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.
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.
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
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.
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.
The Canadian Medical Association (CMA) submission to the House of Commons Standing Committee on Finance discusses the important role of the federal government in ensuring Canada's health care system is cost-effective, accountable and accessible across the country in order to support the country's economic advantage. Investing in health and health care is required to generate wealth. As in other leading industrialized countries, the federal government needs to play a stewardship role in the effective allocation of health-related resources to foster a productive workforce and a strong economy.
The purpose of this brief is to provide decision-makers with information on areas in which the federal government can contribute to improving the health of Canadians and the health care system - an issue Canadians consistently rank as their top concern.
The CMA recommends that:
Recommendation # 1
The federal government endorse the Principles to Guide Health Care Transformation, developed by the CMA together with the Canadian Nurses Association and since endorsed by over 120 national organizations.
The federal government engage the provinces and territories in a consultative process to identify pan-Canadian metrics and measurement that link health expenditures to nationally comparable health outcomes. The purpose of which is to demonstrate accountability to Canadians.
Recommendation # 3
The federal government recognize the implications of the social determinants of health on the demands on the health care system.
Recommendation # 4
The federal government require that the federal cabinet's decision-making process include a Health Impact Assessment.
Recommendation # 5
The federal government, in consultation with provincial and territorial governments and other stakeholders, establish a program of comprehensive prescription drug coverage to be administered through provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drugs.
Recommendation # 6
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.
Recommendation # 7
A targeted health infrastructure fund be established as part of the federal 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.
Recommendation # 8
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.
Recommendation # 9
The federal government establish programs to encourage Canadians to save for their long-term care needs by pre-funding long-term care through for example, private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance, such as an RESP-type savings vehicle.
Recommendation # 10
The federal government develop and implement a national dementia strategy. Such a strategy will contribute to addressing the alternative level of care crisis impacting the efficiency of the overall health care system.
Despite significant investments in health care and improvements in medical treatment and technologies, health outcomes in Canada are not improving. The incidence of chronic disease, such as diabetes and the corresponding risk factors, among them obesity, continues 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. While the federal government's investment in the sector has continually increased, it is generally agreed that, in terms of its health care system, Canada is no longer a strong performer compared to similar nations.
As in other leading industrialized countries, the Government of Canada needs to play a stewardship role in the effective allocation of health-related resources, which in turn will foster a productive workforce and a strong economy. The federal government also has a role in addressing the social and economic factors that affect the health of Canadians. These factors are often referred to as the social determinants of health and were a central theme at the CMA's annual General Council meeting this year.
This brief provides tangible recommendations on how the federal government can contribute to the transformation of Canada's health care system and to improving the health of Canadians.
1. The Role of the Federal Government
Issue: The federal government has the levers to foster a healthy, productive workforce.
This section discusses opportunities for the federal government to address the challenges facing Canada's overall health care system.
Even though the fiscal arrangement for the future Canada Health Transfers has been established, the federal government has other significant responsibilities with respect to the health of Canadians and the overall health care system.
This view is shared by a majority of Canadians. Recent polling found that: 75 per cent of Canadians believe health care should be the federal government's top priority; 87 per cent believe that the federal government should pay more attention to health care, and 85 per cent believe the federal government should play a leading role in protecting and strengthening the health care system.
An important role to be fulfilled by the federal government is to ensure Canada's health care system is cost-effective, accountable and accessible across the country. Health expenditures account for an increasing proportion of provincial and territorial budgets, and many warn of increasing future demands on health care. 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." Measures that transfer costs from one level of government to another do not improve Canada's overall fiscal situation.
Despite the importance of the health care sector to Canada's economy and quality of life, it is generally agreed that in health care, Canada is no longer a strong performer relative to similar nations. For instance, OECD Health Data 2012 ranks Canada seventh highest of 34 member states in per capita health care spending,1 while Canada's health care system continues to rank below most of our comparator countries in terms of performance. In addition, recent projections indicate that the overall spending on health as a percentage of GDP will continue to increase.2
However, the health sector has an important role in sustaining Canada's economic recovery and enhancing economic growth. In fact, the health sector supports a healthy and productive workforce by providing over one million high-value jobs, representing about 10 per cent of Canada's labour force. 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.3
Taken together, these issues highlight significant potential for the health sector, through efficiency improvements gained by health care transformation, to support long-term economic recovery and growth in Canada.
Finally, while the provinces and territories have initiated positive steps to collaborate on the sharing of best practices in health care, federal leadership could contribute to these efforts by addressing the overall performance of the health care system in Canada.
The federal government should collaborate with the provinces and territories to introduce a pan-Canadian framework for reporting to Canadians on performance, outcomes and expenditures, including on whether national standards of quality and timeliness have been met.
