reporting can be built directly into the Electronic Medical Record (EMR). We think this will be a critical element in the bi-directional communicating that ADR reporting requires. It will also enable rapid integration of advisories into the EMR so that they can be available to physicians at the time they are writing a prescription. Before electronic ADR reporting can work, a standard for electronic data should be in place (at present it is not) and Health Canada should develop the capacity to accept data electronically. Health Canada’s discussion paper makes reference to cost-benefit analysis. We recommend that you take great care not to over-emphasize cost-benefit when it comes to enhancing patient safety. Meaningful improvements in the post-market surveillance system will be costly whatever solution Health Canada eventually embraces, and it is impossible to measure financially the value of safety. What is an acceptable cost for one life saved? e) Minimize Over-Reporting The discussion paper acknowledges that not all adverse reactions need be reported. We strongly agree that one of the dangers of mandatory reporting is its potential to overwhelm the system with an unmanageable flood of reports. There is no reason to require reports of minor side effects that are already known to be associated with given drugs. We agree that the reactions Health Canada most needs to know about are those which are severe and/or unexpected. If Health Canada insists on implementing a mandatory reporting system, it should be limited to these reactions (possibly with the corollary that well known serious ADRs would not need to be reported). However, the operating definitions may need clarification, and we recommend that Health Canada consult with health professionals and others on operational guidelines for defining “serious adverse reaction.” Health Canada’s desire to encourage reports on drugs approved within the last 5 years is understandable (though some drugs may be on the market for longer than this before their true risks are known). In practice, however, many physicians do not know which drugs these are, and seeking out this information may impose a heavy administrative burden. As we move toward an EMR-based reporting system, a tag on the Drug Identification Number to tell when the drug was approved will allow physicians to identify which medications require special vigilance. Appropriate reporting could be encouraged, and over-reporting discouraged, by clear guidelines as to what should be reported as well as appropriate compensation for reporting. f) Match Assessment Capacities In our opinion, this is one of the most important sections in the document. What happens once the reports have been received is crucial if we want to identify a serious drug risk as quickly as possible. Under the current system, one of the most significant barriers to physicians’ reporting is lack of confidence that anything meaningful will be done with their reports. Enhancements to the analysis function must be made concurrently with efforts to increase ADR reporting. ADR reports are only cyber-bytes or stacks of paper unless we can learn from them. This requires rigorous data analysis that can sort “signal from noise” – in other words, sift through thousands of reports, find the ones that indicate unusual events, investigate their cause, and isolate those that indicate a serious public health risk. This requires substantial resources, including an adequate number of staff with the expertise and sensitivity required for this demanding task. Unless Health Canada has this capacity, increasing the number of reports will only add to the backlog in analysts’ in-boxes. The CMA recommends that Health Canada allocate sufficient resources to enable it to effectively analyze and respond to ADR reports and other post-market surveillance information. g) Respect privacy Privacy of both patient and physician information is a significant concern. Physicians’ ethical obligation to maintain patient confidentially is central to the patient-physician relationship and must be protected. We acknowledge that issues of privacy and confidentiality must be resolved when designing an ADR reporting system, particularly as we work toward electronic communication of drug surveillance data and its incorporation into an EMR. For example, regulations should explicitly state that ADR reports are to be used only for the purpose for which they were submitted, i.e. for post-market drug surveillance. In addition, Health Canada should ensure that any privacy provisions it develops meet the legislative test outlined in Section 3.6 of CMA’s Health Information Privacy Code (Attachment I). Health Canada can be assured that physicians take their privacy obligations seriously. The CMA has been a strong and pro-active player in debate on this issue, and our Privacy Code lays the groundwork on which we believe any privacy policies involving ADR reporting should be based. h) Compliance through sanctions Physicians are motivated to report ADRs by their concern for public health and their patients’ well-being. In addition, they are guided by the CMA Code of Ethics and governed by regulatory authorities in every province. A clear ethical and professional obligation already exists to report anything that poses a serious threat to patient safety. If physicians do not comply with this obligation, sanctions are available to the provincial regulatory authorities. In fact, the most serious threat for physicians is loss of standing with the professional regulatory authority, not the courts or any external judicial system. It would be superfluous to add a second level of regulation or scrutiny when remedies already exist. The discussion paper presents few alternatives to the existing self-regulatory system. As the paper itself acknowledges, it is unrealistic to impose sanctions based on failure to report an ADR, since it is not always easy to determine whether an adverse effect is attributable to a health product. But the only suggested alternatives - requiring physicians to demonstrate knowledge, or to have the required reporting forms in their office - seem intrusive, crude and unreasonable; they are also meaningless since they have no direct relation to a physician’s failure to report. If Health Canada is considering a large outlay of taxpayers’ dollars for post-market surveillance, we suggest they target those funds to education and awareness raising, and to enhancing the system’s ability to generate and communicate meaningful signal data, rather than to enforcing a mandatory reporting system based on weak compliance measures, with no evidence of its effectiveness in other jurisdictions. Physicians who are in serious breach of their ethical and legal responsibility to report are subject to sanctions by provincial regulatory authorities. Most provincial colleges have policies or guidelines regarding timely reporting and appropriate enforcement mechanisms. Medicine’s tradition of self-regulation has served it well, and we recommend that Health Canada respect and support existing regulatory authorities as they maintain the standards for appropriate professional behaviour. As we have said before - the preferred quality improvement tools to enhance performance and encourage compliance are education and positive reinforcement, not legislation and the threat of sanctions. Conclusion In its discussion paper Health Canada has invited stakeholders to provide their input on how best to develop a mandatory system for reporting ADRs. The Canadian Medical Association believes that the best way to do this is not to develop one at all. Instead, we believe stakeholders should concentrate on building a sustainable, robust and effective post-market surveillance system which: * encourages and facilitates voluntary reporting, by designing a simple and efficient process that can be incorporated into a physician’s daily workflow; * effectively uses reporting data to identify major public health risks; * communicates drug safety information to providers and the public in a timely, meaningful and practical way. The CMA is committed to working, in partnership with Health Canada and other stakeholders, toward the ultimate goal of a responsive, efficient and effective post-market drug surveillance system. This is part of our long-standing commitment to optimizing Canadians’ safety and health, and achieving our vision of a healthy population and a vibrant medical profession.
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CMA's Presentation to the House of Commons Standing Committee on Health : H1N1 Preparedness and Response

https://policybase.cma.ca/en/permalink/policy9699
Date
2009-10-05
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2009-10-05
Topics
Population health/ health equity/ public health
Text
Good afternoon Madame Chair. The Canadian Medical Association is pleased to address the committee as part of its ongoing study of H1N1 planning and response. In the broad context of pandemic planning, the CMA has focused on developing information and education tools on cma.ca to ensure Canada's doctors are equipped to provide the best possible care to patients. We have also engaged in discussions with the Assembly of First Nations to address workforce shortages in First Nations and Inuit communities during a pandemic. Despite the work of governments and others, there remains much to do. To provide optimal patient care, individual physicians - primary care providers and specialists alike - require: * Regular updates on the status of H1N1 in their community; * Timely and easy access to diagnostic and treatment recommendations with clear messages tailored to their service level; * Rapid responses to questions; and * Adequate supplies of key resources such as masks, medications, diagnostic kits and vaccines. The CMA commends federal, provincial and territorial governments for creating the Canadian Pandemic Influenza Plan for the Health Care Sector. The CMA was pleased to provide feedback on elements of the plan and we are participating on the anti-viral and clinical care task groups. There are three issues that still must be addressed: First, the communications gap between public health officials and front-line providers; Second, the lack of adequate resources on the front lines; and finally, variability that exists across the country. The Communications Gap Physicians must be involved in the planning stages and must receive consistent, timely and practical plain-language information. They should not have to seek information out from various websites or other sources, or through the media. This communications gap also includes a gap between information and action. For example, we are told to keep at least a six-foot distance between an infected patient and other patients and staff. This will not be possible in a doctor's waiting room, nor will disinfecting examining and waiting rooms in-between each patient. Adequate resources Patient volumes may increase dramatically and there are serious concerns about how to manage supplies if an office is overwhelmed. There is also considerable concern over whether we can keep enough health care professionals healthy to care for patients, and whether we have enough respirators and specialty equipment to treat patients. Intensive-care units of hospitals can also expect to be severely strained as a second-wave pandemic hits. This speaks to a general lack of surge capacity within the system. Also, pandemic planning for ICUs and other hospital units must include protocols to determine which patients can benefit most when there are not enough respirators and personnel to provide the required care for all who need it. Beyond the need for more supplies, however, there is also the concern that there are only so many hours in a day. Doctors will always strive to provide care for those who need it, but if treating H1N1 cases takes all of our time, who will be available to care for patients with other conditions? Variability across the country CMA has consulted with provincial and territorial medical associations and their level of involvement in government planning as well as the general state of preparedness varies greatly. There is also marked inconsistency province-to-province around immunization schedules. We need a clear statement of recommendation to clear up this variability. In summary, there remains a great deal of uncertainty among physicians about: the vaccine, the supply of antivirals, the role of assessment centres and mass immunization clinics, delegated acts, and physicians' medico-legal obligations and protections. The bottom line is that there is still more work to do at all levels before front-line clinicians feel well prepared with information, tools and strategies they need. The CMA was pleased to meet with Dr. Butler-Jones to discuss our concerns last week and will continue to work closely with Public Health Agency of Canada to identify gaps and to prepare user-friendly information for clinicians. Thank you and I welcome any questions.
