Skip header and navigation
CMA PolicyBase

Policies that advocate for the medical profession and Canadians


19 records – page 1 of 2.

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

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

Chronic Diseases Related to Aging: CMA's Presentation to the House of Commons Standing Committee on Health

https://policybase.cma.ca/en/permalink/policy10226
Date
2011-10-17
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2011-10-17
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association wishes to commend the House of Commons Standing Committee on Health for undertaking this study of the issue of chronic diseases related to aging. It is a timely issue, since the first members of the Baby Boom generation turned 65 in 2011 and it's predicted that by 2031 a quarter of Canada's population will be 65 or older. Though chronic disease is not exclusive to seniors, its prevalence does rise with age: according to Statistics Canada, about 74% of Canadians over 65 have at least one chronic condition such as diabetes, high blood pressure, arthritis or depression and nearly 25% have three or more. The proportion is higher among people 85 years old and over. What are the causes of chronic disease? There are many. Some of them are rooted in unhealthy behaviour: smoking, poor nutrition and, in particular, lack of physical activity. Physicians are concerned about rising obesity rates in Canada, for example, because obesity increases one's risk of developing chronic diseases later in life. But there is more to chronic disease than unhealthy behaviour. It is also affected by a person's biological and genetic makeup, as well as by his or her social environment. Lower income and educational levels, poor housing, and social isolation, which is a greater problem for seniors than for other populations, are all associated with poorer health status. Now the good news: chronic disease is not an inevitable consequence of aging. We can delay the onset of chronic disease, and perhaps even reduce the risk that it will occur. Patients who do have existing chronic disease, their conditions can often be controlled successfully through appropriate health care and disease management, so that they can continue to lead active, independent lives. Thus the CMA supports initiatives promoting healthy aging - which the Public Health Agency of Canada defines as "the process of optimizing opportunities for physical, mental and social health as people age." Healthy lifestyles should be encouraged at any age. For example, the Canadian Physical Activity Guidelines, which CMA supports, recommend that people 65 or older accumulate at least two-and-a-half hours per week of aerobic activity such as walking, swimming or cycling. Experts believe that healthy aging will compress a person's period of illness and disability into a short period just prior to death, enabling a longer period of healthy, independent and fulfilling life. For those who are already affected with chronic diseases, treatment is long term and can be very complex. People with diabetes, for example, need a continuous ongoing program to monitor their blood sugar levels and maintain them at an appropriate level; people with arthritis or other mobility problems may require regular physical therapy. For the patient, chronic disease means a long-term management that is much more complicated than taking antibiotics for an infection. People with two or more chronic conditions may be consulting a different specialist for each, as well as seeking support from nurse counsellors, dieticians, pharmacists, occupational therapists, social workers or other health professionals. Often, management requires medication. The majority of Canadians over 65 take at least one prescription drug, and nearly 15% are on five drugs or more, which increases the possibility that, for example, two of those drugs could interact negatively with each other to produce unpleasant and possibly serious side effects. Long-term, complex chronic disease care is in fact the new paradigm in our health care system. About 80% of the care now provided in the United States is for chronic diseases, and there is no reason to believe Canada is greatly different. Hence, it is worth considering what form, ideally, a comprehensive program of chronic disease management should take, for patients of any age. The CMA believes it should include the following four elements: * First, access to a primary care provider who has responsibility for the overall care of the patient. For more than 30 million Canadians, that primary care provider is a family physician. Family physicians who have established long-standing professional relationships with their patients, can better understand their needs and preferences. They can build a relationship of trust, so that patients are comfortable in discussing frankly how they want to treat their conditions: for example, whether to take medication for depression or seek counselling with a therapist. The family physician can also serve as a co-ordinator of the care delivered by other providers. This leads to our second recommended element: * Collaborative and coordinated care. The CMA believes that, given the number of providers who may be involved in the care of chronic diseases, the health care system should encourage the creation of interdisciplinary teams or, at minimum, enable a high level of communication and coordination among individual providers. We believe all governments should support: o Interdisciplinary primary care practices, such as Family Health Networks in Ontario, which bring a variety of different health professionals and their expertise into one practice setting; o Widespread use of the electronic health record, which can facilitate information sharing and communication among providers; and o A smooth process for referral: for example, from family physician to specialists, or from family physician to physiotherapist. The CMA is working with other medical stakeholders to create a referral process tool kit that governments, health care organizations and practitioners can use to support the development of more effective and efficient referral systems. The patient may also need non-medical support services to help cope with disability related to chronic disease. For example, a person with arthritis who wants to remain at home may need to have grab bars, ramps or stair lifts installed there. Ideally, a coordinated system of chronic disease management would also include referral to those who could provide these services. * The third necessary element is support for informal caregivers. These are the unsung heroes of elder care. An estimated four million Canadians are providing informal, unpaid care to family members or friends. About a quarter of these caregivers are themselves 65 or older. Their burden can be a heavy one, in terms of both time and expense. Stress and isolation are common among caregivers. The federal government has taken steps to provide much-needed support to informal caregivers. The most recent federal budget, for example, increased the amount of its Caregiver Tax Credit. We recommend that the government build on these actions, to provide a solid network of support, financial and otherwise, to informal caregivers. * The fourth and final element is improving access to necessary services. Only physician and hospital services are covered through the Canada Health Act, and many other services are not. All provinces have pharmacare programs for people over 65, but coverage varies widely between provinces and many, particularly those with lower incomes, find it difficult to pay for their necessary medications. Seniors who do not have post-retirement benefit plans - and these are the majority - also need to pay out of pocket for dental care, physiotherapy, mental health care and other needed supports. We recommend that all levels of government explore adjusting the basket of services provided through public funding, to make sure that it reflects the needs of the growing number of Canadians burdened by chronic disease. In particular, we recommend that the federal government negotiate a cost-shared program of comprehensive prescription drug coverage with provincial/territorial governments. In conclusion, the CMA believes the committee is wise to consider how we might reduce the impact - on individual patients, the health care system and society - of chronic disease related to aging. Chronic disease management is a complex problem, but warrants close attention as it is now the dominant form of health care in Canada. We look forward to the results of the Committee's deliberations.
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