The federal government would also fall under this framework, as it is responsible for the delivery of health care services to a large population. In fact, in health care delivery, it is the fifth-largest jurisdiction in Canada.
The CMA recommends that:
* The federal government engage the provinces and territories in a consultative process to identify pan-Canadian metrics and measurement that link health expenditures to nationally comparable health outcomes. The purpose of which is to demonstrate accountability to Canadians.
2. The need for a Health Impact Assessment (HIA)
Issue: All federal government decisions need to be viewed through the lens of their possible impact on health, health care and Canada's overall health objectives.
While a strong health care system is vital, improvements to it alone will not improve health outcomes or reduce the disparities that currently exist in disease burden and health risks. Research suggests that 50 per cent of population health is determined by our social and economic environment.4 What is needed is a process to address the social determinants that can be barriers or enablers to health and 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 any given policy and to identify and recommend strategies to protect and promote health. The HIA is used in several countries, including Australia, New Zealand, Norway, the Netherlands and the United States.
The HIA can ensure that all government departments are able to consider the health impacts of their programs and policies by anticipating possible unintended health consequences or impacts on health care spending. The implementation of an evidence-based HIA is one way in which the federal government can play a leadership role in health care and strengthen accountability to Canadians.
The CMA recommends that:
* The federal government recognize the implications of the social determinants of health on the demands on the health care system; and that,
* The federal government require that the federal cabinet's decision-making process include a Health Impact Assessment to ensure that the health of Canadians is a key factor in every policy decision it makes and unintended consequences are avoided.
3. Contribute to Health Care Transformation (HCT)
Issue: A transformed health care system will be more effective and comprehensive and will strengthen Canada's competitive advantage.
In 2010, as part of its Health Care Transformation (HCT) initiative, the CMA broadly consulted Canadians across the country on their views on health care. Canadians said they do not believe they are getting good value from their health care system, a feeling borne out by studies comparing Canada's health care system to those in leading countries in Europe. Following this consultation, in partnership with the Canadian Nurses Association, the CMA developed Principles to Guide Health Care Transformation in Canada to guide the transformation of Canada's health care system. To date, over 120 national medical, health and organizations have endorsed these principles.
During the HCT consultation, we also heard that Canadians are concerned about inequities in access to care beyond the basic medicare basket, particularly in the area of prescription drugs. In fact, reports in 2002 by the Senate Standing Committee on Social Affairs, Science and Technology (Kirby) and the Commission on the Future of Health Care in Canada (Romanow) forged a consensus on the need for "catastrophic" pharmaceutical coverage, which may be defined as out-of-pocket prescription drug expenditures that exceed a certain threshold of household income.
Under the National Pharmaceuticals Strategy (NPS), cost projections of catastrophic pharmaceutical coverage were explored and seemed to favour the use of a variable percentage threshold linked to income. However, there has been no public reporting on progress since 2006.5 Moreover, there is also an issue of expensive drugs that may be used for common diseases. Finally, as highlighted by recent experiences, Canada does not have a monitoring and early notification system for drug shortages nor a systematic mechanism to prevent interruptions in the provision of medically necessary medications.
Thus far, the term "catastrophic" has been used by First Ministers and the NPS to describe their vision of national pharmaceutical coverage. As defined by the World Health Organization, catastrophic expenditure reflects a level of out-of-pocket health expenditures so high that households have to cut down on necessities such as food and clothing and items related to children's education.6 In the CMA's view, this does not go far enough and what Canada must strive for is "comprehensive" coverage that covers the whole population and effectively pools risk across individuals, public and private plans, and jurisdictions.
There are several indicators that show health care services and coverage are not keeping up with Canadians' needs and vary depending on where one lives in 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. Further, long wait times for medical care can be found in smaller provinces and drug coverage and services for seniors are particularly poor in Atlantic Canada.
The fact remains that one in 10 Canadians cannot afford the medications they are prescribed.7 For this reason, ensuring access by all Canadians to needed prescription drugs is an essential element in the CMA's proposed framework for Health Care Transformation.
By working to establish comprehensive prescription coverage, the federal government would not only uphold its commitment to ensure the best health for Canadians, but also contribute to the transformation of our country's most cherished social program.
The CMA recommends that:
* The federal government endorse the Principles to Guide Health Care Transformation, developed by the CMA together with the Canadian Nurses Association and since endorsed by over 120 organizations.
* The federal government, in consultation with provincial, territorial and other stakeholders, establish a program of comprehensive prescription drug coverage to be administered through provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drugs.
4. Meeting the health and health care needs of Canadians
Issue: Measures should be taken to prepare for the looming demographic change and address the needs of Canada's aging population
Steps need to be taken to ensure that Canada is prepared to handle the growing long-term care needs of its citizens. These should include funding for much-needed infrastructure and additional support for both health care providers and informal caregivers.