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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 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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"More Doctors. More Care:" A Promise Yet Unfulfilled - The Canadian Medical Association's brief to the House of Commons Standing Committee on Health concerning health human resources

https://policybase.cma.ca/en/permalink/policy9438
Date
2009-04-28
Topics
Health systems, system funding and performance
Health human resources
  1 document  
Policy Type
Parliamentary submission
Date
2009-04-28
Topics
Health systems, system funding and performance
Health human resources
Text
The Canadian Medical Association (CMA) brief submitted to the House of Commons Standing Committee on Health makes 12 practical recommendations within the jurisdiction of the federal government for investing in the capacity needed to expand and retain our practising physician population. These recommendations are a clarion call for pan-Canadian planning and innovative thinking to meet an ever-increasing demand for physician services from the Canadian public. CMA's research on Health Care Transformation has shown that a commitment to ensuring an adequate supply of health human resources (HHR) is a common trait shared by high-performing European health systems. The last federal election campaign saw most political parties pledge to urgently address HHR shortages. Now is the time to keep those election commitments. A. Capacity Cuts to medical school enrolment in the 1990s contributed to Canada's significant shortage of physicians. Growing demand for physician services, the aging of the physician population and changing practice styles among younger physicians are further compounding the problem. Seriously addressing HHR shortages is crucial to transforming Canada's health care system into one that is truly patient focused. Canada should strive for self-sufficiency in physician supply and do more to repatriate Canadians studying and practising medicine abroad. The CMA supports bringing into practice qualified international medical graduates (IMGs) already in Canada. IMGs should be assessed according to the same evaluation standards as Canadian graduates and more should be done to reduce the backlog in assessing IMGs. With recent increases to medical school enrolment, more support must also be given for the capital infrastructure and faculty required to ensure the highest standard of medical education. B. Retention Competition for physicians is an issue with both international and inter-provincial/territorial facets. The revised Agreement on Internal Trade (AIT) and bilateral agreements will ease the movement of health professionals across jurisdictions, but may exacerbate retention difficulties in underserviced areas. Canada should be active in retaining and repatriating our health care professionals, particularly since the predicted physician shortage in the United States may result in a return to the physician out-migration seen in the 1990s. C. Innovation Canada must do more to encourage innovation within our health care system. Collaborative care - including care delivered with the assistance of Physician Assistants (PAs) - and advances in information technology hold the promise of helping create a more efficient health care system that provides higher quality care. Introduction Canada has suffered from a significant physician shortage since the mid-1990s. Nationally, we rank 26th of 30 Organisation for Economic Co-operation and Development (OECD) member countries in physician-to-population ratio. We would need 20,000 new physicians just to meet the OECD average. Figure 1: Physicians per 1000 population (including residents) Source: OECD 2008 Health Data; CMA Physician Resources Evaluation Template During the 2008 federal election campaign, four of the five parties represented in the House of Commons recognized the urgency of this situation and promised measures that would address HHR shortages. Following through on these promises is critical if we are to transform Canada's health care system into one that truly puts the needs of patients first. Research conducted for CMA's Health Care Transformation initiative demonstrates that European countries whose health care systems outperform our own all share a strong commitment to HHR, as demonstrated by their higher physician-to-population rankings. A. Capacity First-year medical school enrolment was already in decline when health ministers imposed a further 10% cut resulting in a low of 1,577 places in 1997. While there have been substantial increases since then, it took a decade to rebound. In 2007, first-year enrolment stood at 2,569 - 63% higher than a decade earlier. If we had left our domestic production unchanged, we would have almost 1,300 more physicians than we have today. Canada remains well behind other industrialized countries in the education and training of physicians. In 2005, Canada graduated 5.8 physicians per 100,000 population, 40% below the 9.6 average for the OECD. Currently, between 4 and 5 million Canadians do not have a family physician. Over one-third of all Canadian physicians are over the age of 55. Many will either retire soon or reduce their practice workload. Most are not accepting new patients. Ironically, advances in medicine and lifestyle that are helping Canadians live better and longer also mean increased demand for health care professionals. An aging population with high expectations of the health care system is increasing pressure on health care providers to ensure they maintain a high quality of life through their elder years. A growing culture of 'health consumerism,' facilitated by the Internet has resulted in a very knowledgeable patient population that expects top quality care delivered in a timely manner by the appropriate health professional. Advances in medical diagnostics and technology, new and evolving diseases and increasingly complex protocols and guidelines for medical care all increase the demand for physician services. Declining mortality rates for patients with diseases such as cancer have increased treatment of what have become 'chronic' diseases. In a collaborative care setting, physicians often take responsibility for the most complex patients. There is evidence of a cultural change among physicians to place greater importance on their home life by working less. This trend may have a positive effect on the health of the profession but it means Canada will need more physicians to provide the same volume of services. Greater coordination among jurisdictions is needed to facilitate HHR planning on a national scale. Canada's doctors and other health professions are ready to assist policy-makers in their planning and coordination to better meet the health care needs of Canadians. During the 2008 federal election campaign, most political parties recognized the urgency of addressing HHR shortages. The Conservative Party, specifically, promised to fund 50 new residency positions to increase supply of physicians in areas of priority need. Recommendation 1: The federal government should fulfill its promise to fund 50 new residency positions at a cost of $10 million per year for four years. Support for IMGs The CMA fully supports bringing into practice qualified IMGs already in Canada. Canada has historically benefited from a steady flow of IMGs to our country. In fact, close to one quarter of all physicians in Canada and over 50% of doctors in Saskatchewan are IMGs. Many areas in Canada would have no physicians if not for the contribution of these practitioners. While IMGs are a boon to Canada, actively recruiting from developing countries is not an acceptable solution to our physician shortage. Canada must strive for greater self-sufficiency in the education and training of physicians. In fact, self-sufficiency is a key principle of the government's Advisory Committee on Health Delivery and Human Resources' Framework for Collaborative Pan-Canadian Health Human Resources Planning. CMA supports online assessment tools and websites that provide information to foreign-trained physicians so they know what standards they must meet once they arrive in Canada. In 2006, over 1700 people used the online assessment tool established by the Medical Council of Canada (MCC). CMA also supports applying the same evaluation standards to international graduates as it does to graduates of Canadian medical schools. Despite a four-fold increase in the number of IMGs in ministry-funded postgraduate training programs over the last decade, there is still a backlog of IMGs awaiting entry into these programs. About 1300 IMGs applied for a postgraduate training position last year but only 350 (27%) were successful. CMA recommends that funding be made available to provinces for use in mentoring IMGs towards licensure. This could lower costs for the IMGs, pay the community preceptors, cover operational costs and defray other expenses. It is estimated that up to 1500 Canadians are studying medicine abroad. Two-thirds of these IMGs want to come home to complete their postgraduate training. Canada turns away four good applicants for every student accepted into medical school. Increased training opportunities for all groups of IMGs will ensure that Canada fully utilizes the skills and knowledge of its citizens who have studied medicine. Recommendation 2: The federal government should make $5 million (over five years), available to provinces/territories to address the backlog of IMGs through community preceptorship programs that mentor and assess IMGs for integration into the physician community. Recommendation 3: The federal government should take concrete steps to ensure Canada becomes self-sufficient when it comes to the supply of health care professionals. Recommendation 4: The federal government should continue to fund information tools such as the IMG-Canada website to better inform offshore physicians. Infrastructure and faculty Canada's teaching centres have had to absorb increases in operational and infrastructure costs to accommodate increased enrolment. This includes instructors, space, overhead and supplies. While it appears that the number of faculty members has kept pace with the increased number of medical students, part-time faculty now make up a much larger proportion of the total than 10 years ago. i In addition to the traditional academic centres, much of the training of doctors now occurs in a community environment. Mentoring is provided by physicians who may have less experience or resources than do those in the larger centres. Those who teach often experience lost productivity in their practice and receive little or no remuneration. This deficiency must be addressed to achieve a sustainable educational workforce. Recommendation 5: The federal government should implement a Health Human Resources Infrastructure Fund in the amount of $1 billion over 5 years to expand health professional education and training capacity by providing funding to support the: * Direct costs of training providers; * Indirect or infrastructure costs associated with the educational enterprise; and * Resources that improve Canada's data collection and management capacity in the area of health human resources. B. Retention of Canadian Physicians Competition for physicians is both an international and an inter-jurisdictional challenge. The new Agreement on Internal Trade within Canada and numerous bilateral agreements will no doubt ease the movement of health professionals. This may exacerbate the already difficult task of retaining physicians in underserviced areas. On the positive side, it is hoped this will facilitate the movement of physicians who provide short-term relief for physicians needing time off for continued professional development and vacation (i.e., locum tenens). Repatriation As the political situation and health care plans evolve south of our border, Canada should remain active in the quest to retain the health professionals we have educated and trained and make it easier for those who have emigrated to return to practice in Canada. The Conservative Party committed in the 2008 election campaign to create a repatriation fund for Canadian physicians practising abroad. The federal government should keep this important commitment. Migration to the United States peaked in the late 1990s when Canada lost between 600 and 700 physicians per year. While some physicians returned to Canada each year, our net losses for this period were over 400 per year. Today we are enjoying small net gains each year but this may not last given the predicted shortages in the U.S. of between 80,000 and 100,000 physicians in the years ahead. We can expect U.S. recruiters to ramp up activities in Canada in the near future. Recommendation 6: The federal government should fulfill its election promise to establish a fund of $5 million per year over four years to help Canadian physicians living abroad who wish to relocate to Canada. It is thought this initiative could bring back as many as 300 Canadian physicians over four years. Recommendation 7: The federal government should establish a Health Professional Repatriation Program in the amount of $30 million over 3 years that would include the following: * A secretariat within Health Canada that would include a clearinghouse function on issues associated with health care workers returning to practise in Canada. * An ad campaign in the United States. * A program of one-time relocation grants for returning health professionals. Physician Health and Well Being Ultimately, we hope that healthier physicians will create a more vibrant profession. Hopefully these healthier physicians will in turn create a more healthful professional environment that will support their ability to provide patient care of the highest quality. Through programs and conferences, the CMA has contributed to growing efforts to reduce the stigma surrounding physician ill-health and to support a new, healthier culture for the profession. Given the myriad