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Acting on today's and tomorrow's health care needs: Prebudget submission to the House of Commons Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy14123
Date
2019-08-02
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2019-08-02
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to provide the House of Commons Standing Committee on Finance this pre-budget submission. It provides recommendations to address major pan-Canadian challenges to the health of Canadians: improve how we provide care to our growing elderly population; improve access to primary care across the country; increase digital health literacy to take advantage of the benefits of new health information technologies; and better prepare for and mitigate the health impacts of a changing climate on Canadians. Seniors Care Health systems across the country are currently struggling to meet the needs of our aging population. People aged 85 years and over—many of whom are frail—make up the fastest growing age group in Canadai. Provincial and territorial health care systems (as well as care systems for populations falling under federal jurisdiction) are facing many challenges to meet the needs of an aging population. Canadians support a strong role for the federal government in leading a national seniors strategy and working with the provinces to ensure that all Canadians have the same level of access and quality of services, no matter where they live. The 2017 federal/provincial/territorial funding agreement involving $6 billion over 10 years to improve access to home care services is a welcomed building block. But without greater investment in seniors care, health systems will not keep up. To be truly relevant and effectively respond to Canadians’ present and future needs, our health care system must provide integrated, continuing care able to meet the chronic and complex care needs of our growing and aging population. This includes recognizing the increased role for patients and their caregivers in the care process. The federal government must ensure transfers are able to keep up with the real cost of health care. Current funding levels clearly fail to do so. Health transfers are estimated to rise by 3.6% while health care costs are expected to rise by 5.1% annually over the next decade.ii Recommendation: The federal government ensure provincial and territorial health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer.iii Providing care often comes with a financial cost such as lost income due to the caregiver’s withdrawal from the workforce to provide care. There are also increasing out-of-pocket costs for both caregivers and care receivers for health care-related expenses—privately covered expenditures on home and long-term care for seniors are projected to grow by an average of 5.8 per cent annually—nearly 1.5 times the pace of household disposable income growth. While the federal government offers tax credits that can be claimed by care receivers/caregivers, they are significantly under-utilized. While representing a significant proportion of caregivers, those with low or no income receive little to no federal government support through these programs. Middle-income earners also receive less than those earning high incomes. 4 Recommendation: The federal government create a Seniors Care Benefit that would be an easier, fairer and more effective way to support caregivers and care receivers alike.iv Access to Care Since the mid-1990s, the federal and provincial/territorial governments (FPT) have provided sustained leadership in promoting and supporting the transformation of primary care in Canada. In 2000, the First Ministers concluded the first of three Health Accords in which they agreed to promote the establishment of primary health care teamsv supported by a $800 million Primary Health Care Transition Fund (PHCTF) funded by the federal government, but jointly governed. The PHCTF resulted in large-scale sustained change in primary care delivery models in Ontario, Quebec and Alberta with interest in other jurisdictions as well. However, the job is far from finished. Across Canada, access to primary care is challenging for many Canadians with a persistent shortage of family physicians. In 2017, 4.7 million Canadians aged 12+ reported they did not have a regular health care provider.vi Even those who have a regular provider experience wait time issues. There has been widespread interest in primary care models since the development of the College of Family Physicians of Canada’s (CFPC) vision document Family Practice: The Patient’s Medical Home (PMH), initially launched in 2011vii and recently re-launched.viii The model is founded on 10 pillars depicted in Figure 1. Figure 1. The Patient’s Medical Home, 2019 The updated model places increased emphasis on team-based care and introduces the concept of the patient’s medical neighborhood that sets out connections between the primacy care practice and all delivery points in the surrounding community. While comprehensive baseline data are lacking, it seems 5 safe to conjecture that most Canadians are not enrolled in a primary care model that would measure up to the model’s 10 pillars. Recommendation: The federal government, in concert with provinces and territories, establish a targeted fund in the amount of $1.2 billion to support a new time-limited Primary Health Care Transition Fund that would build on the success of the fund launched in 2000 with the goal of widely introducing a sustainable medical home model across jurisdictions. This would include the following key elements:
Age-sex-weighted per capita allocation across the provinces and territories;
Joint governance of the FPT governments with meaningful stakeholder engagement;
Respect for the Canada Health Act principles;
Common objectives (e.g., modeled on the CFPC Patient’s Medical Home framework);
Operating Principles specifying eligible/ineligible activities;
Reporting provisions and agreed-upon metrics; and
Sustainability plans. Digital/Virtual Care Canada and most industrialized countries will experience a digital health revolution over the next decade with great potential to improve patient and population health. Digital health can be described as the integration of the electronic collection and compilation of health data, decision support tools and analytics with the use of audio, video and other technologies to deliver preventive, diagnostic and treatment services that promote patient and population health. While most Canadian physicians’ offices and health care facilities are now using some form of electronic record keeping and most households have internet access, there remains a large deficit in using virtual care, both within jurisdictions and across provincial/territorial boundaries. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify opportunities for digital health to improve health care delivery, including what regulatory changes are required for physicians to deliver care to patients within and across provincial/territorial boundaries. To take full advantage of digital health capabilities it will be essential for the population to have a functional level of digital health literacy: the ability to seek, find, understand and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.ix This also includes the capability of communicating about one’s health to health care professionals (e.g., e-consults), self-monitoring health (e.g., patient portals) and receiving treatment online (e.g., Web-based cognitive behavioral therapy).x There are no current data available on health literacy in Canada, let alone digital health literacy. One basic barrier to achieving digital health literacy is access to, and usage of the Internet, which has been termed the “digital divide” (e.g., older Canadians and low income households are less likely to have Internet access).Error! Bookmark not defined. 6 In 2001 the federal government established the Financial Consumer Agency of Canada (FCAC). Its mandate includes informing consumers about their rights and responsibilities in dealing with financial institutions and providing information and tools to help consumers understand and shop for financial products and services.xi In 2014 the FCAC appointed a Financial Literacy Leader who has focused on financial literacy, including activities such as conducting financial capability surveys and the development of a National Strategy for Financial Literacy.xii Considering the anticipated growth of digital/virtual care it would be desirable to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy could serve as a template for digital health literacy. Recommendation: The federal government establish a Digital Health Literacy Secretariat to:
Develop indicators and conducting surveys to measure and track the digital health literacy of Canadians;
Develop tools that can be used both by Canadians and their health care providers to enhance their digital health literacy; and
Assess and make recommendations on the “digital divide” that may exist among some population sub-groups due to a lack of access to information technology and lower digital health literacy. Climate Change and Health Climate change is the public health imperative of our time. There is a high level of concern among Canadians about their changing climate. A 2017 poll commissioned by Health Canada demonstrates a high level of concern among Canadians about their changing climate: 79% were convinced that climate change is happening, and of these, 53% accepted that it is a current health risk, with 40% believing it will be a health risk in the future. The World Health Organization (WHO) has identified air pollution and climate change as one of the biggest threats to global health. Health care professionals see first-hand the devastating health impacts of our changing climate including increased deaths from fine particulate matter air pollution and increased heat-related conditions. Impacts are most common in vulnerable populations such as adults over 65 years, the homeless, urban dwellers and people with a pre-existing disease. Canada’s health care system is already treating the health effects of climate change. A lack of progress in reducing emissions and building adaptive capacity threatens both human lives and the viability of Canada’s health system, with the potential to disrupt core public health infrastructure and overwhelm health services, not to mention the economic and social costs. The federal government must provide leadership to deal with the impact already being felt in Canada and around the world. Recommendation: 7 The federal government make strong commitments to minimize the impact of climate change on the health of Canadians by:
Ensuring pan-Canadian and inter-jurisdictional coordination to standardize surveillance and reporting of climate-related health impacts such as heat-related deaths, develop knowledge translation strategies to inform the public, and generate clinical and public health response plans that minimize the health impacts;
Increasing funding for research on the mental health impacts of climate change and psychosocial adaptation opportunities; and
Ensuring funding is provided to the health sector to prepare for climate change impacts through efforts to increase resiliency (i.e., risk assessments, readiness to manage disease outbreaks, sustainable practice). 8 i Statistics Canada. The Chief Public Health Officer's Report on the State of Public Health in Canada, 2014: Public Health in the Future. Ottawa: Statistics Canada; 2015. Available: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2014/chang-eng.php; (accessed 2016 Sep 19). ii The Conference Board of Canada. Meeting the care needs of Canada’s aging population. Ottawa: The Conference Board; 2018. iii Canadian Medical Association. Meeting the demographic challenge: Investments in seniors care. Pre-budget submission to the House of Commons Standing Committee on Finance. August 3, 2018. https://policybase.cma.ca/documents/Briefpdf/BR2018-16.pdf iv The Conference Board of Canada. Measures to Better Support Seniors and Their Caregivers. March 2019. https://www.cma.ca/sites/default/files/pdf/health-advocacy/Measures-to-better-support-seniors-and-their-caregivers-e.pdf v Canadian Intergovernmental Conference Secretariat. News release – First Ministers’ meeting communiqué on health. September 11, 2000. http://www.scics.ca/en/product-produit/news-release-first-ministers-meeting-communique-on-health/. Accessed 04/22/19. vi Statistics Canada. Primary health care providers, 2017. https://www150.statcan.gc.ca/n1/en/pub/82-625-x/2019001/article/00001-eng.pdf?st=NGPiUkM5. Accessed 04/21/19. vii College of Family Physicians of Canada. A vision for Canada. Family Practice: the patient’s medical home. http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf. Accessed 04/22/19. viii College of Family Physicians of Canada. The patient’s medical home 2019. https://patientsmedicalhome.ca/files/uploads/PMH_VISION2019_ENG_WEB_2.pdf. Accessed 04/21/19. ix Norman C, Skinner H. eHealth literacy: essential skills for consumer health in a networked world. J Med Internet Res 2006;8(2):e9. Doi:10.2196/jmir.8.2.e9. x Van der Vaart R, Drossaert C. Development of the digital health literacy instrument: measuring a broad spectrum of health 1.0 and health 2.0 skills. J Med Internet Res. 2017;19(1):e27. Doi:10.2196/jmir.6709. xi Financial Consumer Agency of Canada. About FCAC. xii Financial Consumer Agency of Canada. National Strategy for Financial Literacy. Phase 1: strengthening seniors’ financial literacy. https://www.canada.ca/content/dam/canada/financial-consumer-agency/migration/eng/financialliteracy/financialliteracycanada/documents/seniorsstrategyen.pdf. Accessed 06/24/19. https://www.canada.ca/en/financial-consumer-agency/corporate/about.html. Accessed 07/01/19.
