The CMA brief contains seven recommendations to address pressing needs in the health care system.
Before I get to those, I'd like to highlight why, from my perspective, our health care system is in need of the federal government's attention.
Yesterday, at the Ottawa Hospital, where I am Chief of Staff:
* Our occupancy was 100 per cent.
* 30 patients who came to the emergency department were admitted to the hospital, but we had beds for only four of them.
* 10 are still waiting on gurneys in examining rooms within the emergency department.
* Six patients were admitted to wards and are receiving care in hallways.
* Three surgeries were cancelled - bringing the number of cancellations this year to 480.
* But while all this was happening, we had 158 patients waiting for a bed in a long-term-care facility.
Equally, a few blocks from here and in communities across the country, the health status of our poorest and most vulnerable populations is comparable to countries that have a fraction of our GDP - despite very significant investments in their health.
This is just my perspective. Health care providers of all types experience the failings of our system on a daily basis.
We as a country can do better and Canadians deserve better value for their money.
Canada's physicians are calling for transformative change to build a health care system based on the principles of accessibility, high quality, cost effectiveness, accountability and sustainability.
Through new efficiencies, better integration and sound stewardship, governments can reposition health care as an economic driver, an agent of productivity and a competitive advantage for Canada in today's global marketplace.
The Health Accord expires in March 2014, and we strongly urge that the federal government begin discussions now with the provinces and territories on how to transform our health care system so that it meets patients' needs and is sustainable into the future.
Canadians themselves also need to be part of the conversation.
To help position the system for this transformative change, the CMA brief identifies a number of issues that the federal government should address in the short term:
First, our system needs investments in health human resources to retain and recruit more doctors and nurses.
Although we welcome measures in the last budget to increase the number of residency positions, we urge the government to fulfill the balance of its election promise by further investing in residencies, and to invest in programs to repatriate Canadian-trained physicians living abroad.
Second, we need to bolster our public health e-infrastructure so that it can provide efficient, quality care that responds more effectively to pandemics.
We recommend increased investment:
* to improve data collection and analysis between local public health authorities and primary care practices,
* for local health emergency preparedness, and
* for the creation of a pan-Canadian strategy for responding to potential health crises.
Third, issues related to our aging population also call for action.
As continuing care moves from hospitals into the home, the community, or long-term care facilities, the financial burden shifts from governments to individuals.
We recommend that the federal government study options for pre-funding long-term care - including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance - to help Canadians prepare for their future home care and long-term care needs.
And, as much of the burden of continuing care for seniors also falls on informal, unpaid caregivers, the CMA recommends that pilot studies be undertaken to explore tax credit and/or direct compensation for informal caregivers for their work, and to expand programs for informal caregivers that provide guaranteed access to respite services in emergency situations.
Finally, the government should increase RRSP limits and explore opportunities to provide pension vehicles for self-employed Canadians.
Mr. Chair, a fuller set of recommendations is contained in our report -- Health Care Transformation in Canada: Change that Works. Care that Lasts.
These include universal access to prescription drugs; greater use of health information technology; and the immediate construction of long-term care facilities.
We urge the Committee to consider both our short-term recommendations - and our longer term vision for transforming Canada's health care system.
I look forward to your questions. Thank you.
On behalf of the Canadian Medical Association (CMA), I am pleased to present you with our pre-budget submission for your government's consideration. The CMA appreciates the opportunity to provide input into this government's first budget and to identify strategic investment opportunities for the long term health of Canadians.
While Canada's health system faces many challenges, we believe that immediate action by the federal government in four key areas will offer both short term and long term benefits. They are:
(1) the establishment of a Canada Health Access Strategy to support a patient wait-times guarantee; (2) a proposed Visa position buyback program and a repatriation program to immediately address shortfalls in health human resources; (3) a strengthening of Canada's public health infrastructure; and (4) a remedy for GST-induced distortions in the health care system.We believe these proposals fit well with the government's stated priorities. While information on each of these recommendations is attached for your information and consideration, I would like to provide you with an overview of each.
1. CANADA HEALTH ACCESS STRATEGY
The CMA has been advocating for the implementation of maximum wait time thresholds or care guarantees for a number of years and is pleased that the government has included this as one of its top five priorities. As a first step, the CMA worked with six other specialty societies as part of the Wait Times Alliance (WTA) to develop a set of pan-Canadian wait-time benchmarks or performance goals released last August. We believe this work served as a catalyst for the provincial and territorial governments to move some way toward meeting their commitment in announcing pan-Canadian wait-time benchmarks last December. We must continue to work with governments and the academic community to improve access to medical care beyond the five priority health issues identified in the First Ministers' 2004 10-year health care plan.