other issues that contribute to our doctor shortage, it is clear that Canada cannot afford to lose a single physician to ill health. Our research shows that the most stressful aspect of the medical profession is being on call after hours. Physicians average 50 hours a week in the usual settings of office, hospital or clinic but then 70% are on call for another 30 hours per week. In small communities, physicians are often on call all the time. A quarter of all physicians face some form of mental health challenge that makes their work difficult. This is higher than the 1 in 5 Canadians that will face a mental illness over their lifetime.ii The ongoing pressures experienced by overworked physicians can result in stress related disorders and burn-out and are frequently a precursor to more significant physical and mental health problems. If not addressed early, these conditions can lead to physicians taking prolonged periods of time off work, changing their practice patterns or leaving the practice of medicine altogether. Prevention programs are the key to assisting physicians before they are at significant risk. The CMA visited such a program in Norway which has been shown to significantly reduce burn-out and reduce the subsequent time-off work related to stressiii. A program to enhance physician resiliency and prevent stress related disorders, based on the Norway model, could be expanded to include services for all health professionals. The potential impact would be improved provider health and morale, reduced sick days and fewer long-term leaves. Recommendation 8: The federal government should invest in research directed at assessing the quality of work life among health workers through an interprofessional survey at a cost of $1.5 million. Recommendation 9: The federal government should explore the feasibility of developing a 'made in Canada' Resiliency Program for Health Professionals that would include the development of a feasibility study, including a business case, and a pilot curriculum, at a cost of $500,000. C. Innovation While Canada must do more to increase both our supply and retention of HHR, we must also encourage innovation within our health care system to make better use of our existing health resources. Collaborative models of interprofessional care and advances in information technology hold the promise of helping create a more efficient health care system that provides higher quality care. Physician Assistants Increasingly physicians are working in interprofessional teams that may include professions that are relatively new to Canada's health workforce such as physician assistants (PAs). The CMA accredits PA curricula and has held two conferences to promote the use of PAs in all levels of care. Recommendation 10: The federal government should fund a study to evaluate the impact of physician assistants on access to health care and to determine their cost effectiveness relative to other providers at cost of $150,000. Technology to Support Health Care Delivery Information technology will continue to create a more efficient and effective health care system. It will lead to more patient safety, more Canadians finding a physician, better care, cost avoidance such as eliminating duplicate tests and the establishment of collaborative interprofessional health care teams. Canada's adoption of electronic medical records lags behind other OECD countries. We only spend a third of the OECD average on information technology in our hospitals. The adoption of EMRs in community settings (primary care, home care and long-term care facilities) also trails most other countries (Figure 2iv). This is not due to any general resistance by providers, but rather a combination of: a lack of evidence on how best to use electronic records to improve care delivery; a need to improve the return on investment for physicians by providing value-added solutions such as greater connectivity to lab results, drug data and colleagues; the time it takes to implement a new electronic record capability and a lack of funds to acquire new technology. Recent investments in Canada Health Infoway (CHI) will help address some of these issues but it is estimated that for Canada to have a fully automated health care delivery system we need to invest $ 10 to $12 billionv. An overall investment of $2 billion is required to fully IT enable the community-based health care delivery sector. While Budget 2009 provided $500 million to CHI for EMRs, more is still required. Recommendation 11: The federal government should provide a further investment of $500 million for new technology to fully enable all points of care in the community settings and an enhanced change management program to speed up EMR adoption. Recommendation 12: The federal government should create a $10-million fund to establish an applied research program for the next five years that will provide evidence on how best to integrate information technology into the health care delivery system. D. Conclusion Canada's doctors believe that we can build a health care system where all Canadians can get timely access to quality health care services regardless of their ability to pay. Developing a comprehensive HHR strategy that assures an adequate supply of all health care providers, including physicians, is a pillar of achieving timely access to high quality care. Building such a system requires that we shift our attitude and move to implement new strategies, new ideas and new thinking. That new thinking must begin with a commitment to act now to address Canada's physician shortage. A promise made must be a promise fulfilled. References i Canada's Health Care Providers 2007, Ottawa: CIHI, 2007 ii Frank E. Canadian physicians healthy - national survey finds. A report from the 2008 International Conference on Physician Health. London, UK Nov 2008. iii Isaksson Ro, K et al. Counselling for burnout in Norwegian doctors : One year cohort study. BMJ. November 2008. Vol 337, 1146-9. iv * Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions, access test results, access hospital records; computer for reminders, Rx alerts, prompt test results; easy to list diagnosis; medications, patients due for care. v Vision 2015 - Advancing Canada's Next Generation of Healthcare, Canada Health Infoway, 2008
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A Prescription for Productivity: Toward a more efficient, equitable and effective health system : CMA’s 2005 Pre-Budget Submission to the Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy1946
Last Reviewed
2013-03-02
Date
2005-10-24
Topics
Health systems, system funding and performance
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2013-03-02
Date
2005-10-24
Topics
Health systems, system funding and performance
Text
Introduction This pre-budget submission makes the case that healthier Canadians are more productive Canadians. It also recognizes that the delivery of quality health care, in a timely manner, is paramount and is not mutually exclusive to any productivity agenda. As Emerson once said, “the first wealth is health.” 1 Last fall, the First Ministers recognized this by agreeing on a plan that will, over the next 10-years, add an additional $41 billion federal dollars into our health care system. The Canadian Medical Association applauds the government for spearheading this renaissance in federal health care funding. But like the human body, that is always evolving, the health care system needs to be monitored and trained for optimal performance. The consequences of under investing in health care in the past are haunting us today. Better health … better Canada Canada, which at one time was the most attractive place on earth to live, is falling behind. According to the Conference Board of Canada, Canada’s overall economic performance has fallen from 3rd best in the world, to 6th and now to 12th. One of the drivers of this precipitous fall is – according to the Conference Board’s analysis – the weakened state of our health care system. For example, our infant mortality rates are rising, not falling, in relative terms. We have tumbled from our top-five ranking in the 1980s — to where we are today in the 22nd spot out of 27 countries of the Organization for Economic Co-operation and Development (OECD). That is why, now more than ever, Canada’s economy is in need of strategic federal direct investments in health care as part of an overall productivity enhancing package. The CMA is not alone in linking health care investments to better economic performance. According to the latest economic research, “There is now strong empirical evidence to suggest a two-way relationship: improved health significantly enhances economic productivity and growth. 2 ” Furthermore, the Royal Institute of International Affairs states that, “…improved health supports labour productivity; by augmenting life expectancy, it encourages savings and private investment. Health expenditures are an investment not a cost. It is crucial that governments develop a long-term perspective.” The health care sector in Canada employs over a million people or 7.5% of the labour force. In 2004, Canada invested $130 billion in health care representing 10% of our GDP. The benefits of the health care investments not only accrue to a higher quality of life for all Canadians, but the economic multiplier effect of the initial investment is estimated to create an additional $65 billion in economic activity. 3 The CMA has identified a number of key issues related to health human resources and infrastructure that require immediate attention if the Canadian economy is to retain its competitive position in the global economy. We will make the case that, by making strategic federal direct investments in health human resources and public health, the federal government can make a great leap forward in reinforcing a critical foundation for a healthier more productive Canadian economy. These initiatives involve investments in physical, human and entrepreneurial capital, which if sustained over the long-term, will pay dividends in terms of improved population health. The competition for world class health care labour is becoming more global and will intensify. Unless Canada can provide excellent training, tools and working conditions international demand threatens to undermine the foundations of our system. For example, if Canada were to move today to cap working hours on physicians to 48 hours per week as the European Union has done, Canada would be short a whopping 12,780 physicians. Not only is there international demand for world class medical professionals, but also the stock of these professionals especially in Canada is aging. The United States is expected to be short by 200,000 physicians by 2020. They have looked to Canada before to fill the gap, and they may again. This is why the federal government must play a leadership role in supporting health human resources (HHR) while at the same time sustaining Canadian health care industries. When investments in health are aligned with technology at the right time, they can, as Federal Reserve Chairman Allan Greenspan suggests, “provide key insights into clinical best practices and substantially reduce administrative costs.” One of the key health infrastructure investments that has to be made is the electronic medical record (EMR). For too long Canada has lagged all major industrialized countries in adopting an EMR. A pan-Canadian EMR would deliver higher quality care, faster and at a higher value. An EMR would also allow Canada’s health care system to dramatically increase communication between jurisdictions. Communication and coordination of resources are keys to dealing with natural disasters such as Hurricane Katrina which devastated New Orleans. We need these investments sooner rather than later to avoid making the mistakes (e.g. in the case of SARS) as pointed out by the Naylor Report 4 . One of the key areas where the federal government can make a difference is the creation of a secure communications network linking up public health authorities and health providers across the country. According to Dr. Klaus Stöhr, project leader of the Global Pandemic Project at the World Health Organization, “Once a pandemic virus emerges, it is too late to begin planning or to begin collaboration.” 5 In spite of the imminent threat of a pandemic influenza, there are $34.3 millions in planned cuts to the Public Health Agency of Canada, over the next two years, as a result of program review. We need only look as far as New Orleans to see what an under-funded federal emergency preparedness system can reap. The loss of life in New Orleans was tragic and many agree unnecessary. In Canada we had SARS. Canada did squelch SARS and learned a lot about our capacities, yet we still have not lived up to the potential of being better prepared. Looking ahead, “In the event of a pandemic, the economic effects could be severe, affecting virtually all sectors and regions,” according to Dr. Sherry Cooper Chief Economist, BMO Nesbitt Burns. Dr. Cooper goes on to say that “Awareness is key to preparedness and proper surveillance, planning and preparation are essential to effective response and containment.” 6 Over the last several years, the CMA raised serious concerns about the ability of Canada’s public health system to respond to disasters and made a number of recommendations to address national preparedness in terms of security, health and capacity of the system. The CMA firmly believes that there remain significant shortcomings in our capacity to respond to health care emergencies. As we look to the future it is critical that the federal government make a stronger commitment to public health. Public health programming is too important to be sacrificed in the short-term expenditure review exercises. 