Healthy Living: CMA's Presentation to the House of Commons Standing Committee on Health

https://policybase.cma.ca/en/permalink/policy10058
Date
2011-02-08
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2011-02-08
Topics
Population health/ health equity/ public health
Text
I would like to thank the Committee for inviting the Canadian Medical Association to appear on this very important topic. As a family physician in Saskatoon and the past president of the CMA, I can assure you that Canada's physicians have an acute interest in drawing attention to the health consequences of poor nutrition and lack of physical activity, and the challenge of obesity. We know that obesity is a contributor to a number of chronic diseases, such as diabetes, cardiovascular disease, hypertension and liver disease, as well as breast, colon and prostate cancer. We know that over-consumption of salt, sugars, and saturated and trans fats can be a factor in hypertension, cardiovascular disease and stroke, and kidney disease. And we know that Canadians have become dramatically less physically fit in recent decades. As a country, we need to espouse a culture of health and wellness, based on good nutrition and physical activity. Finding solutions will require a collaborative, system-wide approach involving all levels of government, the health, education, industry, finance and transportation ministries, and the private sector. We know that if provided with support when young, children can adopt healthy life styles. That is why the CMA continues to call on governments across the country to work with school boards to: * provide at least 30 minutes of active daily physical education for all primary and secondary grades, given by trained educators in the field; * provide access to attractive, affordable, healthy food choices and clearly post the nutrition content of the foods they sell; and * ban junk food sales in all primary, intermediate and secondary schools in Canada. The CMA has advocated policies and regulations for food safety, and promoted healthy eating and physical activity as key components of healthy living and the prevention of disease. The CMA policy statement Promoting Physical Activity and Healthy Weights calls for a Canada-wide strategy for healthy living that includes: * information and support for Canadians to help them make healthy choices; * support for health professionals in counselling patients on healthy weight and in treating existing obesity; * community infrastructure that makes healthy living choices easier; and * public policies that encourage healthy eating and physical activity. All Canadians need access to nutritious food at affordable prices. The price of milk, produce and other healthy foods varies greatly in different parts of Canada. In remote areas, they are even more expensive because of high transportation costs. In urban areas, nutritious food may be unaffordable for people on low incomes and unavailable as grocery stores move to the suburbs thus creating "food deserts". Among other strategies, governments should consider: implementing school meal programs; and taking into account the cost of nutritious food when setting social assistance rates. The proliferation of packaged, prepared foods and fast foods has contributed to excess amounts of salt, sugar, saturated and trans fat and calories in our diet. While we welcome the federal government's support for the reduction of trans fats and sodium levels in processed foods, reliance on the food industry to voluntarily reduce these ingredients has not been successful. We believe that regulation is needed to safeguard the health of Canadians. Healthy living begins with an awareness of the impact of food and exercise on health. While individuals must take responsibility for making healthy choices, the CMA believes that governments have an obligation to provide guidance on healthy eating and physical activity that can be easily incorporated into daily lives. We commend the federal and provincial/ territorial governments for their recent Framework for Action to Promote Healthy Weights. Physicians were also pleased to see the revised Canada's Food Guide in 2007, and the recent update to Canada's Physical Activity Guide. The CMA supports nutrition and caloric labeling on packaged foods to help Canadians make informed food choices. The federal nutrition labeling awareness initiative is useful to consumers but we think information can be simplified. For example, the UK is testing front of pack 'traffic light' coding for fats, salt, sugar and calories. The CMA has also called for a clear display of caloric counts, and sodium, trans-fats and protein levels on restaurant and cafeteria menus. The CMA believes encouragement of active transportation, that is walking and cycling, is a way to increase physical activity. Communities need to make it easier for Canadians to be physically active in their day-to-day life by providing sidewalks and pedestrian-friendly intersections; bike lanes, paths and parking spaces; and trails, parks and green spaces. One area that we believe warrants further study is the use of incentives to promote healthy behaviours. By transferring funds or other benefits to an individual, incentives provide immediate rewards for behaviours that can lead to long-term health gains. An example in Canada is the Children's Fitness Tax Credit, which is intended to help children be more active by off-setting some of the costs incurred by families for sports and leisure programs. Government disincentives largely involve the use of regulation and taxation in order to change individual behaviour. This helps to create an environment in which healthy choices are easier to make. It is impossible to overstate the importance of nutrition and physical activity to our health. Encouraging Canadians to make healthy choices requires a wide ranging, long-term and collaborative approach. The CMA believes this challenge should be met urgently. Canada's physicians are more than ready to work with governments to ensure that Canadians can improve and maintain their health.
Documents
Less detail