In its most recent report, the Wait Time Alliance noted a link between the rise in diagnosis of dementia and the rise in alternate-levels-of-care (ALC) patient stays in hospitals. These are patients who are in hospital while they await an alternative level of care in a more appropriate setting, often a long-term facility. The shortage of long-term care facilities is a major impediment to achieving efficiency in the health care system and yet another issue for which the federal government is well positioned to collaborate and coordinate on a pan-Canadian strategy.
Under its next long-term infrastructure program, the federal government should include a targeted health sector infrastructure fund for long-term care facilities. This should be part of a pan-Canadian strategy to redirect care from hospitals to homes, communities and long-term care facilities, where patients can receive more appropriate care at a lower cost.
We can expect that many more facilities will be required to meet the long-term care needs of Canadians. The most recent census data shows that over the last decade there has been a 38 per cent increase in the number of seniors living in special care facilities.8 Based on residency rates of the present population, Canada will need over 800,000 long-term care beds by 2047.
Considering the average size of existing long-term care facilities it is estimated that meeting this future demand will require construction of almost 6,000 additional long-term care facilities over the next 35 years, almost 170 a year.9
Another related issue that has the potential to affect productivity is the burden of providing care to family members. Without adequate long-term care resources and support for home care, Canada's labour force may experience a productivity drag as a result of increased leave and absenteeism to care for elderly relatives.
The 2011 federal budget took a first step at providing tax relief for informal caregivers with the introduction of the Family Caregiver Tax Credit. However, this credit of up to $300 a 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.10 Expanding the Family Caregiver Tax Credit would help, but the CMA believes that additional support for informal caregivers will also be needed in the coming years.
Also, according to a 2012 World Health Organization (WHO) report on dementia,11 Canada is one of the few members of the G7 without a national strategy on dementia. There is a lack of awareness and understanding of dementia, which results in stigmatization and barriers to diagnosis and care, and has an impact on caregivers, families and societies - physically, psychologically and economically. Canada's aging population, and the projected rise in Alzheimer's disease and related dementias, pose an emerging health crisis that require federal leadership.
The CMA recommends that:
* The federal government, in partnership with the provinces and territories, develop and implement an integrated, 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. Such a strategy would help prepare for the looming demographic change and the address the needs of Canada's aging population.
* A targeted health infrastructure fund be established as part of the federal government's next long-term plan for public infrastructure. The purpose of this fund would be to support communities across Canada in addressing infrastructure shortages in the health sector that prevent the optimization of health human resources and exacerbate wait times.
* 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.
* The federal government establish programs to encourage Canadians to save for their long-term care needs by pre-funding long-term care through for example, private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance, such as an RESP-type savings vehicle.
* The federal government develop and implement a national dementia strategy. Such a strategy will contribute to addressing the alternative level of care crisis impacting the efficiency of the overall health care system.
1 OECD Health Data 2012 - http://www.oecd.org/health/healthgrowthinhealthspendinggrindstoahalt.htm
2 CD Howe Commentary Chronic healthcare spending disease: a macro diagnosis and prognosis and
Livio Di Matteo and ROSANNA DI MATTEO, The Fiscal Sustainability of Canadian Publicly Funded Healthcare Systems and the Policy Response to the Fiscal Gap CHSRF series of reports on financing models: Paper 5, January 2012. http://www.chsrf.ca/Libraries/Commissioned_Research_Reports/Dimatteo-Fiscal-E.sflb.ashx
3 KPMG. Competitive Alternatives: KPMG's Guide to International Business Location Costs. 2012 edition
4 The Standing Senate Committee on Social Affairs, Science and Technology Final Report of Senate Subcommittee on Population Health. June 2009.
5 Federal/Provincial/Territorial Ministerial Task Force on the National Pharmaceutical Strategy Progress Report. June 2006. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2006-nps-snpp/2006-nps-snpp-eng.pdf. Accessed 08-05-08.
6 Xu K, Evans D, Carrin G, Aguillar-Riviera A. Designing health financing systems to reduce catastrophic health expenditure. Geneva: World Health Organization, 2005.
7 Law MR, Cheng L, Dhalla IA et al. The effect of cost on adherence to prescription medications in Canada. CMAJ February 21, 2012 vol. 184 no. 3
8 Statistics Canada. September 19, 2012. Living arrangements of seniors: Families, households and marital status Structural type of dwelling and collectives, 2011 Census of Population.
9 According to the Canadian Healthcare Association (New Directions for Facility-Based Long-Term care), in 2007 there were 2,577 long-term care facilities in Canada and 217,969 beds. We used the average number of beds per facility to calculate the number of facilities required to meet expected future demand.