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. Zero-rating the GST on physician practices would remove an unfair tax on health and allow for greater investment in technologies that would result in better care. Summary The CMA’s pre-budget submission has presented the facts on how investments in physical, human and entrepreneurial capital can enhance our health care system and, in turn, make our economy more productive. As our health care system efficiencies improve, the benefits not only accrue to health care workers, but also the ultimate dividend is better patient care and improved population health. Improvements in the quality of care, and especially speed of care, enable the Canadian labour force to increase its performance and fully reach its potential. These health care investments ultimately translate into a stronger, more competitive and more productive economy. CMA’s 10 point productivity plan (with estimated investment) Efficiency Recommendation #1: That Health Canada, in collaboration with Citizenship and Immigration Canada, provincial and territorial governments and Canada’s medical schools, provide funding for 600 postgraduate training positions to enable qualified international medical graduates who are Canadian citizens or landed immigrants to complete medical training requirements. Investment: $45 million per year for 3 years. [600 x $75k (approximate annual training cost per resident]. Recommendation #2: That Health Canada, in collaboration with Foreign Affairs Canada and provincial and territorial governments, carry out a direct ad 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 #3: That the Minister of Finance in collaboration with the Minister of Health allocate $1 billion over 5 years to a Health Human Resource Reinvestment Fund. This fund would be used to implement a needs-based, pan-Canadian, integrated health human resources plan based on the principle of self-sufficiency for Canada. Investment: $1 billion over 5 years. Recommendation #4: That Health Canada, in collaboration with the Department of Human Resources and Skills Development and the provincial and territorial governments, create the Canadian Coordinating Office for Health Human Resources to facilitate pan-Canadian planning of health human resource needs. Investment: $3 million per year. Equity Recommendation #5: That the Minister of Finance introduces legislation to amend the federal Excise Tax Act to zero-rate the Goods and Services Tax (GST) on physician practices. Investment: $84 million per year or 0.27 % of total $31.5 billion GST revenues in 2005/06. Recommendation #6 That the Minister of Finance in collaboration with the Minister of Health provide additional financial support to Canada Health Infoway, to realize the vision of a secure interoperable pan-Canadian electronic medical record, with a targeted investment toward physician office automation. Investment: $1.5 billion over 10 years. Recommendation #7: That the Department of Human Resources and Skills Development introduce changes to the Canada Student Loans Program to extend the interest free status on Canada student loans for medical residents pursuing postgraduate training. Investment: $5 million per year. Recommendation #8: That the Minister of Finance in collaboration with the Minister of Health 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 accelerating the pace of knowledge transfer. Investment: $600 million over 3 years. Effectiveness Recommendation #9: In order to ensure that adequate emergency preparedness and public health capacity is built at both federal and provincial levels, the federal government should provide sustained additional funding, to the Public Health Agency of Canada, and exempt it from expenditure review contributions. Investment: $684.3 million over 3 years (details in Appendix 1). Recommendation #10: That Health Canada and the Public Health Agency of Canada provide a one-time infusion of $100 million, to improve technical capacity to communicate with front-line public health providers in real-time during health emergencies. Investment: A one time investment of $ 100 million. The first wealth is health Canada, which at one time was the most attractive place on Earth to live, is falling behind. According to the Conference Board of Canada, Canada’s overall economic performance has fallen from 3rd best in the world, to 6th and now to 12th. One of the drivers of this precipitous fall is – according to the Conference Board’s analysis – the weakened state of our health care system. For example, our infant mortality rates are rising, not falling, in relative and absolute terms. We have tumbled from our top-five ranking in the 1980s — to where we are today; in the 22nd spot out of 27 OECD countries. That is why, now more than ever, Canada’s economy is in need of strategic federal direct investments in health care as part of an overall productivity enhancing package. According to the latest economic research, “There is now strong empirical evidence to suggest a two-way relationship: improved health significantly enhances economic productivity and growth. 7 ” The health care sector in Canada employs over a million people or 7.5% of the labour force. In 2004, Canada invested $130 billion in health care, representing 10% of our GDP. The benefits of the health care investments not only accrue to a higher quality of life for all Canadians, but the economic multiplier effect of the initial investment is estimated to create an additional $65 billion in economic activity. 8 I. Efficiency – providing tools to improve patient care and productivity A healthy and productive health workforce is the key to a well performing health care system and sets the foundation for a productive labour force. That is the ideal. However, there is a shortage of physicians across Canada. This shortage is creating a tremendous amount of pressure on the health care system. As demand for health care increases and the supply of health care workers is fixed, the pressure on these workers to do “more with less” is enormous. That is why Canadian physicians need the federal government’s support to have the tools and time to build on their productivity. Making human capital investments in physicians (value centres) Federal Health Minister Ujjal Dosanjh acknowledged the value of physicians in his speech to the Canadian Medical Association’s General Council this August 2005 by saying, “I want you to know that our government sees physicians … not as cost centres but as value centres”. It is in this spirit that we urge the government to invest in HHR. In order for the First Ministers Meeting (FMM) Agreement to be successful in improving access to care, governments must make the health workforce a major priority. In particular, the $1 billion in HHR funding in the Wait Times Reduction Fund should be made available immediately to address the crisis in health human resources rather than in the last 4 years of the 10-year agreement as currently projected. Given the current shortages in health human resources, action on HHR must begin now — not in 2010. Investing in physicians, or as Minister Dosanjh eloquently put, “value centres” will have real dividends for Canadians and the health care system. Accordingly, the CMA calls upon the federal government to play a key role in improving the availability of health human resources by developing a pan-Canadian HHR strategy that includes the involvement of health care providers. 9 For as Minister Dosanjh acknowledged, "It is clear to me that, if we are going to achieve the kind of solutions that have the support of Canadians, that our physicians must be engaged as active and valued partners.” The cost of under-investing in health human resources The pressures on human capital within the health care system are clear. Since the cutbacks in medical school admissions in the early 1990s, the gap between the growing demand for medical care and physician supply has widened. Canada’s ratio of 2.1 physicians per 1,000 population remains one of the lowest among the Organization for Economic Co-operation and Development (OECD) countries and below the OECD average of 2.9. With this ratio, Canada ranks 24th out of 30 OECD countries. In addition, as more doctors enter retirement age the shortage of physicians is becoming acute. The cost to patients — and their employers — is manifested in wait times, increasing difficulty to access primary care. In spite of these pressures Canada still does not educate enough doctors to replace those about to retire. The status quo threatens capital stock within the health sector, the general labour force, and even the world. “In the face of a global shortage of health care workers … can a country in which 24% of practicing doctors were educated outside its own borders continue to rely on physicians from countries that can least afford to lose them?” — Dr. Peter Barrett, CMA past president, August 2005 CMA annual meeting. Social and economic dividends of investing in HHR The CMA recommends that Canada’s long-term objective should be to increase enrolments in health disciplines to achieve greater self-sufficiency. The dividend of investing in HHR is a better, more efficient health care workforce who will deliver higher quality care in a timely manner. A well funded public health care system makes all Canadians healthier and more productive in their economic and social roles. In addition, becoming HHR self-sufficient also has the potential benefit of eventually exporting made-in-Canada health sector goods and services. But beyond re-stocking the pool of HHR for the future, attention also needs to be paid to the current stock of physicians. The issue of retention, or keeping physicians interested in working, is especially important now considering that a record number of physicians are about to retire. (i) Maximizing our existing health human capital — providing more training opportunities for international medical graduates As noted earlier, Canada ranks at the bottom among OECD countries in physicians per capita. As blunt an indicator as this may be the recent Supreme Court ruling in the Zeliotis case is a poignant reminder that there is an imbalance in the system between supply (HHR) and demand. We need more health care workers to protect, or save from burnout, the health care human capital investments that Canada has made already. We also need to ensure that Canada’s labour force — our macro human capital — has access to quality care without reasonable delays. Since it takes anywhere from 7 to 10 years to train a new physician, there are limits to how much can be done in the short term to address shortages. One short-term response would be to facilitate the training of qualified international medical graduates (IMGs) who are already in Canada. The CMA has welcomed the federal government’s recent investment of $75 million in the 2005 budget for the integration of internationally trained health workers, and notes that federal funding has already produced tangible results as some medical schools have increased the number of postgraduate training positions available to IMGs. However, there is an issue of clinical training capacity at Canada’s medical schools; consequently this initial investment is insufficient to provide training opportunities for over 600 IMGs and countless other qualified internationally trained health workers who are already in Canada. Accordingly, the CMA recommends that the federal government provide sufficient funding to provide additional training positions to train the existing supply of IMGs who would be eligible to begin a post-MD residency training immediately. The capacity to train these Canadian citizens or landed immigrants exists in Canadian medical schools. Currently, Canadian medical schools are providing postgraduate training opportunities to close to 900 visa trainees from abroad, largely from Persian Gulf countries. The federal government helps redeploy some of this capacity by offering medical schools, on a time-limited basis, to purchase some of these visa trainee positions to train IMGs that can then be deployed in Canada’s health care system. Such funding could also provide for the comprehensive assessments of IMGs that have been developed in several jurisdictions. The CMA also strongly supports the initiative of the Medical Council of Canada (MCC) in developing a pilot for the off-shore electronic administration of the MCC’s evaluation exams. Recommendation #1: That Health Canada, in collaboration with Citizenship and Immigration Canada, provincial and territorial governments and Canada’s medical schools, provide funding for 600 postgraduate training positions to enable qualified international medical graduates who are Canadian citizens or landed immigrants to complete medical training requirements. Investment: $45 million per year for 3 years. [600 x $75k (approximate annual training cost per resident]. (ii) Repatriating human capital - getting our Canadian physicians back home from the US Canada has been a net exporter of physicians to the United States for a generation. As government funding for health care fell in the 1990s exports of Canadian physicians to the US rose. Last year was the first year in which Canada gained more physicians than it sent to the US. There is a window of opportunity to repatriate Canadian physicians from the United States. The quality of Canadian life, competitive remuneration packages and a practice commitment that is characterized by greater physician autonomy are many of the chief drawing points for such a campaign. As the Canadian dollar approaches US $0.90 advertising in the US has also become much more affordable. Recommendation #2: That Health Canada, in collaboration with Foreign Affairs Canada and provincial and territorial governments, carry out a direct ad 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. (iii) Diligence on HHR As Canada’s population ages and as health care technology improves, demand for health care will increase. Health care in economic terms is a superior good: as the population’s standard of living improves, so does the demand for superior goods. But will this increased demand be met with an adequate supply of physicians to provide the kind of care Canadians need in a timely manner? Not likely, but we don’t know for sure because