A Healthy Population for a Stronger Economy: CMA pre-budget consultation submission to the Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy10224
Date
2011-08-12
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2011-08-12
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) submission to the House of Commons Standing Committee on Finance examines how increasing retirement income saving options, improving access to prescription drugs, and planning for a Canadian Health Quality Alliance to promote innovation in the delivery of high quality health care can enhance our health care system and, in turn, make our economy more productive. Higher quality health care and expanded options for meeting the needs of retired and elderly Canadians will contribute to the ultimate goals of better patient care, improved population health and help our country reach its full potential. Polls show that Canadians are becoming increasingly concerned about the future of their health care system, particularly in terms of their ability to access essential care. The CMA's 2011 pre-budget submission responds to these concerns and supports a healthy population, a healthy medical profession and a healthy economic recovery. Our recommendations are as follows: Recommendation # 1 The federal government should study options to expand the current PRPP definition beyond defined contribution pension plans. Also, the federal government should expand the definition of eligible administrators of PRPPs beyond financial institutions to include organizations such as professional associations. Recommendation # 2 Governments, in consultation with the life and health insurance industry and the public, should establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. Recommendation # 3 The federal government should convene a time-limited national steering committee that would engage key stakeholders in developing a proposal for a pan-Canadian Health Quality Alliance with a mandate to work collaboratively towards integrated approaches for a sustainable health care system through innovative practices in the delivery of high quality health care. Introduction Over the past year, the CMA has engaged Canadians across the country in a broad-based public consultation on health care and heard about their concerns and experiences with the system. This exercise was undertaken as part of the CMA's Health Care Transformation (HCT) initiative, a roadmap for modernizing Canada's health care systemi so that it puts patients first and provides Canadians with better value for money. We have heard through these consultations that Canadians do not believe they are currently getting good value from their health care system, a feeling borne out by studies comparing Canada's health care system to those in leading countries in Europe. We also heard that Canadians are concerned about inequities in access to care beyond the basic medicare basket, particularly in the area of access to prescription drugs. While all levels of government need to be involved, it is the federal government that must lead the transformation of our most cherished social program. 1. Retirement Income Improvement Issue: Increasing retirement savings options for Canadians with a focus on improving their ability to look after their long-term care needs. Background The CMA remains concerned about the status of Canada's retirement income system and the future ability of Canada's seniors to adequately fund their long-term and supportive care needs. The proportion of Canadian seniors (65+) is expected to almost double from its present level of 13% to almost 25% by 2036. Statistics Canada projections show that between 2015 and 2021 the number of seniors will, for the first time, surpass the number of children under 14 years of age.ii The CMA has been working proactively on this issue in several ways, including through the recently created Retirement Income Improvement Coalition (RIIC), a broad-based coalition of 11 organizations representing over one million self-employed professionals. The coalition has previously recommended to the federal government the following actions: * increased retirement saving options for all Canadians, particularly the self-employed; * changes to the Income Tax Act, Income Tax Regulations and the Employment Standards Act to enable the self-employed to participate in pension plans; * the approval of Pooled Retirement Pension Plans (PRPP) as a retirement savings program for the self-employed; * changes to the current tax-deferred income saving options (increase the percentage of earned income or the maximum-dollar amount contribution limit for RRSPs); * a requirement that registration to all retirement saving options be voluntary (optional); and * opportunities for Canadians to become better educated about retirement saving options (financial literacy).iii The CMA appreciates that federal, provincial and territorial finance ministers are moving ahead with the introduction of Pooled Registered Retirement Plans (PRPPs). The CMA, as part of the RIIC, has been providing input into the consultation process. However, PRPPs represent only one piece of a more comprehensive retirement savings structure. Recommendation # 1 The federal government should study options that would not limit PRPPs to defined contribution pension plans. Target benefit plans should be permitted and encouraged. Target