10 Chappell, N.L., B.H. Dlitt, M.J. Hollander, J.A. Miller and C. McWilliam. 2004. "Comparative Costs of Home Care and Residential Care." The Gerontologist 44(3): 389-400
Re: Future Mandate of the Health Care Innovation Working Group (the Council of the Federation)
On behalf of the Canadian Nurses Association (CNA) and the Canadian Medical Association (CMA), I am writing in advance of the meeting of the Council of the Federation later this month regarding the future mandate of the Health Care Innovation Working Group with respect to seniors care.
The CNA and CMA welcomed the Council of the Federation's prioritization of seniors care as an area of focus of the Health Care Innovation Working Group. Already, seniors and their families in communities across Canada face significant challenges accessing social supports and health services. These challenges will only intensify as the demographic shift progresses. Based on current trends and approaches, the proportion of provincial/territorial health spending associated with seniors care is forecast to grow by over 15% to almost 62% of health budgets by 2036.
Recognizing the significant pressure this will present for health care systems and provincial/territorial budgets moving forward, it is critical that the Council of the Federation maintain its prioritization of seniors care and meeting the needs of an aging population. As such, we respectfully encourage you in your capacity as Co-Chairs of the Health Care Innovation Working Group to ensure the future mandate of the working group on seniors care be included as part of the agenda at the January 30, 2015 meeting of the Council of the Federation.
The CNA and CMA are actively engaged on this issue and welcome the opportunity to meet with each of you to discuss how we may collaborate to ensure improved health outcomes for seniors, now and in the future.
Christopher S. Simpson, MD, FRCPC, FACC, FHRS
Karima Velji, RN, PhD, CHE
The Canadian Medical Association (CMA) is pleased to present its brief to the House of Commons Standing Committee on Health for consideration as part of its study of "Best Practices and Federal Barriers: Practice and Training of Health Professionals".
The subject under discussion is relevant to both parts of the CMA's mission. The CMA has undertaken considerable activity on the issue. For example, in 2012 and 2013 we participated, with the Canadian Nurses Association and the Health Action Lobby (HEAL) on the Council of the Federation's (CoF) working group on Team-based Care. For many years, the CMA has conducted the National Physician Survey, which develops comprehensive information on physician demographics and practice patterns.
In the past decade a number of health professions have expanded their scopes of practice. In most provinces, for example, pharmacists can now renew prescriptions or provide emergency prescription refills. Ontario has established nurse-practitioner-led primary health care clinics which collaborate with family physicians and others in the community. Nova Scotia has experimented with using paramedics as first-contact primary caregivers in rural or remote areas. Governments expand scopes of practice for a number of possible reasons: cost-effectiveness (i.e. replacing one health professional with a less expensive one); improving access, particularly in areas underserviced by physicians; increasing convenience for patients (for example, allowing a neighbourhood pharmacist to give a flu shot may save the patient from taking time off work for a doctor's appointment): or responding to lobbying by health provider groups.
The CMA believes that ideally, every health care provider should have a scope of practice that is consistent with his or her education and training, and that the health care system should enable them to practice to the fullest extent of this scope. More importantly, the scope of practice of every health professional should enable them to contribute optimally to providing high quality patient-centered care without compromising patient safety. Indeed, the primary reason for expanding the scope of practice of a health professional should be to improve Canadians' health and health care.
In the following pages we will discuss several specific topics related to the Scope of Practice issue, and make recommendations for a possible federal role in supporting best practices among health professionals.
1. A Canada-Wide Approach to Scopes of Practice
Scopes of practice are determined largely by provincial and territorial governments, and each jurisdiction has developed its own regulations regarding what health professional groups may do and under what circumstances. This has led to inconsistency across the country. For example, about half the jurisdictions in Canada allow pharmacists to order laboratory tests and prescribe for minor ailments; provinces vary in the degree to which they fund nurse
practitioner positions; and there is wide variation in how, and even if, physician assistants are regulated.
While recognizing that the authority to determine scopes of practice rests with provincial/territorial governments, CMA believes that it is desirable to work toward consistency in access to health services across Canada.
Recommendation 1: that the federal government work with provincial/territorial governments and with health professional associations to promote a consistent national approach to scope-of-practice expansions
2. Promoting and Facilitating Team-Based Care
The scopes-of-practice issue is closely related to the development of models for team-based care, a development that CMA supports. When Canadians seek health care today, it is mainly to help them maintain their health or to manage chronic diseases. This trend is expected to continue as the population ages and the rate of chronic disease rises correspondingly. For patients who have multiple chronic diseases or disabilities, care needs can be complex and a number of different health and social-services professionals may be providing care to the same person. A patient might, for example, be consulting a family physician for primary health care, several medical specialists for different conditions, a pharmacist to monitor a complex medication regime, a physiotherapist to help with mobility difficulties, health care aides to make sure the patient is eating properly or attending to personal hygiene, and a social worker to make sure his or her income is sufficient to cover health care and other needs.