The second step in implementing patient wait-time guarantees is the issue of honouring the commitment and providing for patient recourse. As a member of the WTA, the CMA strongly supports accelerating the timetable to reduce wait times nationwide. However, the federal government needs to do its part to assist provinces in advancing the timetable by stepping up the flow of funds earmarked for the last four years of the accord. Our proposed Canada Health Access Strategy is comprised of three components directed at making this happen: supporting provinces to expand capacity and to handle surges in demand; supporting the creation of regional and/or national referral networks; and establishing a Canada Health Access Fund for a "safety valve" to help Canadians access care elsewhere when necessary. Details on how this Strategy would work are attached. The point is that this Strategy is necessary to assure Canadians that they get the care they need when they need it.
1. The federal government advance the remaining $1 billion from the 2004 First Ministers Accord that was originally intended to augment the Wait Times Reduction Fund (2010-2014) to support a Canada Health Access Strategy by:
(a) expanding provincial surge capacity : $500 million to be flowed immediately to provinces on a per capita basis in return for agreement to accelerate the timetable for bringing down wait times, as was promised in the recent federal election campaign;
(b) improving national coordination of wait time management: $250 million to support creation of regional and/or national referral networks, a more coordinated approach to health human resource planning, expansion of information technology solutions to wait time management and facilitation of out-of-country referrals; and
(c) establishing a Canada Health Access Fund: $250 million initial investment in an alternative patient recourse system or "safety valve" when and if clinically-indicated maximum wait time benchmarks as agreed to by provinces/territories last December are exceeded.
Addressing Shortfalls in Health Human Resources
As identified by Minister Clement in a recent speech at the "Taming of the Queue III" wait-time conference, addressing shortages in health human resources is a key element of any strategy for reducing lengthy wait-times. Unfortunately, we face serious physician shortages, starting with family physicians. The bad news is that it can take several years to educate and train the necessary professionals. The good news is that there are some strategies that can be undertaken to address the situation in the short term.
2. VISA POSITION BUYBACK FUND
One such strategy is our Visa Position Buyback proposal that would eliminate the backlog of 1,200 qualified international medical graduates (IMGs) over the next five to seven years. Currently, these qualified IMGs, who are either Canadian citizens or landed immigrants, are unable to access the necessary residency training. One existing source for training capacity exists with the positions purchased by foreign governments for visa trainees. We estimate that there are over 900 current visa trainees at all rank levels. By implementing the Visa Position Buyback program, the government is able to take an immediate step that will produce tangible results as soon as a two to four years from now. This initiative would be part of a longer term plan to fully address the shortages in health human resources and help the government meet its commitment to implement a properly functioning patient wait-time guarantee.
2a. The federal government allocate $381.6 million toward the training of up to 1,200 IMGs through to practice over the 2007/08 to 2015/16 period. Funding would be made available in two installments: an immediate investment of $240 million and the remaining $140 million subject to a satisfactory progress report at the end of five years.
Repatriate Health Professionals Working in the United States
Fortunately, another short-term source of health professionals exists that Canada should pursue. Thousands of health care professionals are currently working in the United States including approximately 9,000 Canadian trained physicians. We know that many of the physicians who do come back to Canada are of relatively young age meaning that they have significant practice life left. While a minority of these physicians do come back on their own, many more can be repatriated in the short-term through a relatively small but focussed effort by the federal government led by a secretariat within Health Canada.
2b. The federal government should establish a secretariat within Health Canada that would provide funding to national professional associations to conduct targeted campaigns to encourage the repatriation of Canadian health professionals working in the United States, and act as a clearinghouse on issues associated with returning to Canada (e.g., citizenship, taxation, etc.).
3. PUBLIC HEALTH INFRASTRUCTURE RENEWAL
The CMA remains concerned about the state of Canada's public health system. Public health, including the professionals providing public health services, constitutes our front line against a wide range of threats to the health of Canadians. While there is much talk about the arrival of possible pandemics, Canada's public health system must be ready to take on a broad range of public health issues.
The CMA has been supportive of the Naylor report which provides a blue print for action and reinvestment in the public health system for the 21st century. While this will take several years to achieve, there are some immediate steps that can be taken which will lessen the burden of disease on Canadians and our health care system. These steps include establishing a Public Health Partnership Program with provincial and territorial governments to build capacity at the local level and to advance pandemic planning. In addition, we call on the government to continue its funding of immunization programs under its National Immunization Strategy.
3a. The federal government should establish a Public Health Infrastructure Renewal Fund in the amount of $350 million annually to establish a Public Health Partnership Program with the provincial/territorial governments for the purposes of building capacity at the local level and advancing pandemic planning. In addition, the $100 million per year for immunization programs under the National Immunization Strategy should be continued.
4. A REMEDY FOR GST-RELATED DISTORTIONS IN THE HEALTH SYSTEM
The CMA and many other national health organizations are concerned about the increasing, unintended and negative consequences the GST is having on health care. For example, the 83% rebate originally provided for under the so-called "MUSH" formula is no longer tax neutral and is acting as a deterrent in some cases toward increased use of ambulatory care services such as day surgeries. Over the past 15 years the physicians of Canada have faced a large and growing unfair tax burden due to the GST. Since physicians' services are tax exempt under the law, physicians are unable to either claim input tax credits or pass on the tax because of the prohibition under the Canada Health Act of billing patients directly. This puts physicians in a unique and patently unfair catch 22 that now amounts to over $65 million per year, which further acts as a deterrent to repatriating or retaining Canadian physicians.