Documents
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Building bridges: the link between health policy and economic policy in Canada : A Document prepared by the Canadian Medical Association (CMA)

https://policybase.cma.ca/en/permalink/policy1990
Last Reviewed
2019-03-03
Date
1996-01-30
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
1996-01-30
Topics
Health systems, system funding and performance
Text
I. PURPOSE The objective of this document is twofold: (1) to provide the federal government with a better understanding of the current issues that are of concern to physicians across Canada and are material to the preparation of the 1996-97 federal budget; and (2) to propose some solutions. As part of the government's pre-budget consultation process, the CMA has formally presented a brief to the House of Commons Standing Committee on Finance on November 23, 1995. II. POLICY CONTEXT Canada faces a number of important policy challenges as it moves toward the 21st century. First and foremost is the fiscal challenge to reduce Canada's debt and deficit levels while, at the same time, fostering an environment which provides for future economic growth within a globally-integrated marketplace. As of March 31, 1995 total public debt (federal/provincial/territorial levels of government) was $787.7 billion; the interest paid on the total debt for 1994 was $64.3 billion, and the 1994 total public deficit was $40.8 billion. At a minimum, government is faced with the challenge of addressing short- and long-term economic policy objectives while meeting defined social policy imperatives. In a time of continued fiscal restraint and scarce public sector economic resources, difficult choices will continue to be made. CMA acknowledges that there is an urgent need, now more than ever, for the federal government to balance a number of competing policy challenges. At a time when profound deficit reduction measures are required, all segments of society are being asked to do more with the same or less. Having already dealt with this reality for quite some time, the health care sector is no stranger to this burden. In making policy choices, careful and deliberate thought needs to be given to the repercussions such decisions will have on the Canada of tomorrow and the health and well-being of Canadians. Attacking Canada's federal debt/deficit for short-term economic gain must be balanced against any decision(s) that would serve to increase our longer-term "social" deficit. At a time when Canada is undergoing significant social, political and economic changes, CMA remains dedicated to the delivery of high quality health care and to safeguarding the national integrity of the system. However, given the need for the federal government to gain control over the deficit and national debt, it seems clear that putting Canada's fiscal house in order remains a high priority. That being said, the government must also be clear with Canadians on its intentions and priorities with respect to a long-term commitment to health and social programs, including a cash commitment. Canadians are deeply concerned that reducing the federal deficit will result in the shifting of costs to other levels of government which they cannot absorb. This may very well lead to reduced access to government programs and services, and at some point in the future, higher social costs. This is highlighted in a recent poll where 58% of Canadians reported that they expect the health care system will be worse in the next ten years. 1 It would appear that Canadians believe that the fiscal agenda will overwhelm the social agenda to the extent that the social values and ideals that sustain them will be forgotten or worse, be lost. Surveys indicate that 84% of Canadians view Medicare as a defining characteristic of being Canadian. Furthermore, 84% of Canadians feel that the system provides high quality care. However, 65% of Canadians are concerned about continued accessibility to a full range of publicly-financed benefits. According to the same poll, 83% of Canadians see current financing of the system as being "unsustainable" over the longer-term. 2 While Canadians are expressing strong concerns over the future viability of what we currently have in the area of health care, physicians are also voicing similar worries. In a recent poll, 76% of physicians surveyed agreed with the statement that Canada's health care will be worse in 10 years. 3 III. MANAGING CHANGE AND MEETING POLICY OBJECTIVES Recognizing that change is one constant that will characterize Canadian society for the foreseeable future, any further policy changes affecting the health care system must also be considered in the context of Canadian values and economic policy. Good health policy and good economic policy must reinforce one another. CMA is concerned that any short-term economic decisions on the part of the government which do not reinforce good health policy may be detrimental to the best interests of Canada. If change is to come within an overall policy framework that is strategic, coordinated and fair and preserves (or augments) the integrity of Canada's health care system, we must be careful to avoid short-term, stop-gap initiatives. As the Government's 1994 Throne Speech stated "...the agenda of the government is based on an integrated approach to economic, social, environmental and foreign policy". Accordingly, in establishing an appropriate fiscal framework for health and health care, change must take place within the context of a longer-term integrated view. The principle of aligning good health policy with sound economic policy is critical to managing change while serving to lay down a strong foundation for future economic growth and prosperity in Canada. Moreover, by better synchronizing health and economic policy as a national priority, opportunities can be created to meet a number of important "higher order" policy objectives. They are: (i) Canada building; (ii) economic development; (iii) well being of Canadians and the future of health and health care in Canada, and (iv) putting Canada's financial house in order. Each is discussed in turn. i. Canada Building In many ways, Canada is at a social, political and economic crossroads. The challenge to this government is to balance short-term fiscal pressures against the longer-term need to re-position Canada to take advantage of greater economic opportunities while preserving that which is of fundamental importance to Canadian society as a whole. In this context, of the range of social programs that the federal government supports, Medicare is strongly viewed as a defining characteristic of being Canadian. Medicare is a high priority for Canadians. Some have argued that the declining federal cash commitment to funding Medicare serves to further fragment our health care system and speeds the process of government decentralization. What better opportunity for the federal government to clarify its funding support and relationship to health care in this country? In making a clear, significant and stable financial commitment in support of health care, the government will serve notice that it is prepared to play a leadership role in ensuring that Canadians will have a sustainable, high quality "national" health care system, a value they hold deeply as Canadians. ii. Economic Development From an international perspective, Canada's Medicare system has been acknowledged as one of our greatest assets. Agencies such as the World Economic Forum tell us that Canada's method of financing health care is one of our comparative economic advantages in an evolving new world economic order. Compared to the United States, this takes the form of lower public and private expenditures on health care while maintaining the same or better health status. In terms of our European trading partners, the fact that health insurance programs are financed primarily through consolidated revenues (rather than employment-based taxes), also confers a unit cost advantage to Canadian exporters. In this sense, good health policy and good economic policy reinforce each other and the bridge between the two should be strengthened. By producing "healthier" individuals at lower cost, this relative cost advantage can translate into economic benefits that all Canadian can share in terms of expanded employment opportunities, wealth creation and economic growth. As a 1995 report form the Conference Board of Canada stated "[Canadian business is] unequivocal in terms of the high value they place on the Canadian health care system. Their support rests on their faith that the system has the capacity to deliver high-quality care while keeping public costs under control. They are also aware that Canada's health insurance system seems to provide employers with a competitive advantage over companies in the United States". 4 While the CMA is in support of a publicly-financed health system, there are serious concerns that the series of recent reforms have not been carried out in a reasonable and rational manner. Prior to implementing any further reforms, there is a pressing need to evaluate the effects of these changes. Cutting alone should not continue to be considered a catalyst for change; as an investment in the future of Canada health care is far too valuable. If health policy and economic policy are to be better synchronized, governments must not only consider the level of current public sector resources that are allocated to the health care system, but they must also re-examine the current roles of the public and private sectors. iii. Well-Being of Canadians and the Future of Health and Health Care in Canada For over twenty-five years, the Medicare system has provided all Canadians with the assurance that "it will always be there when you need it", without fear of an individual or family being forced into bankruptcy due to their health care needs. However, the security that Canadians have enjoyed in knowing that their health care system was always there when they needed it is being challenged daily. For example, Canadians are experiencing difficulties in access because of hospital closures, lengthening waiting lists and the departure of physicians from their communities. As well, physicians and patients are increasingly experiencing difficulties in accessing new medical technologies. Canadians are becoming more and more concerned that the universal Medicare system which they have known and supported through their tax dollars may not be available when they need it the most. In stepping forward and playing a leadership role, the federal government can serve to reassure Canadians that preserving the fundamentals of our health care system remains a high priority by making a significant and predictable financial cash contribution. iv. Putting Canada's Financial House in Order CMA recognizes that the federal government must attend to its own fiscal house and is meeting its fiscal targets. CMA believes that we must not pass this massive debt burden - one in which 36 cents of every federal tax dollars goes to debt servicing - onto future generations. This is not, however, to suggest that a "slash and burn" strategy should be adopted: but rather we should seek a measured approach that gains control over spending while fostering an environment of economic growth. This would bring with it increased employment opportunities and expanding societal wealth. Such an approach should be measured, deliberate and responsible. Deficit reduction should not be fought disproportionately on the back of health care, which, if viewed in its proper context, should be considered as an investment good not a consumption good. Health care is an asset to all Canadians, not a liability. IV. CONCLUSION The CMA has attempted to set out a framework that serves as a basis for defining policy objectives to which the government should give serious consideration. These "four pillars" are: (1) Canada building; (2) economic development; (3) well-being of Canadians and the future of health and health care in Canada; and (4) putting Canada's fiscal house in order. In seeking to build stronger bridges between these policy objectives is the unshakeable principle that good health and good economic policy should go hand-in-hand, reinforcing rather than neutralizing one another. The CMA's four pillars are consistent with government policy objectives as set out in the Red Book, and its 1994 throne speech. Using the four pillars as a guide, the key issues that are of immediate concern to the medical profession in a pre-budget consultation context are as follows: * the Canadian Health and Social Transfer (CHST); * Registered Retirement Savings Plan (RRSP); * the Goods and Services Tax (GST); * Non-Taxable Supplementary Health Benefits (NTSHB); * the National Health Research Program (NHRP); and, * Tobacco Taxation. The CMA is prepared to work with the government and others in a collaborative effort, within the above framework to meet sound social, health, economic and fiscal policy objectives. CANADIAN HEALTH AND SOCIAL TRANSFER (CHST) ISSUE The Canadian Medical Association (CMA) is concerned that the decreasing federal cash commitment to health care will eventually result in no federal cash flowing to some provinces in the future. This will seriously undermine the federal government's ability to set and maintain goals and standards in the health care system across the country. CONTEXT * The CMA recognizes that federal finances must be brought under better control. However, 60% of Canadians feel that social programs require federal protection while expenditures are being reduced. 5 Reforms to social programs must be phased in over a defined planning horizon. * Beginning in 1996-97, the Canadian Health and Social Transfer (CHST), a combination of the Established Programs Financing and the Canadian Assistance Plan, will result in a reduction of cash transfers to the provinces and territories of $7 billion. PHYSICIAN PERSPECTIVE * Access to Quality Health Care: Our First Priority Canadian physicians want to maintain and enhance the delivery of high quality health care services. Canadians are experiencing difficulties in access due to hospital closures, lengthening waiting lists and communities losing physicians. Furthermore, physicians and their patients are increasingly experiencing difficulty in accessing new health technologies. Canadians are becoming concerned that the universal Medicare system which they have supported through their tax dollars may not be available when they need it the most. * The CHST Threatens The Principles Of National Health Insurance Continued reductions in the CHST will make it increasingly difficult for the federal government to maintain national standards in health care. Earmarked funding for health care will enable the federal government to ensure the principles encompassed under the Canada Health Act are protected. * A Strong Federal Role Must Be Maintained The Medicare system provides all Canadians with the assurances that "it will be there when you need it"; and "you and your family won't be forced into financial ruin". Surveys indicate that 84% of Canadians see Medicare as a defining characteristic of being Canadian. Furthermore, 84% of Canadians feel that the system provides high quality care. Canadians want governments to spend more energy on the protection of Medicare and other social programs. 6 From an international perspective, Canada's Medicare system has been acknowledged as one of our greatest assets. Compared to the U.S. this takes the form of lower public and private expenditures on health care while maintaining the same or better health status. CMA RECOMMENDS... * Stable, predictable and ear-marked cash transfers with a formula for growth is required to enable all provinces and territories to plan and deliver a defined set of comparable high quality health care services to all Canadians. * A $250 per capita cash transfer for health care for the next 5 years should be established and guaranteed within the CHST framework. After the 5 year period, the federal government must preserve the real value of the cash transfer by means of an appropriate escalator. RATIONALE * Considering all options, a per capita transfer is the fairest, most equitable method of allocating cash for the health care system. It will also operationalize the CHST in such a way so as to reassure Canadians that the federal dollars will continue to be available to sustain the health system. * The Medicare system is a unifying value and defining characteristic that is recognized as a valuable resource by business and provides Canadians with an important sense of well-being. * The above recommendations would assist in ensuring a strong federal role in setting and maintaining national health care standards as promised in the Red Book. Acting on these recommendations will demonstrate to Canadians that the federal government has listened to their concerns about the CHST and the future of the health care system. A federal cash contribution to health care in Canada is important for economic reasons. * Business is growing increasingly concerned that the competitive advantage provided by the Canadian health care system is eroding. Furthermore, the universal nature of the coverage provided by our health system means it cannot be viewed as a subsidy under current trade agreements (e.g., NAFTA). REGISTERED RETIREMENT SAVINGS PLANS (RRSP) ISSUE The Canadian Medical Association (CMA) is concerned about the ability of Canadians to accrue retirement savings that will enable them to retire in dignity. CONTEXT * The numbers of those over the age of 65 continue to expand, in 1994 11.9% of the population was over the age of 65, in 2016 this will increase to 16% and by 2041 increase to 23%. The numbers of those under 18 are shrinking, in 1994 they represented 25% of the population and by 2016 they will represent 20%. 