The complexity of today's health care requires that the system move away from the traditional "silo" method of delivering care and encourage health professionals to work collaboratively to effectively meet patients' needs. The CMA believes that the following factors contribute to the success of inter-professional care:
Patient access to a primary care provider who is familiar with the patient's needs and preferences, and has responsibility for the overall care of the patient, co-ordinating the various providers involved in this care. For more than 30 million Canadians, that primary care provider is a family physician. The College of Family Physicians of Canada believes that family practices can serve as patient's "medical home," in which care is anchored and co-ordinated by a family physician, with access to other health care providers as required.
Mechanisms that encourage collaboration and communication among providers. These include:
o Interdisciplinary primary care practices, such as Family Health Networks in Ontario, which permit patients to access a variety of different health professionals and their expertise from one practice setting;
Widespread use of the electronic health record, which can facilitate information sharing and communication among providers.
A smooth, seamless process for referral from one provider to another.
Role clarity and mutual trust. Each health professional on a care team should have a clear understanding of their own roles and the roles of other team members.
The CoF's Team-Based Care Working Group investigated the critical factors for successful team based care, and identified models in certain provinces that it believed should be considered for rollout across Canada. This rollout could be enhanced if it were encouraged by all governments, including the Government of Canada. In the past, Health Canada has supported demonstration projects in health system reform through the National Primary Care Research Group. The CMA believes that the federal government could take a similar role in future, in supporting and disseminating promising models of inter-professional practice. The dissemination process should be accompanied by a process to rigorously evaluate the effect of such models on health outcomes, quality of patient care, and health care costs.
Recommendation 2: that the Government of Canada support research into and evaluation of innovative models of team-based care, and actively promote the dissemination of successful models nationwide.
Recommendation 3: that Canada Health Infoway work with provinces and territories to increase the adoption of electronic medical records at the point of care and build connectivity among points of care.
3. A Health-Care System That Supports Best Practices in Team-Based Care
We have already discussed the part that governments could play in identifying, disseminating and evaluating models of inter-professional practice. The health care system's planners, funders and managers can also foster team-based care in other ways, such as:
Promoting education in inter-professional care. As the Committee has heard, the Association of Faculties of Medicine of Canada's guiding principles for medical education include valuing inter-professionalism and incorporating it into residency learning and practice. CMA encourages the development of programs to help new physicians and other health professionals acquire the skills needed to function optimally an in inter-professional setting.
Improving access to health services not funded under the Canada Health Act. At present, patients who do not have private health care coverage must pay out of pocket for physiotherapy, dietitian services, mental health care and most social services. This works against the principles of inter-professional care by hindering access to necessary services; this could compromise patient health and safety.
Undertaking an open and meaningful consultation process when changes to scopes of practice are proposed. CMA's experience has been that physicians are more accepting of changes in other professions' scopes of practice if their medical associations have been involved in negotiation on these changes.
Ensuring that the supply of health professionals in Canada is sufficient to the needs of Canadian patients, by developing, implementing and monitoring human resource plans for all major health professions.
Recommendation 4: that the federal government work with provincial/territorial government and national health professional associations to develop and implement a health human resources plan that ensures Canadians' access to all appropriate health care providers.
In conclusion, the Canadian Medical Association recognizes that the great majority of decisions regarding scopes of practice are made at the provincial/territorial level. But we believe that in order to encourage a Canadian health-care system in which all providers work together, contributing their unique skills and expertise to providing patient-centered, seamless, cost-effective care, the support and encouragement of the federal government will be extremely beneficial.
The Canadian Medical Association (CMA) is pleased to provide the information below in
response to questions by the Canada Revenue Agency (CRA) for consideration as part of the
development of regulations following the enactment of the Disability Tax Credit Promoters
Restriction Act. This information is in follow up to CMA’s submission to the CRA dated
December 19, 2014, attached for reference.
As explained in the CMA’s submission attached, the CMA strongly encourages the CRA to
include an exemption for “a health care practitioner duly licensed under the applicable
regulatory authority who provides health care and treatment” from the reporting requirements
in the forthcoming regulations enabled by the Disability Tax Credit Promoters Restriction Act.
This exemption is necessary to ensure CRA does not impose duplicative regulatory oversight
of the medical profession, specific to the provision of this uninsured service. As fully explained
in the CMA’s brief, this exemption would not introduce a potential “loophole”.