benefit plans allow risk to be pooled among the plan members, providing a more secure vehicle than defined contribution plans. Also, the administrators of PRPPs should not be limited to financial institutions. Well-governed organizations that represent a particular membership should be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members. The CMA also continues to be concerned about the ability of Canadians to save for their long-term health care needs. The Wait Time Alliance - a coalition of 14 national medical organizations whose members provide specialty care to patients - reported recently that many patients, particularly the elderly, are in hospital while waiting for more suitable and appropriate care arrangements. Mostly in need of support rather than medical care, these patients are hindered by the lack of options available to them, often due to limited personal income. The CMA has previously recommended that the federal government should study options for pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance. This remains pertinent. 2. Universal access to prescription drugs Issue: Ensuring all Canadians have access to a basic level of prescription drugs. Background Universal access to prescription drugs is widely acknowledged as part of the "unfinished business" of medicare in Canada. In 1964 the Hall Commission recommended that the federal government contribute 50% of the cost of a Prescription Drug Benefit within the Health Services Program. It also recommended a $1.00 contributory payment by the purchaser for each prescription. This has never been implemented.iv What has emerged since then is a public-private mix of funding for prescription drugs. The Canadian Institute for Health Information (CIHI) has estimated that, as of 2010, 46% of prescription drug expenditures were public, 36% were paid for by private insurance and 18% were paid for out-of-pocket.v Nationally there is evidence of wide variability in levels of drug coverage. According to Statistics Canada, 3% of households spent greater than 5% of after-tax income on prescription drugs in 2008. Across provinces this ranged from 2.2% in Ontario and Alberta, to 5.8% in P.E.I. and 5.9% in Saskatchewan.vi Moreover, there is significant variation between the coverage levels of the various provincial plans across Canada. For example, the Manitoba Pharmacare Program is based on total income, with adjustment for spouse and dependents under 18, while in Newfoundland and Labrador, the plan is based on net family income.vii,viii The Commonwealth Fund's 2010 International Health Policy Survey found that 10% of Canadian respondents said they had either not filled a prescription or skipped doses because of cost issues.ix Moreover, there have been numerous media stories about inequities in access across provinces to cancer drugs and expensive drugs for rare diseases. The high cost of prescription drugs was frequently raised during our public consultations this year. The need for a national drug strategy or pharmacare plan was mentioned by an overwhelming number of respondents, many of whom detailed how they had been affected by the high cost of drugs. The cost to the federal government of a program that would ensure universal access to prescription drugs would depend on the threshold of out-of-pocket contribution and the proportion of expenses that it would be willing to share with private and provincial/territorial public plans. Estimates have ranged from $500 millionx, and $1 billionxi, to the most recent estimate from the provincial-territorial health ministers of $2.5 billion (2006).xii Recommendation # 2 Governments, in consultation with the life and health insurance industry and the public, should establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. Such a program should include: * a mandate for all Canadians to have either private or public coverage for prescription drugs; * a uniform income-based ceiling (between public and private plans and across provinces/territories) on out-of-pocket expenditures, on drug plan premiums and/or prescription drugs; * federal/provincial/territorial cost-sharing of prescription drug expenditures above a household income ceiling, subject to capping the total federal and/or provincial/territorial contributions either by adjusting the federal/provincial/territorial sharing of reimbursement or by scaling the household income ceiling or both; * a requirement for group insurance plans and administrators of employee benefit plans to pool risk above a threshold linked to group size; and * a continued strong role for private supplementary insurance plans and public drug plans on a level playing field (i.e., premiums and co-payments to cover plan costs). 