Skip header and navigation
CMA PolicyBase

Policies that advocate for the medical profession and Canadians


15 records – page 1 of 2.

Disability Tax Credit Program : CMA Submission to the Sub-Committee on the Status of Persons with Disabilities (House of Commons)

https://policybase.cma.ca/en/permalink/policy1972
Last Reviewed
2020-02-29
Date
2002-01-29
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2002-01-29
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) welcomes the opportunity to appear before the Sub-Committee on the Status of Persons with Disabilities to discuss issues related to the Disability Tax Credit (DTC). This tax measure, which is recognition by the federal government that persons with a severe disability may be affected by having reduced incomes, increased expenses or both, compared to those who are not disabled i, helps to account for the intangible costs associated with a severe and prolonged impairment. It also takes into account disability-related expenses that are not listed in the medical expense deduction or which are excluded by the 3% threshold in the Medical Expense Tax Credit. Physicians are a key point of contact for applicants of the DTC and, given the way the program is structured, a vital participant in its administration. It is for these reasons that we come before you today to address specific concerns related to the program’s performance. In addition, we would like to discuss the broader issue of developing a coherent set of tax policies in support of health and social policy. The Integration of Tax Policy with Health Policy and Social Policy The federal government, through a variety of policy levers such as taxation, spending, regulation and information, has played a key role in the development of our health care and social systems. To date however, discussion about the federal role in these areas has centered largely on federal transfers to the provinces and territories and the Canada Health Act. However, in looking at how to renew Canada’s health and social programs, we should not limit ourselves to these traditional instruments. Today we have a health system that is facing a number of pressures that will challenge its sustainability. These pressures range from an aging and more demanding population in terms of the specialty care services and technology they will seek; the cry for expanding the scope of medicare coverage to include homecare and pharmacare; and a shortage of health personnel. These are only some of the more immediate reasons alternative avenues of funding health care, and thus ensuring the health and well-being of our citizens, must be explored. In our pre-budget consultation document to the Standing Committee on Finance ii, the CMA recommended that the federal government establish a blue ribbon National Task Force to study the development of innovative tax-based mechanisms to synchronize tax policy with health policy. Such a review has not been undertaken in over 25 years since the Royal Commission on Taxation in 1966 (Carter Commission). The CMA is echoing its call for a National Task Force to develop new and innovative ways to synchronize tax policy with health policy and social policy. A study of this nature would look at all aspects of the taxation system, including the personal income tax system, in which the DTC is a component. The remainder of our brief addresses issues specific to the DTC. Physician Involvement in the DTC Program The CMA has in the past provided input with respect to the DTC program. Our working relationship on the DTC program with the Canada Customs and Revenue Agency (CCRA) has been issue-specific, time-limited and constructive. Our first substantive contact in regard to the DTC program was in 1993 when the CMA provided Revenue Canada with a brief review of the program and the T2201form. It is interesting to note what our observations were in 1993 with regard to this program because many of them still hold true today. Here are just some of the issues raised by the CMA in 1993 during our initial review of the program: * The tax credit program may not address the needs of the disabled, it is too hit and miss. The DTC program should be evaluated in a comprehensive way to measure its overall effectiveness in meeting the needs of persons with disabilities. * The program should be called the “Severe Disability Tax Credit Program” – or something equivalent to indicate that not everyone with a disability is eligible. * The program puts physicians in a potential conflict with patients—the responsibility of the physician to advocate for the patient vs. gate-keeper need for Revenue Canada. The physician role should be to attest to legitimate claims on the patients’ behalf. * Revenue Canada should clarify the multiplicity of programs. There are numerous different federal programs and all appear to have varying processes and forms. These overlapping efforts are difficult for patients and professionals. * A major education effort for potential claimants, tax advisers and physicians should be introduced. * A suitable evaluation of claimant and medical components of the process should be undertaken. The CMA does not have a standardized consultative relationship with the CCRA in regard to this program. An example of this spotty relationship is the recent letter sent by the CCRA Minister asking current DTC recipients to re-qualify for the credit. The CMA was not advised or consulted about this letter. If we had been advised we would have highlighted the financial and time implications of sending 75 to 100 thousand individuals to their family physician for re-certification. We also would have worked with the CCRA on alternative options for updating DTC records. Unfortunately, we cannot change what has happened, but we can learn from it. This clearly speaks to the need to establish open and ongoing dialogue between our two organizations. Policy Measure: The CMA would like established a senior level advisory group to continually monitor and appraise the performance of the DTC program to ensure it is meeting its stated purpose and objectives. Representation on this advisory group would include, at a minimum, senior program officials preferably at the ADM level; those professional groups qualified to complete the T2201 Certificate; various disability organizations; and patients’ advocacy groups. We would now like to draw the Sub-committee’s attention to three areas that, at present, negatively impact on the medical profession participation in the program, namely program integrity, program standardization (e.g., consistency in terminology and out-of-pocket costs faced by persons with disabilities) and tax advisor referrals to health care providers. Program Integrity A primary concern and irritation for physicians working with this program is that it puts an undue strain on the patient-physician relationship. This strain may also have another possible side effect, a failure in the integrity of the DTC program process. Under the current structure of the DTC program, physicians evaluate the patient, provide this evaluation back to the patient and then ask the patient for remuneration. This process is problematic for two reasons. First, since the patient will receive the form back immediately following the evaluation, physicians might receive the blame for denying their patient the tax credit—not the DTC program adjudicators. Second, physicians do not feel comfortable asking for payment when he or she knows the applicant will not qualify for the tax credit. For the integrity of the DTC program, physicians need to be free to reach independent assessment of the patient’s condition. However, due to the pressure placed by this program on the patient-physician relationship, the physician’s moral and legal obligation to provide an objective assessment may conflict with the physician’s ethical duty to “Consider first the well-being of the patient. There is a solution to this problem it’s a model already in use by government, the Canadian Pension Plan (CPP) Disability Program. Under the CPP Disability Program, the evaluation from the physician is not given to the patient but, it is sent to the government and the cost to have the eligibility form completed by a physician is subsumed under the program itself. Under this system, the integrity of patient-physician relationship is maintained and the integrity of the program is not compromised. Policy Measure: The CMA recommends that the CCRA take the necessary steps to separate the evaluation process from the determination process. The CMA recommends the CPP Disability Program model to achieve this result. Fairness and Equity The federal government has several programs for people with disabilities. Some deal with income security (e.g., Canada Pension Plan Disability Benefits), some with employment issues (e.g., Employability Assistance for People with Disabilities), and some through tax measures (e.g., Disability Tax Credit). These government transfers and tax benefits help to provide the means for persons with disabilities to become active members in Canadian society. However, these programs are not consistent in terms of their terminology, eligibility criteria, reimbursement protocols, benefits, etc. CMA recommends that standards of fairness and equity be applied across federal disability benefit programs, particularly in two areas: the definition of the concept of “disability”, and standards for remuneration to the physician. These are discussed in greater detail below. 1) Defining “disability” One of the problems with assessing disability is that the concept itself is difficult to define. In most standard definitions the word “disability” is defined in very general and subjective terms. One widely used definition comes from the World Health Organization’s International Classification of Impairments, Disabilities and Handicaps (ICIDH) which defines disability as “any restriction or inability (resulting from an impairment) to perform an activity in the manner or within the range considered normal for a human being.” The DTC and other disability program application forms do not use a standard definition of “disability”. In addition to the inconsistency in terminology, the criteria for qualification for these programs differ because they are targeted to meet the different needs of those persons with disabilities. To qualify for DTC, a disability must be “prolonged” (over a period of at least 12 months) and “severe” i.e. “markedly (restrict) any of the basic activities of daily living” which are defined. Though CPP criteria use the same words “severe” and “prolonged” they are defined differently (i.e., “severe” means “prevents applicant from working regularly at any job” and “prolonged” means “long term or may result in death”). Other programs, such as the Veterans Affairs Canada, have entirely different criteria. This is confusing for physicians, patients and others (e.g., tax preparers/advisors) involved in the application process. This can lead to physicians spending more time than is necessary completing the form because of the need to verify terms. As a result if the terms, criteria and the information about the programs are not as clear as possible this could result in errors on the part of physicians when completing the forms. This could then inadvertently disadvantage those who, in fact, qualify for benefits. Policy Measures: The CMA would like to see some consistency in definitions across the various government programs. This does not mean that eligibility criteria must become uniform. In addition, the CMA would like to see the development of a comprehensive information package for health care providers that provides a description of each program, its eligibility criteria, the full range of benefits available, copies of sample forms, physical assessment and form completion payment information, etc. 2) Remuneration The remuneration for assessment and form completion is another area where standardization among the various government programs would eliminate the difficulties that some individuals with disabilities currently face. For example, applicants who present the DTC Certificate Form T2201 to their physicians must bear any costs associated with its completion out of their own pockets. On the other hand, if an individual is applying to the CPP Disability Program, the cost to have the eligibility form completed by a physician is subsumed under the program itself. Assessing a patient’s disabilities is a complex and time-consuming endeavour on the part of any health professional. Our members tell us that the DTC Certificate Form T2201 can take as much time and effort to complete as the information requested for CPP Disability Program forms depending, of course, on the patient and the nature of the disability. In spite of this fact, some programs acknowledge the time and expertise needed to conduct a proper assessment while other programs do not. Although physicians have the option of approaching the applicant for remuneration for the completion of the DTC form, they are reluctant to do so because these individuals are usually of limited means and in very complex cases, the cost for a physician’s time for completing the DTC Form T2201 can reach as much as $150. In addition, physicians do not feel comfortable asking for payment when he/she knows the applicant will not qualify for the tax credit. Synchronizing funding between all programs would be of substantial benefit to all persons with disabilities, those professionals completing the forms and the programs’ administrators. Policy Measure: We strongly urge the federal government to place disability tax credit programs on the same footing when it comes to reimbursement of the examining health care provider. Tax Advisor Referrals With the complexity of the income tax system today, many individuals seek out the assistance of professional tax advisors to ensure the forms are properly completed and they have received all the benefits they are entitled to. Tax advisors will very often refer individuals to health professionals so that they can be assessed for potential eligibility for the DTC. The intention of the tax advisors may be laudable, but often, inappropriate referrals are made to health professionals. This not only wastes the valuable time of health care professionals, already in short supply, but may create unrealistic expectations on the part of the patient seeking the tax credit. The first principle of the CMA’s Code of Ethics is “consider first the well-being of the patient.” One of the key roles of the physician is to act as a patient’s advocate and support within the health care system. The DTC application form makes the physician a mediator between the patient and a third party with whom the patient is applying for financial support. This “policing” role can place a strain on the physician-patient relationship – particularly if the patient is denied a disability tax credit as a result a third-party adjudicator’s interpretation of the physician’s recommendations contained within the medical report. Physicians and other health professionals are not only left with having to tell the patient that they are not eligible but in addition advising the patient that there may be a personal financial cost for the physician providing this assessment. Policy Measure: Better preparation of tax advisors would be a benefit to both patients and their health care providers. The CMA would like CCRA to develop, in co-operation with the community of health care providers, a detailed guide for tax preparers and their clients outlining program eligibility criteria and preliminary steps towards undertaking a personal assessment of disability. This would provide some guidance as to whether it is worth the time, effort and expense to see a health professional for a professional assessment. As raised in a previous meeting with CCRA, the CMA is once again making available a physician representative to accompany DTC representatives when they meet the various tax preparation agencies, prior to each tax season, to review the detailed guide on program eligibility criteria and initial assessment, and to highlight the implications of inappropriate referral. Conclusion The DTC is a deserving benefit to those Canadians living with a disability. However, there needs to be some standardization among the various programs to ensure that they are effective and meet their stated purpose. Namely, the CMA would like to make the following suggestions: 1. The CMA would like established a senior level advisory group to continually monitor and appraise the performance of the DTC program to ensure it is meeting its stated purpose and objectives. Representation on this advisory group would include, at a minimum, senior program officials preferably at the ADM level; those professional groups qualified to complete the T2201 Certificate; various disability organizations; and patient advocacy groups. 2. The CMA recommends that the CCRA take the necessary steps to separate the evaluation process from the determination process. The CMA recommends the CPP Disability Program model to achieve this result. 3. That there be some consistency in definitions across the various government programs. This does not circumvent differences in eligibility criteria. 4. That a comprehensive information package be developed, for health care providers, that provides a description of each program, its eligibility criteria, the full range of benefits available, copies of sample forms, physical assessment and form completion payment information, etc. 5. That the federal government applies these social programs on the same footing when it comes to their funding and administration. 6. That CCRA develop, in co-operation with the community of health care providers, a detailed guide for tax advisors and their clients outlining program eligibility criteria and preliminary steps towards undertaking a personal assessment of disability. 7. That CCRA employ health care providers to accompany CCRA representatives when they meet the various tax preparation agencies to review the detailed guide on program eligibility criteria and personal assessment of disability, and to highlight the implications of inappropriate referral. These recommendations would certainly be helpful to all involved - the patient, health care providers and the programs’ administrators, in the short term. However what would be truly beneficial in the longer term would be an overall review of the taxation system from a health care perspective. This could provide tangible benefits not only for persons with disabilities but for all Canadians as well as demonstrating the federal government’s leadership towards ensuring the health and well being of our population. i Health Canada, The Role for the Tax System in Advancing the Health Agenda, Applied Research and Analysis Directorate, Analysis and Connectivity Branch, September 21, 2001 ii Canadian Medical Association, Securing Our Future… Balancing Urgent Health Care Needs of Today With The Important Challenges of Tomorrow”, Presentation to the Standing Committee on Finance Pre-Budget Consultations, November 1, 2001.
Documents
Less detail

Federal tax proposal risks negative consequences for health care delivery

https://policybase.cma.ca/en/permalink/policy11960
Date
2016-11-18
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Date
2016-11-18
Topics
Physician practice/ compensation/ forms
Text
The CMA is the national voice of Canadian physicians. On behalf of its more than 83,000 members and the Canadian public, the CMA’s mission is helping physicians care for patients. In fulfillment of this mission, the CMA’s role is focused on national, pan-Canadian health advocacy and policy priorities. As detailed in this brief, the CMA is gravely concerned that by capturing group medical structures in the application of Section 44 of Bill C-29, the federal government will inadvertently negatively affect medical research, medical training and education as well as access to care. To ensure that the unintended consequences of this federal tax policy change do not occur, the CMA is strongly recommending that the federal government exempt group medical and health care delivery from the proposed changes to s.125 of the Income Tax Act regarding multiplication of access to the small business deduction in Section 44 of Bill C-29. Relevance of the Canadian Controlled Private Corporation Framework to Medical Practice Canada’s physicians are highly skilled professionals, providing an important public service and making a significant contribution to our country’s knowledge economy. Due to the design of Canada’s health care system, a large majority of physicians – more than 90% – are self-employed professionals and effectively small business owners. As self-employed small business owners, physicians typically do not have access to pensions or health benefits, although they are responsible for these benefits for their employees. Access to the Canadian-Controlled Private Corporation (CCPC) framework and the Small Business Deduction (SBD) are integral to managing a medical practice in Canada. It is imperative to recognize that physicians cannot pass on any increased costs, such as changes to CCPC framework and access to the SBD, onto patients, as other businesses would do with clients. In light of the unique business perspectives of medical practice, the CMA strongly welcomed the Finance Committee’s recommendation to maintain the existing small business framework and the subsequent federal recognition in the 2016 budget of the value that health care professionals deliver to communities across Canada as small business operators. Contrary to this recognition, the 2016 budget also introduced a proposal to alter eligibility to the small business deduction that will impact physicians incorporated in group medical structures. What’s at risk: Contribution of group medical structures to health care delivery The CMA estimates that approximately 10,000 to 15,000 physicians will be affected by this federal taxation proposal. If implemented, this federal taxation measure will negatively affect group medical structures in communities across Canada. By capturing group medical structures, this proposal also introduces an inequity amongst incorporated physicians, and incentivizes solo practice, which counters provincial and territorial health delivery priorities. Group medical structures are prevalent within academic health science centres and amongst certain specialties, notably oncology, anaesthesiology, radiology, and cardiology. Specialist care has become increasingly sub-specialized. For many specialties, it is now standard practice for this care to be provided by teams composed of numerous specialists, sub-specialists and allied health care providers. Team-based care is essential for educating and training medical students and residents in teaching hospitals, and for conducting medical research. Put simply, group medical structures have not been formed for taxation or commercial purposes. Rather, group medical structures were formed to deliver provincial and territorial health priorities, primarily in the academic health setting, such as teaching, medical research as well as optimizing the delivery of patient care. Over many years, and even decades, provincial and territorial governments have been supporting and encouraging the delivery of care through team-based models. To be clear, group medical structures were formed to meet health sector priorities; they were not formed for business purposes. It is equally important to recognize that group medical structures differ in purpose and function from similar corporate or partnership structures seen in other professions. Unlike most other professionals, physicians do not form these structures for the purpose of enhancing their ability to earn profit. It is critical that the federal government acknowledge that altering eligibility to the small business deduction will have more significant taxation implication than simply the 4.5% difference in the small business versus general rate at the federal level. It would be disingenuous to argue that removing full access to the small business deduction for incorporated physicians in group medical structures will be a minor taxation increase. As demonstrated below in Table 1, the effect of this federal taxation change will vary by province. Table 1: Taxation impacts by province, if the federal taxation proposal is implemented In Nova Scotia, for example, approximately 60% of specialist physicians practice in group medical structures. If the federal government applies this taxation proposal to group medical structures, these physicians will face an immediate 17.5% increase in taxation. In doing so, the federal government will establish a strong incentive for these physicians to move away from team-based practice to solo practice. If this comes to pass, the federal government may be responsible for triggering a reorganization of medical practice in Nova Scotia. Finance Canada Grossly Underestimating the Net Impact The CMA is aware that Finance Canada has developed theoretical scenarios that demonstrate a minimal impact to incorporated physicians within group medical structures. Working closely with our subsidiary, MD Financial Management, the CMA submitted real financial scenarios from real financial information provided to the CMA from incorporated physicians in group medical structures. These real examples demonstrate that there will be a significant impact to incorporated physicians in group medical structures, if this federal tax proposal will apply to them. The theoretical scenarios developed by Finance Canada conclude the net financial impact to an incorporated physician in a group medical structure would be in the magnitude of hundreds of dollars. In stark contrast to the theoretical scenarios developed by Finance Canada, the CMA submitted financial scenarios of two incorporated physicians in group medical structures. The financial calculations undertaken by the CMA is based on the real financial information of these two physicians. The examples revealed yearly net reduction of funds of $32,510 and $18,065 for each of these physicians respectively. Projecting forward, for the first physician, this would represent a negative impact of $402,330 based on a 20-year timeframe and 4.8% rate of return1. Extending the same assumptions to all incorporated members of that physician’s group medical structure, the long-term impact for the group would be $39.4 million.2 1 Source: MD Financial Management 2 Please note that these projections have not been adjusted for the inherent tax liability on the growth. 3 Source: MD Financial Management 4 Please note that these projections have not been adjusted for the inherent tax liability on the growth. For the second physician, projecting forward, this would represent a negative impact of $223,565, based on a 20-year timeframe and 4.8% rate of return3. Extending the same assumptions to all incorporated members of that physician’s group medical structure, the long-term impact for the group would be $13.4 million.4 Unprecedented Level of Concern Expressed by Physicians Following the publication of the 2016 federal budget, the CMA received a significant volume of correspondence from its membership expressing deep concern with the proposal to alter access to the small business deduction for group medical structures. The level of correspondence from our membership is quite simply unprecedented in our almost 150 year history. As part of the CMA’s due diligence as the national professional organization representing physicians, we informed our membership of Finance Canada’s consultation process on the draft legislative measures. In response, the CMA was copied on submissions by over 1,300 physicians to Finance Canada’s pre-legislative consultation. In follow up, the CMA surveyed these physicians to better understand the impacts of the budget proposal. Here’s what we heard: . Most respondents (61%) indicated that their group structure would dissolve; . Most respondents (54%) said they would stop practicing in their group structure and that other partners would leave (76%); . A large majority (78%) indicated that the tax proposal would lead to reduced investments in medical research by their group; . Almost 70% indicated that the tax proposal would limit their ability to provide medical training spots; and, . Another 70% indicated that the tax proposal will mean reduced specialty care by their group. The full summary of the survey is provided as an appendix to this brief. To further illustrate the risks of this proposal to health care, below are excerpts from some of the communiques received by the CMA from its membership: . “Our Partnership was formed in the 1970s…The mission of the Partnership is to achieve excellence in patient care, education and research activities….there would be a serious adverse effect on retention and recruitment if members do not have access to the full small business deduction…The changes will likely result in pressure to dissolve the partnership and revert to the era of departments services by independent contractors with competing individual financial interests.” Submitted to the CMA April 15, 2016 from a member of the Anesthesia Associates of the Ottawa Hospital General Campus . “The University of Ottawa Heart Institute is an academic health care institution dedicated to patient care, research and medical education…To support what we call our “academic mission,” cardiologists at the institute have formed an academic partnership…If these [taxation] changes go forward they will crippled the ability of groups such as ours to continue to function and will have a dramatic negative impact on medical education, innovative health care research, and the provision of high-quality patient care to our sickest patients.” Submitted to the CMA April 19, 2016 from a member of the Associates in Cardiology . “We are a general partnership consisting of 93 partners all of whom are academic anesthesiologists with appointments to the Faculty of the University of Toronto and with clinical appointments at the University Health Network, Sinai Health System or Women’s College Hospital…In contrast to traditional business partnerships, we glean no business advantage whatsoever from being in a partnership…the proposed legislation in Budget 2016 seems unfair in that it will add another financial hardship to our partners – in our view, this is a regressive tax on research, teaching and innovation.” Submitted to the CMA April 14, 2016 from members of the UHN-MSH Anesthesia Associates Recommendation The CMA recommends that the federal government exempt group medical and health care delivery from the proposed changes to s.125 of the Income Tax Act regarding multiplication of access to the small business deduction, as proposed in Section 44 of Bill C-29, Budget Implementation Act, 2016, No. 2. Below is a proposed legislative amendment to ensure group medical structures are exempted from Section 44 of Bill C-29, Budget Implementation Act, 2016, No. 2: Section 125 of the Act is amended by adding the following after proposed subsection 125(9): 125(10) Interpretation of designated member – [group medical partnership] – For purposes of this section, in determining whether a Canadian-controlled private corporation controlled directly or indirectly in any manner whatever by one or more physicians or a person that does not deal at arm's length with a physician is a designated member of a particular partnership in a taxation year, the term "particular partnership" shall not include any partnership that is a group medical partnership. 125(11) Interpretation of specified corporate income – [group medical corporation] – For purposes of this section, in determining the specified corporate income for a taxation year of a corporation controlled directly or indirectly in any manner whatever by one or more physicians or a person that does not deal at arm's length with a physician, the term "private corporation" shall not include a group medical corporation. Subsection 125(7) of the Act is amended by adding the following in alphabetical order: "group medical partnership" means a partnership that: (a) is controlled, directly or indirectly in any manner whatever, by one or more physicians or a person that does not deal at arm's length with a physician; and (b) earns all or substantially all of its income for the year from an active business of providing services or property to, or in relation to, a medical practice; "group medical corporation" means a corporation that: (a) is controlled, directly or indirectly in any manner whatever, by one or more physicians or a person that does not deal at arm's length with a physician; and (b) earns all or substantially all of its income for the year from an active business of providing services or property to, or in relation to, a medical practice. "medical practice" means any practice and authorized acts of a physician as defined in provincial or territorial legislation or regulations and any activities in relation to, or incidental to, such practice and authorized acts; "physician" means a health care practitioner duly licensed with a provincial or territorial medical regulatory authority and actively engaged in practice; Incorporation Survey, October 2016 *Totals may exceed 100% as respondents were allowed to select more than one response 65% 13% 6% 5% 2% 2% 2% 2% 2% 1% ON AB BC NS MB NL QC SK NB YT % Distribution by Province of Practice 65% 28% 22% 15% 9% 8% 8% 6% 6% 3% 3% 3% 3% Academic health sciences centre Private office / clinic University Community hospital Emergency department (in community hospital or AHSC) Community clinic/Community health centre Non-AHSC teaching hospital Research unit Free-standing lab/diagnostic clinic Free-standing walk-in clinic Nursing home/ Long term care facility / Seniors' residence Administrative office / Corporate office Other % Distribution by Work Setting 20 12 9 8 8 7 7 6 5 5 4 Ottawa Hospital (Ottawa) University Health Network (Toronto) Sunnybrook Health Sciences Centre (Toronto) Foothills Medical Centre (Calgary) St. Joseph's Health Centre (Hamilton) Mount Sinai Hospital (Toronto) London Health Sciences Centre (London) South Calgary Health Campus (Calgary) St. Micheal's Hospital (Toronto) Children's Hospital of Eastern Ontario (Ottawa) Royal Alexandra Hospital (Edmonton) Most frequently mentioned hospitals where respondents work in group medical structures Synopsis 61 54 76 78 67 68 30 36 19 16 23 24 9 10 5 6 10 8 Group medical structure will dissolve Stop practice in your group medical structure Partnering members leave the group medical structure Reduced investments in medical research Reduced medical training spots Reduced provision of specialized care Physicians perceptions about the likelihood of the following outcomes Likely or very likely Unsure Unlikely or very unlikely The federal government is advancing a tax proposal that will alter access to the small business deduction. If implemented, this proposal will affect incorporated physicians practicing in partnership group medical structures. The Canadian Medical Association (CMA) is actively advocating for the federal government to exempt group medical structures from the application of this tax proposal. 94% 2% 4% Importance of Exempting Group Medical Structures from the Tax Proposal Important or very important Unsure Unimportant or very unimportant To support the effectiveness of its advocacy efforts, the CMA conducted an online survey seeking input from members who had voiced their concerns about this issue directly with the Department of Finance and who had copied the CMA on their submissions. Sample: physician type, province, and work setting The survey was sent to 1089 CMA members, of which 174 responded (15.9% response rate). All sample respondents were incorporated and practiced in a group medical structure; 26% were family physicians (N=45) and 74% were specialists (N=129). Most respondents indicated practicing primarily in Ontario (65%) and Alberta (13%). With respect to practice settings, the majority reported working in an academic health sciences centre (65%), followed by a private office/clinic (28%), university (22%), community hospital (15%), emergency department (9%), community clinic/community health centre (8%), non-AHSC teaching hospital (8%), research unit (6%), and free-standing lab/diagnostic clinic (6%). In total, respondents worked in 79 hospitals spread around 36 cities. Likelihood of outcomes resulting from the federal tax proposal When asked about the possible consequences of the proposed changes, the largest share of respondents (78%) felt a reduction in investments in medical research was likely or very likely. Almost as many (76%) also felt that partnering members would likely leave the group medical structure. . Most respondents (61%) indicated that their group medical structure would be likely or very likely to dissolve if the federal tax proposal to change access to the small business deduction was implemented. Less than one-third (30%) felt unsure while only a few (9%) reported it as unlikely or very unlikely. . More than half of respondents (54%) indicated that they would be likely or very likely to stop practicing in their group medical structure if the tax proposal was implemented. More than one-third (36%) were unsure while only a few (10%) reported it as unlikely or very unlikely. . More than three-quarters of respondents (76%) indicated that other partnering members would be likely or very likely to leave their group medical structure if the tax proposal was implemented. About 20% remained unsure while only 5% reported it as unlikely or very unlikely. . Almost 8 in 10 respondents (78%) indicated that implementing the tax proposal would be likely or very likely to reduce investments in medical research for their group medical structure. 16% remained unsure while 6% reported it as unlikely or very unlikely. . Approximately two-thirds of respondents (67%) indicated that implementing the tax proposal would be likely or very likely to reduce the ability of the group medical structure to provide medical training spots. About a quarter (23%) remained unsure and 1 in 10 reported it as unlikely or very unlikely. . Almost 7 in 10 respondents (68%) indicated that implementing the tax proposal would be likely or very likely to reduce provision of specialized care by their group medical structure. Almost a quarter (24%) remained unsure while 8% reported it as unlikely or very unlikely. Importance of exempting group medical structures from the tax proposal More than 9 in 10 respondents (94%) felt that it is important or very important for the federal government to exempt group medical structures from the tax proposal to avoid negatively affecting health care delivery in their province. The remaining respondents were unsure (2%) or considered it unimportant or very unimportant (4%). Other Impacts – Write-in Question Before submitting the survey, respondents were given the chance to provide additional comments about other potential impacts that the proposed changes might produce. Most responses touched upon a few and inter-related themes, including: 1. Impact on education and research will be detrimental and will eventually affect patient care: o “Without the group medical structure, we cannot adequately support teaching education and research activities. Physicians in academic health sciences centres will be forced to use their time to see patients, in order to bill fee-for-service to make a living. Very little time will be left over to spend doing the research that is critical to advancing medical science, to supporting our university, and our nation’s prominent place in the world of medicine” o “Support is given to the academic health sciences centres by the provincial government in order to facilitate research and education. The federal government's changes will penalize physicians who already dedicate much of their time to providing the stepping stones to advance medicine forward. These physicians generally make less income than physicians working in private practice. They are willing to take this monetary hit because they love what they do. However we all need to support our families and put food on the table. With the government's changes, this may not be possible in the current system, and these group medical structures will need to be dissolved and the physicians working will have much less time to dedicate to research and education.” o “Less education, research activity to focus on fee-for-service procedures to compensate for higher taxes.” o Our ability to provide teaching for medical education and research, which are currently not remunerated, would be curtailed. There would be no incentive but rather a significant disincentive to provide these activities because we would be financially penalized compared to physicians in the same specialty that are not in group medical structures.” o “As the main teaching practice structure, we will lose full time faculty who provide the backbone to the program. They currently earn much below the average for Family Physicians in the province and our ability to support education and research will be compromised.” 2. Discourages practice in academic centres: o “Working in an academic center as a general pediatrician means that we already make substantially less money than our community colleagues. There is very little incentive to remain in academic practice if we not only earn less, but are then not entitled to the same tax savings. I would leave academic practice and I suspect many of my colleagues would as well. I think we could see the end of the current group medical structure, as it would no longer support a financially viable model for academic practice.” o “Creates a further divide between working in an academic centre and in the community. It will continue to be more advantageous to work in a smaller community - more money, less cost of living, less administrative and academic hassles, less research funding. Why bother working at an academic centre with such disadvantages.” o “This policy seems to target academic physicians in groups disproportionately. These physicians currently support research and education by reallocating our own funds generated from clinical care. It is puzzling as to why the Federal Government is waging this war on the academic physician workforce.” 3. Physician retention and recruitment will be challenging: o “I will retire sooner than otherwise.” o “At the present time it is very difficult to recruit family doctors who are interested in teaching, research and administration of academic family medicine. This tax change will make it increasingly more difficult to recruit such individuals.” o “I'm concerned that the proposed changes erase any benefits from a corporation structure and leave me with a loss. Work is so stressful and demanding that if I find myself in a disadvantaged situation financially as well, this would be another factor encouraging me either to retire or move outside of Canada. If I'm going to be faced with losses and more stress, why not instead focus on my quality of life instead?” o “It would severely restrict our ability to recruit research and specialty physicians. We would not be able to compete with community centres and would see a dramatic decline in our ability to provide for teaching and research activities now funded through the group structure.” o “I am a dual citizen and would seriously entertain moving to the USA.” o “It will basically force me to go to a free standing walk in clinic.” o “It would be less likely to recruit the best quality of medical staff to academic practice as there will be a significant financial disincentive, especially compared to what that same individual could earn on their own in a community practice. This is on top of the fact that academic practitioners tend to earn less to start with.” 4. Discourages team-based collaborative care: o “The bill sets up an unfair system where it is more attractive to be a solo MD rather than to collaborate and be part of a team.” o “This creates an every person for themselves philosophy.” o “The provision of our group services is required to ensure best patient care. It is wrong to penalize this model of comprehensive care.” 5. Practice will close and services will be limited in certain areas: o “Any reduction in research, administration, academic activity, and members would affect patient care at our facility and therefore be a threat to patient safety. e.g., if multiple physicians leave, then we won't have enough physicians to cover the emergency department appropriately, wait times will increase, and serious patient safety concerns will arise.” o “Reduces productivity of the doctors concerned and hence quality of service provided. Access will also be affected!” o This would be unattractive for some, and they may leave (or others may not join.) If partners leave, the overhead will go up and we would likely close. Because our overhead is already borderline unacceptable. Shared between fewer docs would make it economically impossible. And this could easily happen if docs leave. o “Reduced physician coverage if members opt out of group medical structure, which would have an impact on greater access and the quality of care.” o “Our ability to have a large interdisciplinary team to assist in serving our patients could not continue to exist. Our ability to continue to provide 24/7 on-call and after hours clinics would decrease due to a change in the structure leading to less practitioners.”
Documents
Less detail