7 These demographic trends are of concern to governments and taxpayers. Employment trends indicate that an increasing number of Canadians are self-employed. In 1994, self-employment accounted for an increasingly large share of total employment growth, 25% of the overall employment gain. In 1993, 35% of the total labour force were in employment situations that provide registered pension plans (RPPs). 8 * It appears that Canadians are becoming increasingly more self-reliant when it comes to providing for their retirement years. We understand the government's concerns with respect to the retirement income system, the CMA eagerly anticipates the release of the government's intentions in relation to seniors and pension reform. PHYSICIAN PERSPECTIVE * Ensuring Dignity in Retirement Canadian physicians treat retired patients on a daily basis and are aware of the challenges many of them face. In this context, Canadian physicians are concerned that all Canadians should have the opportunity to achieve a state of financial well-being to provide for themselves in their retirement years. Recognizing Canada's demographic trends and its current fiscal challenges, governments must ensure that suitable financial incentives are in place to encourage a greater reliance on private savings vehicles. * Equal Opportunities to Accumulate Retirement Savings The vast majority of Canadian physicians are self-employed professionals and therefore are not members of an employer/employee sponsored RPP. They, like many other individuals must plan for and fund their own retirement. The principle of equity demands that the self-employed and those employed but reliant on registered retirement savings plans (RRSPs) be afforded the same opportunities and incentives to plan for their retirement as those in employment situations that provide RPPs (i.e., pension equity). * Fair Treatment Of Retirement Savings For those individuals that may suffer the misfortune of declaring bankruptcy, creditors may seize the annuitant's RRSP assets. This is patently unfair. If an employed individual declares personal bankruptcy their RPP is currently protected from creditors, however, they too run the risk of loosing their RRSP to their creditors. CMA RECOMMENDS... * The federal government should strive for equity between RRSPs and RPPs. * The federal government should refrain from making changes to the retirement income system pending a review of the system. * The federal government should consider legislation that would deem RRSP assets credit proof. * The federal government should consider gradually raising the foreign investment limits applicable to RRSPs and/or RPPs. At the end of a defined period of gradual increases, the federal government should consider removing the foreign investment limit completely. RATIONALE * All Canadians should have an equal ability to accumulate retirement savings regardless of their employment status. Assuming the current demographic and employment trends persist, it is important to recognize the role that RRSPs will play in assisting Canadians to live healthy and dignified lives well past their retirement from the labour force. * In keeping with the principles of fairness and equity, retirement income plans should be treated equally under federal legislation (e.g., Tax Act , Bankruptcy Act). Sound investment decisions and strategies are required that will enable Canadians to accumulate retirement savings and achieve financial security in their retirement. * Given the complexity of the retirement income system, changes to RRSPs and or RPPs should only be considered in the context of a thorough review of the pension system and include a thoughtful, open and meaningful consultation process. * For the past ten years the government has supported the laudable objective of attaining equity between RRSPs and RPPs. * Experts have assured Canadians that: "The two fundamental goals (of retirement savings) are: (1) to guarantee a basic level of retirement income for all Canadians, and (2) to assist Canadians to avoid serious disruption of their pre-retirement living standards upon retirement". * As governments' continue to reduce publicly funded benefits and encourage greater self-reliance, there is a need to ensure that Canadians have the ability to invest and save private dollars for their retirement years. * RRSPs and RPPs are legitimate tax deferral mechanisms and should not be viewed as tax avoidance. Income set aside for retirement should be taxed when it is received as a pension. The tax system should encourage and assist Canadians to arrange for their financial security in retirement. GOODS AND SERVICES TAX (GST) ISSUE The CMA has strong concerns regarding the effect of treating most medical services as GST exempt. Unlike other self-employed professionals, physicians are disadvantaged by the fact that they are not able to claim refunds or collect Input Tax Credits (ITCs) for GST paid. Given that medical services are designated as tax exempt, physicians are forced to absorb the additional tax payable as a result of the GST. Moreover, if the government is to proceed with harmonization, this situation will be compounded. CONTEXT * The GST was designed as a tax on "consumers" and not businesses who provide goods and services. Approximately 95% of physicians' services are paid for by the provinces. Provinces do not pay GST based on their constitutional exemption and by agreement with the federal government. In making medical services exempt, GST is payable by the provider of the service and not recoverable as an input tax credit. Therefore physicians are in the position of paying non-recoverable GST on their inputs. Attempts to recover the GST from provincial governments through increased fees have not been possible since the provinces refuse to reimburse for increased costs due to GST since they are constitutionally exempt from GST. * Unlike other professional medical groups such as dentist, physicians do not have the ability to pass increased GST costs along in the form of higher fees. Unlike other institutional health care providers such as hospitals, physicians do not recover these extra GST costs through a rebate mechanism. Therefore, given that most medical services are exempt, physicians are forced to absorb the additional tax payable as a result of the GST. * Because most medical services are treated as exempt, an independent study estimated that self-employed physicians have been forced to absorb an additional $57.2 million of incremental sales tax (net of the Federal Sales Tax) on an annual basis. The study was submitted to the Department of Finance. By the end of 1995, it is estimated that the profession will have absorbed in excess of $286 million because of the current situation. * In the government's Red Book it states: "A Liberal government will replace the GST with a system that generates equivalent revenues, is fairer to consumers and small businesses, minimizes disruptions to small business, and promotes federal-provincial cooperation and harmonization". As self-employed professionals delivering quality health care services to Canadians, physicians face the same financial realities as do other small businesses. As such, the status of medical services as tax exempt is patently unfair to these small businesses. PHYSICIAN PERSPECTIVE * Access To Quality Health Care While hospitals have been afforded an 83% rebate, self-employed physicians must absorb the full GST load on equipment and other purchases. As a result of this differential tax arrangement, a number of physicians are leaving their community-based practices and moving back into institutions. Therefore, the GST is having an adverse effect on movement towards community-based care, and is impeding patient access to physicians who re-locate from the community to institutions. In this regard, good health policy is not reinforced by good economic policy. * Good Health Policy Should Reinforce Good Economic Policy Most of Canada's premiere medical researchers are employed by hospitals. As part of their research, physicians purchase goods and services that are inputs to their investigative activities. Given that physicians work within a facility, hospitals are eligible to claim the 83% on GST paid on input costs. However, some researchers have grown increasingly concerned that the GST that is recoverable by the hospitals is not returned for medical research and serves to "subsidize" other day-to-day activities. In essence, monies that have been earmarked for specific medical research are being allocated to other areas. Increasingly, physicians are organizing themselves within group practices. While this is, in part, a response to providing greater continuity of care to patients, it is also a reaction to the series of economic decisions that have been taken in the area of health care. Currently, it is estimated that the GST "costs" the average physician $1,500 - $2,000 per year. If physicians were able to claim ITCs, this could give them the added flexibility to employ other individuals in the provision of health care. While the direct effects of the GST are significant and measurable, the indirect effects are even more significant though less measurable. It is estimated that the 55,000 physicians employ up to 100,000 Canadians. Given the disproportionate effects of the GST on the medical profession as employers, the employment dampening effects could be significant. * Fairness For many years, the CMA has supported tax reform - provided such reform improves the overall equity and efficiency of Canada's tax system. In June 1987, for example, CMA wrote to the then-Minister of Finance stating "...we at the CMA strongly support the goals of tax reform and efforts to simplify the tax system while at the same time making it more equitable". We have subsequently reiterated our support for the broad objectives of tax reform on several occasions: it remains as strong today as ever. In the area of health care, self-employed physicians (as well as others) have not been accorded the same treatment under the GST as other health groups. For example, hospitals currently receive a rebate of 83% of GST paid on the assumption that the rebate level leaves them no worse off than under the previous tax regime (i.e., whole). As well, prescription drugs are zero-rated, with the same rationale: to ensure that they are whole. Recognizing that drug regimens can play an equally important role as some physician interventions, why would the government choose to distinguish between the two and zero-rate drugs and exempt medical services. CMA RECOMMENDS... * The CMA believes that there are three ways of proceeding to address physician concerns: (1) similar to the formula for Municipalities, Universities, Schools and Hospitals (MUSH), physicians would be accorded a rebate that would leave them no worse off under the GST; an independent study suggests that 69% would leave physicians whole; or (2) to zero-rate all medical services; or (3) to zero-rate those medical services that are funded by the government. RATIONALE The three options above serve to improve overall fairness and simplify the tax system. The CMA has submitted a proposal to the Department of Finance for consideration which recommends that health care services (including medical services) funded by the provinces be zero-rated. * The proposal to zero-rate health care services funded by the provinces means: - services provided by hospitals, charities and other provincially funded organizations would be zero-rated. - the system would treat all persons in the industry in the same manner and would thus be fairer and simpler to administer. - tax cascading would be eliminated. - in the context of the regionalization of health care in Canada difficult interpretive issues (such as what constitutes a hospital or facility) would be removed. - not all government services would become zero-rated but only those for which the provincial governments fund. The remainder would continue to be exempt and thus the government would derive revenues from the tax on inputs used in providing those services. - Some complexities would remain owing to the fact that some health care services would be zero-rated and some would continue to be exempt. Therefore, any person making a mixture of zero-rated and exempt supplies would still be required to allocate inputs between commercial and non-commercial activities. * Such a proposal would put all publicly-funded health care services on the same tax footing. * The proposal does not focus on self-employed physicians only, but has been developed in the broader context of those services that are publicly-funded. * The proposal attempts to be achieve a greater degree of flexibility in the face of regionalization of health care services in Canada. * It would reinforce the principles of fairness and simplicity in the tax system. * To summarize, the CMA has reiterated its position on several occasions. Some of the major recommendations are: (1) Canadian physicians should not pay more than other professions or occupations under the GST or its replacement; (2) all taxes on business expenses be fairly and fully removed under any replacement tax for the GST; (3) that the government assign a high priority to integrating provincial and federal sales taxes in a fair and equitable way; (4) that the federal government take a leadership role in ensuring that any integrated system not perpetuate existing tax inequities facing Canadian physicians; and (5) any provisions of a replacement tax should reinforce good health and economic policy. NON-TAXABLE SUPPLEMENTARY HEALTH BENEFITS (NTSHB) ISSUE The Canadian Medical Association (CMA) is concerned that Canadians' access to health care services will be threatened if the tax status of supplementary health benefits is changed from their current tax treatment. CONTEXT * Approximately, 70% or 20 million Canadians rely on full or partial private supplementary health care benefits (e.g., dental, drugs, vision care, private health care, etc.). As governments reduce the level of public funding, the private component of health expenditures is expanding. Canadians are becoming increasingly reliant on the services of private insurance. In the context of funding those health services that remain public benefits, the government cannot strike yet another blow to individual Canadians and to Canadian business by taxing the very benefits for which taxes were raised. * Changes in health care technology and health care management have resulted in decreased length of stays in hospitals and an increased reliance upon expensive health technologies. Many of these services are covered by private supplementary health plans, especially when individuals are discharged from hospital (e.g., drugs, private home/health care). PHYSICIAN PERSPECTIVE * Access To Quality Health Care Services: First Priority Changing the status of supplementary health benefits from non-taxable to taxable may contribute decreased access to care, and/or possibly, increased costs to these plans coupled with a reduction in service of government funded programs. * Good Tax Policy Should Support Good Health Policy Non-taxable supplementary health benefits is a good tax policy that serves to reinforce good health policy. This incentive fosters risk pooling which reduces the overall cost of premiums for supplementary health benefit plans. * Fundamental Fairness In The Tax System Incentives that enable access to a broad range of quality health care services (beyond those publicly funded) to include all Canadians should be encouraged and expanded. CMA RECOMMENDS... * That the current federal government policy with respect to employment-related supplementary non-taxable health benefits be maintained. RATIONALE * If the supplementary health benefits become taxable, it seems likely that young healthy people would opt for cash compensation instead of paying taxes on benefits they do not receive. It follows that employer-paid premiums would increase as a result of this exodus in order to offset the additional cost of maintaining benefit levels due to diminishing ability to achieve risk pooling. * The federal government is to be congratulated with respect to last years' decision to maintain the non-taxable status of supplementary health benefits. This decision is an example of the federal governments' commitment to maintain a good tax policy that supports good health policy. The federal government should explore opportunities and incentives that would expand access to supplementary health care benefits to all Canadians. * In terms of fairness, it would seem unfair to penalize 70% of Canadians by taxing supplementary health benefits to put them on an equal basis with the remaining 30%. It would be preferable to develop incentives to allow the remaining 30% of Canadians to achieve similar benefits attributable to the tax status of supplementary health benefits. NATIONAL HEALTH RESEARCH PROGRAM (NHRP) ISSUE The Canadian Medical Association (CMA) believes that the health care system must respect and foster medical education and medical research. The CMA also believes that more emphasis should be placed on health services research focussing on health system reforms and their effect on the health of Canadians. Given the magnitude of change, now is the time for an evaluation of the impact before proceeding with any further reforms. CONTEXT * Canada has experienced rapid and significant changes with respect to health care reform which remains a priority at all levels of government. This environment provides a unique opportunity for the federal government to fund a concerted national evaluation strategy of health reform to date. * On the whole, the CMA would continue to encourage the government to protect earmarked monies dedicated for