3. Innovation for Quality in Canadian Health Care Issue: Development of a proposal to establish a Canadian Health Quality Alliance to promote innovation in the delivery of high-quality health care in Canada. Background There is general agreement that Canada's health care system is no longer a strong performer compared to similar nations. Clearly, we can do better. However, progress has been slow on a comprehensive quality agenda for our health care system. At the national level, there is no coordination or body with a mandate to promote a comprehensive approach to quality improvement. Over the past two decades, health care stakeholders in Canada have gradually come to embrace a multi-dimensional concept of quality in health care encompassing safety, appropriateness, effectiveness, accessibility, competency and efficiency. The unilateral federal funding cuts to health transfers that took effect in 1996 precipitated a long preoccupation with the accessibility dimension that was finally acknowledged with the Wait Time Reduction Fund in the 2004 First Ministers Accord. The safety dimension was recognized with the establishment of the Canadian Patient Safety Institute (CPSI) in 2003. Competence has been recognized by health professional organizations and regulatory bodies through the development of peer-review programs and mandated career-long professional development. While six provinces have established some form of health quality council (B.C., Alta., Sask., Ont., Que., N.B.), there is no national approach to quality improvement beyond safety. Given that health care stands as Canadians' top national priority and that it represents a very large expenditure item for all levels of government, the lack of a national approach to quality improvement is a major shortcoming. In the U.S., the Institute for Healthcare Improvement is dedicated to developing and promulgating methods and processes for improving the delivery of care throughout the world.xiii England's National Health Service (NHS) has also created focal points over the past decade to accelerate innovation and improvement throughout their health system. Canadian advancements in the health field have occurred when the expertise and perspective of a range of stakeholders have come together. The CPSI, for example, was established following the deliberations and report of the National Steering Committee on Patient Safety.xiv It is estimated that it would cost less than $500,000 for a multi-stakeholder committee to develop a proposal for a national alliance for quality improvement, including the cost of any commissioned research. Recommendation # 3 The federal government should convene a time-limited national steering committee that would engage key stakeholders in developing a proposal for a pan-Canadian Health Quality Alliance with a mandate to work collaboratively towards integrated approaches for a sustainable health care system through innovative practices in the delivery of high quality health care. This alliance would be expected to achieve the following in order to modernize health care services: * Promote a comprehensive approach to quality improvement in health care; * Promote pan-Canadian sharing of innovative and best practices; * Develop and disseminate methods of engaging frontline clinicians in quality improvement processes; and * Establish international partnerships for the exchange of innovative practices. Such an alliance could be established in a variety of ways: * Virtually, using the Networks of Centres of Excellencexv approach; * By expanding the mandate of an existing body; or * Through the creation of a new body. REFERENCES i Canadian Medical Association. Health Care Transformation in Canada. Change that Works. Care that Lasts. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Advocacy/HCT/HCT-2010report_en.pdf Accessed 13/07/11. ii Statistics Canada. Population Projections for Canada, Provinces and Territories. http://www.statcan.gc.ca/pub/91-520-x/2010001/aftertoc-aprestdm1-eng.htm. Accessed 13/07/11. iii Retirement Income Improvement Coalition. Letter to the federal Minister of Finance and the Minister of State (Finance). March 17, 2011. ivHall, E. Royal Commission on Health Services. Volume 1. Ottawa: Queen's Printer, 1964. vCanadian Institute for Health Information. Drug Expenditure in Canada, 1985 to 2010. Ottawa, 2010. viStatistics Canada. CANSIM Table 109-5012 Household spending on prescription drugs as a percentage of after-tax income, Canada and provinces, annual (percent). http://www5.statcan.gc.ca/cansim/pick-choisir?lang=eng&searchTypeByValue=1&id=1095012. Accessed 05/29/11. vii Manitoba Health. Pharmacare deductible estimator. http://www.gov.mb.ca/health/pharmacare/estimator.html. Accessed 07/28/11. viii Newfoundland Department of Health and Community Services. Newfoundland and Labrador Prescription Drug Program (NLPDP). http://www.health.gov.nl.ca/health/prescription/nlpdp_application_form.pdf. Accessed 07/29/11. ixCommonwealth Fund. International health policy survey in eleven countries. http://www.commonwealthfund.org/~/media/Files/Publications/Chartbook/2010/PDF_2010_IHP_Survey_Chartpack_FULL_12022010.pdf. Accessed 05/29/11. x Senate Standing Committee on Social Affairs, Science and Technology. The health of Canadians - the federal role. Volume six: recommendations for reform. Ottawa, 2002. xi Commission on the Future of Health Care in Canada. Building on values: the future of health care in Canada. Ottawa, 2002. xii Canadian Intergovernmental Conference Secretariat. Backgrounder: National Pharmaceutical Strategy decision points. http://www.scics.gc.ca/english/conferences.asp?a=viewdocument&id=112. Accessed 23/07/11. xiii http://www.ihi.org. Accessed 29/07/10. xiv National Steering Committee on Patient Safety. Building a safer system: a national integrated strategy for improving patient safety in Canadian health care. http://rcpsc.medical.org/publications/building_a_safer_system_e.pdf. Accessed 23/07/11. xv http://www.nce-rce.gc.ca/index_eng.asp. Accessed 29/07/10.
Documents
Less detail