National pharmacare in Canada: Getting there from here

https://policybase.cma.ca/en/permalink/policy11959
Date
2016-06-01
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2016-06-01
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
On behalf of 83,000 physician members, the Canadian Medical Association (CMA) welcomes this opportunity to provide input to the House of Commons Standing Committee on Health study on the Development of a National Pharmacare Program. Recognizing that the term “pharmacare” is used in different contexts, for the purposes of this brief, pharmacare is defined as a program whereby Canadians have comparable access to medically necessary prescription medications, irrespective of their ability to pay, wherever they live in Canada. The Canadian Medical Association (CMA) is the national voice of Canadian physicians. Founded in 1867, the CMA’s mission is helping physicians care for patients. On behalf of its more than 83,000 members and the Canadian public, the CMA performs a wide variety of functions. Key functions include advocating for health promotion and disease/injury prevention policies and strategies, advocating for access to quality health care, facilitating change within the medical profession, and providing leadership and guidance to physicians to help them influence, manage and adapt to changes in health care delivery. Key Facts According to the Canadian Institute for Health Information (CIHI), in 2014, of the estimated $28.8 billion spent in Canada on prescription medications (representing 13.4% of total health spending), governmentsi accounted for 42.0%, and private insurers and out-of-pocket (OOP) payment accounted for 35.8% and 22.2% respectively.1 The CMA is a voluntary professional organization representing the majority of Canada’s physicians and comprising 12 provincial and territorial divisions and over 60 national medical organizations. i Includes federal. Social security fund and provincial/territorial spending 1 Canadian Institute for Health Information. Prescribed drug spending in Canada, 2013: a focus on public drug programs. https://secure.cihi.ca/free_products/Prescribed%20Drug%20Spending%20in%20Canada_2014_EN.pdf. Accessed 05/15/16. 2 Royal Commission on Health Services. Report Volume One. Ottawa: Queen’s Printer, 1964. 3 Canadian Institute for Health Information. National Health Expenditure Database 1975 to 2015. Table D 3.1.1-D3.13.1 https://www.cihi.ca/en/spending-and-health-workforce/spending/national-health-expenditure-trends. Accessed 05/08/16. 4 Statistics Canada. CANSIM Table 203-0022 Survey of household spending (SHS), household spending, Canada, regions and provinces, by household income quintile. Accessed 05/18/16. 5 Cancer Advocacy Coalition of Canada. 2014-15 Report Card on Cancer in Canada. http://www.canceradvocacy.ca/reportcard/2014/Report%20Card%20on%20Cancer%20in%20Canada%202014-2015.pdf. Accessed 05/08/16. 6 Canadian Cancer Society. Cancer drug access for Canadians. http://www.colorectal-cancer.ca/IMG/pdf/cancer_drug_access_report_en.pdf. Accessed 05/08/16. 7Schoen C, Osborn R, Squires D, Doty M. Access, affordability, and insurance complexity are often worse in the United States compared to ten other countries. Health Affairs 2013;32(12):2205-15. 8 Himmelstein D, Woolhandler S, Sarra J, Guyatt G. Health issues and health care expenses in Canadian bankruptices and insolvencies. International Journal of Health Services 2014;44(1):7-23. 9 Law M, Cheng L, Dhalla I, Heard D, Morgan S. The effect of cost on adherence to prescription medications in Canada. CMAJ 2012. 184)3):297-302. 10 Tamblyn R, Eguale T, Huang A, Winslade N, Doran P. The incidence and determinants of primary nonadherence with prescribed medication in primary care. Ann Inter Med 2014;160:441-50. Pharmacare is clearly part of the unfinished business of Medicare. Numerous authors have pointed out that Canada is the only developed country that does not include prescription medications as part of its universal health program. Table 1 below shows how Canada compares with the 22 member countries of the Organization for Economic Cooperation and Development (OECD) on the proportion of public spending for major categories of health expenditure in 2012. Table 1. Public spending as % of total spending: Major health spending categories, Canada and 22 OECD country average, 2012 % Public Spending Prescription Drugs Hospitals Doctors’ Offices Canada 42 91 99 OECD Average 70 88 72 Source: OECD.Stat, Doctors’ offices figure for Sweden is 2009 In the case of prescription medications, Canada was more than one-third (40%) below the OECD average. The Patchwork Quilt of Public-Private Coverage In 1964 the Hall Commission recommended 50/50 cost-sharing between the federal and provincial governments toward the establishment of a prescription drug program, with a $1.00 charge for each prescription. At the time, prescription medications represented 6.5% of spending on personal health services.2 This recommendation was not implemented. It might be further added that the Hall report contained 25 forward-looking recommendations on pharmaceuticals that remain current to this day, including bulk purchasing, generic substitution and a national formulary.2 As a result of the lack of inclusion of prescription medications in Medicare, there is wide variation today in public per capita spending on prescription drugs across the provinces. It may be seen in Table 2 that, for 2014, CIHI has estimated that public per capita expenditure ranged from $219 in British Columbia and $255 in Prince Edward Island (PE) to $369 in Saskatchewan and $437 in Quebec.3 CIHI does not provide estimates of private per capita prescription drug spending (private insurance plus OOP) below the national level. Table 2: Spending on prescription drugs: Selected indicators by province and territory, 2014 Province/ Territory Public spendinga ($ million) Public per capita spendinga ($ ) Private insuranceb ($ million) Average household out-of-pocketc $ NL 156.7 297 177 454 PE 37.3 255 32 516 NS 302.2 321 337 429 NB 210.8 280 284 477 QC 3,588.7 437 2,369 466 ON 4,730.4 346 4,626 324 MB 411.3 321 249 516 SK 415.4 369 192 514 AB 1,383.7 336 1,065 409 BC 1,015.8 219 894 456 YT 14.0 383 - - NT 17.5 400 - - NU 13.6 372 - - Territories 45.1 385 23 - Canada 12,297.4 334d 10,247 408 a CIHI, National Health Expenditure Database 1975-2015, includes all public funding sources b Canadian Life and Health Insurance Association c Statistics Canada, Survey of Household Spending, 2014 d Provincial/territorial average Table 2 also shows the significant role of private insurance in every region of Canada. Data provided by the Canadian Life and Health Insurance Association, shown in Column 3 of Table 2, show that private health insurance companies paid out $10.2 billion for prescription drug claims in 2014, representing 83% of the $12.3 billion paid for by governments. In three provinces — Newfoundland and Labrador, Nova Scotia and New Brunswick — the amount paid by private insurance exceeds that paid by governments. Table 2 also shows that there is wide variation in average household OOP spending on prescription drugs, according to Statistics Canada’s Survey of Household Spending (SHS). In 2014 this ranged from a low of $324 in Ontario to a high of $516 in PE and Manitoba.4 Even more striking variation is evident when looking at household out-of-pocket spending on prescription drugs by income quintile (detailed data not shown). According to the 2014 SHS the poorest one-fifth (lowest income quintile) of PE households spent more than twice as much ($645) OOP on prescription drugs than the poorest one-fifth in Ontario ($300).4 Aside from overall differences in public spending there are also differences in which medications are covered, particularly in the case of cancer drugs. The Cancer Advocacy Coalition of Canada reported in 2014 that four provinces have fully funded access to cancer medications taken at home. In Ontario and Atlantic Canada however, cancer drugs that must be taken in a hospital setting and are on the provincial formulary are fully funded by the provincial government; if the drug is taken outside of hospital (oral or injectable), the patient and family may have to pay significant costs out-of-pocket.5 More generally the Canadian Cancer Society has reported that persons moving from one province to another may find that a medication covered in their former province may not be covered in the new one. 6 Other sources confirm that prescription medication spending is an issue for many Canadians. On the Commonwealth Fund’s 2013 International Health Policy Survey, 8% of the Canadian respondents said that they had either not filled a prescription or skipped doses because of cost issues.7 Himmelstein et al. reported on a survey of Canadians who experienced bankruptcy between 2008 and 2010. They found that 74.5% of the respondents who had had a medical bill within the last two years reported that prescription drugs was their biggest medical expense.8 At least two Canadian studies have documented the impact that out-of-pocket costs, lack of insurance and low income have on non-adherenceii to prescription regimens. Law et al. examined cost-related non-adherence in the 2007 Canadian Community Health Survey and found that those without drug insurance were more than four times as likely to report non-adherence than those with insurance. The predicted rate of non-adherence among those with high household incomes and drug insurance was almost 10 times as high as that among those with low incomes and no insurance (35.6% vs. 3.6%).9 Based on a large-scale study of the incidence of primary non-adherence (defined as not filing a new prescription within nine months) in a group of some 70,000 Quebec patients, Tamblyn et al. reported that there was a 63% reduction in the odds of non-adherence among those with free medication over those with the maximum level of co-payment. They also reported that the odds of non-adherence increased with the cost of the medication prescribed.10 ii Non-adherence can be defined as doing something to make a medication last longer or failing to fill or renew a prescription. Previous Pharmacare Proposals In a recent monograph Katherine Boothe has contrasted the development of national prescription medication programs in Australia and the United Kingdom with the failure to do so in Canada.11 11 Boothe K. Ideas and the pace of change: national pharmaceutical insurance in Canada, Australia and the United Kingdom. Toronto: University of Toronto Press, 2015. 12 National Forum on Health. Directions for a pharmaceutical policy in Canada. http://www.hc-sc.gc.ca/hcs-sss/pubs/renewal-renouv/1997-nfoh-fnss-v2/index-eng.php. Accessed 05/18/16. 13 National Forum on Health. Canada health action: building on the legacy. Ottawa: Minister of Public Works and Government Services, 1997. 14 Bank of Canada. Inflation calculator. http://www.bankofcanada.ca/rates/related/inflation-calculator/?page_moved=1. Accessed 05/18/16. 15 Statistics Canada. Table 051-0001 Estimates of population, by age group and sex for July 1, Canada, provinces and territories. Accessed 05/15/16. 16 Canadian Institute for Health Information. National health expenditure database 1975 to 2015. Table C.3.1. Public health expenditure by use of funds, Canada, 1975 to 2015. https://www.cihi.ca/en/spending-and-health-workforce/spending/national-health-expenditure-trends. Accessed 05/25/16. 17 Berry C. Voluntary medical insurance and prepayment. Ottawa: Queen’s Printer, 1965. 18 Receiver General for Canada. Volume I Public Accounts of Canada for the fiscal year ended March 31, 1969. Ottawa: Queen’s Printer for Canada, 1969. 19 Receiver General for Canada. Volume I Public Accounts of Canada for the fiscal year ended March 31, 1972. Ottawa: Information Canada, 1972. 20 Privy Council Office. Speech from the Throne to open the first session thirty-sixth Parliament of Canada. http://www.pco-bcp.gc.ca/index.asp?lang=eng&page=information&sub=publications&doc=aarchives/sft-ddt/1997-eng.htm. Accessed 05/18/16. 21 Standing Senate Committee on Social Affairs, Science and Technology. The health of Canadians – the federal role. Volume six: recommendations for reform. Ottawa, 2002. 22 Commission on the Future of Health Care in Canada. Building on values: the future of health care in Canada. Ottawa, 2002. 23 Canadian Intergovernmental Conference Secretariat. 2003 First Ministers’ accord on health care renewal. http://www.scics.gc.ca/CMFiles/800039004_e1GTC-352011-6102.pdf. Accessed 05/18/16. 24 Council of the Federation. Premiers’ action plan for better health care: resolving issues in the spirit of true federalism. Communiqué July 30, 2004. http://canadaspremiers.ca/phocadownload/newsroom-2004/healtheng.pdf. Accessed 05/18/16. 25 Canadian Intergovernmental Conference Centre. A 10-year plan to strengthen health care. http://www.scics.gc.ca/CMFiles/800042005_e1JXB-342011-6611.pdf. Accessed 05/18/16. 26 National Pharmaceuticals Strategy. National Pharmaceuticals Strategy progress report. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2006-nps-snpp/2006-nps-snpp-eng.pdf. Accessed 05/18/16. 27 Canadian Intergovernmental Conference Secretariat. Backgrounder: national pharmaceutical strategy decision points. http://www.scics.gc.ca/english/conferences.asp?a=viewdocument&id=112. Accessed 05/18/16. 28 Canada’s Premiers. The pan-Canadian Pharmaceutical Alliance: April 2016 Update. http://www.pmprovincesterritoires.ca/en/initiatives/358-pan-canadian-pharmaceutical-alliance. Accessed 05/18/16. 29 Canadian Medical Association. General Council Resolution GC15-C16, August 26, 2015. 30 Gagnon M. The economic case for universal pharmacare. 2010. https://s3.amazonaws.com/policyalternatives.ca/sites/default/files/uploads/publications/National%20Office/2010/09/Universal_Pharmacare.pdf. Accessed 05/18/16. 31 Gagnon M. A roadmap to a rational pharmacare policy in Canada. Ottawa: Canadian Federation of Nurses Unions, 2014. 32 Morgan S, Law M, Daw J, Abraham L, Martin D. Estimated cost of universal public coverage of prescription drugs in Canada. CMAJ. 2015 Apr 21;187(7):491-7. doi: 10.1503/cmaj.141564. 33 Morgan S, Martin D, Gagnon M, Mintzes B, Daw, J, Lexchin, J. Pharmacare 2020. The future of drug coverage in Canada. http://pharmacare2020.ca/assets/pdf/The_Future_of_Drug_Coverage_in_Canada.pdf. Accessed 05/18/16. 34 Canadian Medical Association. Policy resolution GC15-C19, August 26, 2015. 35 Conference Board of Canada. Federal policy action to support the health care needs of Canada’s aging population. https://www.cma.ca/Assets/assets-library/document/en/advocacy/conference-board-rep-sept-2015-embargo-en.pdf. Accessed 05/18/16. 36 Government of the United Kingdom. Written statement to Parliament NHS charges from April 2016. https://www.gov.uk/government/speeches/nhs-charges-from-april-2016. Accessed 05/18/16. 37 Appleby J. Prescription charges: are they worth it? BMJ 2014;348:g3944 doi: 10.1136/bmj.g3944. Among the several Canadian attempts that she describes, the most activity occurred in the decade following the National Forum on Health (NFH), which was struck in 1994 and reported in 1997. A NFH working group paper on pharmaceutical policy recommended first dollar coverage for prescription medications, but acknowledged that it could not occur overnight: “over time we propose to shift private funding on prescribed pharmaceuticals (estimated at $3.6 billion in 1994) to public funding”.12 The NFH included this recommendation in its final report, noting that “the absorption of currently operating plans by a public system may involve transfer of funding sources as well as administrative apparatus”.13 It is instructive to place the 1994 prescription drug expenditure cited by the NFH in today’s context. According to the Bank of Canada’s inflation calculator, the $6.5 billion in 1994 would have cost $9.5 billion in 2014.14 CIHI estimates that actual spending in 2014 was $28.7 billion1 – 203% above the level of 1994 spending, compared to population growth of 23% over the same time period.15 Annual prescription drug spending increases averaged 7.3% over the period, although they have averaged just over 1% since 2009. 16 A significant shift from private to public funding is not without precedent. A study prepared for the Hall Commission estimated that 9.6 million Canadians, representing 53% of the total population, had some form of not-for-profit or commercial insurance coverage for medical and/or surgical services in 1961.17 With the passage of the Medical Care Act in 1966 these plans were all displaced as the provinces joined Medicare. The funding shift did not occur overnight, although it did move quickly. In the first year, 1968/69, Ottawa paid out $33 million to the provinces pursuant to the Medical Care Act, which grew quickly to $181 million in 1969/70, and reaching $576.5 million in 1971/72.18,19 Since the 1997 NFH report the closest that the federal government has come to acting on pharmacare was a commitment in the 1997 Speech from the Throne to “develop a national plan, timetable and a fiscal framework for providing Canadians with better access to medically necessary drugs”, but nothing further was ever made public.20 Pharmacare was subsequently examined in two national studies, both of which recommended federal involvement in reimbursing “catastrophic” prescription drug expenditures above a threshold of household income. The Senate study on the State of the Health Care System in Canada, chaired by Michael Kirby, was authorized in March 2001 and the Commission on the Future of Health Care in Canada, headed by Roy Romanow, was approved in April 2001. Both issued their final reports in 2002. The Kirby plan was designed so as to avoid the necessity of eliminating existing private plans or the provincial/territorial public plans, not unlike the approach taken by Quebec in 1997. In the Kirby plan, in the case of public plans, personal prescription medication expenses for any family would be capped at 3% of total family income. The federal government would then pay 90% of prescription drug expenses in excess of $5,000. In the case of private plans, sponsors would have to agree to limit out-of-pocket costs to $1,500 per year, or 3% of family incomes, whichever was less. The federal government would then agree to pay 90% of drug costs in excess of $5,000 per year. Both public and private plans would be responsible for the difference between out-of-pocket costs and $5,000, and private plans would be encouraged to pool their risk. Kirby estimated that this plan would cost approximately $500 million per year.21 The Romanow Commission recommended a $1 billion Catastrophic Drug Transfer through which the federal government would reimburse 50% of the costs of provincial and territorial drug insurance plans above a threshold of $1,500 per person per year.22 The advantage of these proposals is that they are fully scalable. The federal government could adjust either the out-of-pocket household income threshold, the ceiling above which it would assume costs, or the percentage of costs that it would pay above the ceiling. Following the Kirby and Romanow reports there was a back and forth exchange between the federal and provincial-territorial (PT) governments on a plan for catastrophic coverage. In their February 2003 Accord, First Ministers agreed to ensure that Canadians would have reasonable access to catastrophic drug coverage by March 2006.23 At their annual summer meeting in 2004 the Premiers later called on the federal government to “assume full financial responsibility for a comprehensive drug program for all Canadians”, with compensation to Quebec for its drug program.24 In the September 2004 Health Accord, First Ministers directed health ministers to develop a nine-point National Pharmaceuticals Strategy (NPS), including costing options for catastrophic coverage.25 A federal-provincial-territorial Ministerial Task Force on the NPS was struck and a progress report was issued in June 2006. The estimates of catastrophic spending were markedly higher than those of the Kirby and Romanow reports. Using a variable percentage of income threshold it estimated that, based on public plan costs, only catastrophic spending represented 42% of total prescription drug spending. If private plan costs were also considered, catastrophic spending would represent 55% of total prescription drug spending. This report proposed four options for catastrophic coverage with estimates for new public funding ranging from $1.4 to $4.7 billion.26 Although no account of the methods was provided it is evident that a significant proportion of existing plan costs were included in the estimates of catastrophic expenditure. At their September 2008 meeting, the PT health ministers called for a national standard for drug coverage not to exceed 5% of net income and for the federal government to share 50/50 in the estimated $5.03 billion cost.27 The uncertainty about the projected cost of a pharmacare plan resulting from widely varying estimates has doubtless contributed to a reluctance of governments to engage on advancing this issue. Recent Developments At the PT level, there has been a concerted effort on price negotiations during the past few years through the pan-Canadian Pharmaceutical Alliance (pCPA) that was established in 2010. As of March 31, 2015, the pCPA reported that price reductions in generic and brand-name prescription medications result in annual savings of an estimated $490 million.28 The federal drug plans are now participating in the pCPA and the CMA has recommended that the pCPA should also invite the participation of private health insurance companies.29 The prospect of savings through lower prices has been foundational to two recent studies that have made the case that a single public payer pharmacare program with little or no co-payment is affordable. The first was by Marc-André Gagnon in 2010. The proposal was developed on the basis of a review of cross-provincial and international practices in pharmaceutical policy. The review formed the basis of a set of 11 assumptions that were used to develop four scenarios that resulted in estimates of prescription drug cost savings over the 2008 baseline expenditure of $25.1 billion that ranged to $2.7 billion to $10.7 billion.30 In a 2014 update Gagnon estimated that a first dollar coverage program would save 10% to 41% of prescription drug costs, representing savings of as much as $11.4 billion annually on a 2012-13 base of $27.7 billion.31 Steve Morgan and colleagues (2015) have estimated that a universal public plan with small co-payments could reduce prescription drug spending by $7.3 billion.32 Subsequently, in Pharmacare 2020 Morgan et al. set out five recommendations calling for the implementation of a single payer system with a publicly accountable management agency by 2020.33 Taking a First Step Forward At its 2015 annual meeting, the CMA adopted a policy resolution that supports the development of an equitable and comprehensive national pharmacare program.34 Reflecting on the experience of the past 40 years since the enactment of the Established Programs Financing Act in 1977 that eliminated 50:50 cost-sharing, it seems highly unlikely that the federal government would take on a new open-ended program in the health and social arena, cost-shared or not. However, notwithstanding the progress of the pCPA, we are unlikely to address the significant access gaps in prescription medication coverage without the involvement of the federal government. These are fiscally challenging times for both levels of government, with budget deficits expected for several years to come. As noted previously, the Kirby and Romanow proposals for a federal funding role in pharmacare are scalable. In 2015 the CMA commissioned the Conference Board of Canada to model the cost of covering prescription medication expenditure beyond a household spending threshold of $1,500 or 3% of gross household income, based on Statistics Canada’s 2013 Survey of Household Spending. The projected costs over the 2016 to 2020 are shown in Table 3 below. The cost to the federal government of covering the entire amount above the ($1,500 – 3%) threshold would be $1.6 billion in 2016.35 Recommendation 1: The Canadian Medical Association recommends that the House of Commons Standing Committee on Health request the Parliamentary Budget Officer to conduct a detailed examination of the financial burden of prescription medication coverage across Canada and to develop costing options for a federal contribution to a national pharmacare program. Recommendation 2: As a positive step toward comprehensive, universal coverage for prescription medications, the Canadian Medical Association recommends that the federal government establish a cost-shared program of coverage for prescription medications. First dollar coverage? The issue of co-payment arises in most discussions of pharmacare. Hall recommended a $1.00 prescription charge in 1964. In England, which does include prescription medications in the National Health Service (NHS), the current prescription charge is £8.40, although the government has previously noted that 90% of prescription items are provided free of charge.36 Appleby has noted however that the NHS’s in Wales, Northern Ireland and Scotland have eliminated prescription charges.37One observational study of dispensing rates in Wales found that the overall impact of removing prescription charges was minimal.38 Table 4 shows the total volume of prescriptions dispensed in Scotland over the period 2009-2015, which straddles the removal of prescription charges on April 1, 2011. It indicates that percentage increases in the annual dispensing volume diminished after 2012 and the increase observed in 2015 was just 1.4%. It should be added, however, that patient charges accounted for less than 4% of Scotland’s dispensing expenditures in 2010.39 It will be interesting to see the results of further studies in these jurisdictions. 38 Cohen D, Alam M, Dunstan F, Myles S, Hughes D, Routledge P. Abolition of prescription copayments in Wales: an observational study on dispensing rates. Value in Health 2010;13(5):675-80. 39 ISD Scotland. Prescribing and medicines. Data tables. http://www.isdscotland.scot.nhs.uk/Health-Topics/Prescribing-and-Medicines/Publications/data-tables.asp?Co=Y. Accessed 05/15/16. 40 Canadian Medical Association. A prescription for optimal prescribing. http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-01.pdf. Accessed 05/18/16. 41 Canadian Medical Association. Vision for e-prescribing; a joint statement by the Canadian Medical Associaiton and the Canadian Pharmacists Association. http://policybase.cma.ca/dbtw-wpd/Policypdf/PD13-02.pdf. Accessed 05/18/16. 42 Department of Finance Canada. Growing the middle class. http://www.budget.gc.ca/2016/docs/plan/budget2016-en.pdf. Accessed 05/18/16. Table 4 Prescription Dispensing in Scotland, 2009 – 2015 Year Number of Prescriptions % increase from previous year (million) 2009 88.4 3.8 2010 91.0 3.0 2011 93.8 3.1 2012 96.6 3.0 2013 98.4 1.9 2014 100.6 2.2 2015 102.0 1.4 Source: annual tabulations - Remuneration and reimbursement details for all prescribing made in Scotland.39 Other Elements of a National Pharmaceuticals Strategy It was noted previously that the Hall Report contained 25 recommendations on pharmaceuticals, and the 2004 Health Accord called for a 9-point National Pharmaceuticals Strategy. Two of the NPS points that the CMA would emphasize are the need to influence prescribing behaviour and the need to advance electronic prescribing (e-prescribing). The CMA refers to the first of these points as “optimal prescribing” and defines it as the prescription of a medication that is: the most clinically appropriate for the patient’s condition; safe and effective; part of a comprehensive treatment plan; and the most cost-effective available to best meet the patient’s needs. Toward this end the CMA has identified principles and recommendations to promote optimal prescribing, including the need for current information on cost and cost-effectiveness.40 The CMA believes that e-prescribing has the potential to improve patient safety, to support clinical decision-making and medication management, and to increase awareness of cost and cost-effectiveness considerations. In 2012 the CMA and the Canadian Pharmacists Association adopted a joint vision statement calling for e-prescribing to be the means by which prescriptions are generated for Canadians by 2015.41 Clearly that date has come and gone and we are not there yet. The current state primarily consists of demonstration projects and “workarounds”. The CMA was pleased to see an amount of $50 million allocated to Canada Health Infoway in the 2016 federal budget to support the advancement of e-prescribing and telehomecare.42 Finally the CMA remains very concerned about ongoing shortages of prescription drugs. We would caution that whatever measures governments might take to implement a pharmacare program these must not exacerbate drug shortages. Recommendation 3: The Canadian Medical Association recommends that the Federal/Provincial/Territorial health Ministers direct their officials to convene a working group on a comprehensive National Pharmaceuticals Strategy that will consult widely with stakeholders representing patients, prescribers, and the health insurance and pharmaceutical industries to report with recommendations by spring 2017. Conclusion In conclusion, few would argue that prescription medications are less vital to the health and health care of Canadians than hospital and medical services. We would not have had the Medicare program that Canadians cherish today without the leadership and financial contribution of the federal government, and similarly without it now we will not have any form of a national pharmacare program.
Documents
Less detail

A new mission for health care in Canada: Addressing the needs of an aging population. 2016 pre-budget submission to the Minister of Finance