research activities. PHYSICIAN PERSPECTIVE * Improving The Quality Of The Health Care: Our First Priority For a variety of reasons , in a more forceful way over the last year, the CMA and physicians expressed their concerns with respect to the future of health and the viability of the health care system. The pace of reform has been rapid and change profound. What has been accomplished needs to be evaluated. In this context, the physicians of Canada have reiterated the need to foster health and medical research. * Health Research Policy Reinforcing Economic Policy Establishing a medical and health services research program will assist in attracting and retaining world-class researchers in Canada. There are positive effects that may occur in the economy as a result of this type of research with respect to the health technology sector -- creating a demand for highly skilled jobs in addition to increasing exports in high-tech, value-added goods and services. CMA RECOMMENDS... * That the federal government continue its commitment to medical education, biomedical and health services research. * That the federal government provide funding for a national initiative in evaluating health reforms. RATIONALE * Changes within the Canadian health care system, a system that is viewed as a model around the world, should not be implemented without a sound evaluation strategy. However, with the limited funding available to health researchers and health policy analysts this aspect of health care reform is often neglected or, at best, given cursory acknowledgement. We should not undertake systemic reforms without analyzing the effects that these will have upon the quality of the health care delivered to Canadians. * It is in the government's best interest to ensure that change within the health care system does not continue without evaluating the effect this will have on Canadians' access to quality health services. Once a certain course is set it may be impossible to turn the ship around. TOBACCO TAXATION ISSUE The Canadian Medical Association (CMA) is concerned that the 1994 reduction in the federal cigarette tax will have a significant effect in slowing the decline in cigarette smoking in the Canadian population, particularly in the youngest age group (15-19). CONTEXT * In an effort to combat the smuggling of cigarettes into in Canada, the federal government announced, in early 1994, a reduction in the federal tax on cigarettes in the amount of $5 per carton. In addition, the federal government offered an additional matching reduction of up to $5 per carton for those provinces making reductions in provincial taxes. * At about the same time, in an attempt to counter the effects of the reduction in tobacco taxation, the government announced increased efforts to reduce the accessibility of tobacco products, particularly to minors, and also launched the Tobacco Demand Reduction Strategy in February, 1994. PHYSICIAN PERSPECTIVE * Smoking is the leading preventable cause of premature mortality in Canada. The most recent estimates suggest that more than 40,000 deaths annually in Canada are directly attributable to tobacco use. * Physicians are concerned that the reduction in tobacco taxation may reverse more than two decades of progress in reducing smoking rates. Based on an examination of four population-based surveys and data on tobacco consumption, a workshop convened by Health Canada in 1994 concluded that, in all likelihood, the prevalence of smoking in the Canadian population continued to decline from 1991 to 1993, reversed itself in 1993 and increased from 1993 to 1994. 9 * The effects of smoking on nonsmokers are of major concern to the CMA. More than 20% of Canadians have a health condition such as heart disease or acute respiratory disease, that is aggravated by secondary exposure to tobacco smoke. CMA RECOMMENDS * It is a matter of longstanding policy that the CMA supports the taxation of tobacco products at a level that will discourage their purchase, the revenue to be earmarked for health care budgets. 10 * The CMA has also recommended to the federal government (1994) that it institute a federal health protection assessment (a specially designated tax) on all Canadian cigarettes at the point of manufacture, regardless of their ultimate site of sale. * The CMA is also a co-signatory, along with eight other national medical and health organizations, of the brief Tobacco Taxation in Canada: New Directions, which was presented to the Honourable Paul Martin in February, 1995, and which sets out eight recommendations for the restoration of tobacco taxes, support for the Tobacco Demand Reduction Strategy and the taxation of the tobacco industry. RATIONALE * the government has made in health promotion campaigns against smoking, and which it has continued through the Tobacco Demand Reduction Strategy. _____________ 1 Posner M., Condition Critical. Maclean's. Vol. 108 No. 46, November 13, 1995, p. 46-59. 2 The Angus Reid Group, The Reid Report. Vol. 8, No. 7, July/August, 1993 and Vol. 8. No. 8. September, 1993. 3 The Medical Post 1995 National Survey of Doctors, Fall 1995, page 24. 4 Alvi S.: Health Costs and Private Sector Competitiveness, The Conference Board of Canada, Report 139-95, Ottawa, June, 1995, page 11. 5 Southam News/CTV/Angus Reid, Public Opinion On Government Cutbacks And The Policy Challenges Facing Canada, December 27, 1995. 6 The Angus Reid Group, The Reid Report. Vol. 8, No. 7, July/August, 1993 and Vol. 8. No. 8. September, 1993. 7 Mitchell, A. Population to hit 30 million in 1996: Globe and Mail, January 10, 1996. pp. B1-2. 8 Frenken, H. Capitalizing on RRSPs: Canadian Economic Observer, December 1995. p. 3.1-3.9. Statistics Canada - Cat. No. 11-010. 9 Stephens T. Workshop report: trends in the prevalence of smoking, 1991-1994. Chronic Diseases in Canada 1995; 16(1): 27-32 10 Canadian Medical Association. Smoking and Health: 1991 Update. Can. Med. Assoc. Journal 1991; 142 (2): 232A-232B.
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CMA presentation to the House of Commons Standing Committee on Finance on Bill C-38

https://policybase.cma.ca/en/permalink/policy10441
Date
2012-05-31
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2012-05-31
Topics
Health systems, system funding and performance
Text
Thank you for this opportunity to appear before this committee on behalf of the CMA and its 76,000 members. Canadians believe that transforming our health care system to meet the needs of 21st century Canada must be among the highest priorities for all levels of government, including the federal government. I would like to begin by commenting on the health transfer framework announced by the Minister of Finance in December. This announcement provided some predictability for the years ahead. However, with the federal government reducing its involvement in several areas affecting health or health care, added costs will end up in the laps of the provinces and territories. So while this budget may enhance the federal government's fiscal prospects, it will do so to the detriment of the provinces and territories. But there's more to this debate than funding. We believe that Canadians would be better served if federal health care transfers came with specific guidelines ensuring that the system provides care of comparable access and quality to Canadians across the country, regardless of their circumstances. We are encouraged that the Minister of Health has indicated she wants to collaborate with the provinces and territories on developing accountability measures to ensure value for money and better patient care. We look forward to the minister's plan for accountability. This budget is notable for other missed opportunities. For many years, groups across the political spectrum have called for a pharmaceutical strategy to reduce national disparities. In fact, such a strategy was committed to by governments under the 2004 Health Accord. Minister Kenney referred to this issue indirectly when he said the recent cancellation of supplemental health benefits for refugee claimants is justified because refugees should not have access to drug coverage that Canadians do not have. Rather than cutting off those desperately vulnerable people, Canada's physicians urge the federal government to work with the provinces and territories to develop a plan that ensures all Canadians have a basic level of drug coverage. Indeed, we now appear to be in a race to the bottom in the way we treat vulnerable groups - by, for example, deferring Old Age Security for two years; and changing service delivery to veterans, mental health programs for our military and the Employment Insurance program. Significant policy changes have been announced since the budget, with little opportunity for debate and little evidence provided. We note, as well, the lack of open consultation with Canadians on matters of great import to their lives. Successful policy requires buy-in, which is best achieved when those interested are able to participate in the policy-making process. This brings me to a wider concern shared by our members - that policy-makers are not paying adequate attention to the social determinants of health, factors such as income and housing that have a major impact on health outcomes. We remind the government that every action that has a negative effect on health will lead to more costs to society down the road. The federal government is the key to change that benefits all Canadians. While there are costs and jurisdictions to consider, the CMA believes the best way to address this is to make the impact on health a key consideration in every policy decision that's made. The federal government has used this approach in the past, in considering rural Canadians, for example. We therefore call for a new requirement for a health impact assessment to be carried out prior to any decision made by cabinet. This would require that, based on evidence, all cabinet decisions take into account possible impacts on health and health care, and whether they contribute to our country's overall health objectives. A similar model is in use in New Zealand and some European countries. For instance, what health impact will cuts in funding to the tobacco strategy have? Such an assessment would in particular have a dramatic impact with regard to poverty. Poverty hinders both human potential and our country's economic growth - and needlessly so as there are many ways to address it effectively. The National Council on Welfare - which will disappear as a result of this budget - reported last fall that the amount it would have taken in 2007 for every Canadian to have an income over the poverty line was $12.6 billion, whereas the consequences of poverty that year added up to almost double that figure. Close to 10 per cent of Canadians were living in poverty in 2009, many of them children, as UNICEF underlined yesterday. This is a huge challenge for our country. In closing, as this budget cycle ends and as you begin to prepare for the next, please bear in mind that as prosperous as our country is, if we do nothing for the most vulnerable in our society - children, the elderly, the mentally ill, Aboriginal peoples - we will have failed. Thank you.
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CMA Presentation to the Senate Standing Committee on Social Affairs, Science and Technology - Prescription Drugs: Clinical Trials and Approval

https://policybase.cma.ca/en/permalink/policy10437
Date
2012-05-09
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2012-05-09
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Good afternoon. My name is Dr. Maura Ricketts and I am the Director of Public Health for the Canadian Medical Association. The CMA appreciates the opportunity to appear before this Committee today as part of your study of clinical trials and drug approvals. The CMA represents more than 76,000 physicians in Canada. Its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with all Canadians, for the highest standards of health and health care. Because prescription drugs are an essential component of health care, the CMA has developed a considerable body of policy on pharmaceutical issues. This work can be distilled into one fundamental principle: The CMA believes that our country requires a National Pharmaceutical Strategy to ensure every individual has timely access to safe, effective and affordable prescription drugs. Despite the commitment in the 2004 Health Accord to the creation of such a strategy, Canadians continue to wait for government leadership on this issue. Drugs replace more costly and invasive medical interventions. They are an essential tool in the physician's tool box. To ensure safety and effectiveness, the CMA also believes in the need for a strong, unbiased, evidence-based system for research and approval. This is at the heart of our commitment to patient-centred care. In evaluating whether to prescribe a new drug to a patient, a physician will weigh several factors: Does this product offer any benefits over what I am prescribing now? Will it be more effective? Will this new drug be safer? Will it solve any tricky clinical problems, such as drug interactions, or reduce side effects that prevent a medication from being used properly? The physician may also ask: What is the evidence that this new drug is an improvement? Can I trust the evidence? Where can I get access to accurate, reliable information and data on this drug? Pre-approval drug research must provide answers to these fundamental questions. Clinical Trials I will now focus on two particular issues of concern to practising physicians with regard to clinical trials: * First, what is being compared to what? Clinical trials may be sufficient for Health Canada's regulatory purposes, but may provide only part of the information a physician needs. For example, is a new cholesterol drug effective on all patients, or only on some of them? Would other patients derive equal benefit from an already existing drug, or from a lifestyle change such as diet or exercise? The CMA recommends that researchers compare a new product to other drugs on the market - and to other interventions, as well. * Second, is timely, reliable and objective information available on all clinical trial results, not just the positive ones? Canadians need to be informed when a drug has performed disappointingly in trials if they are to make informed decisions about their health care. The CMA, therefore, recommends the results of all clinical trials, not just those with positive results, be made available to health professionals and the public. I would like to add that the current documentation is not very user-friendly. We recommend that Health Canada prepare summaries of the most essential data, not only for physicians, but for all Canadians to be able to access this information. The Drug Approval Process Turning now to the drug approval process, the CMA believes the following principles should apply: * The primary criteria for approval should be whether the drug improves health outcomes and offers an improvement over products currently on the market. * The review process should be as timely as is consistent with ensuring optimal health outcomes and the safety of the drug supply. * The review process should be impartial and founded on the best available scientific evidence. * The review process should be open and transparent. * Finally, approval of a drug is not an endpoint, but rather one step in that drug's life cycle. It is not uncommon to identify serious safety hazards after a drug has been approved, because that's when it first goes into wide use. It is important that the approval process be complemented by a rigorous and vigilant post-market surveillance process. We look forward to presenting our recommendations on this subject to your Committee at a future session. Before closing, I would like to briefly address two other matters: First, the issue of drugs for rare disorders. We are aware that the current clinical trial and approval processes, which place a high value on studies with large population samples, may be unable to adequately capture the value of drugs that are prescribed to only a handful of people. Some patient groups active in the area of rare disorders, such as the Canadian MPS Society and Alpha-1 Canada, have shared their concerns about this with us. These groups, along with the Canadian Organization for Rare Disorders, have been advocating for years for a fair process for evaluating drugs for rare diseases. Because Canada doesn't have a rare disorders strategy, Canadian patients have access to fewer therapies than patients in other developed countries. The issue of how to approve drugs for rare disorders merits closer consideration. The CMA recommends that the federal government develop a policy on drugs for rare disorders that encourages their development, call for ongoing evaluation of their effectiveness, and ensures fairness so that all patients who might benefit have reasonable access to them. The second matter is that Health Canada's review process provides little guidance on another question which physicians are increasingly asking: Can my patient afford this drug? It is not sufficient that the Common Drug Review conducts reviews of the cost effectiveness of drugs and that provincial/territorial formularies undertake similar studies, as the fact remains that cost is one of the factors physicians need to consider when deciding whether to prescribe a new drug. This is especially true in the case of new biologics, which are very expensive. Canadian doctors believe that the difficulty of making effective prescribing decisions without information about cost needs to be overcome. This only underscores the necessity of a National Pharmaceutical Strategy. Thank you. We would be happy to answer your questions.