Issue 1: Organizations Responsible for Physician Regulatory Oversight
The statutory authority for the regulatory oversight of physicians rests with the provincial and
territorial medical regulatory colleges. As explained on page 4 of the CMA’s submission,
medical regulatory colleges have statutory, comprehensive regulatory authority of physicians;
this authority captures: medical licensure, governing standards of practice, professional
oversight, and disciplinary proceedings. Included in this authority is broad regulatory
oversight for fees that physicians may charge for uninsured services, which would capture the
fee charged for the Disability Tax Credit form. The Federation of Medical Regulatory
Authorities of Canada (FMRAC) is the umbrella organization representing provincial and
territorial medical regulatory authorities in Canada and can address how best to contact
individual regulatory colleges.1
Issue 2: CMA’s Code of Ethics
In addition to policies, guidance and oversight by provincial and territorial regulatory
colleges, charging a fee associated with the delivery of an uninsured service, in this case a
fee associated with completing the form associated with the Disability Tax Credit, is captured
by Section 16 of the CMA’s Code of Ethics. Section 16 states: “In determining professional
fees to patients for non-insured services, consider both the nature of the service provided and
the ability of the patient to pay, and be prepared to discuss the fee with the patient.”2
Issue 3: Fee Structure for Uninsured Services
As the CRA does not provide remuneration to physicians for the completion of the Disability
Tax Credit form, the delivery of this service by physicians is an uninsured service. As an
uninsured service there is no set fee level. While provincial and territorial medical associations
Canadian Medical Association 3
May 15, 2015
may provide guidance to physicians within their jurisdiction on uninsured services, which may
be referenced in policies by regulatory colleges, this guidance does not constitute a set fee
schedule. As captured in the CMA’s Code of Ethics referenced above, physicians may
consider patient-specific and other factors in determining a fee for the delivery of an
uninsured service. The CMA encourages CRA to review relevant policies and guidance of
individual provincial and territorial regulatory colleges for a comprehensive understanding of
the oversight of uninsured services.
Once again, the CMA appreciates the opportunity to provide further information to support
the development of regulations to enable the new authorities of the Disability Tax Credit
Promoters Restriction Act and to ensure that CRA does not impose redundant and duplicative
regulatory oversight of the medical profession.
1 FMRAC’s Executive Director is Dr. Fleur-Ange Lefebvre and can be reached at email@example.com
2 CMA’s Code of Ethics may be accessed here: https://www.cma.ca/Assets/assetslibrary/
IMPROVING EFFICIENCY IN THE CANADIAN HEALTH CARE SYSTEM
Achieving value in health care systems is an important objective for all nations.1 Health care systems in Canada and elsewhere are examining ways to address inefficiencies to make the system more cost-effective and sustainable while improving the quality, continuity, and comprehensiveness of care. This policy statement puts forth recommendations for system sustainability and improving quality of care. All system stakeholders including providers, funders and patients bear responsibility to ensure the health care system is as efficient as possible. Physician input is a necessary condition for meaningful system improvement and innovation.
Health care systems in Canada and elsewhere are examining ways to address inefficiencies to make the system more cost-effective and sustainable while improving the quality, continuity, and comprehensiveness of care. The concept of efficiency in health care has two applications. The most common is technical efficiency, which is defined as producing maximum output for a given level of inputs, or minimizing input for a given level of output.2 The difference between actual output and the maximum achievable output may be attributed to inefficiency within the system.
The second is called allocative efficiency, which refers to optimizing resource allocation to produce maximum outputs that fulfill societal demands. Canadian research suggests that increasing technical and allocative efficiency rather than increasing spending could solve some of the current challenges regarding health care quality and sustainability. Based on a macro system-level approach to estimating efficiency among its member countries, the Organization for Economic Cooperation and Development (OECD) has estimated that all of its member countries could achieve better value from their health care spending-Canada could save 2.5% of Gross Domestic Product in public spending by 2017 if it were to become as efficient as the most efficient OECD countries.3
2. Health care inefficiencies
The various inefficiencies in the Canadian health care system may be categorized and visualized using the conceptual framework developed by Bentley et al in 2008 for the U.S. health care system 4 (see Figure 1). In Canada, no such framework exists.
The framework of Bentley et al contains three main categories of inefficiencies - clinical, operational, and administrative. Clinical inefficiencies relate to practice variation challenges including, the provision of inappropriate care. Operational inefficiencies include duplication of health care services, inefficient processes, overly expensive inputs, and errors in data collection and processing. Administrative inefficiencies may be generally thought of as excess transaction costs associated with claims payment and excess costs of administration and management over and above what is required to deliver front-line health care.
Figure 1. Typology of health care inefficiencies
Source: Adapted from Bentley et al, 2008.
2.1 Clinical Inefficiencies
Clinical waste and inefficiencies refer to services that provide marginal or no health benefit compared with less costly alternatives. This may include practice variation and the provision of inappropriate and cost-ineffective care, or the underuse of more appropriate care. There is overlap between clinical inefficiencies (e.g., providing the wrong service) with operational inefficiencies (the inefficient production of services).
The chief contributor to clinical inefficiencies or waste in the health care field is practice variation-the reduction of unwarranted care variation is the foundation of the quality movement. John Wennberg and colleagues have pioneered the main body of work in this area through their studies on small area variation in care delivery.5 Over the last quarter century, technical studies on clinical practice guidelines (CPGs) have been developed in increasing numbers to address issues of appropriateness of care and care variation.