https://policybase.cma.ca/en/permalink/policy11803
Date
2016-02-09
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2016-02-09
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) is pleased to confirm its strong support for the federal government's health and social policy commitments, as identified in the ministerial mandate letters. In this brief, the CMA outlines seven recommendations for meaningful and essential federal action to ensure Canada is prepared to meet the health care needs of its aging population. The CMA's recommendations are designed to be implemented in the 2016-17 fiscal year in order to deliver immediate support to the provinces and territories and directly to Canadians. Immediate implementation of these recommendations is essential given the current and increasing shortages being experienced across the continuum of care in jurisdictions across Canada. In 2014, the CMA initiated a broad consultative initiative on the challenges in seniors care, as summarized in the report A Policy Framework to Guide a National Seniors Strategy for Canada. This report highlights the significant challenges currently being experienced in seniors care and emphasizes the need for increased federal engagement. Finally, if implemented, the CMA's recommendations will contribute to the federal government's strategic commitments in health, notably the commitment to the development of a new Health Accord. 1) Demographic Imperative for Increased Federal Engagement in Health Canada is a nation on the threshold of great change. This change will be driven primarily by the economic and social implications of the major demographic shift already underway. The added uncertainties of the global economy only emphasize the imperative for federal action and leadership. In 2015, for the first time in Canada's history, persons aged 65 years and older outnumbered those under the age of 15 years.1 Seniors are projected to represent over 20% of the population by 2024 and up to 25% of the population by 2036.2 It is increasingly being recognized that the projected surge in demand for services for seniors that will coincide with slower economic growth and lower government revenue will add pressure to the budgets of provincial and territorial governments.3 Today, while seniors account for about one-sixth of the population, they consume approximately half of public health spending.4 Based on current trends and approaches, seniors care is forecast to consume almost 62% of provincial/territorial health budgets by 2036.5 The latest National Health Expenditures report by the Canadian Institute of Health Information (CIHI) projects that health spending in 2015 was to exceed $219 billion, or 10.9% of Canada's gross domestic product (GDP).6 To better understand the significance of health spending in the national context, consider that total federal program spending is 13.4% of GDP.7 Finally, health budgets are now averaging 38% of provincial and territorial global budgets.8 Alarmingly, the latest fiscal sustainability report of the Parliamentary Budget Officer explains that the demands of Canada's aging population will result in "steadily deteriorating finances" for the provinces and territories, who "cannot meet the challenges of population aging under current policy."9 Taken together, the indicators summarized above establish a clear imperative and national interest for greater federal engagement, leadership and support for the provision of health care in Canada. 2) Responses to Pre-Budget Consultation Questions Question 1: How can we better support our middle class? A) Federal Action to Help Reduce the Cost of Prescription Medication The CMA strongly encourages the federal government to support measures aimed at reducing the cost of prescription medication in Canada. A key initiative underway is the pan-Canadian Pharmaceutical Alliance led by the provinces and territories. The CMA supports the federal government's recent announcement that it will partner with the provinces and territories as part of the pan-Canadian Pharmaceutical Alliance. In light of the fact that the majority of working age Canadians have coverage for prescription medication through private insurers10, the CMA recommends that the federal government support inviting the private health insurance industry to participate in the work of the pan-Canadian Pharmaceutical Alliance. Prescription medication has a critical role as part of a high-quality, patient-centred and cost-effective health care system. Canada stands out as the only country with universal health care without universal pharmaceutical coverage.11 It is an unfortunate reality that the affordability of prescription medication has emerged as a key barrier to access to care for many Canadians. According to the Angus Reid Institute, more than one in five Canadians (23%) report that they or someone in their household did not take medication as prescribed because of the cost during the past 12 months.12 Statistics Canada's Survey of Household Spending reveals that households headed by a senior spend $724 per year on prescription medications, the highest among all age groups and over 60% more than the average household.13 Another recent study found that 7% of Canadian seniors reported skipping medication or not filling a prescription because of the cost.14 The CMA has long called on the federal government to implement a system of catastrophic coverage for prescription medication to ensure Canadians do not experience undue financial harm and to reduce the cost barriers of treatment. As a positive step toward comprehensive, universal coverage for prescription medication, the CMA recommends that the federal government establish a new funding program for catastrophic coverage of prescription medication. The program would cover prescription medication costs above $1,500 or 3% of gross household income on an annual basis. Research commissioned by the CMA estimates this would cost $1.57 billion in 2016-17 (Table 1). Table 1: Projected cost of federal contribution to cover catastrophic prescription medication costs, by age cohort, 2016-2020 ($ million)15 Age Cohort 2016 2017 2018 2019 2020 Share of total cost Under 35 years 113.3 116.3 119.4 122.5 125.2 7% 35 to 44 years 177.2 183.5 190.5 197.8 204.3 11% 45 to 54 years 290.2 291.9 298.0 299.2 301.0 18% 55 to 64 years 383.7 400.6 417.6 433.1 444.6 25% 65 to 74 years 309.2 328.5 348.4 369.8 391.6 21% 75 years + 303.0 315.5 329.8 345.2 360.1 20% All ages 1,566.8 1,617.9 1,670.5 1,724.2 1,773.1 100% B) Deliver Immediate Federal Support to Canada's Unpaid Caregivers There are approximately 8.1 million Canadians serving as informal, unpaid caregivers with a critical role in Canada's health and social sector.16 The Conference Board of Canada reports that in 2007, informal caregivers contributed over 1.5 billion hours of home care - more than 10 times the number of paid hours in the same year.17 The economic contribution of informal caregivers was estimated to be about $25 billion in 2009.18 This same study estimated that informal caregivers incurred over $80 million in out-of-pocket expenses related to caregiving in 2009. Despite their tremendous value and important role, only a small fraction of caregivers caring for a parent receive any form of government support.19 Only 5% of caregivers providing care to parents reported receiving financial assistance, while 28% reported needing more assistance than they received.20 It is clear that Canadian caregivers require more support. As a first step, the CMA recommends that the federal government amend the Caregiver and Family Caregiver Tax Credits to make them refundable. This would provide an increased amount of financial support for family caregivers. It is estimated that this measure would cost $90.8 million in 2016-17.21 C) Implement a new Home Care Innovation Fund The CMA strongly supports the federal government's significant commitment to deliver more and better home care services, as released in the mandate letter for the Minister of Health. Accessible, integrated home care has an important role in Canada's health sector, including addressing alternate level of care (ALC) patients waiting in hospital for home care or long-term care. As highlighted by CIHI, the majority of the almost 1 million Canadians receiving home care are aged 65 or older.22 As population aging progresses, demand for home care can be expected to increase. Despite its importance, it is widely recognized that there are shortages across the home care sector.23 While there are innovations occurring in the sector, financing is a key barrier to scaling up and expanding services. To deliver the federal government's commitment to increasing the availability of home care, the CMA recommends the establishment of a new targeted home care innovation fund. As outlined in the Liberal Party of Canada's election platform, the CMA recommends that the fund deliver $3 billion over four years, including $400 million in the 2016-17 fiscal year. Question 2: What infrastructure needs can best help grow the economy...and meet your priorities locally? Deliver Federal Investment to the Long-term Care Sector as part of Social Infrastructure All jurisdictions across Canada are facing shortages in the continuing care sector. Despite the increased availability of home care, research commissioned for the CMA indicates that demand for continuing care facilities will surge as the demographic shift progresses.24 In 2012, it was reported that wait times for access to a long-term care facility in Canada ranged from 27 to over 230 days. More than 50% of ALC patients are in these hospital beds because of the lack of availability of long-term care beds25. Due to the significant difference in the cost of hospital care (approximately $846 per day) versus long-term care ($126 per day), the CMA estimates that the shortages in the long-term care sector represent an inefficiency cost to the health care system of $2.3 billion a year.26 Despite the recognized need for infrastructure investment in the continuing care sector, to date, this sector has been unduly excluded from federal investment in infrastructure, namely the Building Canada Plan. The CMA recommends that the federal government include capital investment in continuing care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure. Based on previous estimates, the CMA recommends that $540 million be allocated for 2016-17 (Table 2), if implemented on a cost-share basis. Table 2: Estimated cost to address forecasted shortage in long-term care beds, 2016-20 ($ million)27 Forecasted shortage in long term care beds Estimated cost to address shortage Federal share to address shortage in long term care beds (based on 1/3 contribution) 2016 6,028 1,621.5 540.5 2017 6,604 1,776.5 592.2 2018 8,015 2,156.0 718.7 2019 8,656 2,328.5 776.2 2020 8,910 2,396.8 798.9 Total 38,213 10,279.3 3,426.4 In addition to improved delivery of health care resources, capital investment in the long-term care sector would provide an important contribution to economic growth. According to previous estimates by the Conference Board of Canada, the capital investment needed to meet the gaps from 2013 to 2047 would yield direct economic benefits on an annual basis that include $1.23 billion contribution to GDP and 14,141 high value jobs during the capital investment phase and $637 million contribution to GDP and 11,604 high value jobs during the facility operation phase (based on an average annual capital investment). Question 3: How can we create economic growth, protect the environment, and meet local priorities while ensuring that the most vulnerable don't get left behind? Deliver new Funding to Support the Provinces and Territories in Meeting Seniors Care Needs Canada's provincial and territorial leaders are struggling to meet health care needs in light of the demographic shift. This past July, the premiers issued a statement calling for the federal government to increase the Canada Health Transfer (CHT) to 25% of provincial and territorial health care costs to address the needs of an aging population. It is recognized that as an equal per-capita based transfer, the CHT does not currently account for population segments with increased health needs, specifically seniors. The CMA was pleased that this issue was recognized by the Prime Minister in his letter last spring to Quebec Premier Philippe Couillard. However, the CMA is concerned that an approach to modify the transfer formula would potentially delay the delivery of federal support to meet the needs of an aging population. As such, rather than the transfer formula, the CMA has developed an approach that delivers support to jurisdictions endeavoring to meet the needs of their aging populations while respecting the transfer arrangement already in place. The CMA commissioned the Conference Board of Canada to calculate the amount for the top-up to the CHT using a needs-based projection. The amount of the top-up for each jurisdiction is based on the projected increase in health care spending associated with an aging population. To support the innovation and transformation needed to address the health needs of the aging population, the CMA recommends that the federal government deliver additional funding on an annual basis beginning in 2016-17 to the provinces and territories by means of a demographic-based top-up to the Canada Health Transfer (Table 3). For the fiscal year 2016-17, this top-up would require $1.6 billion in federal investment. Table 3: Allocation of the federal demographic-based top-up, 2016-20 ($million)28 Jurisdiction 2016 2017 2018 2019 2020 All of Canada 1,602.1 1,663.6 1,724.2 1,765.8 1,879.0 Ontario 652.2 677.9 692.1 708.6 731.6 Quebec 405.8 413.7 418.8 429.0 459.5 British Columbia 251.6 258.7 270.3 270.1 291.3 Alberta 118.5 123.3 138.9 141.5 157.5 Nova Scotia 53.6 58.6 62.3 64.4 66.6 New Brunswick 45.9 50.7 52.2 54.1 57.2 Newfoundland and Labrador 29.7 30.5 33.6 36.6. 46.1 Manitoba 28.6 30.6 33.5 32.5 36.6 Saskatchewan 3.5 4.9 7.3 12.7 15.4 Prince Edward Island 9.1 9.7 10.6 10.9 11.5 Yukon 1.4 2.6 2.1 2.5 2.5 Question 4: Are the Government's new priorities and initiatives realistic; will they help grow the economy? Ensure Tax Equity for Canada's Medical Professionals is Maintained Among the federal government's commitments is the objective to decrease the small business tax rate from 11% to 9%. The CMA supports this commitment to support small businesses, such as medical practices, in recognition of the significant challenges facing this sector. However, it is not clear whether as part of this commitment the federal government intends to alter the Canadian-Controlled Private Corporation (CCPC) framework. The federal government's framing of this commitment, as released in the mandate letter for the Minister of Small Business and Tourism, has led to confusion and concern. Canada's physicians are highly skilled professionals, providing an important public service and making a significant contribution to our country's knowledge economy. Canadian physicians are directly or indirectly responsible for hundreds of thousands of jobs across the country, and invest millions of dollars in local communities, ensuring that Canadians are able to access the care they need, as close to their homes as possible. In light of the design of Canada's health care system, the majority of physicians are self-employed professionals and effectively small business owners. As self-employed small business owners, they typically do not have access to pensions or health benefits. In addition, as employers, they are responsible for these benefits for their employees. In addition to managing the many costs associated with running a medical practice, Canadian physicians must manage challenges not faced by many other small businesses. As highly-skilled professionals, physicians typically enter the workforce with significant debt levels and at a later stage in life. For some, entering practice after training requires significant investment in a clinic or a practice. Finally, it is important to recognize that physicians cannot pass on the increased costs introduced by governments, such as changes to the CCPC framework, onto patients, as other businesses would do with clients. For a significant proportion of Canada's physicians, the CCPC framework represents a measure of tax equity for individuals taking on significant personal financial burden and liability as part of our public health care system. As well, in many cases, practices would not make economic sense if the provisions of the CCPC regime were not in place. Given the importance of the CCPC framework to medical practice, changes to this framework have the potential to yield unintended consequences in health resources, including the possibility of reduced access to much needed care. The CMA recommends that the federal government maintain tax equity for medical professionals by affirming its commitment to the existing framework governing Canadian-Controlled Private Corporations. 3) Conclusion The CMA recognizes that the federal government must grapple with an uncertain economic forecast and is prioritizing measures that will support economic growth. The CMA strongly encourages the federal government to adopt the seven recommendations outlined in this submission as part of these efforts. In addition to making a meaningful contribution to meeting the future care needs of Canada's aging population, these recommendations will mitigate the impacts of economic pressures on individuals as well as jurisdictions. The CMA would welcome the opportunity to provide further information and its rationale for each recommendation. Summary of Recommendations 1. The CMA recommends that the federal government establish a new funding program for catastrophic coverage of prescription medication; this would be a positive step toward comprehensive, universal coverage for prescription medication. 2. The CMA recommends that the federal government support inviting the private health insurance industry to participate in the work of the pan-Canadian Pharmaceutical Alliance. 3. The CMA recommends that the federal government amend the Caregiver and Family Caregiver Tax Credits to make them refundable. 4. To deliver the federal government's commitment to increasing the availability of home care, the CMA recommends the establishment of a new targeted home care innovation fund. 5. The CMA recommends that the federal government include capital investment in continuing care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure. 6. The CMA recommends that the federal government deliver additional funding on an annual basis beginning in 2016-17 to the provinces and territories by means of a demographic-based top-up to the Canada Health Transfer. 7. The CMA recommends that the federal government maintain tax equity for medical professionals by affirming its commitment to the existing framework governing Canadian-Controlled Private Corporations. References 1 Statistics Canada. Population projections: Canada, the provinces and territories, 2013 to 2063. The Daily, Wednesday, September 17, 2014. Available: http://www.statcan.gc.ca/daily-quotidien/140917/dq140917a-eng.htm 2 Statistics Canada. Canada year book 2012, seniors. Available: www.statcan.gc.ca/pub/11-402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm 3 Conference Board of Canada. A difficult road ahead: Canada's economic and fiscal prospects. Available: http://canadaspremiers.ca/phocadownload/publications/conf_bd_difficultroadahead_aug_2014.pdf. 4 Canadian Institute for Health Information. National health expenditure trends, 1975 to 2014. Ottawa: The Institute; 2014. Available: www.cihi.ca/web/resource/en/nhex_2014_report_en.pdf 5 Calculation by the Canadian Medical Association, based on Statistics Canada's M1 population projection and the Canadian Institute for Health Information age-sex profile of provincial-territorial health spending. 6 CIHI. National Health Expenditure Trends,1975 to 2015. Available: https://secure.cihi.ca/free_products/nhex_trends_narrative_report_2015_en.pdf. 7 Finance Canada. Update of Economic and Fiscal Projections 2015. http://www.budget.gc.ca/efp-peb/2015/pub/efp-peb-15-en.pdf. 8 CIHI. National Health Expenditure Trends,1975 to 2015. Available: https://secure.cihi.ca/free_products/nhex_trends_narrative_report_2015_en.pdf. 9 Office of the Parliamentary Budget Officer. Fiscal sustainability report 2015. Ottawa: The Office; 2015. Available: www.pbo-dpb.gc.ca/files/files/FSR_2015_EN.pdf 10 IBM for the Pan-Canadian Pharmaceutical Alliance. Pan Canadian Drugs Negotiations Report. Available at: http://canadaspremiers.ca/phocadownload/pcpa/pan_canadian_drugs_negotiations_report_march22_2014.pdf . 11 Morgan SG, Martin D, Gagnon MA, Mintzes B, Daw JR, Lexchin J. Pharmacare 2020: The future of drug coverage in Canada. Vancouver: Pharmaceutical Policy Research Collaboration, University of British Columbia; 2015. Available: http://pharmacare2020.ca/assets/pdf/The_Future_of_Drug_Coverage_in_Canada.pdf 12 Angus Reid Institute. Prescription drug access and affordability an issue for nearly a quarter of Canadian households. Available: http://angusreid.org/wp-content/uploads/2015/07/2015.07.09-Pharma.pdf 13 Statistics Canada. Survey of household spending. Ottawa: Statistics Canada; 2013. 14 Canadian Institute for Health Information. How Canada compares: results From The Commonwealth Fund 2014 International Health Policy Survey of Older Adults. Available: www.cihi.ca/en/health-system-performance/performance-reporting/international/commonwealth-survey-2014 15 Conference Board of Canada. Research commissioned for the CMA, July 2015. 16 Statistics Canada. Family caregivers: What are the consequences? Available: www.statcan.gc.ca/pub/75-006-x/2013001/article/11858-eng.htm 17 Conference Board of Canada. Home and community care in Canada: an economic footprint. Ottawa: The Board; 2012. Available: http://www.conferenceboard.ca/cashc/research/2012/homecommunitycare.aspx 18 Hollander MJ, Liu G, Chappeel NL. Who cares and how much? The imputed economic contribution to the Canadian health care system of middle aged and older unpaid caregivers providing care to the elderly. Healthc Q. 2009;12(2):42-59. 19 Government of Canada. Report from the Employer Panel for Caregivers: when work and caregiving collide, how employers can support their employees who are caregivers. Available: www.esdc.gc.ca/eng/seniors/reports/cec.shtml 20 Ibid. 21 Conference Board of Canada. Research commissioned for the CMA, July 2015. 22 CIHI. Seniors and alternate level of care: building on our knowledge. Available: https://secure.cihi.ca/free_products/ALC_AIB_EN.pdf. 23 CMA. A policy framework to guide a national seniors strategy for Canada. Available: https://www.cma.ca/Assets/assets-library/document/en/about-us/gc2015/policy-framework-to-guide-seniors_en.pdf. 24 Conference Board of Canada. Research commissioned for the CMA, January 2013. 25 CIHI. Seniors and alternate level of care: building on our knowledge. Available: https://secure.cihi.ca/free_products/ALC_AIB_EN.pdf 26 CMA. CMA Submission: The need for health infrastructure in Canada. Available: https://www.cma.ca/Assets/assets-library/document/en/advocacy/Health-Infrastructure_en.pdf. 27 Ibid. 28 Conference Board of Canada. Research commissioned for the CMA, July 2015.
Documents
Less detail

Notes for an address by Dr. Eugene Bereza, Chair, Committee on Ethics, Canadian Medical Association : Bill C-13 - An act respecting assisted human reproduction : Presentation to the House of Commons Standing Committee on Health

https://policybase.cma.ca/en/permalink/policy1963
Last Reviewed
2010-02-27
Date
2002-11-20
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2010-02-27
Date
2002-11-20
Topics
Ethics and medical professionalism
Text
BILL C-13 - AN ACT RESPECTING ASSISTED HUMAN REPRODUCTION Presentation to the House of Commons Standing Committee on Health Ottawa, Ontario November 20, 2002 BILL C-13 - AN ACT RESPECTING ASSISTED HUMAN REPRODUCTION Madame Chair and Members of the Committee: My name is Dr. Eugene Bereza. I am a physician and clinical ethicist at the Royal Victoria Hospital in Montreal and Chair of the Canadian Medical Association Committee on Ethics. I am here today representing our members, more than 54,000 physicians from across Canada. I also wish to speak as a advocate for our patients, especially those affected by infertility and those who are or will suffer from diseases for which medical science is searching for cures. I am accompanied today by Dr. John Williams, our Director of Ethics. You will recall that we appeared before this Committee on October 23, 2001 in company with representatives from eight other national health provider and scientific organizations to present our views on draft legislation on assisted human reproduction. Although we were pleased that your December 2001 report recommended the establishment of an assisted reproduction regulatory body outside the Department of Health, we were disappointed that you did not find favour with other recommendations we put forward. The government responded to your report with Bill C-56, now Bill C-13. It is this bill that we are here to address today. Although there are many details in the bill on which we would like either clarification or changes, we intend to focus our remarks on the issue that we consider of greatest importance for our patient’s wellfare and the practice of medicine. That issue is the use of the criminal power to deal with medical and scientific activities. The Standing Committee Report and Bill C-13 In your December 2001 report, you acknowledged our position on this issue: “Some witnesses recommended the elimination of the prohibited activities category altogether. Citing the benefits of regulatory flexibility, they felt that all activities should come under the controlled activity category, including the more reprehensible activities like reproductive cloning for which licences, arguably, would never be allowed under the regulations” (page 9). However, you rejected this view on the grounds that “a licence-related prohibition of this sort would not carry the same weight or degree of social censure as the statutory prohibition…. An outright statutory ban signals more clearly that certain activities are either unsafe or socially unacceptable. The use of the statutory ban also signals that these activities are of such concern to Canadians that their status as a prohibited activity may not be altered except with the approval of Parliament” (page 9). Bill C-13 reflects your views on this matter. We recognize your good faith in proposing and defending this position but we are convinced that its potential for harm outweighs its potential benefits. And so we are pleased to have this opportunity to reiterate the reason why the CMA believes that Bill C-13 will adversely affect the patient-physician relationship and the advance of medical science. Need to Change Bill C-13 As you know, our position on this matter is supported by legal scholars such as Patrick Healy, McGill University Faculty of Law, Tim Caulfield, Director of the University of Alberta Health Law Institute, and Bartha Knoppers, Université de Montréal Centre de Recherche en Droit Publique. In essence, our position is that the criminal law is a blunt instrument and very difficult to change and is therefore appropriate for activities whose status is unlikely to change over time, such as murder and theft, rather than medical and scientific activities that are constantly developing. The latter are better left to a representative regulatory body to determine if and when changes in health and safety considerations and public attitudes and values might justify allowing certain formerly prohibited activities to take place under specific conditions. Bill C-13 begins with the statement: “This enactment prohibits assisted reproduction procedures that are considered to be ethically unacceptable.” This echoes the conclusions in your report. However, as the transcripts of your hearings demonstrate, many Canadians, especially those who are infertile, do not consider some or all of these procedures to be ethically unacceptable. As a matter of public policy, should Canadians who hold this view be denied access to medical treatment for infertility because others consider such treatments to be ethically unacceptable? Should patients who suffer from conditions for which research that is forbidden in Bill C-13 might lead to a cure be denied that opportunity? We question whether criminal prohibitions are appropriate for dealing with activities on which there is considerable ethical disagreement among Canadians. In Canada legislators have been justifiably reluctant to use the criminal law to deal with medical and scientific issues such as abortion, withdrawal of life-sustaining treatment and the conduct of medical research. Why is an exception being made for assisted reproduction? What sort of precedent will this set for other controversial bioethical issues? We are also concerned about the bill’s penalties for infractions: jail terms up to 10 years and fines up to $500,000. These are disproportionate to the penalties for crimes that injure persons or property and, as such, will create a climate of undue fear and excessive caution for physicians and scientists working in this area, such that they will avoid any activity that is potentially covered by the bill, even to the detriment of patient care. Given the rapid advance of science and medical practice and the difficulty of anticipating new developments, it will be difficult to adjust the law to deal with new applications of prohibited activities that may be ethically acceptable. An Alternate Solution The CMA has stated repeatedly that we are not opposed to the prohibition of certain assisted human reproduction activities. Instead of instituting criminal prohibitions within the legislation, we remain convinced that an independent body on an ongoing basis should determine the activities that are permissible or prohibited on the basis of up-to-date scientific research, public input and ethical review. This can be accomplished very easily in Bill C-13 by moving the procedures listed under “Prohibited Activities” (sections 5-9) to “Controlled Activities” and adding the words “except in accordance with the regulations and a licence” to each of the provisions in sections 5-9. Consistent with this recommendation we consider that the regulatory agency should be established as soon as possible and be given as much authority as possible over the matters that Bill C-13, section 65, reserves to regulations of Governor in Council. We hope that the agency will build upon the experience and expertise of existing organizations and structures in the field of assisted reproduction that deal with practice standards, education, certification and accreditation. Conclusion To summarize, we strongly support government efforts to regulate assisted human reproduction and related activities, including the prohibition of certain practices either temporarily or permanently. However, like others who have appeared before this Committee, we do not believe that criminalizing the medical and scientific activities named in the bill is an appropriate way to achieve those objectives. We consider that the objectives could be as well achieved by far less drastic means than criminalization and, moreover, that criminalization would create major obstacles to legitimate medical and scientific progress in the treatment of infertility. We recommend that the proposed agency be empowered to regulate these practices and that the criminal power be invoked when controlled activities are performed without authority of a licence from the agency or in defiance of the licensing conditions established by the agency. Thank you, Madame Chair and members of the Committee. We will be pleased to respond to your questions.
Documents
Less detail

Notes for an address by Dr. Peter Barrett, Past-President, Canadian Medical Association : Public hearings on primary care reform : Presentation to the Standing Senate Committee on Social Affairs, Science and Technology

https://policybase.cma.ca/en/permalink/policy2011
Last Reviewed
2020-02-29
Date
2002-05-22
Topics
Health systems, system funding and performance
Health human resources
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2002-05-22
Topics
Health systems, system funding and performance
Health human resources
Text
On behalf of the 53,000 physician members of the CMA, we appreciate the opportunity to offer our thoughts on the issue of primary care reform and the recommendations made recently in your April 2002 report. I am very pleased to be presenting today with my CMA colleague, Dr. Susan Hutchison, Chair of our GP Forum along with Dr. Elliot Halparin and Dr. Kenneth Sky from the Ontario Medical Association. Before I begin presenting the CMA’s recommendations, I believe it’s important to make a few points clear in regard to primary care: * First, is that Canada has one of the best primary care systems in the world. (Just ask Canadians, we have. Our 2001 Report Card showed that 60% of Canadians believe that we have one of the best health care systems in the world and gave high marks for both quality of service and system access). * Second, is that primary care reform is not the panacea for all that ails Medicare. * And finally, primary care and specialty care are inextricably linked. I like to expand a bit on the last point because I think it’s an important consideration. There is a tendency to separate medical care into two areas; primary care and specialty care. However, we need to recognize that medical and health care encompasses a broad spectrum of services ranging from primary prevention to highly specialized quaternary care. Primary care and specialty care are so critically interdependent that we need to adapt an integrated approach to patient care. Now, in respect to the CMA’s recommendations on implementing changes for the delivery of primary care, we believe that government must respect the following four policy premises: 1. All Canadians should have access to a family physician. 2. To ensure comprehensive and integrated care, family physicians should remain as the central provider and coordinator of timely access to publicly-funded medical services. 3. There is no single model that will meet the primary care needs of all communities in all regions of the country. 4. Scopes of practice should be determined in a manner that serves the interests of patients and the public safely, efficiently, and competently. Access to Family Physicians A successful renewal of primary health care delivery cannot be accomplished without addressing the shortage of family physicians and general practitioners. The effects of an aging practitioners population, changes in lifestyle and productivity, along with the declining popularity of this field as the career choice of medical school graduates are all having an impact on the supply of family physician. Physician as Central Coordinator While multistakeholder teams offer the potential for providing a broader array of services to meet patients’ health care needs, it is also clear that for most Canadians, having a family doctor as the central provider for all primary medical care services is a core value. As the College of Family Physicians of Canada (CFPC) indicated in its submission to the Royal Commission on the Future of Health Care in Canada, research shows that over 90% of Canadians seek advice from a family physician as their first resource in the health care system. The CFPC also noted that a recent Ontario College of Family Physicians Decima public opinion survey found that 94% agree that it is important to have a family physician who provides the majority of care and co-ordinates the care delivered by others. i A family physician as the central coordinator of medical services ensures efficient and effective use of system resources as it allows for only one entry point into the health care system. This facilitates a continuity of care, as the family physician generally has developed an ongoing relationship with his or her patients and as a result is able to direct the patient through the system such that the patient receives the appropriate care from the appropriate provider. No Single Model for Reform In recent years, several government task force and commission reports, including the report of this Committee, have called for primary care reform. Common themes that have emerged include; 24/7 coverage; alternatives to fee-for-service payment of physicians; nurse practitioners and health promotion and disease prevention. Governments across the country have launched pilot projects of various models of primary care delivery. It is critical that these projects are evaluated before they are adopted on a grander scale. Moreover, we must take into account the range of geographical settings across the country, from isolated rural communities to the highly urbanized communities with advanced medical science centres. Scopes of Practice There is a prevailing myth that physicians are a barrier to change when in fact the progressive changes in the health care system have been more often than not physician lead. Canadian physicians are willing to work in teams and the CMA has developed a “Scopes of Practice” policy that clearly supports a collaborative and cooperative approach. A policy that has been supported in principle by the Canadian Nurses Association and the Canadian Pharmacists Association. Because of the growing complexity of care, the exponential growth of knowledge, and an increased emphasis on health promotion and disease prevention, primary care delivery will increasingly rely on multi-stakeholder teams. This is a positive development. However, expanding the primary care team to include nurses, pharmacists, dieticians, and others, while desirable, will cost the system more, not less. Therefore, we need to change our way of thinking about primary care reform. We need to think of it as an investment. We need to think of it not in terms of cost savings but as a cost-effective way to meet the emerging unmet needs of Canadians. Conclusion To conclude, there is no question that primary care delivery needs to evolve to ensure it continues to meet the needs of Canadians. But we see this as making a good system better, not fundamental reform. Thank you. i College of Family Physicians of Canada. Shaping The Future of Health Care: Submission to the Commission on the Future of Health Care in Canada. Ottawa: CFPC; Oct 25, 2001.
Documents
Less detail

A Prescription for SUFA : CMA Submission to the F/P/T Ministerial Council on Social Policy Renewal