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CMA's Response to Questionnaire From the House of Commons Standing Committee on Finance: 2012-2013 Pre-Budget Consultation

https://policybase.cma.ca/en/permalink/policy10445
Date
2012-08-03
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2012-08-03
Topics
Health systems, system funding and performance
Text
Question 1: Economic recovery and growth (What federal measures are required for sustained economic recovery and growth?) The health sector has an important role in sustaining Canada's economic recovery and enhancing economic growth beginning with supporting a healthy and productive workforce and providing over one million high value jobs, representing about 10 per cent of the labour force. Despite the importance of the sector, there is general agreement that Canada's health care system is no longer a strong performer when compared to similar nations. While the OECD's 2011 Health Data ranks Canada 7th highest of 34 member states in per capita health care spending, the performance of Canada's health care system continues to rank below most of our comparator countries. Health spending accounts for an increasing proportion of provincial and territorial budgets, and many warn of increasing future demands on the overall system. In his Economic and Fiscal Outlook Report of May 17, 2012, the Parliamentary Budget Officer stated that "the provincial-territorial long-term fiscal situation has deteriorated." Taken together, these issues highlight significant potential for the health sector, through efficiency improved gained by health care transformation, to support long-term economic recovery and growth in Canada. While the provinces and territories have initiated positive steps to collaborate on sharing best practices, there are key responsibilities under federal leadership that would contribute to these efforts by addressing the overall performance of the health care system in Canada. The CMA recommends that: - The federal government recognize the relationship of the social determinants of health on the demands of the health care system and that it implement a requirement for all cabinet decision-making to include a Health Impact Assessment (see Question 5 for more detail). - Further to the comments by the Health Minister following the new fiscal arrangement announcement, the federal government should prioritize federal-provincial-territorial engagement focused on accountability and undertake a consultative process with the aim of identifying pan-Canadian metrics and measurement that will link health expenditures and comparable health outcomes. Question 2: Job creation (What federal actions should be taken to promote job creation in a context of enhanced internal and international trade?) A high performing health care system across the country will help support labour mobility and job creation. An effective, comprehensive public health care system provides an important international competitive advantage. The contribution of Canada's health care system to the international competitiveness of our economy has been repeatedly demonstrated in KPMG's Competitive Alternatives report. However, there are several signs that indicate health care services and coverage are not keeping up with Canadians' needs and vary depending on where one lives in Canada. For instance, long wait times for medical care can be found in smaller provinces, while drug coverage and services for seniors are particularly poor in Atlantic Canada. Wide variation in access to pharmaceutical treatments remains the most glaring example of inequity in our health care system-all Canadians should have a basic level of drug coverage. These variations are growing and will hinder job creation in some regions, serving as barriers to labour mobility for Canadians wishing to seek work elsewhere in the country. We believe that Canadians would be better served if federal health care transfers came with specific guidelines ensuring that the system provides care of comparable access and quality to Canadians across the country, regardless of their circumstances. Recognizing the contribution of the health care system to Canada's international competitive advantage, improvements in Canada's health care system would further support job creation. The federal government should focus its efforts towards supporting the transformation of our health care system to better meet the objectives of better care, better health and better value. The CMA recommends that: - The federal government, in consultation with provincial, territorial and other stakeholders, 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 drugs. - The federal government, together with the provinces and territories, develop and implement a pan-Canadian strategy for continuing care which would integrate home care and facility- based long-term, respite and palliative care services fully within health care systems. Question 3: Demographic change (What federal measures should be implemented to help address the aging population and skills shortages?) The CMA remains concerned about the status of Canada's retirement income system and the ability of Canada's seniors to adequately fund their long-term and supportive care needs. Steps need to be taken to ensure that Canada is prepared to handle the long-term care needs of its citizens, including the funding of necessary infrastructure and additional support for both health care providers and informal caregivers. The availability of long-term care facilities has an important role in the efficiency of the overall health care system. For example, in its most recent report, the Wait Time Alliance noted that dementia is a key diagnosis related to the rise in alternate-levels-of-care (ALC) patient stays in hospitals. This is yet another issue facing all provinces and territories for which the federal government is well positioned to coordinate a pan-Canadian strategy. In addition, as part of the next long-term infrastructure program, the federal government should include a targeted health sector infrastructure fund for long-term care facilities as part of a pan-Canadian strategy to redirect care from the hospitals to homes, communities and long-term care facilities, where better care is provided at a lower cost. The CMA recommends that: - The federal government establish programs to encourage Canadians to save for their long- term care needs by pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance, such as an RESP- type savings vehicle. - That a targeted health infrastructure fund be established as part of the government's long- term plan for public infrastructure. The purpose of this fund would be to address infrastructure shortages in the health sector that prevent the optimization of health human resources and exacerbate wait times. The CMA has supported the federal government's efforts to expand retirement savings options by establishing the Pooled Retirement Pension Plans. However, as highlighted by federal, provincial and territorial finance ministers, this is only one component of a larger pension reform framework to address the retirement income adequacy needs of Canadians. The CMA encourages the federal government to continue working with the provinces, territories and stakeholders to implement all elements of this framework. Question 4: Productivity (What federal initiatives are needed to increase productivity in light of labour market challenges such as the aging of Canada's population?) An effective and comprehensive health care system supports the productivity of the Canadian workforce. Failure of our health care system to respond to workers' health needs, on the other hand, leads to loss of productivity and high costs both in terms of lost income for Canadian families as well as foregone tax revenues for governments. Numerous studies have pointed out the enormous cost of waiting (in the billions of dollars per year) affecting both individuals and the economy. Another related issue that has the potential to increasingly affect productivity is the burden of providing care to family members. Without adequate provision of long-term care resources and support for home care, Canada's labour force may experience a productivity drag through increased leaves and absenteeism to care for elderly relatives. The 2011 federal budget took a first step at providing tax relief for informal caregivers through the Family Caregiver Tax Credit. However, this credit of a maximum of $300 per year by no means provides sufficient support for informal caregivers. A 2004 Canadian study estimated that the annual cost of a caregiver's time at market rates for moderately to severely disabled home care clients ranged from $5,221 to $13,374 depending on the community in which they reside. An increase to the Family Caregiver Tax Credit is positive for the development of one aspect of the necessary support informal caregivers require but the CMA believes other enhancements will also be needed in the coming years. In order to meet the needs of our country's aging population, the CMA recommends that: - The federal government expand the relief programs for informal caregivers to provide guaranteed access to respite services for people dealing with emergency situations, as well as increase the Family Caregiver Tax Credit to better reflect the annual cost of family caregivers' time at market rates. - That a targeted health infrastructure fund be established as part of the government's long-term plan for public infrastructure. The purpose of this fund would be to address infrastructure shortages in the health sector that prevent the optimization of health human resources and exacerbate wait times. Question 5: Other challenges (Who is facing most challenges, what are they and what federal action is required?) Despite significant investments in health and improvements in medical treatment and technologies, health outcomes in Canada have not been moving in the right direction. Chronic diseases such as diabetes and the corresponding risk factors, among them obesity, continue to rise. These negative outcomes can have a significant impact on the prosperity of the country as health is necessary for individuals to lead a prosperous and autonomous life. Research suggests that 50 per cent of population health is determined by our social and economic environment. While a strong health care system is vital, changes to medicare alone will not improve health outcomes or reduce the disparities that currently exist in disease burden and health risks. What is needed is a process to address the social determinants of health that can be barriers or enablers to health, a process to ensure healthy public policy for all Canadians. A Health Impact Assessment (HIA) is a systematic process for making evidence-based judgments on the health impacts of a policy and to identify and recommend strategies to protect and promote health. HIA is used in several countries, including Australia, New Zealand, Norway, the Netherlands and the United States. HIA is also used in Canada, most extensively for policy appraisals in Quebec. HIA is necessary for ensuring that all government departments are able to consider the health impacts of their work. Such a tool would have been very beneficial in assessing cuts to program spending to ensure the impact on health would not be counterproductive (i.e., lead to higher overall costs to society once the health impact is taken into account). The adoption of an evidence-based HIA is one way in which the federal government can play a leadership role in health care. The CMA recommends that: - The federal government include a Health Impact Assessment as part of its policy development process to ensure that the health of Canadians is a key factor in every policy decision it makes. - The federal government recognize the relationship of the social determinants of health on the demands of the health care system.
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CMA's Submission to Finance Canada regarding proposed amendments to the Income Tax Act

https://policybase.cma.ca/en/permalink/policy10353
Date
2012-02-14
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Date
2012-02-14
Topics
Physician practice/ compensation/ forms
Text
As previously indicated in the Retirement Income Improvement Coalition's (RIIC) letter to the Minister of Finance on August 10, 2011, the CMA supports the federal government's proposal to expand access to pensions, specifically by establishing a legislative and regulatory framework to permit pooled registered retirement plans (PRPPs). The CMA is concerned that as currently proposed, the PRPP framework, including Bill C-25 and the proposed legislative amendments to the Income Tax Act, would limit the potential for PRPPs to contribute to expanding access to, and investment in, pensions for self-employed individuals. With respect to the pension framework, a critical issue, two principles are central to the CMA's membership of over 76,000 physicians. These are, to encourage the federal government to: 1) ensure that self-employed Canadians can retire with an appropriate level of retirement income (e.g., a 70% of pre-retirement income target); and, 2) expand the retirement savings options that are available to self-employed Canadians. The CMA's comments herein on the proposed amendments to the Income Tax Act are in support of these two principles. As elaborated below, the CMA encourages the federal government to: 1. Increase the retirement savings capacity of self-employed individuals by raising the combined limit for RRSPs; 2. Expand the PRPP framework to include defined benefit and targeted benefit pension plans; and, 3. Clarify the eligibility criteria of "PRPP administrators" to include professional associations. 1. Increase the combined contribution limit for PRPPs and RRSPs As proposed, it is our understanding that the core benefit of the PRPP framework is in providing smaller businesses access to low-cost pension plans, thereby providing a vehicle to encourage employers to establish, and contribute to, pensions for their employees. While the CMA recognizes the value of, and supports, this objective, this proposal in effect maintains the status quo for self-employed individuals. Under Clause 10 of the proposed amendments to the Income Tax Act, the contribution limit to PRPPs would be calculated as an additional component of the current registered retirement savings plan (RRSP) contribution limit. As outlined in the Explanatory Notes, "an employer's contributions to an individual's PRPP account [and...] an individual's PRPP contributions in a taxation year will immediately reduce the individual's ability to make deductible RRSP contributions in that same year." While individuals with employer contributions stand to benefit from increased retirement savings via employer contributions, self-employed individuals are merely provided with access to an alternate retirement savings vehicle. As explained in the Summary Report on Retirement Income Adequacy Researchi, "[h]igher income groups tend to exhibit a greater tendency to substitute one form of saving for another since they tend to be bound by limits...[I]f newly introduced plans are included in limitations imposed on the degree to which contributions may be deductible for tax purposes, saving may not increase for individuals who are constrained (i.e. saving up to their limit), since they would more likely substitute one type of saving for another (e.g., RRSP for a private pension plan)." Therefore, the CMA encourages the federal government to consider increasing the retirement savings capacity of self-employed individuals by raising the combined limit for RRSPs and PRPPs. 2. Include defined benefit and targeted benefit pension plans As noted under Clause 12, the registration criteria for PRPPs will be established by the PRPP Act, Bill C-25. Of concern, Bill C-25 limits PRPPs to defined contribution pension plans by specifically excluding from eligibility of registration: (a) a pension plan as defined by 2(1) of the Pension Benefits Standards Act; (b) an employees' or a deferred profit sharing plan; (c) an RRSP or a retirement compensation arrangement defined by 248(1) of the Income Tax Act; and, (d) any other prescribed plan or arrangement. As highlighted by the Summary Report on Retirement Income Adequacy Research, "defined benefit pension funds and annuities enable investors to share longevity risks as well as pool risky investments to diversify risk." By pooling risk, defined benefit and targeted benefit pension plans provide more secure savings vehicles than defined contributions plans. The CMA encourages the federal government to expand the PRPP framework to include defined benefit and targeted benefit pension plans. While the CMA will advance this recommendation to the House of Commons Finance Committee during its consultation on Bill C-25, we include it as part of this submission as modifications to the proposed amendments to the Income Tax Act would be required. 3. Clarify the eligibility criteria of "PRPP administrators" to include professional associations Further clarification is required on the type of organization that may qualify as a PRPP administrator. As noted under Clause 12, an administrator of a PRPP is authorized under the PRPP Act. As Bill C-25, the PRPP Act, is still in the legislative process, the CMA will elaborate on this issue during the formal Parliamentary consultation. However, as it stands, further clarification is required on the eligibility criteria proposed by Bill C-25. While Bill C-25 can be interpreted to extend administrator eligibility to organizations that are able to fulfill the criteria established by the PRPP Act, Finance Canada's Framework for PRPPs states that eligibility of administrators would be limited to "regulated financial institutions that are capable of taking on a fiduciary role". Well-governed professional organizations that represent a particular membership should be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members. Conclusion While the CMA supports the proposed PRPP framework in principle, the proposed limitations to PRPPs should be addressed to ensure that they also provide value to self-employed Canadians, including physicians. The CMA appreciates the opportunity to comment on the proposed amendments to the Income Tax Act and to once again advance recommendations to Finance Canada on the PRPP framework. i Prepared for the Research Working Group on Retirement Income Adequacy of Federal-Provincial-Territorial Ministers of Finance.