Canada does not currently have a way to assess the ability of our medical schools to meet these future needs across the country. An inadequate physician supply has important implications for human, physical and entrepreneurial capital in Canada’s economy. If the physician supply is not properly aligned with the demographic needs of the population the result is a loss (calculations vary and depend on the individual) in potential human capital as patients postpone treatment or wait too long for treatment. Investments in future physical capital investments may also be misallocated or not made at all if the proper health human resources are not in place. In addition, entrepreneurial capital may also very well flow to places where the optimal health human resources are in place. Why we need a Health Human Resources Reinvestment fund Canada lags behind other countries in the education and training of physicians. For example, as of 2002-2003 there were 12.2 first-year medical school places per 100,000 population in England compared with only 6.5 per 100,000 in Canada. It should be added that the United Kingdom has aggressively expanded medical enrolment since the late 1990s by opening 4 new medical schools and increasing medical school intake by some 2,300 places (60%) between 1997 and 2004. The CMA and other major national medical organizations have called on governments to increase medical school capacity to 3,000 first-year training positions per year in order to stabilize Canada’s physician supply. With recent increases in positions at a number of medical schools, current indications suggest that we have reached about 2,300 positions per year. However, given the growing demand for health services and changing patterns of medical practice, it is likely that medical school capacity will have to be increased much more significantly. For example, if Canada were to move today to cap working hours on physicians to 48 hours per week as the European Union has done, Canada would be short a whopping 12,780 physicians. Accordingly, as was done in the 1960s when the federal government introduced the Health Resources Fund, the CMA urges the federal government to create a Health Human Resource Reinvestment Fund in order to implement a needs-based, pan-Canadian, integrated health human resources plan based on the principle of self-sufficiency for Canada. Recommendation #3: That the Minister of Finance in collaboration with the Minister of Health allocate $1 billion over 5 years to a Health Human Resource Reinvestment Fund. This fund would be used to implement a needs-based, pan-Canadian, integrated health human resources plan based on the principle of self-sufficiency for Canada. Investment: $1 billion over 5 years. (iv) Creation of the Canadian Coordinating Office for Health Human Resources At a broader level, there is also a need for continued coordination of pan-Canadian HHR needs for today and the future. Governments are investing very large sums of funding in health care without having the benefit of a national long-term health human resources strategy. Since health human resources are increasingly mobile in the global economy, it is essential that Canada’s 14 provincial, territorial and federal health care systems devise a coordinated approach to training, recruiting and retaining health human resources. The Canadian Coordinating Office for Health Human Resources would be modeled along the same lines as the Canadian Coordinating Office for Health Technology Assessment (CCOHTA) created in 1989. Presently, there is no overall national coordinating body to assist provinces and territories in the planning of health human resources, particularly one that includes all pertinent stakeholders including physicians and other health care professionals. Building on previous federal investments in health sector studies across a number of health disciplines, the CMA urges the federal government to establish a Canadian Coordinating Office for Health Human Resources involving representation from health care professions — something both the Romanow and Senator Kirby reports recommended. Recommendation #4: That Health Canada, in collaboration with the Department of Human Resources and Skills Development and the provincial and territorial governments, create the Canadian Coordinating Office for Health Human Resources to facilitate pan-Canadian planning of health human resource needs. Investment: $3 million per year. II. Equity: improving health infrastructure and technology to provide better care (v) Freeing-up entrepreneurial capital and retaining physicians Why the GST should not apply to physician practices The CMA is calling on the federal government to remove an insidious tax on health by zero-rating (10 ) the GST on physician practices. 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. This is $1.1 billion that could have been invested in better technology to increase care and productivity. Re-investing the zero-rating of the GST for physician practices Zero-rating the GST would initially cost the federal government $84 million (11) or 0.27% of total GST revenues for 2005/06. However, as physicians across Canada re-invest the zero-rated GST tax back into their practices — and especially in their patients — there would be considerable dividend back to the federal government in terms of healthier Canadians and a more efficient economy. Zero-rating the GST for physician practices is about properly calibrating the tax system with the health care delivery system, in order to help meet our national health and economic goals. Dispelling the myth of a GST precedent Some bureaucrats and politicians believe that zero-rating the GST for physician practices may set a precedent. In fact, the precedent has already been set: significant elements of publicly-funded health care are already zero-rated or qualify for a rebate on GST. For example, prescription drugs, a significant and growing driver of total health care costs, have been zero-rated since 1996. Hospitals have benefited from an 83% rebate since the inception of the GST, and the 2005 budget extended the reach of this rebate to not-for-profit organizations delivering services that were previously delivered in the hospital setting. In addition to hospitals, rebates have been extended to other public and para-public sectors such as municipalities, universities and schools (the so-called “MUSH” sector). The 2004 federal budget confirmed that municipalities would be able to recover 100% of the GST and the federal component of the harmonized sales tax (HST) immediately. Recommendation #5: That the Minister of Finance introduces legislation to amend the federal Excise Tax Act to zero-rate the Goods and Services Tax (GST) on physician practices. Investment: $84 million per year or 0.27 % of total $31.5 billion GST revenues in 2005/06. (vi) Electronic Medical Record — increasing health and productivity In the words of Finance Minister Goodale, “Top-notch physical infrastructure is essential to a successful economy and a rising quality of life.” To be sure, Canada needs better highways, bridges and sewer systems. We need this basic infrastructure to enjoy a basic quality of life. But we want more than a basic life. To achieve a higher quality of life and to ensure international competitiveness, Canada needs to invest in the infrastructure of the 21st century, this is e-infrastructure. A pan-Canadian Electronic Medical Record (EMR) would deliver higher quality care, faster and at higher value. An EMR will save lives and improve efficiencies When investments in health are aligned with technology at the right time, they can as Federal Reserve Chairman Allan Greenspan suggest, “provide key insights into clinical best practices and substantially reduce administrative costs.” Health care delivery in Canada is a $130 billion industry. It represents more than 10% of our country’s gross domestic product. And it continues to grow. Yet we are managing the system with technology that would have been unacceptable to the banking industry even 20 years ago. Studies show (12) that the sooner we have a pan-Canadian EMR in place, the sooner the quality of health care will improve. For too long Canada has lagged all major industrialized countries in adopting an EMR (see Table 2). [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 2 Canada has fallen behind in EMR investments Percent of physicians using electronic records and prescriptions Country Records Prescriptions Britain 59% 87% New Zealand 52% 52% Australia 25% 44% United States 17% 9% Canada 14% 8% Harris Interactive Survey (2001) conducted for Harvard School of Public Health and the Commonwealth Fund's International Health Care Symposium. [TABLE END] An adequate health information infrastructure with pan-Canadian connectivity With an initial investment of $1.2 billion, Canada Health Infoway (CHI) has been working with provincial and territorial governments to put in place key components of a pan-Canadian health information infrastructure. While significant investments have been made in provincial and territorial health information systems, two key concerns have emerged. First, the $1.2 billion investment in CHI, while significant, is only 15% of the estimated cost of implementing a fully interoperable electronic medical record system in Canada. Second, CHI has made very limited progress in building a common, secure and interoperable platform - the backbone of a pan-Canadian system. Accordingly the CMA endorses the recommendations put forward by the Association of Canadian Academic Healthcare Organizations (ACAHO), the Canadian Nurses Association and the Canadian Healthcare Association to provide CHI with significant funding so that it may fulfill its core mission. Empowering investments in e-entrepreneurship for better health One of the gaps in the pan-Canadian EMR is the lack of attention paid to health information infrastructure on the front lines of health care delivery. While medical services across the country are largely publicly – funded, most physicians run their own practices. As entrepreneurs doctors take on the responsibility and risk of investing in new capital equipment from diagnostics to EMRs. Like any other business, doctors must calculate the return on investment for any capital equipment that they buy. In the case of the EMR, most of the return benefits the government, according to a Center for Information Technology Leadership in the United States 13 . A physical capital investment in an EMR improves care and deepens entrepreneurial capital By making all relevant patient information immediately available at the time of any encounter, and by providing equally rapid access to general medical information that assists in clinical decision-making, an EMR significantly enhances a clinician's ability to make good decisions, which will reduce medical errors and their associated costs. The timeliness of information also means that diagnoses are made more quickly, which significantly reduces the amount of time that patients need to spend using costly hospital beds or emergency room resources. Further cost reductions come from diminished duplication: all too often, time is lost and money is spent repeating diagnostic tests that were recently done but whose results are unavailable. Recovery of health information technology investments is almost immediate A Booz, Allan, Hamilton study on the Canadian health care system estimates that the benefits of an EMR could provide annual system-wide savings of $6.1 billion, due to a reduction in duplicate testing, transcription savings, fewer chart pulls and filing time, reduction in office supplies and reduced expenditures due to fewer adverse drug reactions. The study went on to state that the benefits to health care outcomes would equal or surpass these annual savings. Mobilizing physicians to operationalize a pan-Canadian EMR 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 CHI. The CMA is urging the federal government to allocate an additional investment of $1.5 billion to Canada Health Infoway. Criteria would be set for the fund that would restrict investment to automating physician offices through an agreement between the medical division and the appropriate province or territory. The $1.5 billion federal investment would be leveraged on the basis of a 75:25 sharing with physicians to generate $1.5 billion in physician office automation investment over the next 10 years. Specific modalities of disbursements of these funds would be set up by agreements with the provincial medical associations. CHI already has stringent financial controls and processes in place and can extend them to manage this program. Recommendation #6: That the Minister of Finance in collaboration with the Minister of Health provides additional financial support to Canada Health Infoway, to realize the vision of a secure interoperable pan-Canadian electronic medical record, with a targeted investment toward physician office automation. Investment: $1.5 billion over 10 years. (vii) Alleviating medical resident debt ? extend the interest relief on Canada student loans for medical residents Medical students are accumulating unprecedented levels of debt as tuition fees for medical school continue to sky rocket. The increase in debt influences the kind of practice young physicians pursue as well as where they practice. The Canadian Medical Association commends the federal government for its commitment to reduce the financial burden on students in health care professions as announced in the 2004 FMM Agreement and encourages it to act on this promise by extending the interest relief on Canada student loans for medical residents. Extending the interest relief on Canada student loans for medical residents would avoid distorting medical students’ career choices and encourage new graduates to stay in Canada. Deregulation of tuition => increased debt burden => drag on entrepreneurship It wasn’t always this way. The deregulation of medical school tuition fees in some provinces dramatically increased the debt burden of medical students. It is important to note that medical residents are in a unique situation not faced by other students who graduate from university programs. Once students graduate from medical school, they earn the right to be called physicians. However, they cannot practice until they complete a residency program. The program, which takes between 2-10 years to complete, certifies them as a specialist in a number of disciplines ranging from family medicine to radiology to rheumatology. During the compulsory residency program they must act as both student and employee. Table 1 includes the annual salary of medical residents and fellow hospital employees. Medical residents are not paid by the hour; otherwise their wages would be higher as there is no limit on the hours (80+) they work. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 1. Medical residents learn a lot but don’t earn a lot Resident stipend versus fully qualified health care employees Status, Ottawa, Ontario Annual Stipend or Fulltime Salary (as applicable) Minimum Postsecondary Education Requirement Minimum Related Experience Requirement Ontario Resident, PGY-1 (national average is $42,862) $ 44,230 7 + years 7+ years related clinical and other experience acquired through undergraduate medical education and pre-professional experiences, including clerkships, electives, etc. Locksmith/Door Mechanic, Ottawa Hospital $44,051 None. High school diploma required and a course or certificate in locksmithing 5-years relevant experience Supervisor of Housekeeping, Ottawa Hospital $ 41,165 - $48,000 2 years OR certified member of the OHHA CAHA, or related 3-years general supervisory experience [TABLE END] The Cost of under-investing in medical residents hits rural Canada hard As medical debt increases more physicians are choosing to go into some specialties (remunerated at a much higher rate) as opposed to family medicine. This has an impact on the accessibility, quality and overall cost of the health care system. Family practitioners are on the front-lines of medical care, and they treat and prevent millions of illnesses across Canada every year. The fall in demand for family practice in general, and rural family practice in particular, is now having a significant impact on health care and economic performance. The lack of a local family physician is often a determining factor in a company’s decision to make a direct investment in a community. For example, a multi-national company would likely not invest in a multi-billion dollar ski hill if there were no doctors available to treat ski related accidents. Improving access to medical education Canada’s future depends on ensuring that all Canadians have access to our medical schools. This sentiment was recently echoed by Finance Minister Ralph Goodale, “...but such skills are still confined to a minority of our population. We must do better. Canada’s future depends upon it.” Extending the interest-free status on Canada student loans would be an important signal to young Canadians from all socio-economic backgrounds that want to become a doctor. Drawing from a smaller portion of the population limits the experience and variety of community contact. Specific knowledge of a patient group allows a future physician adapt their care for that group. Thus, we should be graduating residents from all across the country from diverse socio-economic backgrounds. This is not unlike an entrepreneur who by tailoring services to a clients need that were previously unmet delivers better service and captures market share. Recommendation #7: That the Department of Human Resources and Skills Development introduce changes to the Canada Student Loans Program to extend the interest free status on Canada student loans for medical residents pursuing postgraduate training. Investment: $5 million per year. (viii) 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), a prominent and innovative feature of the CIHR mandate, has the potential to: * Significantly increase and accelerate the benefits flowing to Canadians from their investments in health research; and  * Establish Canada 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. For example, “Researchers (and research funders) should create more opportunities for interactions with the potential users of their research. They should consider such activities as part of the 'real' world of research, not a superfluous add-on.”(Lavis et al., 2001) 14 Recommendation #8: That the Minister of Finance in collaboration with the Minister of Health 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 accelerating the pace of knowledge transfer. Investment: $600 million over 3 years. III. Effective - an ounce of prevention is worth a pound of cure A little preparation before a crisis occurs is preferable to a lot of fixing up afterward. According to the World Health Organization and the Public Health Agency of Canada (PHAC) an influenza pandemic is inevitable. The consequences of not being adequately prepared will result in more lost lives and a multi-billion dollar hole in our economy, as was the experience in Toronto as a result of SARS in 2003. Looking ahead, PHAC estimates that the impact of pandemic influenza in Canada, if vaccines are not available, is between 11,000 and 58,000 deaths and economic costs of $5 to $38 billion. (ix) Protecting our capital infrastructure through emergency preparedness When SARS hit Canada in the spring of 2003 people got very sick and died. There was public confusion that quickly spilled into the economy. Internal and external trade in Canada was disrupted. According to the Conference Board of Canada the economic impact of the outbreak of SARS in the Greater Toronto Area equaled $1.5 billion. Investments in public health and emergency preparedness will allow the system to function more effectively and alleviate the impact of novel infectious diseases. We have expert advice how to do it – the Naylor Report. Reduce the economic burden of pandemics — close the Naylor Gap The National Advisory Committee on SARS and Public Health (the Naylor Report) estimated that approximately $1 billion in annual funding is required to implement and sustain the public health programming that Canada requires. Although representing an important reinvestment in this country’s public health system, the funding announced in the 2005 budget falls well short of this basic requirement. Dr. Jeffrey Koplan 15 , the past Director of the US Centers for Disease Control and Prevention laid out 7 areas for building capacity and preparedness within a public health system: 1. A well trained, well staffed public health workforce. 2. Laboratory capacity to produce timely and accurate results for diagnosis and investigation. 3. Epidemiology and surveillance to rapidly detect health threats. 4. Secure accessible information systems to help analyze and interpret health data. 5. Solid communication to ensure a secure two-way flow of information. 6. Effective policy evaluation capability. 7. A preparedness and response capability that includes a response plan and testing and maintaining a high state of preparedness. These points apply for both the day-to-day functioning of the public health system and its ability to respond to threats whether it is a new infectious disease, a natural disaster or a terrorist attack. Public health must be ready for all such threats. It is crucial, that the federal government build and maintain its stockpile of supplies for emergency use, its public health laboratories for early detection, its capacity to rapidly train and inform front-line health workers of emerging threats, its ability to assist the provinces and territories, and coordinate provincial responses in the event of overwhelming or multiple simultaneous threats. Vaccination is the most cost-effective health intervention available When a pandemic hits Canada vaccinations are a key component in reducing the impact. According to the Centers for Disease Control and Prevention (CDC) vaccination against childhood diseases is one of the most cost effective health interventions available. For example the measles-mumps-rubella vaccination saves $16.34 in direct medical costs for every dollar spent. The CMA urges the federal government to continue to support the National Immunization Strategy and the consistent availability of National Advisory Committee on Immunization recommended vaccines in all provinces and territories. A clear role for federal leadership – protecting our future The idea that public health is a federal responsibility “is based on the premise that public health matters - particularly emergencies - are so important that the federal government should simply use its powers for ”peace, order and good government” to unilaterally direct how public health matters should be addressed, and to ensure they are fully addressed.” 16 Consequently, the CMA recommends the enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation to allow for a more rapid national response in cooperation with the provinces and territories, based on a graduated systematic approach to emergencies that pose an acute an imminent threat to human health and safety across Canada. Regardless of how well prepared any municipality is, under certain circumstances public health officials will need to turn to the provincial, territorial or the federal government for help. The success of such a multi-jurisdictional approach is contingent upon good planning beforehand between the federal, provincial and territorial and local-level governments. There is an important role for the federal government to urgently improve the coordination among authorities and reduce the variability between various response plans in cooperation with provincial authorities. Public health investments take time 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. As the federal government examines ways of achieving efficiencies and cost savings in federal programs through the Cabinet Committee on Expenditure Review it is critical that the Public Health Agency of Canada be protected from any cuts. Recommendation #9: In order to ensure that adequate emergency preparedness and public health capacity is built at both federal and provincial levels, the federal government should provide sustained additional funding, to the Public Health Agency of Canada, and exempt it from expenditure review contributions. Investment: $684.3 million over 3 years (details in Appendix 1). (x) Investments in effective public health communication are crucial The effectiveness of the public health system is dependent, in large part, on its capacity to communicate authoritative information in a timely way. A two-way flow of information between public health experts and the practicing community is necessary at all times. It becomes essential during emergency situations. The rapid, effective, accessible and linked (REAL) health communication and coordination initiative improves the ability of the public health system to communicate in a rapid fashion by: * Providing a focal point for inter-jurisdictional communication and coordination to improve preparedness in times of emergency. * Developing a seamless communication system leveraging formal and informal networks. * Researching the best way to disseminate emergency information and health alerts to targeted health professionals and public health officials in a rapid, effective and accessible fashion. Recommendation #10: That Health Canada and the Public Health Agency of Canada provide a one-time infusion of $100 million, to improve technical capacity to communicate with front-line public health providers in real-time during health emergencies. A one time investment of $100 million. Conclusion — the economic impact of investments in health care The CMA’s pre-budget submission has presented the facts on how investments in physical, human and entrepreneurial capital can enhance our health care system and, in turn, make our economy more productive. Improvements in the quality of care, and especially speed of care, enable the Canadian labour increase their performance and reach their potential. The 2004 First Minister Health Accord is a positive step in renewing the federal government’s commitment to publicly funded health care, more needs to be done. Like the human body, that is always evolving, the health care system needs to be calibrated for optimal performance. Targeted investments in health human resources as well as health care infrastructure will result in an optimal allocation of resources, better health and a stronger economy. Appendix 1 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY]  CMA’s 10 point productivity plan    (in millions of dollars) 3-year 2006/07 2007/08 2008/09 Total   Efficiency i. Improving access -opening-up training positions for International Medical Graduates 45.0 45.0 45.0 135.0   ii. Repatriating our human capital -getting Canadian physicians home from the U.S. 10.0 0.0 0.0 10.0   iii. Health Human Resource Reinvestment Fund* 100.0 200.0 300.0 600.0   iv. Creating the Canadian Coordinating Office for Health Human Resources 3.0 3.1 3.2 9.3   Efficiency total 158.0 248.1 348.2 754.3   Equity v. Freeing-up entrepreneurial capital -zero-rating the GST on physician practices 84.0 86.1 88.3 258.4 vi. Investing in physical and human capital through physician office automation (CHI transfer)** 1,463.7 0.0 0.0 1,463.7   vii. Providing debt-relief to medical residents - an investment in human capital 5.0 5.1 5.3 15.4   viii. Making health research investments count -supporting knowledge transfer 100.0 200.0 300.0 600.0   Equity total 1,652.7 291.2 393.6 2,337.5   Effectiveness ix. Planning for the worst -pandemic preparation 25.0 25.0 25.0 75.0   Closing the Naylor Gap 75.0 150.0 250.0 475.0   Protection from expenditure review committee reductions*** 16.4 17.9 0.0 34.3   x. Ensuring effective public health communication 100.0 0.0 0.0 100.0   Effectiveness total 216.4 192.9 275.0 684.3   Total 2,027.1 732.2 1,016.8 3,776.1 * Note: additional 2 years of funding at $200 million per year. ** Note: the physician office automation financing plan is a 1-time transfer to Canada Health Infoway (CHI). CHI would deliver funding directly. Estimates are based on information from CHI (October 2005). *** Working Group on a Public Health Agency for Canada In Report: A Public Health Agency of Canada Ottawa: Public Health Agency of Canada; Apr 2004. Available: www.phac-aspc.gc.ca/rpp-2005-06/index.html#2b (accessed Oct 2005). [TABLE END] Appendix 2 10 year Costing of the Physician Automation [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [TABLE END] 1. There are approximately 60,000 licensed physicians in Canada. It is estimated that 20% already have an Electronic Medical Record (EMR) in their clinical office. Therefore this costing analysis is to support the other 48,000 physicians to automate their offices. 