https://policybase.cma.ca/en/permalink/policy1961
Last Reviewed
2010-02-27
Date
2002-10-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2010-02-27
Date
2002-10-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health systems, system funding and performance
Text
It has been over three years since the Social Union Framework Agreement (SUFA) was signed by the federal and provincial/territorial governments, with the exception of Quebec. At the time, it was heralded as an important breakthrough in federal-provincial relations that would clear the way for greater intergovernmental cooperation on pressing social policy issues such as health care renewal. Functional federalism is essential to achieving social policy objectives that will be of benefit to Canadians from coast to coast. While SUFA may not be perfect, it is better than the alternative of federal-provincial paralysis and dysfunction. And as SUFA acknowledges, Canada’s social union is about more that how governments relate to each other: it is about how governments can and should work with external stakeholders and individual Canadians to improve the social policies and programs. The health sector is an important test case for SUFA. It is the most cherished of Canada’s social programs. Canadians want and expect their governments to work together to improve the health care system and ensure its future sustainability. Ironically, it is also the area where government intergovernmental discord has been the greatest. On the eve of the final report of the Commission on the Future of Health Care in Canada, it is timely to reflect on SUFA and its role in the renewal of Canada’s health system. SUFA and the Health Sector – Strengths and Weaknesses The attached table provides a summary of the key elements of SUFA and the CMA’s assessment of how well SUFA provisions have been applied in the health sector. On the positive side, the health sector has fared relatively well in the area of mobility within Canada. Physicians and other regulated health care providers generally enjoy a high degree of mobility. Portability of hospital and medical benefits is largely ensured through interprovincial eligibility and portability agreements. There are, however, two areas of concern. First, there is the longstanding failure to resolve the non-portability of medical benefits for Quebec residents. Second, there is growing disparity in coverage for services that are currently not subject to national standards under the Canada Health Act, particularly prescription drugs and home care. In the area of dispute avoidance and resolution, governments have agreed to a formal process to address concerns with the Canada Health Act. This is a positive step, though few details have been made public. The real test will be whether this new process accelerates the resolution of non-compliance issues (most of which, as the Auditor-General recently pointed out, have remained unresolved for five years or longer), and whether the federal government will have the political will to levy discretionary penalties for non-compliance. There has also been progress on public accountability and transparency as governments have begun reporting results in 14 health indicator areas pursuant to the September 2000 health accord. The CMA is disappointed, however, that governments did not fulfil their pledge to involve stakeholders at all levels in the development of these indicators. Moreover, governments have short-changed Canadians by not providing them with a national roll-up of indicators that would facilitate comparisons across jurisdictions. Looking to the future, it will be critical to put in place a process that moves from benchmarks (indicators) to the bedside (best practices, better outcomes). This must be done in collaboration with health care researchers, providers and health managers—those individuals who understand the importance of taking research and importing it into practice. Clinical researchers across the country are doing this work and must to be supported. Overshadowing these relative successes in the first three years of the Social Union Framework Agreement are three key challenges that must be addressed: * inadequate institutional mechanisms to improve accountability across the system * failure to reduce uncertainty about what the health system will deliver, now and into the future * resistance on the part of governments to engage stakeholders in a true partnership for health system renewal The CMA is concerned that if these fundamental weaknesses are not addressed, they will undermine future attempts to renew Canada’s health system. Improving accountability With the adoption of SUFA, governments have significantly increased emphasis on performance measurement and public reporting. While this is a positive development, it also has the potential to lead towards information overload and paralysis, unless two critical elements are addressed. First, there is a need for a clear accountability framework that sets out the roles, rights and responsibilities of all key players in Canada’s health system: patients, health care providers and governments. This, in turn, requires the creation of a credible arm’s length institution to monitor compliance with this framework and rise above the fray to give Canadians the straight goods on health care. One has to look no further that the recent rekindling of the so-called “shares debate” between the federal and provincial governments as an example of why these changes are necessary. Reducing uncertainty Over the past decade, Canada’s health system has been plagued by an escalating crisis of uncertainty. Patients have faced increasing uncertainty about the accessibility and timeliness of essential health care services. Health care providers have seen working conditions deteriorate. Employers and private insurers have seen their contribution to funding health services increase unpredictably as governments have scaled back their funding commitments. Furthermore, provincial and territorial governments have had to contend with an unstable federal funding partner. Canadians deserve better. They need more certainty that their public health system will care for them when they need it most. They need more transparency from governments about “what’s in” and “what’s out” in terms of public or private coverage. They need their governments to act on their SUFA undertaking to make service commitments for social programs publicly available such as establishing standards for acceptable waiting times for health care. And they need governments to follow through with their SUFA commitment to ensure stable and adequate funding for the health system and other social programs. Fostering real partnerships In the health care field, deliberations and agreements have taken place behind closed doors and governments have discounted the role that non-governmental organizations and citizens should play in decision-making. It is these very providers and patients who are expected to implement and live with the results of such cloistered decision-making. The consequences of this systematic exclusion are all too evident in the current critical and growing shortages of physicians, nurses and other health professionals. If we are to achieve the vision of a sustainable Medicare program, it is critical that governments come clean on their SUFA commitment to work in partnership with stakeholders and ensure opportunities for meaningful input into social policies and programs. CMA’s Prescription for Sustainability – Building on SUFA The Social Union Framework Agreement has created the necessary, but not sufficient, conditions for health system renewal. It has codified the emerging consensus on federal-provincial relations and has clarified the "rules of the game". However, it is an enabling framework that is of limited value in the health sector unless it is given life through institutional mechanisms that establish enduring partnerships not just between governments, but between governments health care providers, and patients. In its final submission to the Commission on the Future of Health Care in Canada entitled “Prescription for Sustainability”, the CMA proposes the implementation of three integrated “pillars of sustainability” that together would improve accountability and transparency in the system: a Canadian Health Charter, a Canadian Health Commission, and federal legislative renewal. Canadian Health Charter A Canadian Health Charter would clearly articulate a national health policy that sets out our collective understanding of Medicare and the rights and mutual obligations of individual Canadians, health care providers, and governments. It would also underline governments’ shared commitment to ensuring that Canadians will have access to quality health care within an acceptable time frame. The existence of such a Charter would ensure that a rational, evidence-based, and collaborative approach to managing and modernizing Canada’s health system is being followed. Canadian Health Commission In conjunction with the Canadian Health Charter, a permanent, independent Canadian Health Commission would be created to promote accountability and transparency within the system. It would have a mandate to monitor compliance with and measure progress towards Charter provisions, report to Canadians on the performance of the health care system, and provide ongoing advice and guidance to the Conference on Federal-Provincial-Territorial ministers on key national health care issues. Recognizing the shared federal and provincial/territorial obligations to the health care system, one of the main purposes of the Canadian Health Charter is to reinforce the national character of the health system. Federal legislative renewal Finally, the CMA’s prescription calls for the federal government to make significant commitments in three areas: 1) a review of the Canada Health Act, 2) changes to the federal transfers to provinces and territories to provide increased and more targeted support for health care, and 3) a review of federal tax legislation to realign tax instruments with health policy goals. While these three “pillars” will address the broader structural and procedural problems facing Canada’s health care system, there is many other changes required to meet specific needs within the system in the short to medium term. The CMA’s Prescription for Sustainability provides specific recommendations in the following key areas: * Defining the publicly-funded health system (e.g. a more rational and transparent approach to defining core services, a “safety valve” if the public system fails to deliver, and increased attention to public health and Aboriginal health) * Investing in the health care system (e.g. human resources, capital infrastructure, surge capacity to deal with emergencies, information technology, and research and innovation) * Organization and delivery of services (e.g. consideration of the full continuum of care, physician compensation, rural health, and the role of the private sector, the voluntary sector and informal caregivers) Conclusion On balance, the Social Union Framework Agreement has been a positive step forward for social policy in Canada, though its potential is far from being fully realized. The CMA’s proposal for a Canadian Health Charter, a Canadian Health Commission and federal legislative review entail significant changes to the governance of Canada’s health system. These changes would be consistent with the Social Union Framework Agreement and would help “turn the corner” from debate to action on health system renewal. The early, ongoing and meaningful engagement of health care providers is the sine qua non of securing the long-term sustainability of Canada’s health system. Canada’s health professionals, who have the most to contribute, and next to patients – who have the most at stake – must be at the table when the future of health and health care is being discussed. The CMA’s Assessment of the Social Union Framework Agreement ANNEX [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] SUFA provisions CMA assessment Principles 1. All Canadians to be treated with fairness and equity 2. Promote equality of opportunity for all Canadians 3. Respect for the equality, rights and dignity of all Canadian women and men and their diverse needs 4. Ensure access for all Canadians to essential social programs and services of reasonably comparable quality 5. Provide appropriate assistance to those in need 6. Respect the principles of Medicare: comprehensiveness, universality, portability, public administration and accessibility 7. Promote the full and active participation of all Canadians in Canada’s economic and social life 8. Work in partnership with stakeholders and ensure opportunities for meaningful input into social policies and programs 9. Ensure adequate, affordable, stable and sustainable funding for social programs 10. Respect Aboriginal treaties and rights [#4] Progress towards the objective of ensuring access to essential health services of reasonably comparable quality is difficult to assess. First, there is no agreed-upon definition of essential health services. Second there the development of indicators and benchmarks of health care quality is still in its infancy. However, the CMA is very concerned that the system is not headed in the right direction, with growing shortages of physicians, nurses and other health care providers. According to Statistics Canada’s recently released survey on access to health care services, an estimated 4.3 million Canadians reported difficulties accessing first contact services and approximately 1.4 million Canadians reported difficulties accessing specialized services. [#6]Although there is broad support for the five principles of Medicare, there continue to be a number of longstanding violations of Canada Health Act that are not being addressed, including the portability of medical benefits for Quebec residents. The emergence of privately-owned clinics that charge patients for medically-necessary MRI scans is also cause for concern. [#8] There is no formal, ongoing mechanism for input from stakeholders and the individual Canadians in debates about national health policy issues. (See also #17 below). [#9] Ensuring adequate, affordable, and stable funding for Canada’s health system is essential to its long-term sustainability. During the 1990s, billions of dollars were siphoned out of the system to eliminate government deficits. To put Medicare back on a sustainable path, governments must make long-term funding commitments to meet the health care needs of Canadians. The CMA has recommended that the federal government should significantly increase its financial contribution to restore the federal-provincial partnership in health care, and increase accountability and transparency through a new earmarked health transfer. Mobility within Canada 11. Removal of residency-based policies governing access to social services 12. Compliance with the mobility provisions of the Agreement on Internal Trade [#11] Residency-based policies are generally not an issue for physician and hospital services, where inter-provincial portability is guaranteed through reciprocal billing arrangements. As noted above, however, the portability of medical benefits for many Quebec residents is limited because the province only reimburses out-of-province services at home-province (as opposed to host-province) rates. [#12] Regulatory authorities initiated work towards meeting the obligations of the Labour Mobility Chapter of the Agreement on Internal Trade in fall 1999. A Mutual Recognition Agreement has been developed and endorsed by all physician licensing authorities. Public accountability & transparency 13. Performance measurement and public reporting 14. Development of comparable indicators to measure progress 15. Public recognition of roles and contributions of governments 16. Use funds transferred from another order of government for purposes agreed and pass on increases to residents 17. Ensure effective mechanisms for Canadians to participate in developing social priorities and reviewing outcomes 18. Make eligibility criteria and service commitments for social programs publicly available 19. Have mechanisms in place to appeal unfair administrative practices 20. Report publicly on appeals and complaints [#13-14] Pursuant to the September 2000 Health Accord, the federal government and provinces have developed common health indicators in 14 areas and have released a first slate of reports. However, the usefulness of these reports is hampered by missing data elements on quality of care (access and waiting times in particular) and the absence of a national roll-up to facilitate inter-provincial comparisons. [#15] Continuing federal-provincial bickering about shares of health funding makes it clear that this provision is not being met. [#16] The CMA’s analysis of the Medical Equipment Fund found that incremental spending by provinces on medical technology accounted for only 60% of the $500 million transferred by the federal government for this purpose. [#17] There is no mechanism in place to ensure ongoing input from Canadians and health care providers in national health policy development. The CMA has recommended the creation of a Canadian Health Commission, with representation from the public and stakeholders to provide advice and input to governments on key national health policy issues. [#18] Although there have been proposals to this effect in a couple of provinces, governments currently do not make explicit commitments about the quality and accessibility of health services. In order to reduce the uncertainty Canadians are feeling with respect to Medicare, the CMA has recommended the creation of a Canadian Health Charter that would set out the rights and responsibilities of patients, health care providers and governments. In particular, the health charter would require all governments to set out care guarantees for timely access to health services based on the best available evidence. [#19-20] The Auditor-General recently reported that Health Canada provides inadequate reporting on the extent of compliance with the Canada Health Act. Governments working in partnership 21. Governments to undertake joint planning and information sharing, and work together to identify priorities for collaborative action 22. Governments to collaborate on implementation of joint priorities when this would result in more effective and efficient service to Canadians. 23. Advance notice prior to implementation of a major policy or program change that will substantially affect another government 24. Offer to consult prior to implementing new social policies and programs that are likely to substantially affect other governments. 25. For any new Canada-wide social initiative, arrangements made with one province/territory will be made available to all provinces/territories. 26. Governments will work with the Aboriginal peoples of Canada to find practical solutions to address their pressing needs [#21-25] The requirement for governments to work together collaboratively is perhaps the most important part of SUFA, yet there it is impossible for organizations and individuals outside of government to assess the degree to which these provisions have been met. This so-called “black box of executive federalism” is not serving Canadians well. In the health sector, there are too many examples of governments developing policy and making decisions with little or no input from those who will ultimately have to implement change. To achieve a true social union, the tenets of good collaborative working relationships – joint planning, advance notice and consultation prior to implementation – must be extended beyond the ambit of federal-provincial decision-making. The CMA’s proposal for a Canadian Health Commission would go some distance in addressing these concerns. A key part of its mandate would be to bring the perspective of health providers and patients into national health policy deliberations and decision-making. Federal spending power 27. Federal government to consult with P/T governments at least one year prior to renewal or significant funding changes in social transfers 28. New Canada-wide initiatives supported by transfers to provinces subject to: a) collaborative approach to identify Canada wide objectives and priorities b) Agreement of a majority of provincial governments c) Provincial discretion to determine detailed design to meet agreed objectives d) Provincial freedom to reinvest funding in related area if objectives are already met e) Jointly developed accountability framework 29. For new Canada-wide initiatives funded through direct transfers to individuals or organizations, federal government to provide 3-months notice and offer to consult [#27-28] There have been three new Canada-wide health initiatives supported by the federal spending power: the $500M Medical Equipment Fund, the $800 Primary Health Care Transition Fund and the $500M fund for health information technology. The Medical Equipment Fund was created to respond to a genuine need for more modern diagnostic and treatment equipment. However, objectives were vague, money was transferred with no strings attached, and there was no accountability framework. The result, as the CMA’s analysis has shown, is that a significant portion of the funding did not reach its destination. The jury is still out in the case of the Primary Care Transition Fund. Delivery of this program through normal government machinery will entail a higher degree of accountability than in the case of the Medical Equipment Fund. However, objectives of this initiative may be too broad to have a significant steering effect on the system as a whole. Canada Infoway Inc. is an arm’s length body created by the federal government to disburse the $500M in health information technology funding. While this model has the advantage of being less politicized than government-run programs; accountability to Parliament and to Canadians is weaker. Dispute avoidance & resolution 30. Governments committed to working together and avoiding disputes 31. Sector negotiations to resolve disputes based on joint fact-finding, including the use of a third party 32. Any government can require a decision to be reviewed one year after it enters into effect 33. Governments will report publicly on an annual basis on the nature of intergovernmental disputes and their resolution [#30-33] Federal and provincial governments have agreed to a formal dispute avoidance and resolution process under the Canada Health Act. The Canadian Health Commission recommended by the CMA could play a useful role as an independent fact-finder. Review of SUFA 34. By the end of the 3rd year, governments will jointly undertake a full review of the Agreement and its implementation. This review will ensure significant opportunities for input and feedback from Canadians and all interested parties, including social policy experts, the private sector and voluntary organizations. [#34] Governments have taken a minimalist approach to the SUFA review by opting for an internet-based consultation and closed meetings with invited external representatives. This approach is not sufficient. Future reviews should be more inclusive of all stakeholders. [TABLE END]
Documents
Less detail