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CMA's Submission to Finance Canada's 2012 Pre-budget Consultations

https://policybase.cma.ca/en/permalink/policy10350
Date
2012-01-12
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2012-01-12
Topics
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) appreciates the opportunity to provide additional comments and recommendations as part of Finance Canada's 2012 pre-budget consultations. The health sector provides essential services and high value jobs supporting communities across Canada. Statistics Canada reports that employment in the health sector accounts for 10% of the Canadian labour force.i In considering possible additional economic stimulus measures that build on the success of Canada's Economic Action Plan, the CMA encourages the federal government to consider investments that target efficiency improvements in the health sector. Efficiency improvements in the health sector yield benefits to all orders of government and Canadians. The following recommendations are advanced for Finance Canada's consideration: * In order to improve the delivery of better care, better health, and better value, the CMA recommends that the federal government work with the provinces, territories and health sector stakeholders to develop a model for accountability and patient-centred care. The CMA encourages the federal government to adopt the Principles to Guide Health Care Transformation, developed by the CMA together with the Canadian Nurses Association and since endorsed by over 60 organizations, as the basis of a pan-Canadian model for accountability and patient-centred care. * Recognizing the significance of nationally comparable metrics on health outcomes and the health care system together with the effectiveness of national public reporting in demonstrating accountability, the CMA recommends that the federal government undertake efforts towards identifying pan-Canadian metrics and measurement that will link health care expenditures to comparable health outcomes. * As the federal government prepares to engage with the provinces and territories to further map out improvements to Canada's health system, the CMA strongly encourages consideration be given to the federal role in coordinating the development of pan-Canadian clinical practice guidelines (CPGs). * While, as previously indicated, the CMA supports the federal government's proposal to expand access to pensions, specifically by developing pooled registered retirement plans (PRPPs), the limitations to PRPPs should be addressed to ensure that they provide value to self-employed Canadians, including physicians. Specifically, addressing the limitations would include: (1) expanding the PRPP framework to include defined benefit and targeted benefit pension plans; (2) increasing the retirement savings capacity of self-employed individuals by either raising the RRSP limit or providing a distinct limit for PRPPs; and, (3) ensuring the PRPP framework expands the eligibility of administrators beyond financial institutions. Introduction The Canadian Medical Association (CMA) appreciates the opportunity to provide additional recommendations to the Government of Canada as part of its 2012 Pre-Budget consultation. Building upon the CMA's recommendations to the House of Commons' Finance Committee, this submission focuses on three issues: (1) improving accountability and patient-centred care in the delivery of new federal health care funding; (2) coordinating the development of pan-Canadian clinical practice guidelines; and (3) addressing limitations in the federal framework for pension reform. 1. Accountability and patient-centred care "Raising sufficient money for health is imperative, but just having the money will not ensure universal coverage. Nor will removing financial barriers to access through prepayment and pooling. The final requirement is to ensure resources are used efficiently." World Health Organization (2010) As the federal government finalizes the Strategic and Operating Review and considers other measures to eliminate the deficit, including scaling down the Economic Action Plan, it must be recognized that improved health systems and the resultant improved productivity pay economic dividends for the country; and, further, that "health" by today's standards is not just the assessment and treatment of illness, but also the prevention of illness, and the creation and support of social factors that contribute to health should also be considered. With the recent announcement by Minister Flaherty with respect to the Canada Health Transfer (CHT) and Canada Social Transfer (CST), the financial parameters for future health care funding have been established. Consistent with previous public opinion research, recent polling by Ekos Research Associates shows that 76% of Canadians identify improving health care as the leading priority for the federal government, ahead of reducing the national debt and deficit.ii However, as we have learned with the 2004 Health Accord, funding alone is not sufficient to ensure Canadian taxpayers benefit from improvements in health care, health outcomes, and value for money. Despite laying out laudable objectives, progress to improve our health care system has been slow following the 2003 and 2004 agreements. There is a general agreement that Canada's health care system is no longer a strong performer when compared to similar nations. The OECD's Health Data, 2011 ranks Canada eighth highest of 34 member states in per capita health care spending, the second highest in hospital spending per discharge, and the seventh lowest in the number of physicians per capita. While Canada outperforms the U.S. on most measures, we fall below the median performance of the OECD on common health quality and system measures. With the new health care funding commitment to 2024, it is now time to plan how to transform the health care system. Principles-based approach is required The CMA is advocating built-in accountability mechanisms to ensure Canada's health care system is focused on delivering improved patient outcomes. Developing a system that is accountable and patient-centred depends on continuously striving to achieve the Institute for Healthcare Improvement's (IHI) Triple Aim objectives of better care, better health and better value. Launched in 2007, the IHI Triple Aim initiative was designed to direct the improvement of the patients' experience of care (including quality, access, and reliability) while lowering the per capita cost of care. It was with the Triple Aim objectives in mind that the CMA jointly developed Principles to Guide Health Care Transformation in Canada with the Canadian Nurses Association (CNA). It is our strong belief that discussions about the future of health care in Canada must be guided by these principles. The CMA-CNA principles are summarized as follows: * Patient-centred: Patients must be at the centre of health care, with seamless access to the continuum of care based on their needs. * Quality: Canadians deserve quality services that are appropriate for patient needs, respect individual choice and are delivered in a manner that is timely, safe, effective and according to the most currently available scientific knowledge. * Health promotion and illness prevention: The health system must support Canadians in the prevention of illness and the enhancement of their well-being, with attention paid to broader social determinants of health. * Equitable: The health care system has a duty to Canadians to provide and advocate for equitable access to quality care and commonly adopted policies to address the social determinants of health. * Sustainable: Sustainable health care requires universal access to quality health services that are adequately resourced and delivered across the board in a timely and cost-effective manner. * Accountable: The public, patients, families, providers and funders all have a responsibility for ensuring the system is effective and accountable. In order to ensure that future federal funding delivers on the Triple Aim objectives of better care, better health and better value, a model for accountability and patient-centred care is required. Such a model would expand upon the CMA-CNA Principles through the development of a set of measurable indicators related to each principle that can be used for setting national standards, monitoring progress and demonstrating accountability to Canadians. The CMA therefore urges the federal government to facilitate discussions with the provinces and territories to identify how resources will be used to improve patient care and health outcomes across the country. To this end, the CMA has urged the Minister of Health to move quickly to engage the provincial and territorial health ministers on transforming the health care system. The CMA recommends that the federal government work with provinces and territories, in consultation with national health sector stakeholders, to develop a model for accountability and patient-centred care. The CMA encourages the federal government to adopt the CMA-CNA Principles to Guide Health Care Transformation as the basis of a pan-Canadian model for accountability and patient-centred care. Improving public reporting: The cornerstone of accountability The federal government has a significant stake in national public reporting on the health of Canadians and on the performance of the health care system. As required by the Canada Health Act, the Minister of Health must publicly report administration, operation and adherence to the Act each year. Further, as the largest contributor to the single-payer system, the federal government has a unique role in demonstrating value for money and reporting on strategies to improve the quality, effectiveness and sustainability of the health care system. To facilitate public reporting, in addition to Statistics Canada, the federal government is supported by the Health Council of Canada and the Canadian Institute for Health Information, both established as government-funded non-profits, however, with distinct mandates. Despite pan-Canadian efforts such as provincial health quality councils and federal and non-governmental reporting, there remains significant room for improvement in the area of monitoring and reporting, both on health outcomes and system performance. As noted in the Commonwealth Fund's report on international health care systems, "reporting on health system performance [in Canada] varies widely across the provinces and territories...there is so far little connection between financial rewards and public reporting of performance." Not surprising, this issue was also identified by the Health Council of Canada in its Progress Report 2011. It highlights the challenges in reporting progress and explains the difficulties inherent to the current patchwork, "[w]here provinces and territories had set and publicized targets, it was easier for us to track progress. Where we could not find targets, assessing progress was more difficult." The CMA has long supported improved pan-Canadian public reporting on health and health care. Most recently, the CMA hosted a symposium with health reporting stakeholders to discuss the current status of national reporting and the need for the development of a pan-Canadian reporting framework. As recognized by the symposium's participants, there is a great deal of excellent data collection work occurring across the country. However, these efforts are largely uncoordinated and do not tell the full story of the health of Canadians or adequately assess the performance of the health care system. Indeed, despite an abundance of metrics and measurement, in many cases, data is not necessarily usable by the public or decision-makers and, unfortunately, is not necessarily comparable between jurisdictions. The CMA recommends that the federal government recognize the significance of nationally comparable metrics on health and the health care system and national public reporting in demonstrating accountability (i.e. better health, better care, and better value). In achieving these objectives, the CMA recommends that the federal government mandate an appropriate national organization, such as the Health Council of Canada, to undertake a consultative process with the aim of identifying pan-Canadian metrics and measurement that will link health expenditures and comparable health outcomes. 2. Coordinate the development of pan-Canadian Clinical Practice Guidelines As the federal government prepares to engage with the provinces and territories to further map out improvements to Canada's health system, the CMA strongly encourages consideration be given to the federal role in coordinating the development of pan-Canadian clinical practice guidelines (CPGs). Such a role would build upon the commitment made by the provinces and territories under the auspices of the Council of the Federation to collaborate on the development of three to five CPGs over the coming year. CPGs are systematically developed, evidence- or consensus-based statements to assist health care providers in making decisions about the most appropriate health care to be provided in specific clinical circumstances. There is compelling evidence in the literature, supported by the experience of other countries, that well-designed and disseminated CPGs can enhance the clinical behaviour of providers and provide a positive impact on patient outcomes. The principle argument in support of CPGs is their ability to enhance quality of care and patient outcomes. In addition, CPGs have been found to: * Provide publicly accessible descriptions of appropriate care by which to gauge health care performance; * Help to reduce inappropriate variations in care across diverse geographical and clinical settings; * Offer the potential of empowering patients as to appropriate care expectations; and, * Contribute to public policy goals, such as cost containment, through encouraging more appropriate provider use of resources. However, in the absence of a pan-Canadian approach, CPGs across Canada are of uneven quality and even excellent guidelines may not be effectively disseminated or implemented. In contrast to Canada, peer-nations such as the United Kingdom, the United States and Australia have committed at a national level to support the development and dissemination of CPGs. In November 2011, the CMA, together with leading national medical and health sector stakeholders, convened a Canadian Clinical Practice Guidelines Summit, attended by representatives of the federal and most provincial and territorial governments, to explore key components of a pan-Canadian strategy on CPGs. Emerging from this summit was a clear consensus that it was the federal role to provide the infrastructure support necessary to facilitate the development and dissemination of high-quality CPGs, customizable to the needs of all jurisdictions in Canada. Guideline development and implementation is a complex, lengthy and resource-intensive process. In the absence of federal coordination in Canada, guidelines are produced by disparate, disease-specific groups, often funded by the pharmaceutical industry. This creates an obvious potential for conflict of interest where the guideline development process is far from transparent. Many guidelines are published without disclosure on conflict of interest or methodology applied. Concern over the quality of guidelines presents one the most persistent barriers to adoption by physicians of the recommended practice. The resulting underutilization of CPGs in Canada is widely documented. Clearly, the development and dissemination of pan-Canadian CGPs present a unique and significant opportunity for improvement in Canada's health care system. The CMA recommends that as part of further discussions with the provinces and territories, the federal government commit to working with the provinces, territories and health sector stakeholders towards the development of a pan-Canadian clinical practice guideline initiative. In particular, the CMA recommends that the federal government commit support for the infrastructure necessary for the development, maintenance, and active dissemination of relevant, high-quality clinical practice guidelines. 3. Address the limitations proposed under the pension reform framework As previously indicated in the August 2011 submission to Finance Canada by the Retirement Income Improvement Coalition (RIIC), the CMA supports the federal government's proposal to expand access to pensions, specifically by developing pooled registered retirement plans (PRPPs). While we are currently assessing the package of proposed Income Tax Act amendments and will provide more detailed comments as part of the legislative process, the CMA is concerned that the framework, as proposed, limits the potential for PRPPs to expand physician access to, and investment in, pensions. Based on preliminary analysis, it is our understanding that the core benefit of the PRPP framework is in providing small businesses access to low-cost pension plans, thereby providing a vehicle to encourage employers to establish, and contribute to, pensions for their employees. Given that a significant proportion of physicians are self-employed, they would not benefit from employer contributions to a PRPP. Further, as proposed, the contribution limit to PRPPs would be calculated as an element of the current RRSP and pension contribution limit. Finally, further clarification is required on the type of organization that may qualify as a PRPP administrator. 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. While the CMA supports the proposed PRPP framework in principle, the limitations to PRPPs should be addressed to ensure that they provide value to self-employed Canadians, including physicians. The CMA recommends that Finance Canada consider amendments to the proposed Income Tax Act amendments to address limitations to PRPPs, specifically: (1) expanding the PRPP framework to include defined benefit and targeted benefit pension plans; (2) increasing the retirement savings capacity of self-employed individuals by either raising the RRSP limit or providing a distinct limit for PRPPs; and, (3) ensuring the PRPP framework expands the eligibility of administrators beyond financial institutions. Conclusion The comments and recommendations provided herein represent the CMA's priority recommendations for targeted federal funding towards the achievement of efficiency improvements in Canada's health sector. It is the CMA's position that these measures will contribute to a healthy, more productive and innovative economy by contributing to better care, better health and better value in the health care system. Once again, the CMA appreciates the opportunity to provide these additional comments and recommendations. i 2006 Census data ii http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/2011/Dec-Poll_en.pdf