CPGs are defined as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances".6 CPGs should contribute to better health, enhance the quality of care by reducing practice variation, and contribute to better value and lower costs by encouraging more appropriate use of resources by care providers.7 Although there has been no systematic approach in Canada to developing and disseminating CPGs, or to ensuring the quality of the CPGs produced, various organizations have developed initiatives to tackle this issue.8
Since the early 1990s, the Canadian Medical Association (CMA) has developed and maintained a CPG Infobase, which contains roughly 1,200 guidelines.9 The uptake of CPGs is a crucial component and insufficient resources are applied to necessary clinical practice change processes. Moreover, CPGs should be distillable to actionable points-of-care recommendations suited to the intended end user (e.g., family physicians).
In January 2012, the Council of the Federation (CoF) established the Health Care Innovation Working Group, which comprises all provincial and territorial health ministers, to determine practical and innovative ways to increase the value and effectiveness of care.10 The group's CPG recommendations focused on cardiovascular disease and diabetes - two of the most prevalent and highest-costing chronic diseases in Canada (see Appendix A for list of CPGs). In accordance with the CoF, the CMA recommends:
1. Developing chronic disease management and other supportive strategies for vulnerable patients at risk of frequent readmission to the acute care system.
2. Integrating clinical practice guidelines with electronic medical records.
3. Implementing a pan-Canadian clinical practice guidelines strategy.
4. Using evidence-informed clinical practice guidelines to evaluate patient outcomes, appropriateness, and cost-effectiveness.
5. Developing deployment strategies to ensure maximum use of clinical practice guidelines by physicians.
Clinical practice guidelines need regular updating as new evidence emerges. Therefore, a Pan-Canadian strategy should include a system of regular review and updating using development methods that would exclude the possibility of industry bias. Canada's physicians are taking a leading role on this matter through such initiatives as Choosing Wisely Canada (see below).
There is an increasing trend in health care utilization in areas such as medical procedures, drugs, and physician services.11 Questions remain about whether or not people are receiving care that is appropriate and based on the best available scientific information.12 Inappropriate care, such as the hospitalization of patients who need community-based services or prescribing antibiotics for upper respiratory infections that are likely viral in origin, is another source of clinical inefficiency, using scarce resources for marginal or no health benefit.
The CMA recently defined appropriate care as the right care, provided by the right provider, to the right patient, in the right venue, at the right time:
* "right care" is based on evidence for effectiveness and efficacy in the clinical literature, and not only implies appropriateness of use, but inappropriateness of failure to use;
* "right provider" is based on ensuring the provider's scope of practice adequately meets but does not far exceed the skills and knowledge to deliver the care;
* "right patient" acknowledges that care choices must be matched to individual patient characteristics and preferences;
* "right venue" emphasizes that some settings are better suited in terms of safety and efficiency to delivering a specific type of care than others;
* "right time" indicates care is delivered in a timely manner consistent with agreed upon bench marks.
As a corollary to this definition, if all five components are present, high quality care has been delivered with the optimal use of resources, that is, waste has been eliminated and the best value has been obtained.
Appropriateness is primarily determined by analyses of the evidence of clinical effectiveness, safety, and other health system impacts.13 The practical application of appropriateness is made when these analyses are qualified by (a) clinician judgment, particularly in atypical circumstances14 and (b) societal and ethical principles and values, including patient preferences.
There are a number of perverse incentives that can contribute to the delivery of inappropriate care across the system. These exist at the system level (e.g., patients staying in hospitals longer than needed due to the lack of community services), as well as at the individual encounter level (changes in fee codes for insured medical services such as new consult fees to see a patient every six months). Physicians and payers such as governments need to work together to eliminate perverse incentives based on available medical evidence. Physician incentives should align with system needs. The challenge is getting governments, health authorities and provincial and territorial medical associations, and individual providers agreeing on system goals and objectives.
In the U.S., an innovative appropriateness initiative called Choosing Wisely was established in 2011 with the goal of improving care quality and reducing harm to patients by avoiding unnecessary interventions, with the added benefit of possible cost reductions.15 The initiative challenged specialty societies to identify five clinical activities in their field that are generally of little value or are potentially harmful to patients.16
In Canada, CMA's 2013 General Council called for the formation of a collaborative working group to develop specialty-specific lists of clinical tests/interventions and procedures for which benefits have generally not been shown to exceed the risks. Choosing Wisely Canada was launched on April 2, 2014 with the release of eight lists produced by nine specialty societies (one list was released jointly by the CMA's Forum on General and Family Practice Issues (GP Forum) and the College of Family Physicians of Canada (CFPC)). Twelve additional medical specialty societies released lists in October 2014. The Choosing Wisely Canada campaign is endorsed and supported by over 35 national specialty societies representing a broad spectrum of physicians, as well as by all provincial medical associations, patient organizations, accrediting bodies and others (Website: www.choosingwiselycanada.org). Choosing Wisely Canada aims to promote physician-patient communication about unproductive care and conserve resources by eliminating unneeded activities. This initiative also serves as an example of the role of public education campaigns to help improve appropriate care.