A Prescription for sustainability

https://policybase.cma.ca/en/permalink/policy1967
Last Reviewed
2020-02-29
Date
2002-06-06
Topics
Health systems, system funding and performance
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2002-06-06
Topics
Health systems, system funding and performance
Text
Medicare emerged from the 1990s bent, but not broken — in large measure due to the tireless efforts of health professionals whose commitment has always been, first and foremost, to their patients. However, this level of effort cannot continue. Canadian health providers and the facilities they work in are stretched to the limit. Over the past decade there have been countless studies on what is wrong with Canada’s health care system. However, very little action has been taken to solve the problems identified in the reports because very few of these reports provided a roadmap with concrete recommendations on how to achieve change. Furthermore, many decisions regarding the health care system have been made by governments without meaningful input from health professionals. As we indicated in our first submission, there is clearly a need for a collaborative approach to “change management” that is based on early, ongoing and meaningful involvement of all key stakeholders. However, before consideration is given to how to solve the woes of the health care system, it is essential to establish a shared vision of Canada’s health care system. Several attempts have been made to this end; however, few have included health care providers or the public in the process. The CMA has established its own vision for a sustainable health care system, upon which the recommendations we have presented in this submission are based. To ensure that our health care system in Canada is sustainable in the future, longer-term structural and procedural reforms are required. The CMA proposes 5 recommendations involving the implementation of three integrated “pillars of sustainability” that together will improve accountability and transparency in the system. These pillars would also serve as the basis for addressing the many short- to medium-term issues facing Medicare today and into the future. To this end, we put forward 25 recommendations suggesting specific “hows” for solving these critical problems. The three “pillars” are: a Canadian Health Charter, a Canadian Health Commission, and a renewal of the federal legislative framework. A Canadian Health Charter would underline governments’ shared commitment to ensuring that Canadians will have access to quality health care within an acceptable time frame. It would also clearly articulate a national health policy that sets out our collective understanding of Medicare and the rights and mutual obligations of individual Canadians, health care providers, and governments. The existence of such a Charter would ensure that a rational, evidence-based, and collaborative approach to managing and modernizing Canada’s health system is being followed. In conjunction with the Canadian Health Charter, a permanent, independent Canadian Health Commission would be created to promote accountability and transparency within the system. It would have a mandate to monitor compliance with and measure progress towards Charter provisions, report to Canadians on the performance of the health care system, and provide ongoing advice and guidance to the Conference on Federal-Provincial-Territorial ministers on key national health care issues. Recognizing the shared federal and provincial/territorial obligations to the health care system, one of the main purposes of the Canadian Health Charter is to reinforce the national character of the health system. The federal government would be expected to make significant commitments in a number of areas, including a review of the Canada Health Act, changes to the federal transfers to provinces and territories, and a review of federal tax legislation. While these three “pillars” will address the broader structural and procedural problems facing Canada’s health care system, there are many other changes required to meet specific needs within the system in the short to medium term. The CMA has provided specific recommendations in the following key areas: * Meaningful stakeholder input and accountability * Defining the public health system (e.g. core services, a “safety valve”, Public Health, Aboriginal health) * Investing in the health care system (e.g. human resources, capital infrastructure, surge capacity, information technology, and research and innovation) * Health system financing * Organization and delivery of services (e.g. consideration of the full continuum of care, physician compensation, rural health, the private sector, the voluntary sector and informal caregivers) The following is a summary of the key recommendations set out in A Prescription for Sustainability. While we have put an emphasis on having the recommendations as self-contained as possible, readers are encouraged to consult the corresponding section of this paper as appropriate for further details. The first five recommendations refer specifically to the three pillars. The remaining recommendations address the more specific and immediate needs of the health care system. Recommendation 1 That the governments of Canada adopt a Canadian Health Charter that * reaffirms the social contract that is Medicare * acknowledges the ongoing roles of governments in terms of overall coordination and health planning * sets out the accessibility and portability rights and responsibilities of residents of Canada * sets out the rights and responsibilities of the governments, providers and patients in Canada * provides for a “Canadian Health Commission.” Recommendation 2 That a permanent Canadian Health Commission be established and operate at arm’s length from governments. The Commission’s mandate would include * monitoring compliance with the Canadian Health Charter * reporting annually to Canadians on the performance of the health care system and the health status of the population * advising the Conference of Federal-Provincial-Territorial Ministers of Health on critical issues. Recommendation 3 That the federal government undertake a review of the Canada Health Act with the view to amending it * to embody the Canadian Health Charter within it * to provide for the Canadian Health Commission and * to allow for a broader definition of core services and for certain service charges under certain terms and conditions. Recommendation 4 (a) That the federal government’s contribution to the publicly funded health care system * be harmonized with the five-year review of the federal equalization program * be locked-in for a period of five years, with an escalator tied to a three-year moving average of per capita GDP * rise to a target of 50% of provincial/territorial per capita health spending for core services * provide for notional earmarking of funds for health. (b) That the federal government create special purpose, one-time funds totalling $2.5 billion over five years (or build on existing funds) to address pressing issues in the following areas * health human resources planning * capital infrastructure * information technology * accessibility fund. Recommendation 5 That a blue ribbon panel of Parliament be established to work with the Canadian Health Commission to review the current provisions of federal tax legislation with a view to identifying ways of enhancing support for health policy objectives through tax policy. Recommendation 6 That governments and regional health authorities initiate or enhance significant efforts to secure the participation of and input from practicing physicians at all levels of health care decision-making. Recommendation 7 That all Canadians be provided coverage for a basket of core services under uniform terms and conditions. Recommendation 8 (a) That the scope of the basket of core services be determined and be updated regularly to reflect and accommodate the realities of health care delivery and the needs of Canadians. (b) That the scope of core services should not be limited by its current application to hospital and physician services, provided that access to medically necessary hospital and physician services is not compromised. Recommendation 9 (a) That the scope of the basket of core services be determined and regularly updated by a federal-provincial-territorial process that has legitimacy in the eyes of Canadians – patients, taxpayers and health care professionals. (b) That the values of transparency, accountability, evidence-based, inclusivity and procedural fairness should characterize the process used to determine the basket of core services to include under Medicare. Recommendation 10 (a) That governments develop a new framework to govern the funding of a basket of core services with a view to ensuring that * Canadians have reasonable access to core services on uniform terms and conditions in all provinces and territories * governments, providers and patients are accountable for the use of health care resources * no Canadian is denied essential care because of her or his personal financial situation. (b) That legislation be amended to permit at least some core services to be cost-shared under uniform terms and conditions in all provinces and territories. (c) That once the basket of core services is defined, minimum levels of public funding for these services be uniformly applied across provinces and territories, with flexibility for individual governments to increase the share of public funding beyond these levels. Recommendation 11 (a) That Canada’s health system develop and apply agreed upon standards for timely access to care, as well as provide for alternative care choices – a “safety valve” – in Canada or elsewhere, if the publicly funded system fails to meet these standards. (b) That the following approach be implemented to ensure that governments are held accountable for providing timely access to quality care. * First, governments must establish clear guidelines and standards around quality and waiting times that are evidence-based and that patients, providers and governments consider reasonable. An independent third-party mechanism must be put in place to measure and report on waiting times and other dimensions of health care quality. * Second, governments must develop a clear policy which states that if the publicly funded health care system fails to meet the specified agreed-upon standards for timely access to core services, then patients must have other options available to them that will allow them to obtain this required care through other means. Public funding at the home province rate would follow the patient in this circumstance, and patients would have the opportunity to purchase insurance on a prospective basis to cover any difference in cost. Recommendation 12 (a) That governments demonstrate healthy public policy by making health impact the first consideration in the development of all legislation, policy and directives. (b) That the federal government provide core funding to assist provincial and territorial authorities in improving the coordination of prevention and detection efforts and the response to public health issues among public health officials, educators, community service providers, occupational health providers, and emergency services. (c) That governments invest in the human, infrastructure and training resources needed to develop an adequate and effective public health system capable of preventing, detecting and responding to public health issues. (d) That governments undertake an immediate review of Canada’s self-sufficiency in preventing, detecting and responding to emerging public health problems and furthermore, facilitate an ongoing, inclusive process to establish national public health priorities. Recommendation 13 That the federal government adopt a comprehensive strategy for improving the health of Aboriginal peoples which involves a partnership among governments, nongovernmental organizations, universities and the Aboriginal communities. Recommendation 14 (a) That the federal government establish a $1 billion, five-year Health Resources Education and Training Fund to (1) further increase enrolment in undergraduate and postgraduate medical education (including re-entry positions), (2) expand the infrastructure (both human and physical resources) of Canada’s 16 medical schools in order to accommodate the increased enrolment and (3) enhance continuing medical education programs. (b) That the federal government increase funding targeted to institutions of postsecondary education to alleviate some of the pressures driving tuition fee increases. (c) That the federal government enhance financial support systems for medical students that are (1) non-coercive, (2) developed concomitantly or in advance of any tuition increase, (3) in direct proportion to any tuition fee increase and (4) provided at levels that meet the needs of the students. (d) That incentives be incorporated into medical education programs to ensure adequate numbers of students choose medical fields for which there is greatest need. Recommendation 15 (a) That governments and communities make every effort to retain Canadian physicians in Canada through non-coercive measures and optimize the use of existing health human resources to meet the health needs of Canadian communities. (b) That the federal government work with other countries to equitably regulate and coordinate international mobility of health human resources. (c) That governments adopt a policy statement that acknowledges the value of the health care workforce in the provision of quality care, as well as the need to provide good working conditions, competitive compensation and opportunities for professional development. Recommendation 16 (a) That a national multistakeholder body be established with representatives from the health professions and all levels of government to develop integrated health human resource strategies, provide planning tools for use at the local level and monitor supply, mix and distribution on an ongoing basis. (b) That scopes of practice should be determined in a manner that serves the interests of patients and the public, safely, efficiently, and competently. Recommendation 17 (a) That hospitals and other health care facilities conduct a coordinated inventory of capital infrastructure to provide governments with an accurate assessment of machinery and equipment. (b) That the federal government establish a one-time catch-up fund to restore capital infrastructure to an acceptable level. (see Recommendation 4(b).) (c) That governments commit to providing adequate, ongoing funding for capital infrastructure. (d) That public-private partnerships (P3s) be explored as a viable alternative source of funding for capital infrastructure investment. Recommendation 18 That the federal government cooperate with provincial and territorial governments and with governments of other countries to ensure that a strong, adequately funded emergency response system is put in place to improve surge capacity. Recommendation 19 That federal government make an additional, substantial, ongoing national investments in information technology and information systems, with the objective of improving the health of Canadians as well as improving the efficiency and effectiveness of the health care system. Recommendation 20 That governments adopt national standards that facilitate the collection, use and exchange of electronic health information in a manner which ensures that the protection of patient privacy and confidentiality are paramount. Recommendation 21 That the federal government’s investment in health research be increased to at least 1% of national health expenditures. Recommendation 22 (a) That the provincial and territorial governments’ commitment to funding core services be locked-in for an initial five-year period with an escalator tied to provincial population demographics and inflation. (b) That governments establish a health-specific contingency fund to mitigate the effects of fluctuations in the business cycle and to promote greater stability in health care financing. Recommendation 23 That any effort to change the organization or delivery of medical care take into account the impact on the whole continuum of care. Recommendation 24 (a) That governments work with the provincial and territorial medical associations and other stakeholders to draw on the successes of evaluated primary care projects to develop a variety of templates of primary care models that would * suit the full range of geographical contexts and * incorporate criteria for moving from pilot projects to wider implementation, such as cost-effectiveness, quality of care and patient and provider satisfaction. (b) That family physicians remain as the central provider and coordinator of timely access to publicly funded medical services, to ensure comprehensive and integrated care, and that there are sufficient resources available to permit this. Recommendation 25 (a) That governments develop a national plan to coordinate the most efficient access to highly specialized treatment and diagnostic services. * This plan should include the creation of defined regional centres of excellence to optimize the availability of scarce specialist services. * Any realignment of services must accommodate and compensate for the relocation of providers. * That the federal government create an accessibility fund that would support interprovincial centres of excellence for highly specialized services. Recommendation 26 That governments respect the principles contained in the CMA’s policy on physician compensation and the terms of duly negotiated agreements. Recommendation 27 That governments work with universities, colleges, professional associations and communities to develop a national rural and remote health strategy for Canada. Recommendation 28 That Canada’s health care system make optimal use of the private sector in the delivery of publicly financed health care provided that it meets the same standards of quality as the public system. Recommendation 29 That governments examine ways to recognize and support the role of the voluntary sector in the funding and delivery of health care, including enhanced tax credits. Recommendation 30 That governments support the contributions of informal caregivers through the tax system. 1. Introduction Medicare emerged from the 1990s bent, but not broken — in large measure, due to the tireless efforts of professionals whose commitment has always been, first and foremost, to their patients. But this level of effort cannot continue. Canadian health care providers and the facilities they work in are stretched to the limit. Our system is truly at a crossroads. The Commission on the Future of Health Care in Canada has a unique opportunity to sculpt a health care system that will meet the needs and expectations of Canadians for the 21st century. Fundamentals and principles of change management must be satisfied for change to be of lasting value. Decision-making processes must become more accessible, accountable and transparent to those most affected. Canadians are tired of the “blame game,” and physicians and other health providers are tired of being marginalized. Why is it that those who have the most at stake and those who have the most invested in the health system — namely patients, physicians and other providers — have the least say in system change? All parties need to be at the table. Health professionals have not been involved in an early, ongoing or meaningful way in discussions about the future of their health and health care systems. This must change. Another prerequisite for effective change is to reaffirm that there is more to health than health care. Although Canada has led the world in thinking about the overall determinants of health, the same cannot always be said when it comes to action. Canada needs broad consensus around a multi-year, national health action plan — one that is developed in collaboration with all the key players in the system and one that has clear goals, objectives and milestones. At the same time, sustainability must be seen as ensuring that Canadians have access to required services at the time and to the extent of their need. Canadians have lost confidence that the system will be there for them and for their children. Sustainability is about the legacy of Medicare. These are some of the key issues and challenges that the CMA stressed in earlier submissions to the Commission. In our first report, entitled Getting the Diagnosis Right (November 2001; see Appendix A), we described the signs and symptoms of a system in distress. Earlier this year, in our interim submission, entitled Getting It Right (Appendix B), we outlined some of the broad choices that we have to make as a society to help stabilize the Medicare “patient” and transport it into a sustainable future. As part of this future, the interim report proposed a Canadian Health Charter, which has received considerable attention. In this, our final submission to the Commission, we have built on the earlier work and ask the Commission to consider our Prescription for Sustainability. It is important to note that the recommendations we present to the Commission are integrated; and therefore we ask that they not be “cherry-picked”. This document also refers to a number of appendices that will be available as a separate volume. A great deal of policy research has been done on what changes are needed to make progress. The weak link has been in dealing with the “how.” The CMA believes that if we get the structures and processes right in terms of accountabilities, positive health outcomes will follow for our patients and for the future sustainability of the system. 2. Vision Several attempts have been made over the years to articulate a national vision for Medicare, but they have all proven inadequate. However laudable these attempts may be, they all suffer the fatal flaw of isolationism: they were all developed by governments — federal, provincial or territorial — in isolation from health care providers and the public. Goodwill, collaboration and partnership cannot be legislated or dictated from on high. In planning for the future, we have consistently argued for a values-based approach centred on a shared vision. The CMA has established a vision for Medicare that forms the basis of our recommendations for improving the design and functioning of the health care system. CMA’s Vision for a Sustainable Health System The goal of Canada’s health system is to preserve, protect and improve the health and well-being of each Canadian. This will be achieved through timely access to services that not only keep people well or restore health, but also enhance their quality of life and add longevity. Health care is an investment in both economic and social terms, providing benefits of value to both individuals and society. The objective of publicly funded health care is timely access to quality care through a defined set of core services that — as the principal building blocks of Canada’s overall health care system — must be provided on a sustainable basis. These core services must be determined and regularly reviewed in an inclusive and transparent manner. This will result in clear choices as to which services will be fully publicly funded, partly publicly funded and fully privately funded. The special nature of care related to illness — the original focus of Medicare — must continue to be recognized. Core services must reflect the immediacy with which such care is required, the potential to place a financial burden on individuals and families, and the unpredictability as to when such care will be required by an individual. Canadians should be able to choose who will provide their care, what the treatment(s) will be and where it will be provided. Every Canadian should have access to a physician of their choice and, in particular, should be encouraged to select a primary care physician who provides continuity of care. Physicians play key roles as agents and advocates for their own patients and for the public at large; they seek a health care system that respects the integrity and primacy of the patient–physician relationship. Payment and delivery mechanisms should be structured to foster and support these roles and to protect clinical and professional autonomy. Evidence-based care with explicit standards and benchmarks (e.g., maximum, acceptable waiting times) is a prerequisite to achieving high-quality health care — a primary objective of the public system. Individuals should have the opportunity to purchase health services where they are not publicly funded and where the public system does not meet agreed-upon standards. 3. Three Pillars of Sustainability The CMA believes that the current health policy decision-making system is fundamentally flawed and that three steps must be taken to help put the health of Canadians first. The three inextricably linked “pillars of sustainability” presented here are long-term structural and procedural reforms needed to improve accountability and transparency and, thus, enhance the overall sustainability of the system. In Getting the Diagnosis Right, we contended that Canadians had lost confidence that the system would be there for them and their families at the time and to the extent of their need. In our interim report, we also indicated that Canadian health care providers have never felt more demoralized or disenfranchised. The shortages of providers, poor access, resource constraints and passive privatization that occurred through most of the 1990s have combined to create uncertainties around the scope of coverage and the standard of care Canadians can expect from their health care system. The CMA believes that these uncertainties that accompany unplanned changes have also had a deleterious effect on the Canadian economy and a demoralizing effect on the health care community. On both counts, a clarification of the social contract for health is required at the highest level. 3.1 Canadian Health Charter The need to renew the social contract underlying Medicare raises a number of fundamental questions. What will this new social contract look like? Where will it be vested? Who will oversee its development and implementation? And what difference will it make for Canadians? The answers to these questions are set out below in the CMA’s proposal for a Canadian Health Charter. 3.1.1 What is it? The concept of a Canadian Health Charter is not new. The 1964 report of the Royal Commission on Health Services chaired by Justice Emmett Hall recommended a charter that set out a vision for a universally accessible system of prepaid health care, including the roles and responsibilities for individual Canadians, providers and governments. Currently, neither the Canada Health Act nor the Charter of Rights and Freedoms offers Canadians an explicit right of access to quality health care delivered within an acceptable time-frame.1 Moreover, Canadians do not have the benefit of a clearly articulated national health policy that sets out our shared understanding of Medicare and the rights and mutual obligations of individual Canadians, health care providers and governments. Without such a national policy statement to set the broad parameters around which Canada’s health system can be managed and modernized, the Medicare debate will continue to be characterized by rhetoric, hidden agendas and fruitless finger-pointing. To be certain, the notion of a Canadian Health Charter raises many issues in a decentralized federation such as Canada, where the constitutional responsibility for health care delivery lies with provinces and territories. Having examined the relevant legal, political and health policy considerations, the CMA is proposing the development and formal approval of a Canadian Health Charter based on a renewed partnership between levels of government and with the agreement of patients and providers.2 3.1.2 What would it look like? The CMA envisions a charter with three main parts: a vision statement, a section on national planning and coordination and a section on roles, rights and responsibilities. The CMA has developed an illustrative example of a charter in a separately released paper, Charter at a Glance. Vision Although there is no shortage of vision statements for Medicare, there is no single shared vision. The federal government, provinces and territories and individual stakeholders have all developed their own visions for various purposes and at various times. In some cases, such as the September 2000 Health Accord, governments have gone as far as issuing jointly approved vision statements. What is needed is for all parties to come together and achieve consensus on a shared vision that will lay out a modern view of Canada’s health system. The CMA has articulated its own vision in section 2, above. National planning and coordination The Canadian Health Charter would set out the requirement for national planning and coordination based on such principles as collaboration, evidence-based decision-making, stable and predictable funding, regional and local flexibility, and accountability. It could also specify areas where national planning and coordination are required, particularly with respect to the determination and regular review of core health care services; the development of national benchmarks for timeliness, accessibility and quality of health care; health system resources including health human resources and information technology; and the development of national goals and targets to improve the health of Canadians. The charter would also provide for the creation of a Canadian Health Commission to monitor compliance with and measure progress towards charter provisions, report to Canadians on the performance of the health care system, and provide ongoing advice and guidance to the Conference of Federal–Provincial–Territorial Ministers on key national issues. Roles, rights and responsibilities One of the key aims of the charter would be to develop a common understanding of the roles, rights and responsibilities of the key players in the renewal of Medicare. Key aspects of understanding would include * Acknowledgement of the ongoing role of governments in terms of overall coordination and health planning * Reinforcement of the accessibility and portability rights of the residents of Canada by a clear and unequivocal statement that governments must do everything in their power to provide reasonably comparable access to timely, high-quality health care3 * Establishment of the rights and responsibilities of patients, providers and governments in Canada. 3.1.3 Development and implementation of a charter Key features of our proposed Canadian Health Charter are as follows. * National mandate: It will be an inclusive document — one that is truly national as opposed to federal or interprovincial or interterritorial. * Values-based: It will be consistent with publicly accepted values and principles. * Enforceable: It will achieve compliance to its provisions through administrative mechanisms rather than through the courts. * Non-derogational: It will respect federal, provincial and territorial jurisdictional boundaries. The Canadian Health Charter will only be as good as the process put in place to develop it and to oversee its implementation. Although it may be too early to speculate on how this would be orchestrated, we make the following observations. * The development of the Canadian Health Charter will require a broad consultative process. Although this process could be led by governments, it should be developed in an inclusive manner with all stakeholders, including organizations representing health care providers and consumers. * Once consensus is reached on a proposed Canadian Health Charter, it will be important for the federal, provincial and territorial governments to give it formal approval. This could be accomplished in a number of ways, including approval at a first ministers meeting, through the elected assemblies or by way of a royal proclamation.4 Recommendation 1 That the governments of Canada adopt a Canadian Health Charter that * reaffirms the social contract that is Medicare * acknowledges the ongoing roles of governments in terms of overall coordination and health planning * sets out the accessibility and portability rights and responsibilities of residents of Canada * sets out the rights and responsibilities of the governments, providers and patients in Canada * provides for a “Canadian Health Commission.” 3.2 Canadian Health Commission What is clear from the past decade — through numerous provincial Commissions, a three-year National Health Forum, a Senate study and now the Commission on the Future of Health Care in Canada — is that strategic health planning is a never-ending challenge. This is why we need a permanent, depoliticized forum at the national level for ongoing dialogue and debate — a Canadian Health Commission. 3.2.1 Structure, composition and mandate Our thinking on the development of a Canadian Health Commission has been guided by a number of precedents and models that have been used in the Canadian context, beginning with the Dominion Council of Health, which was provided for in the Act constituting the Department of Health in 1919. It was formed to facilitate coordination with the provinces and territories and various private organizations on health matters and was the principal advisory agency to the Minister of National Health and Welfare. Membership comprised the federal deputy minister (chair), provincial deputy ministers and external members representing women’s organizations, labour, agriculture and medical science. We also examined more recent models of national advisory and oversight bodies. More details on the structures and basic mandates of these bodies are provided in Appendix C. Our assessment of these Commissions, roundtables and councils leads us to a number of conclusions about the structure and composition of the Canadian Health Commission: * Independence: The Commission should be at arm’s length from governments and have the freedom to conduct research and advise governments on a broad range of health and health care issues. However, it should have close links with government agencies such as the Canadian Institute for Health Information and the Canadian Institutes for Health Research to facilitate its work. * Transparency: The Commission should be open and transparent. We do not want to recreate the black box of executive federalism. Government representatives would be welcome as observers, and the Commission’s deliberations would be made public. * Credibility: The composition of the Commission should reflect a broad range of perspectives and expertise necessary fulfill its mandate. Appointments should not be constituency-based, to ensure that constituency politics do not interfere with the Commission’s deliberations. * Legitimacy: Although the Commission would be established by the federal government, its structure, composition and mandate will have to be legitimate in the eyes of provincial and territorial governments. * Permanence: The Commission should be permanent and it should be afforded adequate resources to do its job, subject to a regular review of its mandate and effectiveness. * Stakeholder engagement: The Commission should include representation from the general public and should seek to engage Canadians at large through research, consultation and public education activities. * Authoritative leadership: The Commission should be chaired by a Canadian Health Commissioner, who would be an officer of Parliament (similar to the Auditor General) appointed for a five-year term by consensus among the federal, provincial and territorial governments. The Health Commissioner would not be a substitute for the federal minister of health. The minister of health would continue to be responsible to Parliament for federal health policies and programs, as well as for promoting intergovernmental collaboration on a range of health and health care issues. The Commissioner would be afforded the powers necessary to conduct the affairs of the Commission, such as the power to call witnesses before hearings of the Commission. The Commission’s mandate would include the following responsibilities: * Monitor compliance with the Canadian Health Charter * Report annually to Canadians on the performance of the health care system and the health status of the population * Advise the Conference of Federal–Provincial–Territorial Ministers of Health on critical questions such as: - defining the basket of core services that would be publicly financed - establishing national benchmarks for timeliness, accessibility and quality of health care - planning and coordinating health system resources at the national level, including health human resources, information technology, and capital infrastructure - developing national goals and targets to improve the health of Canadians. Recommendation 2 That a permanent Canadian Health Commission be established and operate at arm’s length from governments. The Commission’s mandate would include * monitoring compliance with the Canadian Health Charter * reporting annually to Canadians on the performance of the health care system and the health status of the population * advising the Conference of Federal-Provincial-Territorial Ministers of Health on critical issues. 3.3 Renewing the Federal Legislative Framework Flowing from the Canadian Health Charter will be a number of moral and political obligations directed at the federal, provincial, and territorial governments, providers and patients. Recognizing the shared federal, provincial and territorial obligations to the health care system, one of the main purposes of the Charter is to reinforce the national character of Canada’s health system. The federal government would be expected to make significant commitments in a number of areas. 3.3.1 The Canada Health Act The Canada Health Act (CHA) was adopted by Parliament in 1984 as the successor to federal legislation governing cost-sharing agreements for hospital and medical insurance. Its principles have become the cornerstone of Medicare. The CHA articulates the underlying vision and values of Medicare and sets out the five conditions with which provincial and territorial health insurance plans must comply — universality, accessibility, comprehensiveness, portability and public administration — to receive the full federal financial contribution that they are entitled to under the Canada Health and Social Transfer (CHST). Thus, the Canada Health Act is the linchpin that holds together 13 separate provincial and territorial health systems. Although the CHA has been a lightning rod for several federal–provincial–territorial disputes over the years, the reasons for these disagreements have had more to do with politics than with the substance of the act. In fact, if there is one public policy issue in Canada over which there is near unanimity across provinces and territories and across political parties, it is that the principles of the CHA are sound. Recently, federal, provincial and territorial governments agreed to establish a formal dispute avoidance and resolution mechanism to deal more openly and transparently with issues arising from the interpretation of the Canada Health Act. The CMA applauds this development. In section 5.1.3 of this report, the CMA calls for the establishment of a process at the national level to determine and review regularly the basket of core services in an open, transparent and evidence-based manner. The CHA should be amended to provide for such a process. Finally, and perhaps most importantly, the CHA should be amended to reflect the Canadian Health Charter. This would include changing the preamble to ensure that it reflects a modern vision and values of Medicare, provides for a Canadian Health Commission, recognizes the federal role and reflects the accessibility and portability rights of Canadians. Recommendation 3 That the federal government undertake a review of the Canada Health Act with the view to amending it * to embody the Canadian Health Charter within it * to provide for the Canadian Health Commission and * to allow for a broader definition of core services and for certain service charges under certain terms and conditions. 3.3.2 Transfers to provinces and territories The nature of Canada’s publicly funded health care system creates unique challenges and opportunities regarding accountability and sustainability. Provinces and territories have the constitutional responsibility for health care and provide most of the funding; the federal government’s role includes funding and is based on the desire of Canadians to have the semblance of a national health care program. The CMA has been a strong advocate of stable, predictable and adequate federal funding for health care. The federal government has responded by introducing a cash floor for the CHST and by restoring some of the cuts made during the 1990s. However, the federal government still has a long way to go. Cash transfers must be increased if the federal government is to be considered a credible partner in Medicare. A larger and continuing federal role in health care financing is required, and the allocation of funds must be done more transparently and in support of a longer planning horizon. Transparency in federal funding for health care means that the federal government can no longer claim to be spending its CHST contribution three ways. Canadians have a right to know how much of their federal tax dollars is being transferred to provinces and territories to support Medicare. The same should hold for transfers related to postsecondary education and social services. Although this may be at odds with the prevailing doctrine in the ministries of finance and intergovernmental affairs, it is the least that Canadians can expect from their governments in terms of accountability. It also serves to underscore the fact that the underlying purpose of fiscal federalism is to support Medicare and other important social programs, not the reverse. In addition to the transfer of block funds to provinces and territories, the sheer magnitude and pressing nature of many issues facing Medicare warrant the use of one-time only, targeted, special-purpose transfers. Precedents for these types of transfers include the National Health Grants Program created in 1948 to develop hospital infrastructure across the country, as well as the more recent funds created to support early child development, medical equipment, the health infoway and primary care renewal. This type of approach, coupled with more stringent accountability provisions to ensure that the funds are spent as intended, should be used to address serious system shortcomings in the areas of health human resources, capital infrastructure and information technology. Recommendation 4 (a) That the federal government’s contribution to the publicly funded health care system * be harmonized with the five-year review of the federal equalization program * be locked-in for a period of five years, with an escalator tied to a three-year moving average of per capita GDP * rise to a target of 50% of provincial/territorial per capita health spending for core services * provide for notional earmarking of funds for health. (b) That the federal government create special purpose, one-time funds totalling $2.5 billion over five years (or build on existing funds) to address pressing issues in the following areas * health human resources planning * capital infrastructure * information technology * accessibility fund. 3.3.3 Tax policy in support of health In the past, the Government of Canada has relied heavily on its spending power and legislation to influence the development of Medicare across Canada. However, increasing concern associated with Canada’s health care system has obliged the federal government to maximize all its available policy levers, including taking another look at how the tax system can be used to support renewal of the health sector. Although taxes are widely used as a public policy tool, to date the role of taxation in the area of health has been relatively small. In total, personal income tax assistance (i.e., foregone government revenue) for health was estimated at $3.8 billion in 2001, equal to only a little more than 3.7% of total health expenditures for that year. The tax system interfaces with the health sector at three levels — health care financing, health care inputs and lifestyle choices. Key questions of reform that could be addressed through a review of the tax system at these levels include the following. Health care financing * Could tax incentives be used to improve access to private supplemental insurance? * How could increased tax relief be provided to people with high out-of-pocket medical expenses? * Should the tax system be used to encourage personal savings for long-term care? Health care inputs * How could tax incentives be used to address health human resource issues (e.g., attracting physicians and nurses to rural and remote areas, off-setting high costs of medical education, promoting continuing education)? * How can the federal government proceed with changes to the tax system to ensure equitable treatment of all health providers (e.g., GST)? * Could enhanced tax credits be developed to support informal caregivers? * Could tax incentives be used to promote research and innovation in health care beyond the pharmaceutical sector? Lifestyle choices * How could the tax system be used to encourage healthy lifestyles (e.g., incentives to eat well and exercise; disincentives for unhealthy choices)? The level of support provided by the tax system for people facing high out-of-pocket expenses is 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 2002? Are there ways to enhance this provision to reduce financial disincentives facing many Canadians when they have to pay for health services that may not be medically necessary, but are beneficial and worthy of government support? The CMA encourages the federal government to undertake a comprehensive review of these and other tax questions pertaining to health. Clearly, we do not believe tax policy will, by itself, solve all of the challenges facing Canada’s health care system. Nevertheless, 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. Recommendation 5 That a blue ribbon panel of Parliament be established to work with the Canadian Health Commission to review the current provisions of federal tax legislation with a view to identifying ways of enhancing support for health policy objectives through tax policy. 4. Meaningful Stakeholder Input and Accountability In the Commission’s interim report, the question was posed: why are those who have the most to contribute, who are the most committed — Canada’s health professionals — not at the table when the future of health and health care is being discussed by this country’s leaders? Physicians individually and collectively feel disempowered and disengaged. They feel frustrated, marginalized and left out at all levels of decision-making. Nowhere is this more evident than at the national level, where physicians and other health care providers have tried in vain to gain access to the “black box” of executive federalism. Physicians and other providers have been systematically excluded from participating in decisions about the future of health and health care. During the past decade, with the exception of successful joint management ventures at the provincial, territorial or regional levels, physicians have been increasingly marginalized in terms of policy decisions. At the federal–provincial–territorial level, physicians have been frozen out since the late 1980s. At the federal level, organized medicine had no opportunity for formal input to the National Forum on Health. Physicians were specifically excluded from many regional boards when they were established in the early 1990s. Finally, the consolidation of many local governance structures (e.g., hospital boards) into regional boards has reduced opportunities for local decision-making. A basic principle of justice states that those who are affected directly by decisions ought to be present when such decisions are made. Physicians, nurses and others bring much to the table. The grounds for exclusion are often not clear, but tend to be a result of the misguided notion that self-interest might prevail over the collective interest. In today’s environment, with the rapid turnover of senior health officials, we believe the pendulum must swing toward building a table where enlightened self-interest is promoted. Whereas elected officials are in the health business for only a short time, physicians and other providers have their careers on the line. We have the most invested, the most to give and, next to our patients, the most to lose. Why is it that we have the least say in decisions about the future of health and health care? Why is it that we learn about decisions after the fact and are then expected to support them? Canada has paid an enormous price for this policy of exclusion. Ill-informed policy decisions in human health resources planning have had catastrophic results. Recently, the shell game around investments in medical technology has typified how federal, provincial and territorial governments working behind closed doors tend to promote solutions that minimize friction between the two levels of government, but are of little or no concrete benefit to the health care system. We need a more transparent and accountable process. Recommendation 6 That governments and regional health authorities initiate or enhance significant efforts to secure the participation of and input from practicing physicians at all levels of health care decision-making. 5. Defining the Public Health Care System Sustainability and accountability are overarching themes of this submission, and our ultimate goal is timely access to quality care for all Canadians. The time has come to stop making excuses for rationing the publicly funded health care system. Our patients deserve health care that is available to them in a timely fashion in their own country. Canada’s physicians support publicly funded health care, but not if it means patients are denied timely access to quality care and not if it means rationing and denial of necessary care. We strongly believe that all Canadians, regardless of where they live, should have access to high-quality health care. 5.1 Core Services One of the pathways identified in our initial submission was the need to strike a better balance among everything and everyone. No country in the world has been able to provide first-dollar5 coverage for timely access to all services. In light of the rapidly transforming delivery system with its shift from institutional to community-based care, a re-examination of the Medicare “basket” is overdue. 5.1.1 Uniform coverage for all Canadians All Canadians should have coverage for basic health care services under uniform terms and conditions, regardless of where they live. A clearly defined basket of core services is an essential requirement for a national program in a decentralized system of health care such as Canada’s. This basket would ensure that a minimum level of coverage is applied uniformly across all provinces and territories. However, it is important to acknowledge that variation will occur in health care priorities across provinces and territories; as a result, provinces and territories may choose to add to this basket. Recommendation 7 That all Canadians be provided coverage for a basket of core services under uniform terms and conditions. 5.1.2 Redefining core services Since the inception of Medicare in Canada, core services have generally been understood to be those subject to the five program criteria set out in the Canada Health Act. These include medically necessary hospital services, physician services and surgical dental services provided to insured persons. However, as health care delivery has evolved, more and more services have migrated out of the hospital setting, effectively reducing the relative size of the basket of core services. For example, while hospital and physician expenditures accounted for 56% of total health spending in 1984, by 2000 this had declined to 45%. Many services previously provided in hospitals are now delivered through a combination of community-based services and drug therapy. Services that continue to be provided in hospitals are increasingly being provided on a “day surgery” basis (requiring no admission) or during a much shorter stay. If Medicare is to continue to meet the needs of Canadians, then the notion of core services must be changed to cover an array of services consistent with the realities of health care in the 21st century. Specifically, the definition of core services should be reviewed to determine the extent to which it should go beyond hospital and physician services. Recommendation 8 (a) That the scope of the basket of core services be determined and be updated regularly to reflect and accommodate the realities of health care delivery and the needs of Canadians. (b) That the scope of core services should not be limited by its current application to hospital and physician services, provided that access to medically necessary hospital and physician services is not compromised. 5.1.3 A process for clarifying what is in and what is out There is no simple way to decide what the basket of core services should include or exclude. It involves making difficult value judgements and trade-offs and achieving consensus among a broad cross-section of perspectives and interests. For several years, the CMA has advocated a balanced approach to the determination of core services that addresses the issues of ethics, quality (evidence) and economics (Appendix D). The risks of not making these difficult decisions have become all too clear: a health system that is locked into antiquated notions of health care and is increasingly out of touch with the needs of Canadians. The process used to determine core services should be inclusive and transparent. Decisions should be evidence-based and not biased in favour of any single provider or setting in which care is provided. The special nature of care related to illness should be recognized ? emergent vs. non-emergent conditions, the potential financial burden on individuals and families, and the inability to predict when such care will be required. Most important, whoever is assigned the task of defining and updating the basket of core services must have legitimacy in the eyes of the public. The CMA believes that the values listed below should characterize the process used to determine the basket of core services covered under Medicare. Values for Determining Core Services Transparency: The process and principles or rules on which decisions are based should be open to scrutiny and made public. Accountability: Decision makers should have proper authority to make these decisions and provisions should be in place for them to be held accountable for the decisions they make. Evidence-based: The decision-making process should incorporate relevant empirical evidence as available and appropriate. Inclusivity: Parties having an important stake in the decisions, should be identified, consulted and included in decision-making. Recommendation 9 (a) That the scope of the basket of core services be determined and regularly updated by a federal-provincial-territorial process that has legitimacy in the eyes of Canadians – patients, taxpayers and health care professionals. (b) That the values of transparency, accountability, evidence-based, inclusivity and procedural fairness should characterize the process used to determine the basket of core services to include under Medicare. 5.1.4 Funding core services - finding a new Canadian compromise Under the Canada Health Act, provinces and territories must ensure that medically necessary physician and hospital services are provided on a first-dollar basis. Beyond these core services, provinces and territories provide varying degrees of coverage for other services, which are funded through a mix of government funding and patient cost-sharing. Some services are completely funded from private sources. Beyond hospital and physician services, there is no uniformity across provinces and territories in the terms and conditions under which services may be partly covered under the public funding umbrella. If the basket of core services is to be expanded beyond its focus on physician and hospital care, then certain realities must be addressed. First, although first-dollar coverage may be required to maintain access to services for the most vulnerable in society, its universal application creates the illusion that health care services are free when they clearly are not. Second, given limited fiscal resources and political priorities, governments will likely not be able to afford first-dollar coverage for an expanded set of core services. Without additional funding, resources will have to be reallocated from hospital and physician services to finance other services added to the basket. This argues for a different approach to the funding of core services — one that is more pragmatic and less ideologically driven. Under this approach, health services would be divided into three categories: those that are exclusively publicly funded, those that are partly publicly funded, and those that are exclusively privately funded. The services in the first two categories would be defined as core services. As discussed earlier, the basket of core services would be determined and regularly updated by a legitimate, multistakeholder group using an evidence-based process; it should no longer be defined on the basis of whether the services are 100% publicly financed. If core services are redefined to include services that are currently financed through a mix of private and public funding, then Canadians must be prepared to review the use of first-dollar coverage to ensure that it is applied where it is most needed to maintain access to core services. Uniform terms and conditions for core services with mixed private–public funding must also be developed, i.e., by defining the minimum level of public funding from all provinces and territories. The development of uniform terms and conditions around those services that receive a mix of public and private funds has never been addressed in Canada. Even though the criteria of the Canada Health Act ? universality, accessibility, comprehensiveness, portability and public administration ? should be relatively easy to apply in a world of first-dollar coverage, Canada’s health system has not been able to satisfy all of them consistently. It is essential that these criteria be more diligently applied to core services that are funded on the basis of first-dollar coverage. In addition, they must be adapted to provide an effective framework of terms and conditions to govern access to services with mixed private–public funding. There is a need for a more rational discussion of the role of patient cost-sharing in the Canadian health care system. Many types of mechanisms for cost-sharing are in place today, including premiums, deductibles, co-payments, charges at point of service and taxation of health benefits. Here again, governments should adopt approaches that promote transparency and accountability, while ensuring that no one is denied care because they cannot afford to pay. Service charges are an acceptable part of the provision of many important health-related products and services such as pharmaceuticals and dental care. Furthermore, the Canada Health Act makes an explicit provision for chronic care co-payments. However, other services such as physician and hospital services are currently considered off-limits. Certain services that possess an “amenity” component, such as some pharmaceuticals, prostheses and certain elements of home care could continue to include a service charge to cover a portion of the service. However service charges are applied, it should be done in a fair and equitable manner that takes into consideration those at a financial disadvantage so that it does not impede access to necessary care, but encourages appropriate use of the health care system. In addition, patient cost-sharing arrangements for core services must be consistent across provinces and territories. Minimum thresholds for the public share of financing could be established for different categories of core services; however, any jurisdiction would be free to increase its share to a level above the minimum. Recommendation 10 (a) That governments develop a new framework to govern the funding of a basket of core services with a view to ensuring that * Canadians have reasonable access to core services on uniform terms and conditions in all provinces and territories * governments, providers and patients are accountable for the use of health care resources * no Canadian is denied essential care because of her or his personal financial situation. (b) That legislation be amended to permit at least some core services to be cost-shared under uniform terms and conditions in all provinces and territories. (c) That once the basket of core services is defined, minimum levels of public funding for these services be uniformly applied across provinces and territories, with flexibility for individual governments to increase the share of public funding beyond these levels. 