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CMA's Submission to the House of Commons Standing Committee on Finance: Amending Bill C-25 to expand the PRPP framework to provide value to self-employed Canadians

https://policybase.cma.ca/en/permalink/policy10355
Date
2012-02-24
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Date
2012-02-24
Topics
Physician practice/ compensation/ forms
Text
The Canadian Medical Association (CMA) supports the Government of Canada's efforts to improve Canada's retirement income system, specifically by establishing a legislative framework to permit pooled registered pension plans (PRPPs) as proposed in Bill C-25, the PRPP Act. The CMA has long supported the Government of Canada's efforts to expand access to pensions, including by permitting PRPPs. However, the CMA is concerned that as currently proposed, Bill C-25 limits the potential for PRPPs to expand the access to, and investment in, pensions of self-employed individuals. The CMA has participated in, and made recommendations to, Finance Canada over the course of the department's multi-year consultative process, including responding to the 2010 consultative paper Ensuring the Ongoing Strength of Canada's Retirement Income System. The CMA has also made recommendations to Finance Canada as a member of the Retirement Income Improvement Coalition (RIIC), which consists of 11 national professional associations representing over 1 million self-employed professionals. The following discussion and recommendations align with those previously made by the CMA and the RIIC. The pension framework is a critical issue to CMA's membership of over 76,000 physicians. In addressing the pension framework, including permitting PRPPs, two principles are central to the CMA's membership: to ensure that self-employed Canadians can retire with an appropriate level of retirement income (e.g., a target of 70% of pre-retirement income); and, to expand the retirement savings options that are available to self-employed Canadians. The CMA's comments herein, and recommendations to the Finance Committee to amend Bill C-25, are in support of these two principles. As elaborated below, the CMA encourages the Finance Committee to: 1. Amend Bill C-25 to raise the combined limit for RRSPs and PRPPs in order to increase the retirement savings capacity of self-employed individuals. 2. Amend Section 12(1) of Bill C-25 to expand the PRPP framework so it includes defined benefit and targeted benefit pension plans, which provide more secure savings vehicles than defined contributions plans. 3. Ensure the eligibility clauses of Bill C-25 (Sections 14-26) would allow well-governed professional organizations that represent a particular membership to be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members. 1. Increase the combined contribution limit It is our understanding that the core benefit of the proposed PRPP framework is in providing smaller businesses access to low-cost pension plans, thereby providing a vehicle to encourage employers to establish, and contribute to, pensions for their employees. However, as explained by the Explanatory Notes accompanying the proposed Income Tax Act amendments, "an employer's contributions to an individual's PRPP account [and...] an individual's PRPP contributions in a taxation year will immediately reduce the individual's ability to make deductible RRSP contributions in that same year." While the CMA recognizes the value of, and supports, this objective, this proposal in effect maintains the status quo for self-employed individuals. Like the Canadian population at large, physicians represent an aging demographic - 38% of Canada's physicians are 55 or older - for whom retirement planning is an important concern. In addition, the vast majority of CMA members are self-employed physicians and, as such, they are unable to participate in workplace registered pension plans (RPPs). At present, physicians are more reliant on registered retirement savings plans (RRSPs) relative to other retirement savings vehicles. While individuals with employer contributions stand to benefit from increased retirement savings via employer contributions, self-employed individuals are merely provided with access to an alternate retirement savings vehicle. As explained in the Summary Report on Retirement Income Adequacy Researchi, "[h]igher income groups tend to exhibit a greater tendency to substitute one form of saving for another since they tend to be bound by limits...[I]f newly introduced plans are included in limitations imposed on the degree to which contributions may be deductible for tax purposes, saving may not increase for individuals who are constrained (i.e. saving up to their limit), since they would more likely substitute one type of saving for another (e.g., RRSP for a private pension plan)." Therefore, the CMA encourages the Finance Committee to consider amending Bill C-25 to increase the retirement savings capacity of self-employed individuals by raising the combined limit for RRSPs and PRPPs. 2. Include Defined Benefit and Targeted Benefit Pension Plans As currently proposed, Section 12(1) of Bill C-25 limits PRPPs to defined contribution pension plans by specifically excluding from eligibility of registration: (a) a pension plan as defined by 2(1) of the Pension Benefits Standards Act; (b) an employees' or a deferred profit-sharing plan; (c) an RRSP or a retirement compensation arrangement defined by 248(1) of the Income Tax Act; and, (d) any other prescribed plan or arrangement. As highlighted in the Summary Report on Retirement Income Adequacy Research, "defined benefit pension funds and annuities enable investors to share longevity risks as well as pool risky investments to diversify risk." By pooling risk, defined benefit and targeted benefit pension plans provide more secure savings vehicles than defined contribution plans. The CMA encourages the Finance Committee to amend Bill C-25 to expand the PRPP framework to include defined benefit and targeted benefit pension plans. 3. Clarify the eligibility criteria of "PRPP administrators" to include professional associations Further clarification is required on the type of organization that may qualify as a PRPP administrator under Bill C-25. While Sections 14-26 of Bill C-25 can be interpreted to extend administrator eligibility to organizations that are able to fulfill the criteria it establishes, Finance Canada's Framework for Pooled Registered Retirement Plans states that eligibility of administrators would be limited to "regulated financial institutions that are capable of taking on a fiduciary role." The CMA encourages the Finance Committee to ensure that the eligibility clauses of Bill C-25 would allow well-governed professional organizations that represent a particular membership to be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members. Conclusion While the CMA supports the proposed PRPP framework in principle, the limitations currently proposed by Bill C-25 should be addressed to ensure that PRPPs also provide value to self-employed Canadians, including physicians. The CMA appreciates the opportunity to comment to the Finance Committee as part of its study of Bill C-25. Summary of Recommendations Recommendation 1 Amend Bill C-25 to raise the combined limit for RRSPs and PRPPs in order to increase the retirement savings capacity of self-employed individuals. Recommendation 2 Amend Section 12(1) of Bill C-25 to expand the PRPP framework so it includes defined benefit and targeted benefit pension plans, which provide more secure savings vehicles than defined contributions plans. Recommendation 3 Ensure the eligibility clauses of Bill C-25 (Sections 14-26) would allow well-governed professional organizations that represent a particular membership to be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members. i Prepared for the Research Working Group on Retirement Income Adequacy of Federal-Provincial-Territorial Ministers of Finance.
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CMA's Submission to the House of Commons Standing Committee on Health: Drug Shortages

https://policybase.cma.ca/en/permalink/policy10382
Date
2012-03-29
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2012-03-29
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association (CMA) is pleased to provide this submission to the House of Commons Health Committee for consideration as part of its study on drug supply in Canada. The severe impact of the disruption in production at one pharmaceutical company's manufacturing facility has demonstrated the significant shortcomings in how drug shortages are managed in Canada. This submission focuses on what is needed to ensure Canada's health care system delivers patient-centred care. In order to deliver the best possible care to patients, physicians require timely, comprehensive and accurate information about current and anticipated drug supply shocks and constraints. With this objective in mind, we have provided input to the government and to the pharmaceutical industries. Further, Canada requires an uninterrupted supply of medically necessary medication for patients. Impacts on Patients and the Health Care System Canada's doctors are deeply concerned about the persistent shortages of drugs that they and their patients are encountering. Prescription drugs can prevent serious disease, reduce hospital stays, replace surgical treatment and improve a patient's capacity to function productively in the community. Pharmaceuticals benefit the health care system by reducing costs in other areas such as hospital stays and disability payments. Disruptions in the supply of pharmaceuticals can impact patient care, patient health and the efficiency of the overall health care system. At the CMA, patient organizations are telling us about the anxiety, pain and harm that drug shortages are inflicting on patients. Below are excerpts of these experiences: * According to the Brain Injury Association of Canada: "Any drug medication shortage endangers Canadian patients. In the brain injury community, anti-depressants are prescribed to some, as is pain medication, so if there is a shortage some members in the community will be endangered even if the medication is altered." * The interim-president of the Canadian Arthritis Patient Alliance, Louise Bergeron, wrote CMA to say: "Actually, I have had this happen to me on three occasions and it is quite scary when you know you will not have access to certain drugs for an extended period of time, since you know your health will be on the line." * Sharon Baxter, Executive Director, of the Canadian Hospice Palliative Care Association, says: "All are encouraging the government to find a solution very quickly as pain medication at the end of life is essential and urgent. I don't think we are at the stage where people are dying without access, but getting to that end is totally unacceptable in a country like Canada." Among the impacts of drug shortages are: * delays in access to needed medication; * delays or disruptions to clinical treatment; * delayed or cancelled surgeries; * loss of therapeutic effectiveness when an appropriate alternate therapy is not available; * increased risk of side effects when alternate therapies are used; and * increased non-compliance when patients, particularly those on long-term therapy, find it harder to comply with a new medication regime. Any one of these situations can impact patient health, particularly in patients with complex problems. In many instances, this in turn leads to a greater demand on the health care system, whether in physician visits or emergency room treatments. In a survey of physicians conducted by the CMA in 2011, two-thirds of respondents said that the shortage of generic drugs had had negative consequences for their patients or practice. Of these physicians, 22 per cent indicated that the consequences were that their patient suffered clinical deterioration because an alternate drug was substituted. Similarly, in a survey of pharmacists by the Canadian Pharmacists Association in 2011, 69 per cent of respondents indicated that they believed that patients' health outcomes had been adversely affected by drug shortages. Notably, of the physicians who indicated the shortage of generics resulted in consequences to their patients or practice, 28 per cent reported that their patient did not fill the substitution prescription due to the cost of the medication. Numerous respondents raised concerns about the financial impact of substitute medications on patients. Survey responses also shed light on the increased demand on the health care system created by the lack of information on drug shortages provided to physicians. When physicians are not made aware of a drug shortage, and prescribe that medication, they later have to provide the patient with a new prescription, which often requires an additional patient visit. Better informing physicians about drug shortages can reduce demand on the health care system by eliminating the inefficiencies associated with drug shortages. Scope of Drug Shortages In an attempt to outline the scope of the problem, the Canadian Agency for Drugs and Technologies in Health (CADTH) stated that: "It is difficult to quantify and determine the extent of drug shortages in Canada because manufacturers are not required to report disruptions in drug supply to Health Canada and because there is no single accountable Canadian organization that provides system-wide drug distribution oversight."i Surveys by the CMA and the Canadian Pharmacists Association (CPA) shed light on the lack of drug shortages management in Canada. Taken together, the results of these surveys paint an alarming picture of drug shortages management in Canada and underscore the need to improve our system. In terms of notification, the majority of physicians and pharmacists indicated they never (51 per cent and 29 per cent) or infrequently (32 per cent and 33 per cent) receive advance notice of shortages. Ironically, given the high proportion of pharmacists reporting they never or infrequently receive notice, 65 per cent of physicians indicated that they receive notification from pharmacists. Meanwhile, 30 per cent of physicians also indicated that they were notified of drug shortages by their patients. Alarmingly, 81 per cent of the pharmacists surveyed indicated they had trouble locating medications to fill a prescription during their last shift prior to completing the survey and 93 per cent had difficulty over the week prior. This is not a new problem, but since we surveyed CMA members in the fall of 2011, the situation has worsened. Currently about 250 medications are listed on Canadian drug shortage websites. Before the dire impact of the loss of production at Sandoz, Canadian hospitals were already dealing with shortages in the supply of sterile injectables - critical in specialties like surgery, oncology and anesthesia. What Canada's Doctors Require to Provide Care Physicians have expressed their frustration at the time it takes to find an appropriate drug for substitution - time taken from the physician, the pharmacy and the patient. Time better spent with patients is being used by physicians to work with pharmacists to identify alternative drugs and therapies. Of greatest concern are those drugs that are single sourced. When single source medications are in short supply, there are no clear substitutes. The impact of this is being felt now in hospitals across the country as they grapple with the loss of numerous Sandoz products and are forced to ration the remaining stock. The majority of physicians surveyed by the CMA indicated that greater knowledge of drug supply issues would allow them to deliver better patient care. To this end, the CMA strongly supports the development of a comprehensive system for monitoring and responding to domestic shortages of medically necessary drugs. Canada needs a sustainable, adequately resourced system to: identify shortages, rapidly and proactively inform health care professionals, and respond quickly to allocate supply as needed to resolve shortages. The CMA has provided input to both industry and government on the key information needs of doctors. These are: * Information about the product in short supply; * Expected duration of the shortage; * Therapeutic alternatives; * Regions affected; * Notification of the end of the shortage. While the recent establishment of the online inventories by the pharmaceutical industry associations marks an improvement in Canada's management of drug shortages, significant issues remain to be addressed. These include the need for: complete and more consistent information; automatic notifications to alert physicians, pharmacists and other health care providers; a mechanism to prevent potential disruptions; and a mechanism to seek new or interim sources of supply during a shortage. The CMA recognizes that other countries are also grappling with drug shortages. Canada must also work with its partners abroad to find an international solution to this phenomenon. Conclusion Drug shortages management in Canada has significant shortcomings that impact patients, doctors and the health care system. With the current shortage of injectable drugs teetering on the verge of a crisis, quick action and cooperation are required to address the supply shock. The CMA calls on Members of Parliament to exercise leadership to ensure that Canada's health care providers have access to the information necessary for them to care for their patients, and that Canadians have access to medically necessary drugs. i Canadian Agency for Drugs and Technologies in Health. (2011) "Environmental Scan: Drug Supply Disruptions." Ottawa: CADTH, accessed online at: http://www.cadth.ca/media/pdf/Drug_Supply_Disruptions_es-18_e.pdf, 1.