4a. That the federal government, in the course of reducing the GST from 7% to 5% further to its campaign commitments, remove the large and growing deterrent effects of the GST on the efficient and effective delivery of health care in Canada.
In summary, the CMA is providing you with recommendations on strategic investments to help your government honour its commitment to timely access to care and to improve the health of Canadians. Our recommendations are financially reasonable, making good use of Canadians' tax dollars.
We look forward to meeting with you on April 19 to discuss our proposals with you.
Ruth L. Collins-Nakai, MD, MBA, FRCPC, MACC
c.c. The Honourable Tony Clement, Health Minister
Good afternoon. As was said in my introduction, my name is Anne Doig and like the chair, I am a family physician. I practice as a "full service" family physician, which means that I provide care in hospital as well as in my office, including obstetrical services. I have practiced in Saskatoon for almost 32 years.
It is my pleasure to be here today. As President of the Canadian Medical Association, I represent all physicians, but today, I am proud to represent women participating in what is now a traditional occupation for them, that is, medicine.
Joining me today is Dr. Mamta Gautam, a specialist and champion of physician health and well-being. For 20 years, she worked as a psychiatrist treating physicians exclusively in her private practice in Ottawa, and has been hailed as "the Doctor's Doctor."
The Association of Universities and Colleges of Canada has reported full-time university enrolment increased by more than 190,000, or 31%, between 2000 and 2006 and now stands at record levels.
Full-time male enrolment has passed 350,000 students and full-time female enrolment has passed 460,000.
Women account for two-thirds of full-time enrolment growth since 1971, a surge driven by the rapid increase in women's participation in the professions, including medicine.
As it stands now, the males outnumber females among practicing physicians by 67%-33%. While there are still more men than women in practice, the percentage of female first-year residents in 2008 was 57%. This is a reversal of the percentage when I graduated, and an increase from 44% fifteen years ago. This means that a significant majority of physicians close to the beginning of their medical careers, are women.
Not surprisingly, given those figures, there are many medical disciplines where the proportion of females is much higher than it was even just a few years ago.
For instance, in general surgery - long held to be a bastion of male physicians - females comprised 18% of the 1993 first year residents compared to 40% in 2008. Just over half of first-year family medicine residents in 1993 were female compared to 64% today.
However, women medical graduates still tend to choose to pursue residency training in family medicine, pediatrics, and obstetrics/gynecology in greater proportions than their male counterparts. As has always been the case, males continue to have a stronger preference for surgery - 23% compared to 11% of females - although that gap is narrowing.
So, the overall numbers of women physicians are increasing as are the percentages of those going into what one might call non-traditional specialties, albeit at a slower rate.
The so-called feminization of medicine brings with it several other issues and I will touch on two major ones.
First, work-life balance.
The rise in the number of women physicians is bringing a positive shift in the way physicians practice and the hours that they keep.
Very few of today's young physicians - male or female - are willing to work the long hours that physicians of previous generations did.
That said, data from the 2007 National Physician Survey, which included responses from over 18,000 physicians across the country, show that, on average, male doctors still work nearly 54 hours per week, while female doctors work 48 - although many work more than that. These figures do not include time on call, nor time spent on child care or other family responsibilities. Many members of the Committee can empathize with this level of commitment.
In contrast, the European Union Work Time Directive has said that the maximum work week must be 48 hours. If Canada were to try to apply that directive to physicians our health care system would grind to a halt.
The number of physicians opting to be paid by a means other than pure fee-for-service has dramatically increased. FFS rewards the doctor financially for seeing more patients. Female physicians typically spend more time in each patient encounter, a trait that is valued by patients but not rewarded by FFS remuneration.
The second issue is stress.
In spite of their increasing numbers, women in medicine still report higher rates of incidents of intimidation, sexual harassment and abuse than their male colleagues.
As well, many female physicians continue to assume primary responsibility for home and family commitments in addition to their practice workload, thus compounding their stress levels.
Female physicians are more likely to work flexible hours; flexibility in work schedules has been the method by which female physicians balance their professional and personal lives. Yet, as they take on more and strive to be more flexible that in itself creates more stress as they battle to be "all things to all people".
The CMA identified the need to address and mitigate the unique demands on women physicians in its 1998 policy on Physician Health and Well-Being. I have brought copies to be shared with you today.
As I mentioned at the start, I am joined today by Dr. Gautam who has considerable expertise in the stressors faced by physicians - and women physicians in particular - and in managing them.
We will be happy to discuss the participation of women in medicine and to answer questions that you may have.