5.2 Care Guarantee and “Safety Valve” A common frustration in recent years among many physicians and patients has been the lack of any recourse or alternative care in Canada when the publicly funded health system fails to provide timely access to health care. For Canadians, the only alternative since the inception of Medicare has been to turn to the United States or other countries for medical care. This may have been acceptable in the early days of Medicare when public funding was plentiful and the need to seek care outside of Canada was more theoretical than real; however, in 1998, the National Population Health survey estimated that some 17,000 Canadians traveled to the United States to seek medical care. Clearly, this is not an option for most Canadians. Recent court cases have held provincial governments accountable for providing timely care. An increasing number of Canadians are seeking private care in Canada, such as at private magnetic resonance imaging (MRI) clinics, even though this service is potentially in conflict with the principles of the Canada Health Act. The public has, in effect, built its own safety valve. This is a concrete example of what happens when the publicly funded system fails to respond to a legitimate demand. This gap in Canadian health policy must be addressed in a way that compels the system to provide timely care while preserving the right of Canadians to seek alternate care if the public system fails to deliver. The first step in addressing these issues is to define core services. The second step is to establish guidelines and standards around quality and waiting times that are evidence-based and that patients, providers and governments consider reasonable. To date, the best example of such benchmarking in Canada has been by the Cardiac Care Network in Ontario. The CMA has reviewed progress toward the development of benchmarks in A Canadian Health Charter: A Background Discussion Paper, which examines Canadian and international experience with health charters. We have also written a policy on operational principles for the measurement and management of waiting lists (Appendix E). If the publicly funded health care system fails to meet the specified agreed-upon standards for timely access to core services, then patients must have other options to allow them to obtain this required care through other means. Step three involves setting up a “safety valve” to address situations where the established time guarantees cannot be met. This safety valve provision would allow patients and their physicians to seek required care wherever it is available. Attempts would be made to find care geographically close to the patient — first within the province or territory, then in another province or territory or even out of country. The public funds that would have been used to pay for the patient’s care if the time guarantee had been met would be used to pay for the service wherever it is provided. In some cases, the cost of this service will be more than what would have been charged had the service been available in a timely manner from the public system in the patient’s home province or territory. Patients would be able to purchase supplementary private insurance on a prospective basis to cover this difference in cost. Ideally, Canadians would never have to use this “safety valve.” However, its inclusion in Canadian health policy will provide assurances and help restore public confidence in the health system. It will also remind governments about the repercussions of not living up to mutually agreed-upon commitments to provide timely access to care. Recommendation 11 (a) That Canada’s health system develop and apply agreed upon standards for timely access to care, as well as provide for alternative care choices – a “safety valve” – in Canada or elsewhere, if the publicly funded system fails to meet these standards. (b) That the following approach be implemented to ensure that governments are held accountable for providing timely access to quality care. * First, governments must establish clear guidelines and standards around quality and waiting times that are evidence-based and that patients, providers and governments consider reasonable. An independent third-party mechanism must be put in place to measure and report on waiting times and other dimensions of health care quality. * Second, governments must develop a clear policy which states that if the publicly funded health care system fails to meet the specified agreed-upon standards for timely access to core services, then patients must have other options available to them that will allow them to obtain this required care through other means. Public funding at the home province rate would follow the patient in this circumstance, and patients would have the opportunity to purchase insurance on a prospective basis to cover any difference in cost. 5.3 Public Health Canada has been a leader in recognizing that there is more to health than health care. The Hon. Marc Lalonde’s 1974 New Perspective on the Health of Canadians, which has since become world renowned, introduced the health field concept that emphasized the role of environmental and lifestyle determinants of health. Public health is often associated with measures to prevent illness, such as safe drinking water, sanitation, waste disposal, immunization programs, well-baby clinics or programs promoting healthy lifestyles. It is the organized response of society to protect and promote health and to prevent illness, injury and disability. Public health carries out its mission through organized, interdisciplinary efforts that address the physical, mental and environmental health concerns of the population at risk of disease and injury. These efforts require coordination and cooperation among individuals, governments (federal, provincial, territorial and municipal), community organizations and the private sector. Putting patients first means, among other things, making sure that the health system is capable of stretching to capacity to meet unforeseen circumstances. The need for this “surge capacity” is discussed in more detail in section 6.3. Canadian physicians have long recognized the value of health promotion and disease prevention and have incorporated these elements into their practices. The CMA and its divisions and affiliates have also been active in the field of public health. For its part, the CMA * Worked with the CBC on the first series of public health broadcasts * Was the first organization to call for a ban of smoking on airplanes * Developed a tool to help physicians determine medical fitness to drive * Launched a campaign to reduce traffic injuries (seatbelts, breathalyzers, etc) * Carried out a national Bicycle Helmet Safety Program * Supported warning labels on tobacco products. Public health is complex, and the current status of the public health system in Canada requires a full and open review. In 1999, the auditor general found Health Canada unprepared to fulfill its responsibilities in the area of public health: communication among multiple agencies was poor and weaknesses in the key surveillance system impeded the effective monitoring of communicable and noncommunicable diseases and injuries. It is imperative that various departments and sectors coordinate and communicate effectively to synergize efforts and to avoid duplication. The capacity of the public health care sector to deliver disease prevention and health promotion programs is inadequate, and its ability to respond varies across the country. This situation is due to a lack of trained professionals and a lack of operational funds. Greater commitment is needed from governments at all levels to ensure that adequate human resources and infrastructure are available to respond to public health issues when they arise. This includes the expansion of the public health training programs. Once a public health issue has been identified, it is the responsibility of professionals within the system to use effective means of control. The public health system must be supported by a strong and viable infrastructure to allow them to meet such challenges. Major public health issues facing Canadians include, but are not limited to, high rates of obesity, tobacco and other substance use, mental health challenges, ensuring a clean and safe environment and prevention of injury and violence. The ability of the public health system to respond to these issues directly affects the well-being of Canadians, in a manner as important as the ability of the acute care system to respond to medical emergencies. However, investment in public health initiatives must not be made at the expense of acute and long-term care. Since the 1970s, the World Health Organization and national governments around the world have paid increasing attention and put greater effort into establishing goals for improving public health and into monitoring achievement. Numerous examples can be cited in the United States, England and Australia. In Canada, although the federal government has not attempted to establish goals, several provinces have undertaken such an exercise. Public health priorities or goals are considered to be an asset to a health care system in that they * Provide a baseline assessment of a population’s health and a tracking system for monitoring change * Encourage an increase in the breadth and intensity of health improvement activities and improve the efficiency and effectiveness of existing activities * Facilitate evaluation of the impact of health improvement activities * Foster unity of purpose, organization, participation and spirit of cooperation through consensus * Build awareness of and support for health programs among policymakers and the public * Guide decision-making and funding allocations. At their meeting in September 2000, the first ministers made several commitments to improve public health * Promote the public services, programs and policies that extend beyond care and treatment and that make a critical contribution to the health and wellness of Canadians * Develop strategies and policies that recognize the determinants of health, enhance disease prevention and improve public health * Further address key priorities for health care renewal and support innovations to meet the current and emerging needs of Canadians * Report regularly to Canadians on health status, health outcomes and the performance of publicly funded health services, and the actions taken to improve these services. Unfortunately, there has been little progress to date. Canada must develop a strategic approach to sustain and strengthen the capacity of the public health system to prevent, detect and respond to public health issues. Recommendation 12 (a) That governments demonstrate healthy public policy by making health impact the first consideration in the development of all legislation, policy and directives. (b) That the federal government provide core funding to assist provincial and territorial authorities in improving the coordination of prevention and detection efforts and the response to public health issues among public health officials, educators, community service providers, occupational health providers, and emergency services. (c) That governments invest in the human, infrastructure and training resources needed to develop an adequate and effective public health system capable of preventing, detecting and responding to public health issues. (d) That governments undertake an immediate review of Canada’s self-sufficiency in preventing, detecting and responding to emerging public health problems and furthermore, facilitate an ongoing, inclusive process to establish national public health priorities. 5.4 Aboriginal health Despite improvements in many areas, First Nations, Métis and Inuit people continue to have a poorer health status than the general Canadian population. The current health status of Canada’s Aboriginal peoples is a result of a broad range of factors. It is generally acknowledged that improving it will take a lot more than simply increasing the quantity of health services. The underlying roots of the problem must be addressed; for example, poverty, low levels of education, unemployment and underemployment, exposure to environmental contaminants, inferior housing, substandard infrastructure and maintenance, low self-esteem and loss of cultural identity. A problem of this magnitude and complexity must be addressed in a comprehensive way, with all components of health, government and other sectors working in full partnership with the Aboriginal community. In recognition of this need, in February 2002 the CMA signed a letter of intent with the National Aboriginal Health Organization (NAHO) (Appendix F) to collaborate on activities in four areas of mutual interest: 1. Workforce initiatives: To increase recruitment and retention of physicians and other health professionals, particularly of Aboriginal descent, who serve Aboriginal communities. 2. Research and practice enhancement initiatives: To promote research into Aboriginal health issues and the translation of research into effective clinical practice through means such as dissemination of best-practice information and the development of user-friendly practice tools. 3. Public and community health programs: To address and develop initiatives to promote healthy living for Aboriginal communities. 4. Leadership programs: To develop and implement leadership development initiatives including mentoring programs for Aboriginal physicians. The exploration of these and other areas is essential to improve Aboriginal health status so that it is on par with the rest of the Canadian population. Recommendation 13 That the federal government adopt a comprehensive strategy for improving the health of Aboriginal peoples which involves a partnership among governments, nongovernmental organizations, universities and the Aboriginal communities. 6. Investing in the Health Care System 6.1 Health Human Resources Governments must demonstrate their commitment to the principle of self-sufficiency in the production of physicians to meet the medical needs of the Canadian population. Coverage means nothing without access, and access means nothing without availability of health care professionals. Unfortunately, there are shortages of human resources in various health care disciplines, and these shortages will be exacerbated by the demographics of the Canadian population and of each provider group and by changing public expectations. The population in general is becoming older. Older age groups experience an increased incidence of illness and disability, and thus place higher demands on the health care system. At the same time, significant numbers of health care providers are approaching retirement; in many cases, there are not enough young people entering the professions to replace those who will soon be leaving. Over the past two decades, one of the most striking changes in the medical workforce in Canada has been the increased proportion of female medical graduates: in 1980, women represented 32% of medical graduates; by 1996, this proportion reached 50%. Women now represent 30% of the practising profession in Canada and this will approach 40% by the end of the decade. Although more research is needed, it is clear that male and female physicians have different practice patterns. The changing gender distribution must be taken into consideration when examining the problem of physician supply. A more highly educated population and the widespread use of information sources such as the Internet are contributing to a heightened sense of patient empowerment, higher expectations and consumerism. These factors will increase pressure for high-quality health services. Although we encourage patients to be informed, we must be prepared for the added demands on the health system that this enhanced knowledge will create, especially in terms of the supply of health human resources. The human resources crisis is one of the most important issues facing health care today. Solutions must be found to address the many specific problems that are plaguing all health provider groups. The nursing field is suffering from many of the same challenges as physicians, including attrition and the “brain drain.” The accessibility crisis is compounded by shortages of laboratory technologists and others in the health care field, who directly support the work of physicians. Although these problems must all be addressed to make our health care system sustainable for the future, this document focuses on the professionals about whom the CMA has the greatest knowledge and expertise: physicians. 6.1.1 Supply, training and continuing education All areas of the health care continuum are experiencing a shortage of physicians. The key factors underlying this shortage include physician demographics (e.g., age and gender distribution), changing lifestyle choices and productivity levels (expectations of younger physicians and women differ from those of older generations) and the insufficient numbers entering certain medical fields. According to 2001 data from the Organisation for Economic Co-operation and Development (OECD), Canada ranked 21st out of 26 countries in terms of the ratio of practising physicians to the population. In addition to the factors affecting physician supply mentioned above, other drivers of change, such as technological innovation and information technology, are adding further pressure to an already overworked medical profession. The OECD report further states that empirical evidence shows that lower doctor numbers are closely linked with higher mortality, after taking other health determinants into consideration. Yet, in terms of female and male life expectancy at birth, Canada ranks 7th and 6th, respectively.6 This is a powerful testament to the efforts of Canadian health professionals in putting patients first. Increasing numbers of Canadians feel the impact of the widespread physician shortages when they are unable to find a family physician or they experience delays in seeing specialists. Physicians themselves are finding that they must reduce the time they can spend doing research, teaching and pursuing continuing medical education in order to focus on direct patient care. In November 1999, the Canadian Medical Forum7 (CMF) and the Society of Rural Physicians of Canada met with the federal, provincial and territorial governments to present a detailed report on physician supply containing five specific recommendations. The CMA and the other CMF organizations were encouraged to see that many jurisdictions across Canada agreed with the need to increase enrolment in undergraduate medical education programs, although we are still far from the 2,000 medical students by year 2000 that was recommended. The necessary increases in undergraduate enrolment in medicine require funding not only for the positions themselves, but also for the infrastructure (human and physical resources) needed to ensure high-quality training that meets North American accreditation standards. The concomitant increases in postgraduate positions that will be required three to four years later must also be resourced appropriately. This is in addition to the extra positions recommended in the November 1999 CMF report, which are needed to increase flexibility in the postgraduate training system; the capacity to provide training to international medical graduates; and opportunities for re-entry for physicians who have been in practice. The CMA remains very concerned about high and rapidly escalating increases in medical school tuition fees across Canada. According to data from the Association of Canadian Medical Colleges (ACMC), in just five years (1996 to 2001), average first-year medical school tuition fees increased by 100%. In Ontario, they went up by 223% over the same period. Student financial support through loans and scholarships has not kept pace with this rapid escalation in tuition fees. The CMA is particularly concerned about the impact this will have on the physician workforce and the Canadian health care system. High tuition fees will have a number of consequences. They create barriers to application to medical school and threaten the socioeconomic diversity of future physicians serving the public. They also exacerbate the “brain drain” of physicians to the United States where newly graduated physicians can pay down their large student debts much more quickly. Medical education does not end with earning the title MD; in fact, this is just the beginning of a physician’s learning. The continuously evolving nature of medicine requires that physicians remain up-to-date on emerging medical technologies, new treatment modalities and numerous other developments. In the early 1990s, the conventional wisdom was that medical knowledge was doubling every five years. Now, a time of less than two years is more commonly cited. Clearly, there is an increasing role for continuing medical education (CME), underscored by explicit requirements for self-directed activities to promote maintenance of certification for both family practitioners and specialists. Historically, this is an area where physicians have largely had to fend for themselves. For its part, the CMA has sponsored the Physician Manager Institute, which provides training for physicians moving into leadership positions. Although many provincial and territorial medical associations have negotiated CME benefits with their governments, it is essential that academic health science centres be supported to expand capacity in the area of CME. In the early days of Medicare, the federal government played a leadership role in building the infrastructure for health education through the Health Resources Fund, which distributed $500 million during 1966–1980. The purpose of this fund was to help provinces bear the capital costs of constructing, renovating and acquiring health training facilities and research institutions. More recently, the federal government supported a rebuilding of the university research infrastructure generally through the $800-million Canada Foundation for Innovation fund, which was announced in the 1997 budget, and the $900-million Canada Research Chairs program, which was announced in the 2000 budget to support the establishment of 2,000 research chairs by 2000. The health field will be a significant beneficiary of these funds. However, considering the shortage of health professionals that we face today and that will soon worsen, as well as the prospect of diminished access to professional education as a result of higher tuition, there is an urgent need for targeted federal funds to address this situation immediately. Recommendation 14 (a) That the federal government establish a $1 billion, five-year Health Resources Education and Training Fund to (1) further increase enrolment in undergraduate and postgraduate medical education (including re-entry positions), (2) expand the infrastructure (both human and physical resources) of Canada’s 16 medical schools in order to accommodate the increased enrolment and (3) enhance continuing medical education programs. (b) That the federal government increase funding targeted to institutions of postsecondary education to alleviate some of the pressures driving tuition fee increases. (c) That the federal government enhance financial support systems for medical students that are (1) non-coercive, (2) developed concomitantly or in advance of any tuition increase, (3) in direct proportion to any tuition fee increase and (4) provided at levels that meet the needs of the students. (d) That incentives be incorporated into medical education programs to ensure adequate numbers of students choose medical fields for which there is greatest need. 6.1.2 Physician retention and recruitment As important as investments in medical education may be, they will only begin to pay off in terms of increased supply of physicians in the medium- to long-term. In the short-term, shortages of family physicians and specialists will persist and possibly worsen. There is no quick fix for this problem; we must manage the best we can. This means making sure that we retain the physicians who are now practising in communities across the country. Physician turnover is a chronic problem in both rural and urban areas. The loss of a physician in a community has a very real impact in terms of continuity of care. There are unmeasured costs to patients, such distress and turmoil, as well as to the remaining physician(s) and communities that must cope with the repeated loss of valued physicians. Canada is both an exporter and an importer of physicians. The two-way flow, mainly between Canada and the United States, is tracked by the Canadian Institute for Health Information. Since tracking began in the 1960s, Canada has been a net exporter of physicians to the United States. During the mid-1990s, the net loss exceeded 400 ? roughly equal to 4 graduating medical classes. Since then, it has abated to 164 in 2000, but this is still the equivalent of 1.5 medical classes. Conversely, Canada is a net importer of physicians from the rest of the world. Although the figure is more difficult to quantify, it is estimated that Canada is a net importer of 200–400 international medical graduates, who are most typically recruited to work in rural and remote communities. Short-term responses to the physician shortage include repatriating Canadian physicians working abroad and integrating qualified international medical graduates and other providers. Canada must recognize that there is a global shortage of physicians ? and a global marketplace for our services; a widespread, organized recruitment of physicians from other countries, especially from those that are also experiencing physician shortages, is not the way to solve Canada’s health human resources problems.8 Recommendation 15 (a) That governments and communities make every effort to retain Canadian physicians in Canada through non-coercive measures and optimize the use of existing health human resources to meet the health needs of Canadian communities. (b) That the federal government work with other countries to equitably regulate and coordinate international mobility of health human resources. (c) That governments adopt a policy statement that acknowledges the value of the health care workforce in the provision of quality care, as well as the need to provide good working conditions, competitive compensation and opportunities for professional development. 6.1.3 The need for integrated health human resources planning Health human resource planning is complex. The CMA seeks to build consensus within the medical profession on major program and policy initiatives concerning the supply, mix and distribution of physicians and to work with major stakeholders in identifying and assessing issues of mutual importance. Planning for the provision of services by a broad array of providers to meet changing health care needs should focus on having the right providers in the right places doing the right things. This first requires the determination of the needed supply, mix and distribution of physicians, which will assist in the development of a similar assessment for all other providers. Resource planning must be based on the health care needs of Canadians rather than driven by cost. The CMA has developed principles and criteria for the determination of scopes of practice. The primary purpose is to meet health care needs and to serve the interests of patients and the public safely, efficiently and competently. These principles and criteria (listed below) have been endorsed by the Canadian Nurses Association and the Canadian Pharmacists Association. See Appendix G for more details. Principles and Criteria for the Determination of Scopes of Practice Principles: * Focus * Flexibility * Collaboration and cooperation * Coordination * Patient choice Criteria: * Accountability * Education * Competencies and practice standards * Quality assurance and improvement * Risk assessment * Evidence-based practices * Setting and culture * Legal liability and insurance * Regulation The CMA remains sensitive to Canada’s provincial and territorial realities with respect to the fact that health human resource planning requires assessment and implementation at the local or regional level. However, there is a need for a national body to develop and coordinate health human resources planning initiatives. Recommendation 16 (a) That a national multistakeholder body be established with representatives from the health professions and all levels of government to develop integrated health human resource strategies, provide planning tools for use at the local level and monitor supply, mix and distribution on an ongoing basis. (b) That scopes of practice should be determined in a manner that serves the interests of patients and the public, safely, efficiently, and competently. 6.2 Capital Infrastructure The crisis in health human resources is exacerbated by an underdeveloped capital infrastructure ? bricks, mortar and tools. This is seriously jeopardizing timely access to quality care within the health care system. In our 2001 discussion paper, Specialty Care in Canada, the CMA indicated there has been inadequate investment in buildings, machinery and equipment and in scientific, professional and medical devices. Provincial and territorial government spending on construction, machinery and equipment for hospitals, clinics, first-aid stations and residential care facilities has remained, on average, 16.5% below its peak in 1989. Specifically, real capital expenditures on new building construction decreased 5.3% annually between 1982 and 1998. Investment in new hospital machinery and equipment declined by 1.8% annually between 1989 and 1998. In 1998, hospital expenditures on scientific, professional and medical devices were nearly 17% below 1994 levels. While these cutbacks were occurring, significant innovations in medical technology were being introduced worldwide. Although hospitals are still providing most acute care services, whether patients are treated as inpatients or outpatients, the equipment required is not keeping pace with the growth of new technologies, the health needs of the patients and the increase and aging of the population. Equipment and machinery in the hospital sector are overaged due to a lack of replacement capital. In the absence of timely access to current and emerging health technologies, Canadians face the prospect of unrestrained progression of disease, increased stress and anxiety over their health status and, possibly, premature death. Meanwhile, society bears the direct and indirect costs associated with delayed access. On September 11, 2000, the federal government announced a new $1 billion transfer to provinces and territories for the purpose of purchasing new medical equipment. A recent analysis by the CMA found that just over half of this fund can be accounted for as being spent as intended (Appendix H). The question remains as to what has happened to the remainder of the fund. Governments have been placing a lower priority on capital investment when allocating financial resources for health care. It will not be enough simply to bring Canada’s health infrastructure up to par; a commitment to ongoing funding to maintain the equipment must also be made. This, in turn, requires continuous inventory maintenance for regular replacement. Therefore, it may be necessary for hospitals to develop innovative approaches to financing capital infrastructure. The CMA agrees with other organizations such as the Canadian Healthcare Association on the need to explore the concept of entering into public–private partnerships (P3s) 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. Recommendation 17 (a) That hospitals and other health care facilities conduct a coordinated inventory of capital infrastructure to provide governments with an accurate assessment of machinery and equipment. (b) That the federal government establish a one-time catch-up fund to restore capital infrastructure to an acceptable level. (see Recommendation 4(b).) (c) That governments commit to providing adequate, ongoing funding for capital infrastructure. (d) That public-private partnerships (P3s) be explored as a viable alternative source of funding for capital infrastructure investment. 6.3 Surge Capacity Putting patients first means, among other things, making sure that the health care system is capable of stretching its capacity to meet unforeseen circumstances, that the system is monitored for quality, that compensation is available when unintended harm occurs and that patient privacy and confidentiality are respected. The tragic events of September 11, 2001, followed closely by the distribution of anthrax through the United States postal service, provided a grim reminder of the necessity of having a strong public health infrastructure in place at all times. As was demonstrated quite vividly, we do not have the luxury of time to prepare for these events. Although it is not possible to plan for every contingency, certain scenarios can be sketched out and anticipated. To succeed, all communities must maintain a certain consistent level of public health infrastructure to ensure that all Canadian residents are protected from threats to their health. In addition to external threats, the Canadian public health system must also cope with domestic issues such as diseases created by environmental problems (e.g., asthma), sexually transmitted diseases and influenza, among many others. Even before the spectre of bioterrorism, this country’s public health experts were concerned about the infrastructure’s ability to deal with multiple crises. Like our hydro system, “surge capacity” must be built into the system nationally to enable hospitals to open beds, purchase more supplies and bring in the health care professionals they require to meet the need. The CMA’s 2001 pre-budget submission lays out comprehensive recommendations to address this issue (Appendix I). Recommendation 18 That the federal government cooperate with provincial and territorial governments and with governments of other countries to ensure that a strong, adequately funded emergency response system is put in place to improve surge capacity. 6.4 Information Technology Much of the recent debate about the future of the health care system has focused on the need to improve its adaptability and overall integration. One critical ingredient in revitalizing the system is establishing the information technology (IT) and information systems (IS) that physicians and other health care professionals must have at their disposal. Effective and efficient networks will facilitate integrated and coordinated care, as well as better management of clinical information. Although health care is information-intensive, health care systems in Canada and abroad have generally been slow to adopt IT. Other sectors of the economy have invested heavily in IT/IS over the past two decades and have reaped enormous benefits in efficiency and service to clients. IT should be viewed as a “social investment” in the acquisition of knowledge. Patients will benefit through potential reductions in rates of mortality and morbidity due to misdiagnosis and improper treatment, as well as reductions in medication errors that come with access to online drug reference databases and the virtual elimination of handwritten prescriptions. IT will permit better access to diagnostic services and online databases, such as clinical practice guidelines, that are widely available but underused. Health promotion and disease prevention will be enhanced through superior monitoring and patient education (e.g., e-libraries), and decision-making by providers and patients will be improved. These represent only a subset of the potential benefits to Canadians. A great deal of effort is currently being devoted to the development of a secure electronic health record (EHR) that provides details of all health services provided to a patient. An EHR will not generate new information on patients; it will simply make existing information more readily accessible to the physician or appropriate health care provider. We are still at the infant stage of EHRs. Implementation will require a process of continual expansion, beginning with the most basic of patient information and evolving into a comprehensive record of all of the patient’s encounters with the health care system ? as well legislation protecting personal privacy and unwarranted access. It is widely accepted in industry that 4 – 5% of financial budgets is a reasonable target for information technology spending. It is equally widely accepted that in Canada the health care sector falls well short of this target. As part of the September 2000 Health Accord, the federal government invested $500 million to create the Canada Health Infoway with a mandate to accelerate the development and adoption of modern systems of IT, such as electronic patient records. The CMA applauds this investment, but notes that the $500-million down-payment is only a fraction of the $4.1 billion that the CMA estimates it would cost to fully connect the Canadian health care system. A number of provincial and territorial governments are also moving ahead with the development of IT in health care, but further financial support is required. The CMA is prepared to play a pivotal partnership role in achieving the buy-in and cooperation of physicians and other health care providers through a multistakeholder process. Toward this end, the CMA has developed principles for the advancement of EHRs (Appendix J). The CMA’s involvement would be a critical success factor in helping the federal government make an electronic health care system a realizable goal in the years to come. Recommendation 19 That federal government make an additional, substantial, ongoing national investments in information technology and information systems, with the objective of improving the health of Canadians as well as improving the efficiency and effectiveness of the health care system. Recommendation 20 That governments adopt national standards that facilitate the collection, use and exchange of electronic health information in a manner which ensures that the protection of patient privacy and confidentiality are paramount. 6.5 Research and Innovation Research and innovation in the health sector are producing an expanding array of treatments and therapies that improve quality of life and longevity, e.g., pharmaceuticals, surgery, human genome, etc. Health research provides substantial economic, social and health care benefits to society. It * Creates high-quality, knowledge-based jobs that drive economic growth * Supports academic institutions across the country and helps train new health professionals in the latest health care technologies and techniques * Supports health care delivery and is key to maintaining centres of excellence for highly specialized care * Leads directly to better ways to treat patients and promote a healthier population. In Canada, health research is carried out by a mix of public, voluntary and private-sector organizations with the federal government being the main player in publicly funded health research. Several provinces have their own health research funding agencies. Canada’s health charities play an important role in funding research on a range of diseases and conditions. The pharmaceutical industry, especially the name-brand companies, invests heavily to develop new drugs. Recent federal investments have begun to revitalize Canada’s health research capacity. With the creation of the Canadian Institutes for Health Research (CIHR), Canada now has a modern funding agency that integrates biomedical, clinical, health services and population health research. New programs have been introduced to attract world-class scientists, modernize research infrastructure and equipment and support research in genomics. As significant as these investments have been, Canada still ranks second-to-last among G7 countries in terms of support for health research. The United States’ National Institutes of Health has a budget that is 50 times that of the CIHR for a population only 10 times bigger than Canada’s. Other countries are increasing their investment in health research to keep pace. If Canada is to improve it position vis-à-vis our key competitors, the federal government must map out a plan to increase its investment in health research to internationally competitive levels. The federal government’s investment in health research currently stands at about 0.5% of total health expenditures. There is a broad consensus in the health community that this should be increased to at least 1% of total health expenditures. Recommendation 21 That the federal government’s investment in health research be increased to at least 1% of national health expenditures. 7. Health System Financing Governments’ contributions to funding Canada’s health system should support the long-term sustainability of the system and the provision of high-quality health care for all Canadians. Governments’ contribution to Medicare should promote greater public accountability, transparency and a linkage of sources with their uses. Changes in health system financing have played a central role in the crisis facing Medicare. Significant and unpredictable funding cuts at both federal and provincial–territorial levels have wreaked havoc in the planning and delivery of a very complex array of services. Health care costs that were previously covered by provincial and territorial health insurance plans have been gradually shifted to individuals (“passive privatization”) leaving those without private insurance coverage increasingly vulnerable. Mounting evidence of unacceptably long waits for treatment and poor access to services has underlined the risks attached to having a single-payer system, with insufficient accountability for timeliness and accessibility of care. Growing problems of access and declining provider morale, combined with constant bickering about funding between federal and provincial–territorial governments have led to deterioration of public confidence in the system. The message from the front lines is clear: restoring the health care system to a sustainable footing cannot be accomplished by simply managing our way out of this crisis. As Medicare is renewed, it is essential that its underlying financing framework is modernized, taking into account the multiple policy objectives served by health financing mechanisms. 10 Policy Objectives for Health Financing Mechanisms 1. Stable and sustainable funding 2. Risk-pooling 3. Equity (between population subgroups, across regions) 4. Responsible use 5. Administrative simplicity 6. Transparency and accountability 7. Choice 8. Efficiency 9. Meet current needs 10. Fairness between generations (intergenerational equity) Our recommended changes to the legislation governing federal transfers to provinces and territories are set out in section 3.3.2. To restore the federal–provincial–territorial partnership in health, we recommend that the federal contribution to the public health care system be locked in for a 5-year period, with a built-in escalator tied to increases in GDP, rising to a target of 50% of spending for core services. We also recommend that the federal government establish special purpose, one-time funds to address a number of pressing issues. Given their constitutional responsibility in the area of health care, provinces and territories will continue to play the lead role in regulating the flow of public funding for health care. Once the basket of core services is determined according to the process outlined in section 5.1, provinces and territories will have to commit sufficient funding to ensure that these services are available and accessible in a timely way. The funding commitment of provinces and territories will, therefore, drive the federal government’s 50% contribution. In addition to providing half of public funding for core services, provinces and territories will also have the option of funding additional health services beyond the national minimum core basket, much as they do now. Although adequate and stable funding for health care is imperative at the federal level, it is equally important at the provincial and territorial level. Provincial and territorial commitment to funding core services must also be locked-in for a five-year period with an escalator tied to provincial demographics and inflation. To ensure stability, a buffer will also be needed to protect provincial and territorial health care budgets from the ebbs and flows of the business cycle. Currently, the federal Fiscal Stabilization Program compensates provinces if their revenues fall substantially from one year to the next due to changes in economic circumstances. However, this program is not health-specific and only takes effect when provincial revenues drop by over 5%. It is also funded from general revenues, which makes it more vulnerable to economic and political factors. A more robust approach to guaranteeing stability of public funding for health care would be to create a stand-alone contingency fund to which all governments would contribute. Excess revenues would be collected into this fund during periods of high economic growth, and could be used during less prosperous periods when governments experience fiscal capacity shortfalls. Recommendation 22 (a) That the provincial and territorial governments’ commitment to funding core services be locked-in for an initial five-year period with an escalator tied to provincial population demographics and inflation. (b) That governments establish a health-specific contingency fund to mitigate the effects of fluctuations in the business cycle and to promote greater stability in health care financing. 8. Organization and Delivery of Services 8.1 The Medical Care Continuum There is a tendency to separate medical care into two areas; primary care and specialty care. However, we must recognize that medical and health care encompass a broad spectrum of services ranging from primary prevention to highly specialized care. Primary and specialty care are so closely interrelated that the renewal of either should not be attempted without considering the impact on the rest of the care continuum. Recommendation 23 That any effort to change the organization or delivery of medical care take into account the impact on the whole continuum of care. 8.1.1 Primary care services In recent years, several government task force and Commission reports have called for primary care reform. Common themes include improving continuity of care (including 24/7 coverage); establishing alternatives to fee-for-service payment of physicians; placing greater emphasis on health promotion and disease prevention; and adopting team models that involve nurse practitioners and other health care providers working collaboratively with physicians. Governments have responded by launching pilot projects to evaluate different models of primary care delivery. It is critical to evaluate these projects before moving ahead with them on a broader scale and to consider the implications of their system-wide implementation. Although some jurisdictions have moved forward with ambitious proposals to change the structure of primary care and the remuneration of physicians, the CMA urges the Commission not to view primary care renewal as a panacea for all that ails Medicare. Primary care renewal should not be used as a pretext for changing how doctors are paid nor should it focus on substituting the lowest cost provider. The focus should be on patient need. Any changes to the delivery of primary care should respect the following principles: * All Canadians should have access to a family physician. * No single model will meet the primary care needs of all communities in all regions of the country. Successful renewal of primary health care delivery cannot be accomplished without also addressing the shortage of family practitioners. Not only is the supply of these physicians affected by an aging physician population and by changes in lifestyle and productivity, but the popularity of primary care as a career choice among medical graduates is also declining. According to the Canadian Resident Matching Service (CaRMS), in 1997, only 10% of positions that were still vacant after the first round of the residency match were in family medicine. By 2000, family medicine’s share of vacant positions after the first iteration peaked at 57%; since then it has remained close to 50%. Furthermore, before 1994, more graduates were choosing family medicine than there were positions available. Since then, the situation has reversed with fewer graduates consistently choosing family medicine than there are positions available.9 A major factor in this trend may be the 1993 change in the residency program, which removed graduates’ ability to do a first-year rotation in family medicine, then have the choice of continuing in the family medicine program or switching into a specialty. Now, any graduate who chooses family medicine is committed to that program. The dramatic shift in the number of graduates choosing family medicine in 1994 is likely due to the assumption that it is easier to switch out of a specialty into family medicine than vice versa. The uncertainty of the future of primary care caused by these constant reform efforts has also contributed to the decline in popularity of family medicine among medical graduates. Efforts must be made to remove these perceived barriers so that the public’s need for primary care services can be met. Multidisciplinary teams, both formal and informal, are common in primary care today. The reliance on the team approach will likely grow because of the increased complexity of care, the exponential growth of knowledge, the greater emphasis on health promotion and disease prevention, and the choice of patients and providers. Although desirable, primary care teams ? physicians, nurses, pharmacists, dieticians and others ? will cost the system more, not less, than the traditional fee-for-service physician approach. Funding these initiatives must not come at the expense of the provision of illness care. The add-on costs of primary care teams, including informational technology (IT) and information systems (IS), must be looked upon as an investment in the health of Canadians. (IT and IS opportunities must also be available to all physicians, regardless of how they are paid or their patterns of practice.) Although multidisciplinary teams may provide a broader array of services, for most Canadians having a family doctor as the central provider of all primary medical care services is a core value. As the College of Family Physicians of Canada (CFPC) indicated in its submission to the Commission on the Future of Health Care in Canada, over 90% of Canadians seek advice from a family physician as their first resource in the health care system. The CPFC also reports that a recent Ontario College of Family Physicians public opinion survey, conducted by Decima, found that 94% of people agree that it is important to have a family physician who provides the majority of primary care and coordinates the care delivered by others.10 A family physician as the central coordinator of medical services promotes the efficient and effective use of resources. This facilitates continuity of care because the family physician generally has the benefit of developing an ongoing relationship with his or her patients and their families and, as a result, can advise and direct the patient through the system so that the patient receives the appropriate care from the appropriate provider. Canada has one of the best primary care systems in the world, but it can be improved through better integration and coordination of care. This requires investment to increase quality and productivity through improved IT and connectivity to support physicians in their expanded roles as information providers, coordinators and integrators of care, and to support the integrated care of primary care teams. Recommendation 24 (a) That governments work with the provincial and territorial medical associations and other stakeholders to draw on the successes of evaluated primary care projects to develop a variety of templates of primary care models that would * suit the full range of geographical contexts and * incorporate criteria for moving from pilot projects to wider implementation, such as cost-effectiveness, quality of care and patient and provider satisfaction. (b) That family physicians remain as the central provider and coordinator of timely access to publicly funded medical services, to ensure comprehensive and integrated care, and that there are sufficient resources available to permit this. 8.1.2 Specialty care services Much of the focus in recent years has been on primary care renewal. Countless reports indicating a major crisis in the area of primary care delivery have overshadowed the problems that are plaguing other areas of the health care continuum. For example, a severe physician shortage is occurring in specialty care at the generalist level. The Royal College of Physicians and Surgeons of Canada reports that a third of general surgeons are aged 55 or older and nearly 40% more general surgeons are retiring than are graduating from medical schools.11 Canada cannot afford to continue to ignore this key segment of the care continuum. A concerted effort must be made to increase the visibility of secondary care specialists and to encourage medical students to enter general specialties. As highly specialized care and technology have advanced, there has been increasing pressure at the tertiary level of the health care system to provide the highest level of care possible. Delivering tertiary care in the ways to which Canadians are accustomed cannot be sustained into the future; and such tertiary care cannot be available in all areas of the country. Alternative approaches to delivering and receiving high-level specialty care are both required and inevitable. The aging population, the challenges posed by Canada’s geography, rapidly expanding high-cost technologies and the lack of a critical mass of highly specialized health care providers necessitate a change in thinking. The health system has reached the point where certain types of care are neither universally nor readily available. The shortage of specialists and the high cost of technology and pharmaceuticals will exacerbate this situation. The future challenge is to design delivery systems that are built around a series of regional centres of excellence, without abandoning the concept of “reasonable” access. As these highly specialized services are realigned interprovincially, resources must also be realigned to accommodate and compensate for the relocation of providers and to ensure that patients have equitable access to treatment. At their January 2002 meeting in Vancouver, the premiers recognized that some types of surgery and other medical procedures are performed infrequently and that the necessary expertise cannot be developed and maintained in each province and territory. Building on the experience in Canada’s three territories and Atlantic Canada, they agreed to share human resources and equipment by developing sites of excellence in such fields as pediatric cardiac surgery and gamma knife neurosurgery. This should lead to better care for patients and more efficient use of health care dollars. At the provincial–territorial level, this strategy has led to regional centres and hospitals with responsibilities for province- and territory-wide programs and services. The concept of centres of excellence can be further supported by the adoption of telemedicine and telehealth technologies which will permit rapid access to or exchange of electronic diagnostic information (e.g., imaging) and enable remote consultation and treatment. Determining where care is available will become an increasingly relevant policy matter ? especially as costs such as travel and lost income could be downloaded onto patients and their families. Efforts will be required to optimize the use of scarce specialist services, improve care and availability, assure continuity and enhance provider morale. In the interests of quality care, patient safety and the economical use of scarce resources interjursidictionally, there is a need for a Canadian Accessibility Fund. This fund would be modeled after the Portability Fund established to support the Federal–Provincial–Territorial Eligibility and Portability Agreements under the Medical Care Act. The cost of the new fund, like the old, would be 50–50 cost-shared by the federal and provincial–territorial governments. It would require an initial investment of $100 million. Access to the fund would be determined by a mutually agreed upon set of criteria, and any monies withdrawn would be used to facilitate access to highly specialized health care services that are not available in the patient’s home province. Recommendation 25 (a) That governments develop a national plan to coordinate the most efficient access to highly specialized treatment and diagnostic services. * This plan should include the creation of defined regional centres of excellence to optimize the availability of scarce specialist services. * Any realignment of services must accommodate and compensate for the relocation of providers. * That the federal government create an accessibility fund that would support interprovincial centres of excellence for highly specialized services. 8.2 Physician Remuneration It is a common misconception that successful renewal of the health care system involves simply changing how physicians are paid ? specifically, abolishing fee-for-service. In their analysis of primary care in Canada, Hutchison and colleagues note that governments’ preoccupation with the “big bang” approach — that typically involves the adoption of inappropriate funding and remuneration methods — is a major contributor to the failure of many primary care projects.12 Every system of remuneration has its strengths and weaknesses. Canadians should not be led to think that movement away from fee-for-service remuneration of physicians will provide them with better care. How physicians (and other health care providers) are paid should be a means to an end, not an end unto itself. Nevertheless, physicians are willing to consider other appropriate methods of remuneration in appropriate circumstances. Physicians must be given a choice about their method of payment. Experience has taught us that a “one size fits all” approach to compensation does not work. Furthermore, any remuneration arrangement must preserve and protect physician autonomy and the ability of the physician to act as an advocate for his or her patients. In 2001, the CMA developed a policy on physician compensation (Appendix K) that is based on the following principles. CMA Policy on Physician Compensation: Basic Principles * Medical practitioners must receive fair, reasonable and equitable remuneration for the full spectrum of their professional activities. * Physicians need to receive reasonable consideration and compensation when facilities and programs are discontinued, reduced or transferred. * Individual medical practitioners have the liberty to choose among payment methods. * Payment systems must not compromise the ability of physicians to provide high-quality cost-effective medical services. * Payment mechanisms must allow for a reasonable quality of life. * Provincial and territorial government resources and funding for physician services must be allocated directly to physicians for services provided. * All physicians, including those indirectly affected, have the right to representation in negotiations on issues of payment, funding, and the terms and conditions of their work. * Paying agencies must fulfill the terms of agreement negotiated with legitimate agents of the medical profession and be obliged to honour a mutually agreed-upon and established process of negotiation with those agents. * In the event of failure of negotiations relating to physician compensation, such disagreement must be resolved by a mutually agreed-upon, timely process of dispute resolution. * The federal minister of health must enforce the provisions of the Canada Health Act relevant to physician compensation (section12.2). Recommendation 26 That governments respect the principles contained in the CMA’s policy on physician compensation and the terms of duly negotiated agreements. 8.3 Rural Health Care Canadian physicians and other health care professionals are greatly frustrated by the impact that health care budget cuts and reorganization have had, and continue to have, on the timely provision of quality care to patients and on general working conditions. For physicians who practise in rural and remote communities, this impact is exacerbated by the breadth of their practice, long working hours, lifestyle restrictions created by on-call responsibilities, geographic isolation and lack of professional backup and access to specialist services. In 2000, the CMA developed a policy statement on rural and remote practice (Appendix L) to help governments, policymakers, communities and others involved in the retention of physicians understand the various professional and personal factors that must be addressed to retain and recruit physicians to rural and remote areas. The 28 recommendations address training, compensation and work and lifestyle support issues. Training for rural practice must span the full medical career lifecycle, from recruitment of candidates likely to enter rural practice to special skills training, retraining and continuing professional development. Compensation must reflect the degree of isolation, level of responsibility, frequency of on-call duty, breadth of practice and additional skills. Consideration must also be given to the broader social issues of the physician and his or her family, as well as the need to facilitate the availability of locum tenens, particularly across jurisdictional boundaries. There is a need to ensure that there is sufficient availability of physicians so that on-call requirements are manageable and that adequate professional backup is provided, e.g., locum services currently offered through provincial and territorial medical associations. We concur with the observation made by the Society of Rural Physicians of Canada in their August 2001 submission to the Commission that Canada needs a national rural health strategy. The aim of the strategy would be to look at the systemic barriers to meeting the needs of rural Canadians and to provide strategic program funding to catalyze change. Recommendation 27 That governments work with universities, colleges, professional associations and communities to develop a national rural and remote health strategy for Canada. 8.4 Emerging and Supportive Roles in Health Care Delivery 8.4.1 Private sector Canada has a mixed system of public–private delivery and public–private financing, as illustrated in the following diagram with all four possible combinations. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Delivery Public Private Financing Public Public delivery/ public financing (e.g., public hospital services) Private delivery/ public financing (e.g., doctor’s office care) Private Public delivery/ private financing (e.g., private room in a public hospital) Private delivery/ private financing (e.g., cosmetic surgery) [TABLE END] No issue in Canadian health policy has generated more controversy than the role of the private sector. As we move forward with the renewal of Medicare, it will be important for Canadians to understand the distinction between private delivery and private funding. The appropriate mix of public and private should not be based on ideology, but rather on the optimal use of resources. Health care is delivered mainly by private providers including physicians, pharmacists, private not-for-profit hospitals, private long-term care facilities, private diagnostic and testing facilities, rehabilitation centres. (In addition, supplies from food and laundry to drugs and technology are provided almost exclusively by the private sector.) This significant level of private-sector delivery has served Canada well. Accordingly, the CMA supports a continuing and major role for the private sector in the delivery of health care. However, we are not proposing a parallel private system. There may be a growing role for private delivery. We would encourage this as long as the services can be provided cost-effectively. As with the public sector, any private-sector involvement in health care must be patient-centred as well as open, transparent and accountable. Furthermore, it must be strictly regulated to ensure that high standards of quality care are being met and monitored. Recommendation 28 That Canada’s health care system make optimal use of the private sector in the delivery of publicly financed health care provided that it meets the same standards of quality as the public system. 8.4.2 Voluntary sector The voluntary sector, including many charities and consumer advocacy groups, has played a critical role in the development of the public health system ? providing and funding services, programs, equipment and facilities. Much of the capital infrastructure development, especially in hospitals, has been made possible through the fundraising efforts of charity foundations and service organizations. In addition, many patient support services such as “Meals on Wheels” exist only because of the efforts of volunteer groups. Although the voluntary sector is a major asset for Canada’s health care system, it is critical for governments to fulfill their obligation to support publicly financed health care. Governments must avoid passing off their responsibilities to the voluntary sector, which is already stretched to the limit. Governments should not abuse the voluntary sector, but should properly fund the public health system’s ongoing operating costs and capital expenditures. The voluntary sector should be formally recognized for the contribution it makes to the health care system. Many of these organizations operate on a shoestring budget with limited capacity to respond to the increasing demands being placed on them. Recommendation 29 That governments examine ways to recognize and support the role of the voluntary sector in the funding and delivery of health care, including enhanced tax credits. 8.4.3 Informal caregivers Informal caregivers ? particularly those who provide care for ailing relatives and friends ? play an essential role in the health care system. The massive off-loading onto these caregivers has gone unrecognized. The costs of providing this kind of care go beyond identifiable dollar amounts such as loss of income. Many indirect costs, including emotional strain on the caregivers and their families, must also be acknowledged with support provided by governments and employers. Patients often prefer to receive their care at home, but it cannot be assumed that care provided at home is better for the patient than that provided within a health care institution. Resources must be made available to ensure that the care patients receive at home is acceptable. Increased financial support should be provided to informal caregivers through the tax system. Refundable tax credits and a program for family leave are two examples of this support. Recommendation 30 That governments support the contributions of informal caregivers through the tax system. Conclusions Canada’s health care system is at a crossroads. We need to act now to ensure that our health care system will be able to meet the current and future health care needs of Canadians. Canadians are looking for real solutions that will have meaningful results. This means not only addressing the most critical issues such as health human resources, infrastructure and delivery mechanisms, but also implementing system-wide structural and procedural changes. It also means involving all key stakeholders in the decision-making process at all levels. In this second submission to the Commission on the Future of Health Care in Canada, the CMA has offered solutions that are patient-centred and reflect Canadian values of a publicly funded system that is sustainable and accountable and provides timely access to high-quality care. These recommendations form a complete, integrated package that should be implemented as a whole to be successful. The CMA would like to thank the Commission for providing this opportunity to submit our Prescription for Sustainability and we wish the Commission every success in developing a concrete plan for revitalizing our cherished Canadian health care system. 1 A recent article by Patrick Monahan and Stanley Hartt published by the C.D. Howe Institute argues that Canadians have a constitutional right to access privately funded health care if the publicly funded system does not provide access to care in a timely way. 2 Although the word “charter” has a legal connotation, it has been used in other contexts. An example is the 1986 Ottawa Charter for Health Promotion, an international call for action on health promotion that has received worldwide acclaim. 3 This could be linked to the equalization provision in Section 36(2) of the Constitution Act (1982). 4 Proclamations are issued by the Queen’s representative in the particular jurisdiction. An example of a proclamation that has been issued this way is the “Proclamation Recognizing the Outstanding Service to Canadians by Employees in the Public Service of Canada in Times of Natural Disaster” (13 May, 1998). 5 100% government-funded without patient cost-sharing. 6 Organisation for Economic Co-operation and Development. Health at a glance. Paris, France: OECD; 2001. 7 CMF membership includes: CMA, Association of Canadian Medical Colleges, College of Family Physicians of Canada, Royal College of Physicians and Surgeons of Canada, Canadian Federation of Medical Students, Canadian Association of Internes and Residents, Federation of Medical Licensing Authorities of Canada, Medical Council of Canada, and Association of Canadian Academic Healthcare Organizations. 8 See for example the Melbourne Manifesto: A Code of Practice for the International Recruitment of Health Care Professionals, which was adopted at the 5th Wonca World Conference on Rural Health in May 2002. It puts the onus on every country to train enough health professionals to meet their own needs (www.wonca.org). 9 Canadian Resident Matching Service. PGY-1 Match Report 2002. History of family medicine as a career choice of Canadian graduates. [http:// http://www.carms.ca/stats/stats_index.htm]. Ottawa: CaRMS; 2002. 10 College of Family Physicians of Canada. Shaping the Future of Health Care. Submission to the Commission on the Future of Health Care in Canada. Ottawa: CFPC; 25 Oct. 2001. 11 Royal College of Physicians and Surgeons of Canada. Health care renewal through knowledge, collaboration, and commitment. Ottawa: RCPSC; 31 Oct. 2002. 12 Hutchison B, Abelson J, Lavis J. Primary care in Canada: so much innovation, so little change. Health Aff 2001 May/Jun; 20(3):116-31.
Documents
Less detail