A Healthy Population for a Stronger Economy: The Canadian Medical Association's Presentation to the Standing Committee on Finance's pre-budget consultations

https://policybase.cma.ca/en/permalink/policy10228
Date
2011-10-18
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2011-10-18
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
Thank you for the opportunity to appear before this committee. Over the past year, the Canadian Medical Association has engaged in a wide-ranging public consultation on health care and heard from thousands of Canadians about their concerns and experiences with the system. This exercise was undertaken as part of the CMA's Health Care Transformation initiative, a roadmap for modernizing our country's health care system so that it puts patients first and provides Canadians with better value for money. The CMA found there is a groundswell of support for change among other health care providers, stakeholders and countless Canadians who share our view that the best catalyst for transformation is the next accord on federal transfers to provinces for health care. That said, while looking ahead to what we would like to see in the next health care accord, we have identified immediate opportunities for federal leadership in making achievable, positive changes to our health care system that would help Canadians be healthier and more secure and help ensure the prudent use of their health care dollars. During our consultation, we heard repeated concerns that Canada's medicare system is a shadow of its former self. Once a world leader, Canada now lags behind comparable nations in providing high quality health care. Improving the quality of health care services is key if Canada is ever going to have a high performing health system. The key dimensions of quality, and by extension, the areas that need attention are: Safety, Effectiveness, Patient-Centeredness, Efficiency, Timeliness, Equitability and Appropriateness. Excellence in quality improvement in these areas will be a crucial step towards sustainability. To date, six provinces have instituted health quality councils. Their mandates and their effectiveness in actually achieving lasting system wide improvements vary by province. What is missing, and urgently needed, is an integrated, Pan-Canadian approach to quality improvement in health care in Canada that can begin to chart a course that will ensure that Canadians ultimately have the best health and health care in the world. Canadians deserve no less and, with the resources at our disposal, there is no reason why this should not be achievable. The CMA recommends that the Federal Government funds the establishment, and adequately resources the operations, of an arms length Canadian Health Quality Council with the mandate to be a catalyst for change, a spark for innovation and a facilitator to disseminate evidence based quality improvement initiatives so that they become embedded in the fabric of our health systems from coast to coast to coast. Canadians are increasingly questioning whether they are getting value for the $190 billion a year that go into our country's health care system... with good reason as international studies indicate they are not getting good value for money. Defining, promoting and measuring quality care are not only essential to obtaining better health outcomes, they are crucial to building the accountability to Canadians that they deserve as consumers and funders of the system. We also heard during our consultation that Canadians worry about inequities in access to care beyond the hospital and doctor services covered within medicare, particularly when it comes to the high cost of prescription drugs. Almost 50 years ago, the Hall Commission recommended that all Canadians have access to a basic level of prescription drug coverage, yet what we have now is a jumble of public and private funding for prescription drugs that varies widely across the country. Last year, one in 10 Canadians either failed to fill a prescription or skipped a dose because they couldn't afford it. Universal access to prescription drugs is widely acknowledged to be part of the unfinished business of medicare in Canada. Our second recommendation, therefore, is that governments establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. This should be done in consultation with the life and health insurance industry and the public. In the 21st century, no Canadian should be denied access to medically necessary prescription drugs because of an inability to pay for them. Our third and final recommendation relates to our aging population and the concerns Canadians share about their ability to save for their future needs. We recommend that the federal government study options that would not limit PRPPs to defined contribution pension plans. Target benefit plans should be permitted and encouraged as they allow risk to be pooled among the plan members, providing a more secure vehicle than defined contribution plans. As well, the administrators of PRPPs should not be limited to financial institutions. Well-governed organizations that represent a particular membership should be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members. The CMA appreciates that governments are moving ahead with the introduction of Pooled Registered Retirement Plans. However, we note that PRPPs represent only one piece of a more comprehensive saving structure. We also continue to be concerned about the ability of Canadians to save for their long-term health care needs. Many patients, particularly the elderly, are in hospital waiting for more suitable care arrangement. These patients are hindered by a lack of available options, often because they lack the means to pay for long-term care. They and their families suffer as a result, and so, too, does our health care system. While not in this pre-budget brief, the CMA holds to recommendations we have made in previous years that the federal government study options to help Canadians pre-fund long-term care. In closing, let me simply say that carrying out these recommendations would make a huge and positive impact, soon and over the long term, in the lives of literally millions of Canadians from every walk of life. Thank you for your time. I would be happy to answer your questions.
Documents
Less detail