2. The cost to automate an office is based on the work carried out by the Alberta government and the Alberta Medical Association through the Physician Office Support Program (POSP).They have used a four year cost of $41,000 which covers capital, installation, training and operational costs over the four years. First year costs are $26,000 with $5,000 over the remaining three years. References 1 Ralph Waldo Emerson (1803–1882), essayist, poet, philosopher. “Power,” The Conduct of Life (1860). 2 According to the Royal Institute of International Affairs who also quote two Nobel Laureates in Economics. In, Health Expenditure and Investment Rather than a Cost? International Economics Program, Chatham House. 07/05. Available: www.chathamhouse.org.uk/index.php?id=189&pid=245 (accessed Oct 2005). 3 The additional economic activity generated by the health care sector is based on a conservative 1.5 multiplier. The CMA is pursuing precise estimates of the benefits of health care investments in Canada. 4 Learning from SARS - Renewal of Public Health in Canada A report of the National Advisory Committee on SARS and Public Health. Ottawa: Health Canada; Oct 2003. Available: www.phac-aspc.gc.ca/publicat/sars-sras/naylor/(accessed October 2005) 5 5 Cooper S. Don’t fear fear or panic panic an economist’s view of pandemic flu Toronto: BMO Nesbitt Burns; October 2005. Avalable www2.bmo.com/news/article/0,1257,contentCode-5047_divId-4_langId-1_navCode-112,00.html 6 ibid 7 According to the Royal Institute of International Affairs who also quote two Nobel Laureates in Economics. In, Health Expenditure and Investment Rather than a Cost? International Economics Program, Chatham House. 07/05. Available: www.chathamhouse.org.uk/index.php?id=189&pid=245 (accessed Oct 2005). 8 The additional economic activity generated by the health care sector is based on a conservative 1.5 multiplier. The CMA is currently pursuing precise economic multiplier estimates of the benefits of health care investments in Canada. 9 The CMA and the Canadian Nurse Association go into greater depth concerning the pressures on a strategy for HHR in, “Planning Framework for Health Human Resources. A Green Paper. June 2005 Available: www.cna-nurses.ca/CNA/documents/ pdf/publications/CMA_CNA_Green_Paper_e.pdf. 10 Zero-rated supplies refer to a limited number of goods and services that are taxable at the rate of 0%. This means there is no GST/HST charged on the supply of these goods and services, but GST/HST registrants can claim an input tax credit (ITC) for the GST/HST they pay or owe on purchases and expenses made to provide them. Available: www.cra-arc.gc.ca/tax/business/topics/gst/glossary-e.html (accessed September 2005) 11 An independent study by KPMG estimated that physicians have “overcontributed” in terms of unclaimed ITCs by approximately $57.2 million in 1992. In 2005, this comes to an inflation adjusted figure of $84 million. 12 Booz, Allan, Hamilton Study, Pan-Canadian Electronic Health Record, Canada’s Health Infoway’s 10-Year Investment Strategy, March 2005-09-06 13 The Center for Information Technology Leadership (www.citl.org) is non-profit research organization established in 2002 to guide the health care community in making more informed strategic IT investment decisions. 14 Lavis, J., Ross, S., Hurley, J., Hohenadel, J., Stoddart, G., Woodward, C., Abelson, J. Reflections on the Role of Health-Services Research in Public Policy-Making. Paper 01-06. 15 Koplan JP. Building Infrastructure to Protect the Public’s Health. Public Health Training Network Broadcast Available: www.phppo.cdc.gov/documents/KoplanASTHO.pdf (accessed Oct 2005). 16 Report: A Public Health Agency for Canada Building a Foundation for Intergovernmental Harmony and Cooperation Available: www.phac-aspc.gc.ca/publicat/phawg-aspgt-noseworthy/2_e.html (accessed Oct 2005)
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Study on Mental Health, Mental Illness and Addiction in Canada : Supplementary Submission to the Senate Standing Committee on Social Affairs, Science and Technology

https://policybase.cma.ca/en/permalink/policy1945
Last Reviewed
2013-03-02
Date
2005-10-11
Topics
Population health/ health equity/ public health
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2013-03-02
Date
2005-10-11
Topics
Population health/ health equity/ public health
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association, Canadian Paediatric Society, Canadian Psychiatric Association, Canadian Society of Addiction Medicine and College of Family Physicians of Canada are pleased to provide a joint supplementary submission to the Senate Standing Committee on Social Affairs, Science and Technology study on mental health, mental illness and addiction in Canada. This submission provides advice on the areas that we believe require the most immediate attention from the federal government over the short term, and that will have the most direct benefit for those affected by mental illness, poor mental health and addiction. The four areas are: 1. Federal Leadership &Capacity 2. Access Benchmarks and Surveillance Information 3. Best practices in mental illness, mental health and addiction 4. Human resource planning This submission also provides recommendations for specific “priority tasks” under each of these four general areas. 1. Federal Leadership & Capacity Federal leadership and capacity must be rapidly and significantly enhanced in order to address the existing deficiencies in the mental health system. This will signal and institutionalize a renewed commitment by the federal government and will ultimately provide support for Canadians impacted by mental illness, poor mental health and addictions. Federal capacity can be enhanced through one of 3 models: a unit in an existing federal department, a federal arm’s length agency, or a pan-Canadian arm’s length agency. Model 1: Unit within an existing federal department Under this option, a new Branch led by an assistant deputy minister (ADM) would be created within Health Canada to provide policy leadership and deliver federal programs and services in the area of mental health, mental illness and addiction. The ADM would have general authority for its management and direction, be answerable to the deputy minister, and work with all other federal departments and agencies to develop and coordinate policies, programs and services in this area. Model 2: Creation of a federal arm’s length Centre for Mental Illness, Mental Health and Addiction This option would entail the creation of a more independent organization within the purview of the federal government. The ‘Centre for Mental Illness, Mental Health and Addiction’ would be structured as a federal agency in which decision-making powers are vested in a Board of Directors with a CEO responsible for the daily operations. This Board would be representative of all relevant stakeholders including health providers, health researchers, governments and affected populations. The Centre would remain under the health portfolio, with accountability through the Minister of Health. The Centre’s main function would be to deliver federal programs and services, working closely with Health Canada, the Public Health Agency of Canada, Department of Justice and other organizations such as the Canadian Centre for Substance Abuse. While the Centre would provide advice, the responsibility for federal policy development with respect to mental illness and mental health would continue to reside within Health Canada. Model 3: Pan-Canadian arm’s length institute This option consists of incorporating an Institute as a not-for-profit entity with the federal and provincial governments as shareholders. This model has been used in other areas where federal-provincial collaboration is essential, such as the Canadian Institute for Health Information. As in the previous model, the Institute for Mental Illness, Mental Health and Addiction would have a board, and a CEO. However, instead of direct accountability to the Minister of Health, the institute would be accountable to the Conference of F-P-T Ministers of Health. It would be responsible for delivering pan-Canadian programs and services that are complementary to provincial and territorial mental health/illness programs and services. Policy development responsibilities for mental health, mental illness and addiction would continue to reside with federal and provincial/territorial governments. Each of the models outlined above has strengths and weakness. It is also possible that we could move from one model to another over time once the system is stabilized. However, for the short term, we contend that Model 1, a dedicated unit within Health Canada, would be the best fit with our objective of enhancing federal leadership and capacity to address mental illness, mental health and addiction issues. The strength of Model 1 is that by elevating responsibility for mental health /illness issues to the branch level it raises the profile and importance of these issues. This would reinstate and indeed increase the capacity that had existed within Health Canada but was lost through numerous reorganizations and resource reallocations. In addition intra-departmental and inter-departmental synergies can be maximized with this model. Should this model be chosen, it is important that the federal government demonstrate the kind of collaborative leadership that it has shown in the area of primary care through initiatives funded via the Primary Health Care Transition Fund. 1 The same leadership principles apply to reform of the mental health system in that while there are common problems and solutions across Canada there are also the needs of specific communities which must be addressed individually. Of immediate priority for this unit are initiatives to reduce stigma and to address the mental health needs of First Nations and Inuit Peoples. Stigma Reduction A stigma reduction strategy is an on-going function that must be core to the activities of the federal government. Stigma involves thoughts, emotions and behaviours, thus a comprehensive approach includes interventions to target each of these dimensions at both the individual and population level. The strategy should include aspects of: * Public awareness and education to facilitate understanding about the importance of early diagnosis, treatment, recovery and prevention; * Enhanced provider/student education and support; * Policy analysis and modification of discriminatory legislation; * Support for a strong voluntary sector to voice the concerns of patients and their families; * Exposure to positive spokespeople (e.g. prominent Canadians) who have mental illness and/or addiction in order to highlight success stories; * Researching stigma. The stigma associated with mental illness in children can hinder early identification and intervention and places them on a damaging path of suffering and pain. The effective treatment and community reintegration of people with mental illness and/or addiction will not only improve the lives of those directly affected but will also work to reduce stigma in the long term. First Nations and Inuit Peoples All people with mental illness and/or addiction have a right to programs and services that facilitate recovery and/or improve their quality of life. It is clear that the First Nations and Inuit peoples of Canada experience mental illness, addiction and poor mental health at rates exceeding that of other Canadians. Individual, community and population level factors contribute to this including socioeconomic status, social environment, child development, nutrition, maternal health, culture and access to health services. The urgent need to work with these communities, and identify the structures and interventions to reduce the burden of mental illness and addiction is critical to the health and wellness and future of First Nations and Inuit peoples. Enhanced federal capacity should be created through First Nations and Inuit Health that will provide increased funding and support for First Nations and Inuit community mental health strategies. The establishment of a First Nations and Inuit Mental Health Working Group that is comprised of First Nations and Inuit mental health experts and accountable to First Nations and Inuit leadership is essential for the success of this initiative. Both expert and resource supports are integral elements to facilitate and encourage culturally appropriate mental health strategies and programming in these communities. We believe that as a population, the First Nations and Inuit peoples should be the priority for the federal government in the provision of much need treatment and support. Priority tasks: A. Establish a Mental Health, Mental Illness and Addiction Branch at Health Canada. B. Implement a Stigma Reduction Strategy C. Improve the capacity of First Nations and Inuit peoples to address the mental health needs of their communities in a culturally appropriate manner. 