A Public Health Perspective on Cannabis and Other Illegal Drugs : CMA Submission to the Special Senate Committee on Illegal Drugs

https://policybase.cma.ca/en/permalink/policy1968
Last Reviewed
2020-02-29
Date
2002-03-11
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2002-03-11
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Cannabis has adverse effects on the personal health of Canadians and the well-being of society. In making this submission to the Special Senate Committee on Illegal Drugs, the Canadian Medical Association (CMA) wishes to make it clear that any change to the criminal status of cannabis must be done so with the recognition that cannabis is an addictive substance and that addiction is a disease. The CMA believes that the government must take a broad public health policy approach to address cannabis use. Focusing on the decriminalization issue alone is inadequate to deal with the complexity of the problem. Changes to the criminal law affecting cannabis must not promote normalization of its use, and must be tied to a national drug strategy that promotes awareness and prevention, and provides for comprehensive treatment. Under such a multidimensional approach the CMA would endorse decriminalization. In this document, we primarily focus on the health effects of cannabis use. However, we also present information and recommendations on the use of other illegal drugs. While we understand that this goes beyond the intended scope of the Senate Committee's study, this information is important to the development of comprehensive policy, which we believe is required. We also recognize and welcome the fact that many of the CMA's recommendations will require a closer working relationship among health providers, justice officials and law enforcement. The CMA's recommendations are: Section 1: Illegal Drugs 1. A National Drug Strategy: The federal government develop, in cooperation with the provinces and territories and the appropriate stakeholder groups, a comprehensive national drug strategy on the non-medical use of drugs. 2. Redistribution of Resources: The vast majority of resources dedicated to combating illegal drugs are directed towards law enforcement activities. Government needs to re-balance this distribution and allocate a greater proportion of these resources to drug treatment, prevention, and harm reduction programs. Law enforcement activities should target the distribution and production of illegal drugs. 3. Addiction is a Disease: Addiction should be regarded as a disease and therefore, individuals suffering with drug dependency should be diverted, whenever possible, from the criminal justice system to treatment and rehabilitation. Additionally, the stigma associated with addiction needs to be addressed as part of a comprehensive education strategy. 4. Increased Research: All governments commit to more research on the cause, effects and treatment of addiction. Further research on the long- term health effects associated with chronic cannabis use is specifically required. Section 2: Cannabis 1. National Cannabis Cessation Program: The federal government develop, in cooperation with the provinces and territories and the appropriate stakeholder groups, a comprehensive program to minimize cannabis use. This should include, but not be limited to: * Education and awareness raising of the potential harms of cannabis use including risks associated with use in pregnancy; use by those with mental illness; chronic respiratory problems; and chronic heavy use; * Strategies to prevent early use in adolescence; and, * Availability of assessment, counselling and treatment services for those experiencing adverse effects of heavy use or dependence. 2. Driving Under the Influence Prevention Policy: The CMA believes that comprehensive long-term efforts that incorporate both deterrent legislation and public awareness and education constitute the most effective approach to reducing the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports a similar multidimensional approach to the issue of the operation of a motor vehicle while under the influence of cannabis. 3. Decriminalization: The severity of punishment for simple possession and personal use of cannabis should be reduced with the removal of criminal sanctions. The CMA believes that resources currently devoted to combating simple marijuana possession through the criminal law could be diverted to public health strategies, particularly for youth. To the degree that having a criminal record limits employment prospects the impact on health status is profound. Poorer employment prospects lead to poorer health. Use of a civil violation, such as a fine, is a potential alternative. However, decriminalization should only be pursued as part of a comprehensive national illegal drug strategy that would include a cannabis cessation program. 4. Monitoring and Evaluation: Any changes need to be gradual to protect against any potential harm. In addition, changes to the criminal law in connection with cannabis, should be rigorously monitored and evaluated for their impact. This document also contains the policies and recommendations of the CMA affiliated association that has specific expertise in the field of substance use disorders the, Canadian Society of Addiction Medicine (CSAM). In addition, for an even broader health-sector perspective, the CMA has attached information on the policy positions of other key medical organizations from Canada and the United States in regard to decriminalization of cannabis. A PUBLIC HEALTH PERSPECTIVE ON CANNABIS AND OTHER ILLEGAL DRUGS INTRODUCTION The Canadian Medical Association (CMA) welcomes the opportunity to participate in the deliberations of the Special Senate Committee on Illegal Drugs. This document was developed by the CMA's new Office for Public Health in consultation with our Affiliate Societies, in particular the Canadian Society of Addiction Medicine, and our 12 provincial and territorial divisions. The use of illegal drugs and relevant policies is an extremely broad, multi-disciplinary and at times, controversial subject. Considering the breadth of this subject, the limited time-lines and the areas of particular interest of the Committee, this document will focus on the following: * What are the known health effects of cannabis and other illegal drugs? * What experience has there been with the decriminalization of cannabis? * What has been the impact of law enforcement on illegal drug use? * What changes need to be considered in Canada's approach to illegal drug use including the potential decriminalization of drugs? In addition to the above, this document will provide an overview of the relevant policy position statements and recommendations regarding cannabis and drug policy from other key medical organizations from both Canada and the United States. PUBLIC HEALTH PERSPECTIVE ON DRUG USE There are many different perspectives on the use of drugs including ethical and moral frameworks. This paper is prepared from a public health perspective where minimizing any harms associated with use is of primary concern. 1 This requires consideration of health issues related not only to the individual user and the drug being used, but also the key social factors associated with use. Drug use is a complex behaviour that is influenced by many factors. It is not possible to identify a single cause for drug use, nor will the set of contributing factors be the same among different drug users and populations. Public health objectives will vary depending upon the circumstances: preventing drug use in those who have not initiated use (e.g. pre-teens); avoiding use in circumstances associated with a risk of adverse outcomes (e.g. drug use and driving motor vehicle); assisting those who wish to stop using the drug (e.g. treatment, rehabilitation); and assisting those who intend to continue to use the drug to do so in such a manner as to reduce the risk of adverse effects (e.g. needle exchange program to reduce risk of HIV). To address this complexity, what is required is a public health strategy to combat drug use utilizing a comprehensive, multi-component approach. Public health strategies focus on the various predisposing, enabling, and re-enforcing factors that influence healthy behaviours and choices. 2 These sets of factors recognize the many influences upon individual behaviour including: individual and social attitudes, beliefs and values; skills; support, self-efficacy and re-enforcement. Public health actions can be grouped into the following major categories: 3 * Developing Personal Skills - education and skill-building (e.g. mass media, skill development to resist peer pressure, thinking skills); * Healthy Public Policy - policies, formal and informal that support health (e.g. school policy, substance use and driving, harm reduction initiatives); * Creating Supportive Environments - social and physical environments (e.g. adequate housing and food, community safety, non-chemical coping mechanisms); * Strengthen Community Action - community involvement in finding solutions (e.g. self-help, social support, community participation); * Health Services - range of services to meet needs (e.g. prevention, assessment, early intervention, treatment, rehabilitation, harm-reduction initiatives). This framework is useful in identifying the range of program components that need to be considered. Relative emphasis between components and the specific interventions selected will vary depending upon the target population (e.g. school students vs. injection drug users). The key is a balanced approach that will influence the factors contributing to less healthy behaviours with support for behaviour change and maintenance. CANNABIS Several commissions and task forces, in Canada and elsewhere, have addressed the issue of how to deal with cannabis use, although frequently their recommendations have not been implemented. 4, 5, 6 It has been suggested that "cannabis is a political football that governments continually duck...(but that) like a football, it bounces back." 7 This section of the paper will review current Canadian levels of use, health effects, law enforcement issues, and experience with decriminalization in other jurisdictions. Current Use The Ontario Student Drug Use Survey is conducted every two years in grades 7, 9, 11, and 13, although in 1999 all grades from 7-13 were surveyed. Use of cannabis within the preceding year increased from 11.7% of students in 1991, to 29.2% in 1999. 8 Increases were also observed for several other drugs during the same time period (tobacco, alcohol, glue, other solvents, hallucinogens, cocaine, PCP, and ecstasy). Increases in adolescent drug use have also been observed in the US, Europe and Australia through the 1990s. Compared with earlier cohorts, fewer students in 1999 reported early onset of cannabis use (before grade 7) compared with similarly aged students in 1997 and 1981. Past year drug use of cannabis, alcohol and tobacco by grade year is shown in Table 1. The proportion of students who have used one of these drugs increases with increasing grade level. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 1 - Past Year Drug Use (%) by Grade Level, Ontario Students, 1999 7 8 9 10 11 12 13 Alcohol 39.7 53.7 63.1 74.9 82.0 84.6 83.0 Tobacco 7.4 17.8 27.8 37.4 41.7 38.6 38.0 Cannabis 3.6 14.9 25.5 36.4 48.1 39.4 43.3 1999 Ontario Student Drug Use Survey 9 [TABLE END] The last national survey of illicit drug use in Canada was conducted in 1994. 10 At that time, 23% of Canadians, aged 15 and over, reported having used cannabis more than once during their lifetime with 7% having used it within the preceding year. Current use is much more common in those under the age of 25 and diminishes significantly with age, (Table 2). Most cannabis use is sporadic with the majority of adult and adolescent users using it less than once a week. 11 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 2 - Lifetime and Current Use of Cannabis in Canada, 1994 Age Lifetime Use (%) Current Use (%) (past 12 months) 15-17 30 24.0 18-19 32.9 23.8 20-24 37.7 19.0 25-34 38.2 9.6 35-44 32.9 5.7 45-54 14.8 1.4 55-64 3.7 - 65+ 0.8 - Canada's Alcohol and Other Drugs Survey: 1994 [TABLE END] Health Effects Our understanding of the health effects of cannabis continues to evolve. Hall summarizes the effects into acute and chronic effects and whether these are probable or possible (Table 3). 12 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 3 - Summary of Probable and Possible Health Effects of Cannabis Use Pattern of Use Acute Chronic Probable anxiety, dysphoria, panic, cognitive impairment, psychomotor impairment; chronic bronchitis, lung cancer, dependence, mild cognitive impairment, exacerbation of psychosis; Possible (possible but uncertain, confirmation required in controlled studies) increased risk of traffic accident, psychosis, low-birth-weight babies; cancers in offspring, impaired immunity From CMAJ 2000; 162: 1690-1692. [TABLE END] Tetrahydrocannabinol (THC) is the main psychoactive substance in cannabis. THC is inhaled in the mainstream smoke and absorbed through the lungs, rapidly entering the bloodstream. Effects are perceptible within seconds and fully apparent in a few minutes. Cannabis combines many of the properties of alcohol, tranquilizers, opiates and hallucinogens; it has anxiolytic, sedative, analgesic and psychedelic properties. 13 Its acute toxicity is extremely low, as no deaths directly due to acute cannabis use have ever been reported. The main feature of its use is that it produces a feeling of euphoria (or 'high'). Toxic dose-related effects include anxiety, panic, depression or psychosis.14 It should also be noted that a significant incident of co-morbid addiction occurs in those with physical and mental diseases. People with major mental illnesses such as schizophrenia are especially vulnerable in that cannabis use can provoke relapse and aggravate existing symptoms. A chronic lack of energy and drive to work in chronic users has been referred to as an "amotivational syndrome," which is currently believed to represent an ongoing intoxication in frequent users. 14 Cannabis slows reaction times, impairs motor coordination and concentration as well as the completion of complex tasks. 13 Due to the extended presence of metabolites in the bloodstream, it is difficult to correlate blood levels with acute impairment making interpretation of crash data difficult. However, it is generally accepted that cannabis use is associated with an increased risk of motor vehicle and aircraft crashes. Impairments of attention, memory and the ability to process complex information can last for prolonged periods of time, even years, after cessation of heavy, chronic cannabis use. A cannabis withdrawal syndrome similar to alcohol, opiate and benzodiazepine withdrawal symptoms exist. 14 Cannabis use increases heart rate and causes blood vessels to dilate. These present a risk for those with pre-existing cardiac disease. Smoke from cannabis preparations contains many of the same compounds as tobacco cigarettes including increased levels of tar. Chronic cannabis smoking is associated with bronchitis and emphysema. Chronic cannabis use may have risks of chronic lung disease and lung cancer comparable to cigarette smoking. With increasing study and experience, it is clear that cannabis, like other substances such as tobacco or alcohol, can have a number of adverse physical and psychological effects. 15 Law Enforcement The 1997 data is the latest year with national drug offences' data for possession, cultivation, trafficking and importation (Figure 1). 16 The proportion of drug incidents is heavily skewed towards cannabis. This is intriguing since the health concerns of cannabis are substantially less than those of heroin or cocaine. [FIGURE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Figure 1: Proportion of All Drug Incidents by Drug Type, Canada, 1997 [FIGURE END] Of the 66,500 drug incidents in Canada in 1997, over 70% (47,908) were cannabis related. Of these, over two thirds (32,682) were for possession. The rate of cannabis offences has increased 34% since 1991 with cannabis-possession rates increasing steadily from 1991-1996 with a slight drop in 1997. Most (86%) of those charged with cannabis offences were under 25 years of age. It has been estimated that about 2,000 Canadians are sent to jail every year for cannabis possession.17 Despite the current level of enforcement, cannabis use has been increasing with over 40% of grade 11, 12 and 13 students having used cannabis in the preceding year. While it is obvious that only a small percentage of users are being charged, thousands of teens and young adults are being charged every year, receiving criminal records that can impact future employment, future interactions with the justice system, and be a barrier to acquiring citizenship. 11 Findings from several studies indicate that perceived health risk and social disapproval were much more important disincentives to cannabis use than legal threats. 18 Experience with Decriminalization in Other Jurisdictions A number of other jurisdictions have implemented alternative enforcement approaches to the personal use of cannabis. While none of these experiences directly predict what would happen in Canada, they do provide information to address some of the issues raised when decriminalization is considered. Despite the obvious interest in the impact of these policy changes, there is a paucity of well-designed evaluations (i.e. evaluations which were designed and implemented prior to policy change, rather than post-hoc analyses on available data). United States In the 1970s, several US states reduced the legal sanctions for possession of small amounts of cannabis to a maximum penalty of a fine. Despite the substantial potential interest in the effects of such policy changes, evaluative studies were relatively sparse. The available data, though based upon national high school student survey data as well as evaluations in two states, indicated that there was no apparent increase in cannabis use that could be attributed to decriminalization. 19 The high school student national survey data showed that while use of cannabis had increased in those states that had decriminalized possession, the rates of use had increased by a greater amount with stricter laws. California was one of the states which decriminalized possession, and similar to other states, experienced a decrease in cannabis use during the 1980s which based upon student surveys appeared to be due to changing perceptions of health risks rather than changes in the legal status of the drug. 19 Netherlands The Netherlands is the most frequently identified example of a country that altered its approach to marijuana. The Dutch impose no penalties for the possession of small amounts of cannabis and allow a number of coffee shops to openly sell the drug. 20 This policy therefore is not simply removing the potential for criminal records and imprisonment with possession, but actually partially legalized cannabis sales. This process began in 1976 and coffee shops were not allowed to advertise, could not sell hard drugs, no sales to minors, no public disturbances, and no sales transactions exceeding certain quantity thresholds. Initially this threshold was set at 30 gm of cannabis, a rather large amount which was reduced to 5 gm in 1995. Attempts have been made to compare the prevalence of cannabis use in the Netherlands with other countries. Since cannabis use changes dramatically with age and over different time periods, surveys need to be of similar populations during similar time periods to be comparable. Differences in the wording of questions between surveys also make comparison difficult. A recent review by MacCouin et al makes 28 comparisons between the Netherlands and the US, Denmark, West Germany, Sweden, Finland, France and the UK.21 Overall, it appears that Dutch rates are lower than rates of use in the US but somewhat higher than those of some of its European neighbours. Cannabis use is higher in Amsterdam compared to other Dutch cities and is comparable to use in the US. A limited number of surveys appear to show that from 1984 to 1992, there was a substantial increase in adolescent (aged 16 - 20) use of cannabis that did not occur in other countries. The increases observed from 1992 to 1998 however, were similar to the increases observed in other countries including Canada. Overall, it appears that while the increases in Dutch adolescent use started earlier than other countries, their prevalence of use was much lower than comparison countries so that by the late 1990s they had comparable rates of use to the US and Canada. Australia From 1987 to 1995, three Australian states decriminalized the possession and cultivation of cannabis for personal use by replacing penal sanctions with fines. 22 The courts in other states have tended to utilize non-penal sanctions such as a fine or a suspended sentence with a criminal record. The limited number of surveys conducted in Australia has failed to find evidence of any large impact on cannabis use (some of the surveys had small sample sizes and the trend in usage has been upwards in Australian states which did not decriminalize as well as in other countries that continue to prohibit cannabis use). Interestingly, despite the decriminalization, the number of notices issued by police exceeds the number of cannabis offences prior to the change in law. Summary The preceding sections have suggested that cannabis use is relatively common (particularly in teens and young adults); most use is sporadic; its use is increasing; and it is not harmless. Because of these potential harms, one would not wish to encourage its use. There is however, no necessary connection between adverse health effects of any drug or human behaviour and its prohibition by law. 22 The issue is therefore whether there are less coercive ways to discourage its use. Despite the current criminal justice approach where the bulk of all illegal drug charges are cannabis-related and the majority of these are for possession, use is increasing with thousands of teens and young adults receiving criminal records for possession each year. The available evidence from other jurisdictions suggests that decriminalization would not result in a substantial increase in use beyond baseline trends. Considering current trends, a comprehensive approach to discourage current usage is required. OTHER ILLEGAL DRUGS Illegal drugs other than cannabis present a different set of issues and concerns. While these drugs are not the primary focus of the Special Senate Committee's study, we have included a few key issues to better put the cannabis issue in proper context. Current Use The Ontario Student Drug Use Survey of students in grades 7, 9, 11 and 13 has shown that following a lengthy period of decline in drug use during the 1980s, there has been a steady increase in adolescent drug use. 8 Past year drug use in 1999 was reported as follows: ecstasy (4.8%); PCP (3.2%); hallucinogens (13.8%), and cocaine (4.1%). By comparison, tobacco, alcohol and cannabis were 28.3%, 65.7%, and 29.2% respectively. Canadian survey data of those aged 15 and over in 1994 found that about one in twenty reported any lifetime use of LSD, speed or heroin, or cocaine. 10 Rates of use of these drugs within the preceding year were 1% and 0.7% respectively. Health Effects The adverse effects of drugs such as heroin and cocaine are related not just to the drugs themselves, but also increasingly to their method of intake, which is predominantly by injection. Injection drug use (IDU) is an efficient delivery mechanism of drugs, but is also an extremely effective means of transmitting bloodborne viruses such as hepatitis B, hepatitis C and HIV. The proportion of HIV infections attributable to IDU has increased from 9% prior to 1985 to over 25% by 1995. 23 IDU is also the predominant means of hepatitis C transmission responsible for 70% of cases. 24 The increasing use of cocaine, which tends to be injected on a more frequent basis, increases the subsequent exposure to infection. It has been estimated that up to 100,000 Canadians inject drugs (not counting steroids). 25 Transmission of bloodborne pathogens is not limited to injection drug users as the disease can then be further spread to sexual contacts, including the sex trade, and vertical transmission from infected mother to child. An epidemic of overdose deaths among injection drug users has been experienced in British Columbia with over 2000 such deaths in Vancouver since 1991. 17 Despite the seriousness of the potential adverse effects of illegal drug use and the potential for this situation to worsen with increasing transmission of bloodborne diseases, on a population basis, legal drugs (alcohol and tobacco) are responsible for substantially more deaths, potential years of life lost and hospitalizations. 26 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 4 - The Number of Deaths, Premature Mortality and Hospital Separations for Illicit Drugs, Alcohol and Tobacco, Canada, 1995. Deaths Potential Years of Life Lost Hospital Separations Illicit Drugs 805 33,662 6,940 Alcohol 123,734 172,126 82,014 Tobacco 34,728 500,350 193,772 From: Single et al. CMAJ 2000: 162: 1669-1675 [TABLE END] Expenditures on Illegal Drugs The direct costs associated with illicit drugs based on 1992 Canadian data are shown in the figure below: [FIGURE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [FIGURE END] The vast majority of expenditures related to illegal drugs are on law enforcement. Considering the distribution of drug incidents, a substantial proportion of these are related to cannabis offences although health and other costs will predominantly be associated with other drugs. A substantial proportion of drug charges are for possession as compared with trafficking or importation (cocaine 42%; heroin 42%; other drugs 56%). 16 Despite illegal drug use being primarily a health and social issue, current expenditures do not reflect this and are heavily skewed towards a criminal justice approach. Unfortunately, prisons are not an ideal setting for treating addictions with the potential for continued transmission of bloodborne viruses. RECOMMENDATIONS The Need for Balanced, Comprehensive Approaches Reasons for drug use, particularly "hard drugs," are complex. It is not clear how a predominantly law enforcement approach is going to address the determinants of drug use, treat addictions, or reduce the harms associated with drug use including overdoses and the transmission of bloodborne viruses including HIV. Costs of incarceration are substantially more than the use of effective drug treatment. 27 It appears that there is an over dependence on the law when other models might be more effective in achieving the desired objective of preventing or reducing harm from drug use. 18 Aggressive law enforcement at the user level could exacerbate these harms by encouraging the use of the most dangerous and addictive drugs in the most concentrated forms, 28 because these are easier to conceal and the efficacy of injecting is greater than that of inhaling as drug costs increase in response to prohibition and enforcement. 29 There have been several recent sets of recommendations from expert groups regarding the need for a comprehensive set of approaches to address the public health challenges due to drug use, particularly those associated with injection drug use (IDU). 17, 25, 30, 31 Recommendations include the following components: * address prevention; * treatment and rehabilitation; * research; * surveillance and knowledge dissemination; * national leadership and coordination. Many of the recommendations will require close working relationships with justice/enforcement officials. Drug abuse and dependency is a chronic, relapsing disease for which there are effective treatments.32 A criminal justice approach to a disease is inappropriate particularly when there is increasing consensus that it is ineffective and exacerbates harms.33 The CMA's recommendations have been separated into two separate sections. The first set of recommendations is focused on policies affecting illegal drugs in general. While this goes beyond the intended scope of the Senate Committee's study, in our opinion, these recommendations are equally important for the Committee to consider. The second set of recommendations is specifically focused on cannabis. Our recommendations in this section take into consideration the health impact profile of cannabis, current levels of use, extent and impact of law enforcement activities and experience from other jurisdictions. Section 1: Illegal Drugs The CMA recommends: 1. A National Drug Strategy: The federal government develop, in cooperation with the provinces and territories and the appropriate stakeholder groups, a comprehensive national drug strategy on the non-medical use of drugs. 2. Redistribution of Resources: The vast majority of resources dedicated to combating illegal drugs are directed towards law enforcement activities. Government needs to re-balance this distribution and allocate a greater proportion of these resources to drug treatment, prevention, and harm reduction programs. Law enforcement activities should target the distribution and production of illegal drugs. 3. Addiction is a Disease: Addiction should be regarded as a disease and therefore, individuals suffering with drug dependency should be diverted, whenever possible, from the criminal justice system to treatment and rehabilitation. Additionally, the stigma associated with addiction needs to be addressed as part of a comprehensive education strategy. 4. Increased Research: All governments commit to more research on the cause, effects and treatment of addiction. Further research on the long- term health effects associated with chronic cannabis use is specifically required. Section 2: Cannabis The CMA recommends: 1. National Cannabis Cessation Program: The federal government develop, in cooperation with the provinces and territories and the appropriate stakeholder groups, a comprehensive program to minimize cannabis use. This should include, but not be limited to: * Education and awareness raising of the potential harms of cannabis use including risks associated with use in pregnancy; use by those with mental illness; chronic respiratory problems; and chronic heavy use; * Strategies to prevent early use in adolescence; and, * Availability of assessment, counselling and treatment services for those experiencing adverse effects of heavy use or dependence. 2. Driving Under the Influence Prevention Policy: The CMA believes that comprehensive long-term efforts that incorporate both deterrent legislation and public awareness and education constitute the most effective approach to reducing the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports a similar multidimensional approach to the issue of the operation of a motor vehicle while under the influence of cannabis. 3. Decriminalization: The severity of punishment for simple possession and personal use of cannabis should be reduced with the removal of criminal sanctions. The CMA believes that resources currently devoted to combating simple marijuana possession through the criminal law could be diverted to public health strategies, particularly for youth. To the degree that having a criminal record limits employment prospects the impact on health status is profound. Poorer employment prospects lead to poorer health. Use of a civil violation, such as a fine, is a potential alternative. However, decriminalization should only be pursued as part of a comprehensive national illegal drug strategy that would include a cannabis cessation program. 4. Monitoring and Evaluation: Any changes need to be gradual to protect against any potential harm. In addition, changes to the criminal law in connection with cannabis, should be rigorously monitored and evaluated for their impact. CANADIAN SOCIETY OF ADDICTION MEDICINE The Canadian Society of Addiction Medicine (CSAM), which was formed in 1989, is a national organization of medical professionals and other scientists interested in the field of substance use disorders. Vision The Society shares its overall goals with many other organizations and groups in Canada; namely, the prevention of problems arising from the use of alcohol and other psychoactive substances, and the cure; improvement or stabilization of the adverse consequences associated with the use of these drugs. This Society aims to achieve these goals through the fostering and promotion of medical sciences and clinical practice in this field in Canada, particularly by: * fostering and promotion of the roles of physicians in the prevention and treatment of alcohol and drug related problems; * improvement in the quality of medical practice in the drug and alcohol field through: establishment and promotion of standards of clinical practice; fostering and promotion of research; and fostering and promotion of medical education; * promotion of professional and public awareness of the roles that physicians can play in the prevention and treatment of alcohol and drug related problems; * fostering and promotion of further development of programs for the prevention and treatment of problems of alcohol and drug use in physicians; and * contributing to professional and public examination and discussion of important issues in the drug and alcohol field. Policy Statement The CSAM National Drug Policy statement requires that: Canada must have a clear strategy for dealing with the cultivation, manufacture, importation, distribution, advertising, sale, possession and use of psychoactive substances regardless of whether they are classified as legal or illegal. Drug possession for personal use must be decriminalized and distinguished from the trafficking or illegal sale/distribution of drugs to others that must carry appropriate criminal sanctions. The individual and public health impact of substance use, substance abuse and substance dependence must be taken into account at all times. An assessment to ascertain the extent of a substance use disorder and screening for addiction must be an essential part of dealing with someone identified as an illicit drug user or possessor. Appropriate funding must be made available for supply reduction and demand reduction of various psychoactive substances that carry an abuse or addiction liability. Recommendations 1. National policies and regulations must present a comprehensive and coordinated strategy aimed at reducing the harm done to individuals, families and society by the use of all drugs of dependence regardless of the classification of "legal" or "illegal" 2. Prevention programs need to be comprehensively designed to target the entire range of dependence-producing drugs to enhance public awareness and affect social attitudes with scientific information about the pharmacology of drugs and the effects of recreational and problem use on individuals, families, communities and society. 3. Outreach, identification, referral and treatment programs for all persons with addiction need to be increased in number and type until they are available and accessible in every part of the country to all in need of such services. 4. Law enforcement measures aimed at interrupting the distribution of illicit drugs need to be balanced with evidenced based treatment and prevention programs, as well as programs to ameliorate those social factors that exacerbate addiction and its related problems. 5. Any changes in laws that would affect access to dependence-producing drugs should be carefully thought out, implemented gradually and sequentially, and scientifically evaluated at each step of implementation, including evaluating the effects on: * access to young people and prevalence of use among youth; * prevalence of use in pregnancy and effects on offspring; * prevalence rates of alcoholism and other drug dependencies; * crime, violence and incarceration rates; * law enforcement and criminal justice costs; * industrial safety and productivity; * costs to the health care system; * family and social disruption; * other human, social and economic costs. 6. CSAM opposes * any changes in law and regulation that would lead to a sudden significant increase in the availability of any dependence-producing drug (outside of a medically-prescribed setting for therapeutic indications). All changes need to be gradual and carefully monitored. * any system of distribution of dependence-producing drugs that would involve physicians in the prescription of such drugs for other than therapeutic or rehabilitative purposes. 7. CSAM supports * public policies that would offer treatment and rehabilitation in place of criminal penalties for persons with psychoactive substance dependence and whose offense is possession of a dependence-producing drug for their own use. Those who are found guilty of an offense related to Addiction, proper assessment and treatment services must be offered as part of their sentence. This goal may be attained through a variety of sentencing options, depending upon the nature of the offense. * an increase in resources devoted to basic and applied research into the causes, extent and consequences of alcohol and other drug use, problems and dependence, and into methods of prevention and treatment. RELEVANT POSITION STATEMENTS OF OTHER MEDICAL HEALTH ORGANIZATIONS The purpose of this section is to provide the Special Senate Committee on Illegal Drugs with information on the policy positions of other key medical organizations from Canada and the United States in regard to decriminalization of cannabis. Canadian Centre for Addiction and Mental Health34 The Centre for Addiction and Mental Health (CAMH) does not encourage or promote cannabis use. CAMH emphasizes that the most effective way of avoiding cannabis-related harms is through not using cannabis, and encourages people to seek treatment where its use has become a problem. Cannabis is not a benign drug. Cannabis use, and in particular frequent and long-term cannabis use, has been associated with negative health and behavioural consequences, including respiratory damage, problems with physical coordination, difficulties with memory and cognition, pre- and post-natal development problems, psychiatric effects, hormone, immune and cardio-vascular system defects, as well as poor work and school performance. The consequences of use by youth and those with a mental disorder are of particular concern. However, most cannabis use is sporadic or experimental and hence not likely to be associated with serious negative consequences. CAMH thus holds the position that the criminal justice system in general, and the Controlled Drugs and Substances Act (CDSA) specifically, under which cannabis possession is a criminal offence, has become an inappropriate control mechanism. This conclusion is based on the available scientific knowledge on the effects of cannabis use, the individual consequences of a criminal conviction, the costs of enforcement, and the limited effectiveness of the criminal control of cannabis use. CAMH thus concurs with similar recent calls from many other expert stakeholders who believe that the control of cannabis possession for personal use should be removed from the realm of the CDSA and the criminal law/criminal justice system. While harmful health consequences exist with extensive cannabis use, CAMH believes that the decriminalization of cannabis possession will not lead to its increased use, based on supporting evidence from other jurisdictions that have introduced similar controls. CAMH recommends that a more appropriate legal control framework for cannabis use be put into place that will result in a more effective and efficient control system, produce fewer negative social and individual consequences, and maintain public health and safety. An alternative legal control system for the Canadian context can be chosen from a number of options that have been tried and proven adequate in other jurisdictions. CAMH further recommends that such an alternative framework be explored on a temporary and rigorously evaluated trial basis, and that an appropriate level of funding be provided/maintained for prevention and treatment programs to minimize the prevalence of cannabis use and its associated harms. American Society of Addiction Medicine 35 The Society's 1994 policy which was updated September 2001 recommends the following: 1. National policy should present a comprehensive and coordinated strategy aimed at reducing the harm done to individuals, families and society by the use of all drugs of dependence. 2. Reliance on the distinction between "legal" and "illegal" drugs is a misleading one, since so-called "legal" drugs are illegal for persons under specified ages, or under certain circumstances. 3. Prevention programs should be comprehensively designed to target the entire range of dependence-producing drugs as well as to produce changes in social attitudes. (See ASAM Prevention Statement.) 4. Outreach, identification, referral and treatment programs for all persons suffering from drug dependencies, including alcoholism and nicotine dependence, should be increased in number and type until they are available and accessible in every part of the country to all in need of such services. 5. Persons suffering from the diseases of alcoholism and other drug dependence should be offered treatment rather than punished for their status of dependence. 6. The balance of resources devoted to combatting these problems should be shifted from a predominance of law enforcement to a greater emphasis on treatment and prevention programs, as well as programs to ameliorate those social factors that exacerbate drug dependence and its related problems. 7. Law enforcement measures aimed at interrupting the distribution of illicit drugs should be aimed with the greatest intensity at those causing the most serious acute problems to society. 8. Any changes in laws that would affect access to dependence-producing drugs should be carefully thought out, implemented gradually and sequentially, and scientifically evaluated at each step of implementation, including evaluating the effects on: a. prevalence of use in pregnancy and effects on offspring; b. prevalence rates of alcoholism and other drug dependencies; c. crime, violence and incarceration rates; d. law enforcement and criminal justice costs; e. industrial safety and productivity; f. costs to the health care system; g. family and social disruption; h. other human, social and economic costs. 9. ASAM opposes any changes in law and regulation that would lead to a sudden significant increase in the availability of any dependence-producing drug (outside of a medically-prescribed setting for therapeutic indications). Any changes should be gradual and carefully monitored. 10. ASAM opposes any system of distribution of dependence-producing drugs that would involve physicians in the prescription of such drugs for other than therapeutic or rehabilitative purposes. 11. ASAM supports public policies that would offer treatment and rehabilitation in place of criminal penalties for persons who are suffering from psychoactive substance dependence and whose only offense is possession of a dependence-producing drug for their own use. 12. ASAM supports public policies which offer appropriate treatment and rehabilitation to persons suffering from psychoactive substance dependence who are found guilty of an offense related to that dependence, as part of their sentence. This goal may be attained through a variety of sentencing options, depending upon the nature of the offense. 13. ASAM supports an increase in resources devoted to basic and applied research into the causes, extent and consequences of alcohol and other drug use, problems and dependence, and into methods of prevention and treatment. 14. In addition, scientifically sound research into public policy issues should receive increased support and be given a high priority as an aid in making such decisions. 15. Physicians and medical societies should remain active in the effort to shape national drug policy and should continue to promote a public health approach to alcoholism and other drug dependencies based on scientific understanding of the causes, development and treatment of these diseases. US Physician Leadership on National Drug Policy 32 The Physician Leadership on National Drug Policy (PLNDP) was started in 1997 when 37 senior physicians from virtually every medical society* met and agreed that the "current criminal justice driven approach is not reducing, let alone controlling drug abuse in America." Their extensive review of the literature found: * drug addiction is a chronic, relapsing disease, like diabetes or hypertension; * treatment for drug addiction works; * treating addiction saves money; * treating drug addiction restores families and communities; * prevention and education help deter youth from substance abuse, delinquency, crime and incarceration. In follow-up to an extensive review of the literature, their key policy recommendations are: * Reallocate resources toward drug treatment and prevention; * Parity in access to care, treatment benefits, and clinical outcomes; * Reduce the disabling regulation of addiction treatment programs; * Utilize effective criminal justice procedures to reduce supply and demand (e.g. community coalitions, community policing, drug courts); * Expand investments in research and training; * Eliminate the stigma associated with the diagnosis and treatment of drug problems; * Train physicians and (medical) students to be clinically competent in diagnosing and treating drug problems. REFERENCES 1 Mosher JF, Yanagisako KL. Public health, not social warfare: a public health approach to illegal drug policy. J Public Health Policy 1991; 12: 278-323. 2 Precede - proceed model of health promotion. Institute of Health Promotion Research. Available from: http://www.ihpr.ubc.ca/frameset/frset_publicat.htm. Accessed: Nov 27, 2001. 3 World Health Organization. Ottawa charter for health promotion. Ottawa: World Health Organization, 1986. 4 Dean M. UK government rejects advice to update drug laws. Lancet 2000; 355: 1341. 5 Curran WJ. Decriminalization, demythologizing, desymbolizing and deemphasizing marijuana. Am J Public Health. 1972; 62: 1151-1152. 6 Report of the Canadian Government Commission of Inquiry into the non-medical use of drugs. Ottawa, 1972. 7 Anonymous. Deglamorising cannabis. Lancet 1995; 346: 1241. (editorial) 8 Edlaf EM, Paglia A, Ivis FJ, Ialomiteanu A. Nonmedicinal drug use among adolescent students: highlights from the 1999 Ontario Student Drug Use Survey. CMAJ 2000; 162: 1677-1680. 9 Centre for Addiction and Mental Health. The 1999 Ontario Student Drug Use Survey - executive summary. Available from: http://www.camh.net/addiction/ont_study_drug_use.html. Accessed: October 15, 2001. 10 MacNeil P, Webster I. Canada's alcohol and other drugs survey 1994: a discussion of the findings. Ottawa: Health Canada, 1997. 11 Single E, Fischer B, Room R, Poulin C, Sawka E, Thompson H, Topp J. Cannabis control in Canada: options regarding possession. Ottawa, Canadian Centre on Substance Abuse, 1998. Available from: http://www.ccsa.ca/. 12 Hall W. The cannabis policy debate: finding a way forward. CMAJ 2000; 162: 1690-1692. 13 Ashton CH. Pharmacology and effects of cannabis: a brief review. Br J Psychiatr 2001; 178: 101-106. 14 Johns A. Psychiatric effects of cannabis. Br J Psychiatr 2001; 178: 116-122. 15 Farrell M, Ritson B. Br J Psychiatr 2001; 178: 98. 16 Tremblay S. Illicit drugs and crime in Canada. Juristat 1999; 19. 17 Riley D. Drugs and drug policy in Canada: a brief review and commentary. November, 1998. Available from: http://www.parl.gc.ca/37/1/parlbus/commbus/senate/com-e/ill-e/library-e/riley-e.htm. Accessed: October 15, 2001. 18 Erickson PG. The law, social control, and drug policy: models, factors, and processes. Int J Addiction 1993; 28: 1155-1176. 19 Single EW. The impact of marijuana decriminalization: an update. J Public Health Policy 1989; 10: 456-66. 20 MacCoun R. Interpreting Dutch cannabis policy: reasoning by analogy in the legalization debate. Science 1997; 278: 47-52. 21 MacCoun R, Reuter P. Evaluating alternative cannabis regimes. Br J Psychiat 2001; 178: 123-128. 22 Hall W. The recent Australian debate about the prohibition on cannabis use. Addiction 1997; 92: 1109-1115. 23 Centre for Infectious Disease Prevention and Control. HIV/AIDS among injecting drug users in Canada. May 2001. Available from: http://www.hc-sc.gc.ca/hpb/lcdc/bah/epi/idus_e.html. Accessed Oct 17, 2001. 24 Hepatitis C - prevention and control : a public health consensus. Can Communic Dis Rep 1999; 25S2. Available from: http://www.hc-sc.gc.ca/hpb/lcdc/publicat/ccdr/99vol25/25s2/index.html. Accessed: Oct 17, 2001. 25 F/P/T Advisory Committee on Population Health et al. Reducing the harm associated with injection drug use in Canada: working document for consultation. March 2001. Available from: http://www.aidslaw.ca/Maincontent/issues/druglaws.htm. Accessed: Oct 14, 2001. 26 Single E, Rehm J, Robson L, Van Truong M. The relative risks and etiologic fractions of different causes of death attributable to alcohol, tobacco and illicit drug use in Canada. CMAJ 2000: 162: 1669-1675. 27 Marwick C. Physician Leadership on National Drug Policy finds addiction treatment works. JAMA 1999; 279: 1149-1150. 28 Grinspoon L, Bakalar JB. The war on drugs - a peace proposal. N Eng J Med 1994: 330: 357-360. 29 Hankins C. Substance use: time for drug law reform. CMAJ 2000: 162: 1693-1694. 30 National Task Force on HIV, AIDS and Injection Drug Use. HIV/AIDS and injection drug use: a national action plan. Canadian Centre for Substance Abuse and Canadian Public Health Association. May 1997. Available from: http://www.ccsa.ca/docs/HIVAIDS.HTM. Accessed: Oct 15, 2001. 31 Canadian HIV/AIDS Legal Network. Injection drug use and HIV/AIDS: legal and ethical issues. Montreal: Network, 1999. 32 Physician Leadership on National Drug Policy. Position paper on drug policy. January 2000. Available from: http://center.butler.brown.edu/plndp/. Accessed: Nov 27, 2001. 33 The Fraser Institute. Sensible solutions to the urban drug problem. 2001. Available from: http://www.fraserinstitute.ca/publications/books/drug_papers/. Accessed: Nov 29, 2001. 34 Canadian Centre for Addiction and Mental Health. CAMH Position on the legal sanctions related to cannabis possession/use. April 2000. Available from: www.camh.net/position_papers/cannabis_42000.html. Accessed Oct 9, 2001. 35 American Society of Addiction Medicine. Public policy of ASAM. Adopted 1994. Updated Sept 29, 2001. Available from: www.asam.org. Accessed: Nov 27, 2001. ?? ?? ?? ?? A healthy population...a vibrant medical profession Une population en santé...une profession médicale dynamique A Public Health Perspective on Cannabis and Other Illegal Drugs Ottawa, March 11, 2002 Page 21 Canadian Medical Association
Documents
Less detail