Improving Accountability in Canada's Health Care System: The Canadian Medical Association's Presentation to the Senate Standing Committee on Social Affairs, Science and Technology

https://policybase.cma.ca/en/permalink/policy10230
Date
2011-10-19
Topics
Health care and patient safety
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2011-10-19
Topics
Health care and patient safety
Health systems, system funding and performance
Text
The CMA appreciates the opportunity to appear before this committee as part of your review of the 10-Year Plan to Strengthen Health Care. An understanding of what has worked and what hasn't since 2004 is critical to ensuring the next accord brings about necessary change to the system. Overview of 2004 Accord On the positive side of the ledger, the 2004 accord provided the health care system with stable, predictable funding for a decade - something that had been sorely lacking. It also showed that a focused commitment, in this case on wait times, can lead to improvements. However, little has been done on several other important commitments in the Accord, such as the pledge that was also made in 2003 to address the significant inequity among Canadians in accessing prescription drugs. Along with the lack of long-term, community and home-based care services, this accounts for a major gap in patient access along the continuum of care. We also know that accountability provisions in past accords have been lacking in several ways. For instance, there has been little progress in developing common performance indicators set out in previous accord. i The 2004 accord has no clear terms of reference on accountability for overseeing its provisions. Vision and principles for 2014 What the 2004 accord lacked was a clear vision. Without a destination, and a commitment to getting there, our health care system cannot be transformed and will never become a truly integrated, high performing health system. The 2014 Accord is the perfect opportunity to begin this journey, if it is set up in a way that fosters the innovation and improvements that are necessary. By clearly defining the objectives and securing stable, incremental funding, we will know what changes we need to get us there. Now is the time to articulate the vision- to say loudly and clearly that at the end of the 10-year funding arrangement, by 2025, Canadians will have the best health and health care in the world. With a clear commitment from providers, administrators and governments, this vision can become our destination. As a first step to begin this long and difficult journey, the CMA has partnered with the Canadian Nurses Association, and together we have solicited support from over 60 health care organizations for a series of "Principles to Guide Health Care Transformation in Canada." These principles define a system that would provide equitable access to health care based on clinical need; care that is high quality and patient-centred; and that focuses on empowering patients to attain and maintain wellness. They call for a system that provides accountability to those who use it and those who fund it; and that is sustainable - by which I mean adequately resourced in terms of financing, infrastructure and human resources, and measured against other high-performing systems, with cost linked to outcomes. Based on our experience working within the provisions of the 2004 accord, we would like to suggest three strategies to ensure the next accord leads to a sustainable, high-performing health care system. They are: a focus on quality; support for system innovation; and the establishment of an accountability framework and I will touch briefly on each one. Focus on quality First, the crucial need to focus on improving the quality of health care services. The key dimensions of quality, and by extension, the areas that need attention are: safety, effectiveness, patient-centredness, efficiency, timeliness, equitability and appropriateness. Excellence in quality improvement in these areas will be a crucial step towards sustainability. To date, six provinces have instituted health quality councils. Their mandates and their effectiveness in actually achieving lasting system-wide improvements vary. What is missing and urgently needed is an integrated, pan-Canadian approach to quality improvement in health care that can begin to chart a course to ensure Canadians ultimately have the best health and health care in the world. Canadians deserve no less and, with the resources at our disposal, there is no reason why this should not be achievable. The CMA recommends that the federal government fund the establishment and resource the operations of an arms-length Canadian Health Quality Council, with the mandate to be a catalyst for change, a spark for innovation and a facilitator to disseminate evidence-based quality improvement initiatives so that they become embedded in the fabric of our health systems from coast to coast to coast. To help expand quality improvement across the country, the Institute for Healthcare Improvement's Triple Aim provides the solid framework. Our health care systems will benefit inordinately from a simultaneous focus on providing better care to individuals and better health to populations, while reducing the per-capita cost. There is ample evidence that quality care is cost effective care. This approach, when adopted and applied as the pan-Canadian framework for any and all structural