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CMA's Submission to the Senate Committee on Social Affairs, Science and Technology - Prescription Pharmaceuticals in Canada: The Post-Approval Monitoring of Prescription Pharmaceuticals

https://policybase.cma.ca/en/permalink/policy10631
Date
2012-10-24
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2012-10-24
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association is pleased to take part in the second phase of the study of prescription pharmaceuticals by the Senate Standing Committee on Social Affairs, Science and Technology. During the first phase, we presented the CMA's policy position regarding clinical trials and the process for approving new drugs for use. In this phase we will discuss our position and recommendations on post-approval surveillance of prescription drugs. The Canadian Medical Association represents 76,000 physicians in Canada. Its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care. Prescription drugs are a very important part of high quality and cost-effective health care. They can prevent serious disease, reduce the need for hospital stays, replace surgical treatment and improve a patient's capacity to function productively in the community. Therefore, the CMA has developed a substantial body of policy on pharmaceutical issues, including on the post-approval surveillance of prescription drugs. The essence of our position is contained in our first recommendation: Recommendation 1: The CMA recommends that federal and provincial/territorial governments collaborate to develop and implement a national pharmaceutical strategy to ensure that every Canadian has timely access to an adequate supply of safe and effective prescription drugs. This recommendation has two elements: "safe and effective" and "adequate supply," both of which we will discuss in this submission. 2) Ensuring Safety and Effectiveness As we have previously told this Committee, the CMA supports a robust regulatory framework and system for researching and approving new pharmaceutical products. But however strong Canada's pre-approval system is, it will not identify all potential problems with a new drug. Pre-approval clinical trials tend to focus on small numbers of patients, and exclude vulnerable groups such as children and the elderly. They also tend to be of short duration, whereas in the real world, patients may take these drugs for years. As a consequence, problems with a drug are often identified only after widespread, long-term use in the general population. For this reason, it is essential that Canada have in place a robust regulatory framework that includes a timely system to monitor the performance of prescription drugs after they come on the market. The Government of Canada has taken several recent steps to enhance its drug surveillance system. In 2009, it established the Drug Safety and Effectiveness Research Network. In 2008, it introduced Bill C-51, An Act to Amend the Food and Drugs Act, to improve drug safety and effectiveness monitoring by Health Canada. Unfortunately, the bill died with the 2008 election call and has not been re-introduced. That is why we are pleased that the Senate has chosen to re-open this issue. What would a comprehensive post-approval surveillance regulatory framework and system look like? In order to effectively monitor the safety and effectiveness of the country's drug supply, the CMA believes it should include: a) Comprehensive processes for gathering drug safety and effectiveness data In gathering data about adverse drug reactions (ADRs) in Canada, Health Canada has traditionally relied on spontaneous reports from manufacturers and health professionals. The government could enhance its capacity to gather information by: * making it easier for physicians and other health professionals to report ADRs voluntarily. This can be accomplished by making the reporting system user-friendly and easy to incorporate into a practitioner's busy schedule. Health Canada has improved the process by introducing online reporting, which may have contributed to the significant increase in the number of ADR reports over the past 10 years. The reporting process could be made even more efficient by incorporating it directly into the Electronic Medical Record (EMR) as this is developed. * augmenting spontaneous reports with information gathered through other, more systematic means. These could include formal post-market studies of specific drugs, or recruitment of "sentinel" groups of health care providers who would contract to report ADRs in detail, and who, because of these contractual obligations, would be committed to assiduous reporting. b) A capacity for rigorous and timely data analysis to identify significant threats to drug safety. Information gathering does not in itself constitute post-market surveillance. In our opinion, the most important element of the process is the monitoring and analysis that occurs once an adverse drug reaction (ADR) report has been received. Monitoring capacity requires rigorous data analysis that can sort "signal from noise" - in other words, sift through the reports, find the ones that indicate unusual events, investigate their cause, and isolate those that indicate a serious health risk. It also requires that the analysis be timely: we note that in 2011 the Auditor General was particularly critical of Health Canada's post-market surveillance timeliness, noting that it could take several years for reports to be reviewed internally. Post-market monitoring should do more than identify safety risks. It should also provide information about a drug's efficacy and effectiveness. Does it achieve the health outcome for which it is being marketed? Does it perform better than other drugs or therapies for the same condition? c) Communication of useful information to health care providers and the public. When new information is uncovered about a prescription drug, it is important that physicians and other health professionals are made aware of it as quickly and efficiently as possible. Therefore, post-approval surveillance requires a system for communicating timely, reliable and objective information to physicians and other health professionals, which they can absorb quickly and incorporate into their everyday practice. Ideally, this communication would report not the safety problem alone but also its implications for their patients and practice: for example, whether some patients are particularly at risk, or whether therapeutic alternatives are available. Recommendation 2: The CMA recommends that Health Canada continue to improve the capacity of its post-approval surveillance system to: * Make it easier for health professionals to submit voluntary ADR reports; * Analyze the data that has been gathered in a rigorous and timely manner; and * Communicate essential information to health care providers and the public in a timely and user-friendly manner. d) Increased regulatory authority for Health Canada Drug safety is a serious issue; recent research has revealed that nearly a quarter of new drugs approved in Canada will eventually receive a serious safety warning1. Given the potential risks to patient safety we believe Health Canada should have the legal authority to take strong action when a safety problem is identified. The CMA recommends that Health Canada should be given the authority to: * require post-market studies of newly approved drugs if clinical trials identify possible safety risks; * require manufacturers to disclose information if Health Canada thinks it germane to making a decision in the interest of patient safety; and * take action if post-market research uncovers new safety concerns. This could mean ordering changes to product labels, or pulling a product off the market. Granting Health Canada this regulatory authority is only the first step. Health Canada should not hesitate to use this authority if the situation warrants. 3) Ensuring an Adequate Drug Supply In the past few years Canada's doctors have become deeply concerned about the persistent shortages of drugs that they and their patients are encountering. In a survey of physicians conducted by the CMA in September 2012, two-thirds of respondents said that the shortage of drugs was a significant issue in terms of its impact on patient care and outcomes. Of these physicians, 70 per cent indicated that their patient received a less effective medication, and 20 per cent had patients who had suffered clinical deterioration because an alternate drug was substituted. This in turn leads to a greater demand on the health care system, whether in physician visits or emergency room treatments. Twenty-three per cent reported that their patient suffered financially due to the cost of the substituted medication, since many of the drugs in short supply are older, low-cost generics. The lack of information about shortages compounds the stress of dealing with them. When physicians prescribe a medication, unaware that it is in short supply, they later have to provide the patient with a new prescription, which often requires an additional patient visit. Physicians have expressed their frustration at the time it takes to find an appropriate substitute drug - time which could better be spent in patient care. As a consequence, the CMA strongly supports the development of a comprehensive system for monitoring domestic shortages of medically necessary drugs. To be of greatest benefit to doctors, such a system should include: * Information about the product in short supply; * Expected duration of the shortage; * Therapeutic alternatives; * Regions affected; * Notification of the end of the shortage. Although pharmaceutical industry associations and drug manufacturers are now supporting a drug shortage reporting website (http://www.drugshortages.ca/drugshortages.asp), there is room for improvement. The reporting website does not yet capture all of the drug product shortages. It must become more user friendly for health practitioners and the public, with search and sort functions to easily find product listings. In addition, a mechanism to obtain information on possible therapeutic substitutions would be of value to practitioners. Recommendation 3: The CMA recommends that Health Canada work with provincial and territorial governments, industry groups and health professionals to enhance the current system for reporting drug shortages and ensure its sustainability. Finally, while a reporting system to provide information to health professionals and Canadians on drug shortages is valuable, it is essential that Canada address the root causes of drug shortages. A review of the supply processes, both domestic and international, is strongly recommended. While the CMA acknowledges that provinces are responsible for purchasing drugs, we believe that solutions will be stronger if all provinces, and the federal government, work together on them. And since drug shortages are an international concern, it is the responsibility of the Government of Canada to work with other countries in seeking solutions. Recommendation 4: The CMA supports an investigation into the underlying causes of prescription drug shortages in Canada. 4) Other Important Elements of a National Pharmaceutical Strategy As Recommendation 1 states, the CMA believes that Canada's federal and provincial/territorial governments should implement a national pharmaceutical strategy, one of whose objectives would be to ensure an adequate supply of prescription drugs. The strategy should address other important objectives, as well, notably: * ensuring comprehensive prescription drug coverage for all Canadians. According to a recent CMA survey, one in 10 Canadians has gone without a prescription drug because they couldn't afford it. Governments should work with private insurers and other stakeholders to develop a system to provide equitable, comprehensive prescription drug coverage to all Canadians. * encouraging optimal prescribing by health professionals. To accomplish this, the CMA has recommended a strategy that includes education, user-friendly guidelines and practice tools, and the provision of impartial information to health professionals and the public. 5) Conclusion Once again, we commend the Senate Social Affairs Committee for bringing this issue to your table. Canada's physicians are prepared to work with governments, health professionals and the public in strengthening Canada's post-approval surveillance system, to ensure that the prescription drugs Canadians receive are safe and effective and in adequate supply. 1 Lexchin J. New drugs and safety: what happened to new active substances approved in Canada between 1995 and 2010? Arch Intern Med. 2012;():1-2. doi:10.1001/archinternmed.2012.4444.
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