Reducing barriers to physician mobility and for a more uniformed healthcare system in Canada

https://policybase.cma.ca/en/permalink/policy11850
Date
2016-05-12
Topics
Health human resources
  1 document  
Policy Type
Parliamentary submission
Date
2016-05-12
Topics
Health human resources
Text
On behalf of 83,000 physician members, the Canadian Medical Association (CMA) welcomes this opportunity to provide input to the Standing Senate Committee on Banking, Trade and Commerce study on internal barriers to trade. For the purposes of this brief, an internal barrier to trade is any regulation or policy that restricts mobility or otherwise creates a perverse incentive for mobility. Basic Facts on the Canadian Physician Workforce The physician workforce in Canada has always been a mobile one. As of January 2016, just over one in four (26%) licensed physicians who graduated from one of Canada’s 17 medical schools was practising in a different province from the one where they obtained their medical degree.1 It might be added that only 8 of Canada’s 13 provinces and territories have medical schools. Another important dimension of mobility is the fact that Canada continues to rely to a significant degree on the medical services provided by International Medical Graduates (IMGs). Presently, IMGs represent 24% of practising physicians in Canada, and this figure has remained steady over the past two decades (and previously) despite significant increases in medical enrolment.1 A key reason for this dependence is that Canada trains fewer physicians relative to population than other developed countries. According to the Organization for Economic Cooperation and Development (OECD), in 2013, Canada ranked 28th out of 34 member countries in terms of medical graduates per 100,000 population; at 7.5 graduates per 100,000, Canada was one-third below the OECD average of 11.1.2 Another key consideration of the physician workforce in Canada is that beyond the tuition that medical students pay at the undergraduate level, it is virtually exclusively publicly funded. By way of illustration, in 2012, 99% of physician professional incomes came from the public purse in Canada, compared to an average of 72% for the 22 OECD countries for which data were available.3 1 Canadian Medical Association Physician Masterfile, January 2016. 2 Organization for Economic Cooperation and Development. OECD Health Statistics, 2015. http://stats.oecd.org/Index.aspx?DataSetCode=HEALTH_REAC. Accessed 05/05/16. 3 Organization for Economic Cooperation and Development. OECD. Stat. Accessed 05/05/16. 4 Internal Trade Secretariat. Agreement on Internal Trade. http://www.ait-aci.ca/agreement-on-internal-trade/. Accessed 05/05/16. 5 Federation of Medical Licensing Authorities of Canada, Association of Canadian Medical Colleges, Medical Council of Canada. Licensure, postgraduate training and the Qualifying Examination. Can Med Assoc J 1992;146(3):345. 6 Federation of Medical Regulatory Authorities of Canada. Model standards for medical registration in Canada. Ottawa, 2016. 7 Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources. Report of the Canadian Task Force on Licensure of International Medical Graduates. Ottawa, 2004. 8 Medical Council of Canada. Practice-ready assessment. http://mcc.ca/about/collaborations-and-special-projects/practice-ready-assessment/. Accessed 05/08/16. 9 Canadian Heritage. The Canadian Charter of Rights and Freedoms. http://publications.gc.ca/collections/Collection/CH37-4-3-2002E.pdf. Accessed 05/08/16. 10 Canada. Canada Health Act R.S.C., 1985, c. C-6. http://laws-lois.justice.gc.ca/PDF/C-6.pdf. Accessed 05/08/16. 11 Canadian Institute for Health Informaiton. Prescribed drug spending in Canada, 2013: a focus on public drug programs. https://secure.cihi.ca/free_products/Prescribed%20Drug%20Spending%20in%20Canada_2014_EN.pdf. Accessed 05/08/16. National Standards for Eligibility for Licensure The medical profession was well out in front of the 1994 Agreement on Internal Trade (AIT) and its objective in Chapter Seven of eliminating or reducing measures maintained by the provinces and territories that restrict or impair labour mobility in Canada.4 In 1992, the Federation of Medical Licensing Authorities of Canada, the Association of Canadian Medical Colleges and the Medical Council of Canada adopted a standard for portable eligibility of licensure in all provinces except Quebec.5 When the AIT was revisited in the late 2000s, the Federation of Medical Regulatory Authorities of Canada (FMRAC) worked on the development of an agreement on national standards that was endorsed in all jurisdictions in 2009. This has continued to evolve, and presently, the Model Standards for Medical Registration in Canada set out the: . Canadian standard for full licensure; . route from a provisional license to a full license (which would apply to most IMGs that do not come through the post-MD system in Canada); and . requirements for provisional licensure.6 The result of this effort is that the number of different medical licences in Canada has been reduced from more than 140 to fewer than 5. Since the early 2000s the federal government has played a strong leadership role in assisting the professions to come into compliance with the labour mobility provisions of the AIT. In the case of the medical profession, the key issue has been the mobility of IMGs. In 2002, the federally funded Advisory Committee on Health Delivery and Human Resources established the Task Force on Licensure of International Medical Graduates, which brought together representatives from national and provincial/territorial health ministries, medical regulatory and certifying bodies and medical schools with a mandate to aid in the integration of IMGs into the Canadian medical workforce. The recommendations in the 2004 final report of the Task Force essentially set out a workplan that has resulted in considerable progress on several initiatives.7 Federal funding through programs such as Employment and Social Development Canada’s (ESDC) Foreign Credential Recognition Program and Health Canada’s Internationally Educated Health Care Professional Program, in addition to significant investments by the medical bodies themselves, has contributed to several successful initiatives on the part of the Medical Council of Canada (MCC) and FMRAC and its provincial/territorial members. These have included: . $3.5 million from Health Canada to MCC to develop programs to facilitate the integration of IMGs into the physician workforce such as the National Assessment Collaboration examination, a standardized examination that assesses the readiness of an IMG for entrance into the Canadian post-MD training system; . $8.4 million from Human Resources and Skills Development Canada/ESDC to MCC to streamline and standardize the processes of application for medical licensure and to develop physiciansapply.ca, a single electronic web-based application process for registration with each of the 13 medical regulatory authorities; and . $6.7 million from ESDC to MCC to develop a more flexible MCC Qualifying Examination Part I that can be administered internationally, which will enable IMGs thinking of immigrating to Canada to assess whether they have one of the requirements for full licensure. The work to date has contributed significantly to the integration of IMGs but much remains to be done. Many IMGs enter practice in Canada without entering the post-MD system through a process of provisional licensure. One process that jurisdictions have developed over the past decade to facilitate this route to practice is called Practice Ready Assessment (PRA). PRA is an assessment process to determine if an IMG is able to provide safe medical care to the Canadian public under provisional licensure. This consists of a period of practice under supervised direct observation of a licensed physician in a clinical setting with patients. This has the advantage of expediting the process of assessment to approximately 12 weeks versus 2+ years in a residency program. To the present, PRA programs have been developing in a non-standardized way across jurisdictions. With support from Health Canada, an initiative is underway at the MCC with collaboration from FMRAC, the regulatory bodies, the certifying colleges and provincial IMG assessment programs to develop a pan-Canadian PRA program.8 The goal of this program is to address pan-Canadian specialty areas of need, including family medicine, psychiatry and internal medicine. The elements of this program will include: . IMG candidate orientation to the Canadian health care context; . identification of core competency for each specialty; . clinical assessor training; . standardized assessment tools; and . guidelines. This initiative is presently in the implementation phase, and the plan includes development of additional work-based assessment tools.i i For further information contact MCC – www.mcc.ca or FMRAC – www.fmrac.ca Recommendation one: The Canadian Medical Association recommends that the federal government continue to support the Medical Council of Canada and the Federation of Medical Regulatory Authorities of Canada in the implementation of a pan-Canadian Practice Ready Assessment Program for International Medical Graduates and the development of work-based assessment tools. Mobility and Medicare The right of Canadian citizens and permanent residents to move freely and pursue a livelihood in any jurisdiction is set out in the 1982 Canadian Charter of Rights and Freedoms.9 This is supported in the objectives of the AIT that refer to an “open domestic market” and “free movement of persons”. 4 This is certainly the spirit in which Canada’s Medicare program was established, beginning in the 1950s, and which has now come to be regarded as a much-cherished basic right by Canadians. The preamble of the 1984 Canada Health Act (CHA) includes the objective “to facilitate reasonable access to health services without financial or other barriers”, and portability of health insurance from one jurisdiction to another is one of five criteria for eligibility for federal funding (subject to a three month waiting period in which benefits are paid for by the originating jurisdiction).10 However, the letter of the CHA defines insured health services as “hospital services, physician services and surgical-dental services provided to insured services”10 and that is how it continues to be interpreted by the provinces and territories. An issue that has been identified in many recent reports is the uneven access to prescription drugs. The Canadian Institute for Health Information (CIHI) has estimated that in 2014, the federal and provincial governments accounted for 42% of prescription drug spending, with the majority accounted for by private insurance (36%) or out-of-pocket (22%) spending.11 There is wide variation in public per capita spending on prescription drugs across the provinces. In 2015, CIHI has estimated that expenditure ranged from $219 in British Columbia and $256 in Prince Edward Island (PEI) to $369 in Saskatchewan and $441 in Quebec.12 Even more striking variation is evident when looking at household out-of-pocket spending on prescription drugs by income quintile. Statistics Canada’s 2014 Survey of Household Spending shows that the poorest one-fifth (lowest income quintile) of PEI households spent more than twice as much ($645) on prescription drugs than the poorest one-fifth in Ontario ($300).13 Aside from overall differences in public spending, there are also differences in which drugs are covered, particularly in the case of cancer drugs. For example, the Cancer Advocacy Coalition of Canada reported in 2014 that in Ontario and Atlantic Canada, cancer drugs that must be taken in a hospital setting and are on the provincial formulary are fully funded by the provincial government; if the drug is taken outside of hospital (oral or injectable), however, the patient and family may have to pay significant costs out-of-pocket.14 More generally, the Canadian Cancer Society has reported that persons moving from one province to another may find that a drug covered in their former province may not be covered in the new one. 15 12 Canadian Institute for Health Information. National Health Expenditure Database 1975 to 2015. Table A.3.1.1. https://www.cihi.ca/en/spending-and-health-workforce/spending/national-health-expenditure-trends. Accessed 05/08/14. 13 Statistics Canada. CANSIM Table 2013-0026 Survey of household spending (SHS), household spending, by age of reference person. Accessed 03/27/16. 14 Cancer Advocacy Coalition of Canada. 2014-15 Report Card on Cancer in Canada. http://www.canceradvocacy.ca/reportcard/2014/Report%20Card%20on%20Cancer%20in%20Canada%202014-2015.pdf. Accessed 05/08/16. 15 Canadian Cancer society. Cancer drug access for Canadians. http://www.colorectal-cancer.ca/IMG/pdf/cancer_drug_access_report_en.pdf. Accessed 05/08/16. 16 Ipsos Reid. Supplementary health benefits research. Final report, 2012. 17 Conference Board of Canada. Federal policy action to support the health care needs of Canada’s aging population. https://www.cma.ca/Assets/assets-library/document/en/advocacy/conference-board-rep-sept-2015-embargo-en.pdf. Accessed 05/08/16. 18 Hall E. Canada’s national-provincial health program for the 1980’s ‘A commitment for renewal’. 1980. 19 Canada. Statutes of Canada 2012 Chapter 19. http://laws-lois.justice.gc.ca/PDF/2012_19.pdf. 20 Canadian Medical Association. Submission to the Minister of Finance: Small Business Perspectives of Medical Practice in Canada. https://www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/cma-brief-medical-practice-as-small-business-march-17-2016.pdf Another consequence of the “patchwork quilt” of prescription drug coverage in Canada is the potential for “job lock” among those with employer sponsored benefits. Research carried out by Ipsos Reid for the CMA in 2012 among Canadian adults found that 51% of respondents had employer-sponsored supplementary benefits, with almost all of them reporting prescription drug coverage. Among those with employer benefits, just over four in 10 (42%) indicated that their employer benefits program would be a factor in whether or not they would switch jobs.16 Uneven access to and coverage of prescription drugs across Canada raises two concerns with respect to population mobility. On one hand, there could be a temptation to move to another jurisdiction with better access and coverage, and on the other, there could be a reluctance to move to another jurisdiction for fear of lesser access and coverage. Uncertainty about health care coverage should not be a factor in Canadians’ decisions about where they choose to live and work. One concrete step that the federal government could take to mitigate these concerns would be to introduce a program of drug coverage that would cap high out-of-pocket drug costs for individual Canadians. In 2015, the Conference Board of Canada conducted research for the CMA to estimate the cost of a drug program that would cover prescription drug costs that are greater than either $1,500 per year or 3% of household income (so-called catastrophic costs). They estimated that this would cost the federal government $1.6 billion in 2016.17 Recommendation two: As a positive step toward comprehensive, universal coverage for prescription medication, the Canadian Medical Association recommends that the federal government establish a new program for catastrophic coverage of prescription medication. The Canada Health Act and Physician Mobility In his 1979 review of the Medicare program that led to the CHA, Justice Emmett Hall clearly recognized the power imbalance of the shift to an exclusive public payer for physician services, stating “I reject totally the idea that physicians must accept what any given Province may decide unilaterally to pay. I reject too, as I did in the report of the Royal Commission, the concept of extra-billing.” Justice Hall’s recommended solution to this imbalance was provision for that “when negotiations fail and an impasse occurs, the issues in dispute must be sent to binding arbitration, to an arbitration board consisting of three persons, with an independent chairperson to be named by the chief justice of the relevant Province and one nominee from the profession and one from the Government”.18 Provision for reasonable compensation was built into the CHA in sections 12 (1) and (2). In most jurisdictions, bargaining disputes between the government and the medical association over the amounts that physicians should be paid are subject to a binding dispute resolution mechanism that includes some form of arbitration, as Justice Hall envisioned. However, in Ontario, the physicians have been without a contract since March 31, 2014, and Nova Scotia has given Royal Assent to, but not yet proclaimed the Public Services Sustainability (2015) Act, which suspends the right of the medical association (Doctors Nova Scotia) to arbitration. As noted in the basic facts enumerated above, Canadian physicians are highly mobile, but they should not be motivated to move on the basis of unfair treatment by the government, as is currently the case in Ontario. There is recent precedent for amending the CHA. In 2012, the Jobs, Growth and Long-term Prosperity Act amended the CHA to remove members of the Royal Canadian Mounted Police from the list of exclusions of insured persons.19 Recommendation three: The Canadian Medical Association recommends that Section 12(2) of the Canada Health Act be amended to require: (a) Provincial and territorial governments to enter into an agreement with the provincial/territorial organization(s) that represent(s) practising medical practitioners in the province; and (b) The settlement of disputes relating to compensation through, at the option of the provincial/territorial organization(s) referred to in paragraph (a), conciliation or binding arbitration that is equally representative of the provincial/territorial organization(s) and the province/territory and that has an independent chairperson, to satisfy the “reasonable compensation” criterion in s. 12(1)(c) of the Act for full federal funding. Incorporation Eligibility and Access to the Small Business Deduction A significant proportion of Canada’s physicians are self-employed, small business owners, whose medical practices are incorporated as Canadian-Controlled Private Corporations (CCPCs). The ability to incorporate and access to the small business taxation rate play an important role in the allocation of resources in Canada’s health care system. As explained in the CMA’s recent submission to the Minister of Finance20, incorporation eligibility for medical professionals has been advanced by provincial governments to support the achievement of health policy objectives and, in part, to level the playing field with other self-employed individuals. The CMA strongly welcomed the federal government’s recognition in the budget of the contribution of health care practitioners as small businesses. However, the CMA has significant concerns with the proposed amendments (clause 54 of the Notice of Ways and Means Motion to Amend the Income Tax Act and Other Tax Legislation) to alter eligibility to the small business deduction. It is not clear whether these measures will impact group medical structures. The results of a recent survey by the CMA of its membership confirms that the CCPC framework provides a critical tax equity measure that recognizes the unique challenges they face as small business owners and is critical to the operation of the practice model, particularly supporting community-based care. In some cases, the practice model is only economical within this framework. An important fact is that unlike other small business owners, physicians cannot pass on any increases in compliance or operating costs to patients, given the design of Canada’s public health care system. Of significance to the committee’s study on internal trade, approximately 26% of survey respondents indicated that they would be very or somewhat likely to relocate to another provincial/territorial jurisdiction (26%) or to the U.S. or another country (22%) if they were no longer able to incorporate under the CCPC framework. Recommendation four: Given the potential for negative unintended consequences, such as rendering group medical structures economically unviable or introducing perverse incentives for mobility, particularly out of country, the Canadian Medical Association strongly encourages the federal government to provide clarification regarding the 2016 budget measures with regard to the Canadian-Controlled Private Corporation framework.
Documents
Less detail

15 records – page 1 of 2.