changes and quality improvement initiatives, will not only serve patients well, but will also enhance the experience of health care providers on the front lines. System innovation The second strategy revolves around system innovation. Innovation and quality improvement initiatives are infinitely more likely to be successful and sustained if they arise out of a commitment by frontline providers and administrators to the achievement of a common goal. We need to shift away from compliance models with negative consequences that have little evidence to support their sustainability. Innovative improvements in health care in Canada are inadequately supported, poorly recognized, and constrained from being shared and put into use more widely. This needs to change. The 2014 accord, with a focus on improving Canadians' health and health care, can facilitate the transformation we all seek. Building on the success of the 2004 Wait Times Reduction Fund and the 2000 Health Accord Primary Health Care Transition Fund, the CMA proposes the creation of a Canada Health Innovation Fund that would broadly support the uptake of health system innovation initiatives across the country. A Working Accountability Framework And, third, there needs to be a working accountability framework. This would work three ways. To provide accountability to patients - the system will be patient-centred and, along with its providers, will be accountable for the quality of care and the care experience. To provide accountability to citizens - the system will provide and, along with its administrators and managers, will be accountable for delivering high quality, integrated services across the full continuum of care. And to provide accountability to taxpayers - the system will optimize its per-capita costs, and along with those providing public funding and financing, will be accountable for the value derived from the money being spent. We have done all of this because of our profound belief that meaningful change to our health care system is of the essence, and that such change can and must come about through the next health accord. Therefore I thank this committee for your efforts on this important area. I would be happy to answer your questions. Appendix A Issues identified in 2004 Accord and Current Status [NOTE: see PDF for correct dispaly of table] Issue Current Status Annual 6% escalator in the CHT to March 31, 2014 Has provided health care system with stable, predictable funding for a decade. Adoption of wait-time benchmarks by December 2005 for five procedural areas Largely fulfilled. However, no benchmarks were set for diagnostic imaging. The Wait Time Alliance is calling for benchmarks for all specialty care. Release of health human resource (HHR) action plans by December 2005 Partially fulfilled. Most jurisdictions issued rudimentary HHR plans by the end of 2005; F/P/T Advisory Committee on Health Delivery and Human Resources issued a paper on a pan-Canadian planning HHR framework in September 2005. First-dollar coverage for home care by 2006 Most provinces offer first-dollar coverage for post-acute home care but service varies across the country for mental health and palliative home care needs. An objective of 50% of Canadians having 24/7 access to multidisciplinary primary care teams by 2011 Unfulfilled: Health Council of Canada reported in 2009 that only 32 per cent of Canadians had access to more than one primary health care provider. A 5-year $150 million Territorial Health Access Fund Fulfilled: Territorial Health System Sustainability Initiative (THSSI) funding extended until March 31, 2014. A 9-point National Pharmaceuticals Strategy (NPS) Largely unfulfilled: A progress report on the NPS was released in 2006 but nothing has been implemented. Accelerated work on a pan-Canadian Public Health Strategy including goals and targets F/P/T health ministers (except Quebec) put forward five high-level health goals for Canada in 2005, although they were not accompanied by operational definitions that would lend themselves to setting targets. Continued federal investments in health innovation Unknown-no specificity in the 2004 Accord. Reporting to residents on health system performance and elements of the Accord P/T governments ceased their public reporting after 2004, and only the federal government has kept its commitment (at least to 2008). Formalization of the dispute advance/resolution mechanism on the CHA Done but not yet tested. i P/T governments ceased their public reporting after 2004, and only the federal government has kept its commitment (at least to 2008).Government of Canada. Healthy Canadians: a federal report on comparable health indicators 2008. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/system-regime/2008-fed-comp-indicat/index-eng.pdf. Accessed 06/21/11.
Documents
Less detail

International Medical Graduates : Notes for an address by Dr. Albert J. Schumacher, President, Canadian Medical Association : Presentation to the Standing Committee on Citizenship and Immigration

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

Letter to the International Joint Commission on the 2004 Progress Report addressing air quality

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

Mental Health, Mental Illness & Addiction : CMA Submission to the Standing Committee on Social affairs, Science and Technology

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

19 records – page 1 of 2.