2. Access Benchmarks and Surveillance Information Access to services, both public and private, currently acts as a barrier to treatment and recovery from mental illness, poor mental health and addiction. Promotion of collaborative care models along with better coordination of services would greatly improve the quality of care received. Governments must facilitate integration and access to these services. Recently, the Supreme Court decision in the case of Chaoulli and Zeliotis vs Quebec struck down two provisions in Quebec’s health insurance legislation that prohibit Quebec residents from purchasing private insurance for insured health services. This decision suggests that if Canadians wish to keep their “single-tier” system of universal, first dollar public coverage for health care, then governments must ensure that needed services are available to all Canadians at the time and to the extent of need, including mental health services. Governments must provide timely access to essential services within the public system in order to maximize potential for recovery and quality of life. With the support of the federal government, and on behalf of the medical community, we (CMA, CPA, CPS, CSAM, CFPC) can coordinate and implement a process to develop medically acceptable wait time benchmarks for access to mental illness and addiction care for children and adults. The outcome of this process would be to provide all governments with performance goals to strive for in providing timely access to mental illness and addiction services. With the establishment of benchmarks we will be able to measure how the system is performing. A basic mental illness surveillance system exists and the primary dissemination product is “A Report on Mental Illness in Canada”. However, there is agreement that the current information is limited for several reasons: * There is limited data in the system regarding mental health, addiction and many mental illnesses; * The quality of the data in the system has not been validated for many mental illnesses and addictions; * Not all data sources have been accessed for the surveillance system; * Since many supports and services for mental illness and addictions lie outside the formal health system, the collection of these data has not been possible with current constraints; * There is a need for a broader dissemination system. An expanded mental illness surveillance system should work closely with other chronic disease surveillance initiatives to ensure that indicators of common interest are obtained collaboratively and in an efficient manner. Priority Tasks: A. Federal government financially support the coordination and implementation of a process to develop wait time benchmarks for accessing mental illness and addiction services developed by the CMA, CPA, CPS, CSAM, CFPC. B. Creation of an enhanced mental illness surveillance system to produce: * Information about the prevalence and incidence of mental illnesses, addiction and risk factors at the national, provincial/territorial and regional level. * Progress on improving the availability and accessibility to services. * The availability and accessibility of community resources to support people with mental illness and addiction. * Progress on improving the availability and accessibility to community resources. * Information about the cost of mental illness, poor mental health and addiction to people with the conditions, their families and the health system. * Wait list information for mental health services. 3. Best practices in mental illness, mental health and addiction There are numerous interventions that are effective for various mental illnesses and addiction but ensuring optimal use of effective interventions in the real world has been a challenge. Several factors including lack of use by physicians, failure to prescribe or implement in the recommended manner, costs associated with treatment, and undesirable side effects limit the effectiveness of proven therapies for individual patients. A key element in our capacity to prevent and offer treatment for mental illness and addiction rests with the application of evidence or the promotion of best practices. Therefore we are proposing a pan-Canadian program that can facilitate knowledge exchange across disciplines to optimize outcomes for this population. We are aware that there is currently an initiative led by the Public Health Agency of Canada to establish a Consortium of Best Practices for Chronic Disease prevention. The goal of the Consortium is to create a Pan-Canadian forum for knowledge exchange between governments, researchers, non-governmental organizations and consumers. This initiative is a positive step and should be closely aligned with our proposed program for mental illness, mental health and addiction. The program we are proposing would go further than just prevention, to include treatment and policy alternatives, both within and outside the health domain. The program would serve to enhance best practice approaches through activities such as: * Development of a clearing house to hold evidence-based information for mental illness, mental health and addiction by searching, reviewing and summarizing the current literature and web resources; * Identification of gaps in knowledge, and gaps between evidence and practice; * Development of tools to promote best practices relating to mental illness, mental health and addiction, such as the Canadian Collaborative Mental Health Initiative Tool Kit. Priority Task: A. Establish a program to specifically promote inter-disciplinary best practices in prevention, treatment, community interventions and social supports across the continuum of research, policy, to support practice for evidence-based decision making in the area of mental health, mental illness and addiction. 4. Human resource planning Improving access to specialized and primary mental health diagnostic and treatment services with psychosocial community services that support early intervention, prevention of further disability, rehabilitation, improvement of quality of life and recovery should be considered a fundamental underlying goal of a pan-Canadian action plan. Several initiatives are currently under way in various parts of the country to enhance collaborative approaches to care among health care providers and to better integrate primary and secondary health care services. However, these efforts are taking place in a context of relative shortage of addiction specialists, psychiatrists, paediatricians, family physicians and other mental health care professionals. Family doctor and specialist shortages and changing practice patterns have created serious gaps in the availability of mental health services for many Canadians. Health human resource planning needs to consider and address functionally sub-specialized areas of practice as growing numbers of family doctors are moving into these areas, for example general practice psychotherapy and addiction medicine. Health human resource planning must also continue to ensure sustainability of current initiatives and continued access to care. Early interventions in general and with children specifically are critical to preventing long term disability and minimizing the devastating impact of mental illness. There are far too few mental health professionals to help children, insufficient resources allocated to support their mental health needs, and inadequate research being conducted to fill the gaps in knowledge which exist in this area. We believe that improving the mental health of Canada’s children, including strategies that increase the amount of health providers with expertise in this area must be a priority for the federal government. Priority Tasks: * Establish a pan-Canadian mental health human resource infrastructure responsible for collecting data, monitoring, conducting research, reporting, and making recommendations related to Canada’s ongoing mental health human resources needs, with a priority focus on children’s services, in order to ensure a sustainable supply of health human resources; * Introduce toolkits to assist health practitioners and consumers to implement best practices in collaborative care and develop new models of care in the area of mental health; * Support the evaluation of new models of care in achieving patient centred objectives and improving outcomes; * Increasing research capacity and resources in the area of children’s mental health. Conclusion: Again, our organizations, representing the medical community, appreciate the opportunity to submit to the Committee further elaboration on key initiatives to ensure federal leadership is taken. We want to thank the committee not only for seeking our advice but also for bringing national attention to issues related to mental illness, mental health and addiction. End Notes 1 The Primary Health Care Transition fund supported provinces and territories in their efforts to reform the primary health care system in addition to supporting various pan-Canadian initiatives to address common barriers. Although the Primary Health Care Transition Fund itself was time-limited, the changes which it supported were intended to have a lasting and sustainable impact on the health care system.
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Supply of Medical Isotopes : CMA's Presentation to the House of Commons Standing Committee on Health

https://policybase.cma.ca/en/permalink/policy9703
Date
2009-11-23
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2009-11-23
Topics
Health systems, system funding and performance
Text
It is my pleasure to address the committee as part of its monitoring of the situation related to the supply of medical isotopes. While I am not an expert in nuclear medicine, I do refer patients for diagnostic and treatment services that require the use of medical isotopes. First and foremost, I want to note that the CMA is proud of the efforts and dedication of health care providers from across the country who have stepped up to help meet patients' needs during this ongoing, stressful and demanding time. Through their concerted efforts, and those of the industry and governments, the system appears to be "coping." Patients are receiving needed diagnostic and treatment services, either through radiopharmaceutical models or their alternatives. However, there are reports of sporadic adverse events, as has been the case since the beginning of this situation. These include delays of 48-72 hours and suboptimal imaging due to the extensive use of thallium-201 rather than technetium-99m, which is in short supply. The CMA and representatives from the nuclear medical community continue to work with Health Canada to mitigate the impact of the shortage of medical isotopes. Scheduling appropriate care commensurate with the expected supply of isotopes has been aided by the efforts of Lantheus and Covidien, suppliers of generators and radiopharmaceuticals, who regularly share vital production information with the nuclear medical community. This has improved communications and allowed for the better predictability of supply than had been the case last May and June. Lest you interpret my comments to mean "all is well", let me be clear: Much is being done, but the current situation is neither optimal nor sustainable and there appears to be no long term plan. Canada's physicians are concerned about the toll the current shortage of isotopes is taking on the health care system as a whole. In particular, the resulting increased demand on resources - both human and financial - and especially now in the midst of a pandemic, is not sustainable. Therefore, we have called upon governments to invest in a five-year action plan, that includes an emergency fund, to increase the use of positron emission technology and the production of associated radiopharmaceuticals across Canada. At our annual meeting this August, Canada's physicians expressed their concerns by passing a series of motions calling for government action. This action included demands that the federal government: * retain Canada's leadership and ability to produce and export medical isotopes, and reconsider its decision to withdraw from their production; * appoint an international independent expert panel to assess thoroughly the decision to abandon the MAPLE I & II nuclear reactors at Chalk River: and * release promptly the conclusions and recommendations of the panel to the public. Our delegates also demanded that the federal government conduct open, meaningful and ongoing consultations with nuclear medicine physicians and their respective national associations on any and all federal decisions directly affecting the supply of medical isotopes. Concern was expressed that decisions have been, and will continue to be, made for political and financial expediency without taking into account medical ramifications of those decisions. We appreciated having the opportunity to participate in discussions with the Expert Review Panel on Medical Isotope appointed by the Minister of Natural Resources. While it is anticipated the panel will report to the Minister by the end of this month, we do not know when that report will be made public and how long it will take to move recommendations to action. Canadian physicians also urge the federal government to invest immediately in research in basic and clinical science to find viable alternative solutions to the production and use of technetium-99m. The announcement of $6 million for research into alternatives to medical isotopes through a partnership between the Canadian Institutes of Health Research (CIHR) and the Natural Sciences and Engineering Research Council of Canada (NSERC) is a good start. We must emphasize that bench to bedside research is critical - there must be a clinical translation of new technology to the provision of care. To conclude, the CMA remains concerned about health care providers' and the health care system's ability to sustain the current shortage; Canada's ability to ensure a long-term stable and predictable supply of medically necessary isotopes and our lack of contingency planning for the next shortage. The CMA will continue to work with all involved to ensure Canadians have access to the best possible care and treatment.
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11 records – page 1 of 2.