The development of a Canadian version of the Choosing Wisely initiative assists in operationalizing the Institute for Healthcare Improvement's (IHI) Triple Aim concept of better care, better health, better value. Specific benefits include:
* Improving accountability by providing transparent, evidence-informed care;
* Facilitating patients to make the right care decisions;
* Enhancing physician-patient relationships: improve communication and decision-making between patients and their physician; and
* Reducing clinical inefficiencies.
The ultimate objective and impetus for adopting a Choosing Wisely initiative must be to improve patient outcomes. Cost savings to the system should occur as a byproduct. Physicians are in the best position to identify which medical services are unnecessary.
Both patients and providers need to be aware of the costs associated with each treatment option, recognizing there is a balance to strike between cost and value. To facilitate this process, the CMA recommends:
6. Making available data on the cost and cost-effectiveness of treatment options at the point of care.
7. Collecting information to evaluate cost-effective care.
8. Posting costs generated by requests for diagnostic and laboratory tests in electronic medical records.
Evaluation should take place to ensure the posting of costs is targeted to areas where it will be most effective.
2.2 Operational inefficiencies
Examples of operational waste include: undertaking tests or procedures more frequently than clinically necessary (e.g., duplication of tests); unnecessary time spent waiting for medical services or time wasted from processes that add little value; using brand drugs for patients who get equal benefit from generics; and health and cost consequences of medical errors or the use of defective medical devices.
These system inefficiencies can amount to very significant costs to the health care system, patients and the economy. For instance, lengthy waits can have serious health consequences for patient outcomes and result in the substitution of additional health care services while waiting (e.g., use of pain medication). A 2008 study calculated the economic impact of excessive wait times for five procedures (hip and knee replacement surgery, MRIs, CABG surgery and cataract surgery) in all 10 provinces. It found that, in addition to the obvious emotional, physical and financial toll endured by patients and their families, lengthy waits for these medical treatments cost Canada's economy an estimated $14.8 billion overall in 2007 in reduced economic activity by patients ($16.9 billion in 2014 dollars). This included a $4.4 billion reduction in federal and provincial government revenues.17
Notwithstanding a shortage in health care infrastructure, there is general consensus that not all hospital infrastructure is used to its fullest capacity, contributing to lengthy wait times for many patients. This can include excessive turnover time between cases or limited operating room hours that can result in the last patient of the day being unable to receive their surgery at great cost to the patient and their family. In many instances, urban hospitals must cancel surgeries due to overbooked operating room time when in smaller and rural communities, operating rooms are not fully utilized. Strategies should be explored to enable greater use of health infrastructure resources in smaller community hospitals that will serve to enhance timely access to care for patients. This would also ensure that staff had a level of activity that would maintain their skills.
There has been significant uptake of operations research and quality improvement processes to help eliminate operational waste and address unnecessary waiting by patients. To this end, CMA will continue to work with its partners in the Wait Time Alliance to identify strategies to improve timely access to care for patients across the continuum. The CMA will also study the potential health applications of the Theory of Constraints within the Canadian health care system.18
There can also be system-wide inefficiencies in the various health systems operating in the country and in terms of how health systems interact with other systems such as economic and social support systems (e.g., lack of services to address homelessness). Changes in one component of the health care system can negatively affect the efficiency in another component. For instance, cuts made to home care services can lead to a rise in the number of alternate-level-of care (ALC) patients in hospitals, increased wait times in emergency departments, and elective surgery cancelations. A more recent source of system inefficiency has been occurring due to the piecemeal adoption of electronic medical records and information systems (EMR) throughout the country. The multitude of systems adopted by different segments of the health care system has resulted in problems with system inter-operability that often exacerbate administrative and clinical inefficiencies such as preventing the electronic attachment of test results leading to the reordering of tests.
The Canadian Institute for Health Information (CIHI) developed a model to measure and evaluate "health system efficiency" within Canada. It measures the average efficiency of health systems in Canada's health regions and the factors that help explain variations in estimates of system efficiency (measured as the reduction in potential years of life lost (PYLL) from treatable causes of death). The study found that equitable access to physician care is positively associated with efficiency.19 Unfortunately, over 4 million Canadians still do not have a regular family physician.20
In addition, the CIHI study found that factors related to the social determinants of health can also affect system efficiency (e.g., missed prevention opportunities). Frequently, the health care system is relied on to address preventable health needs that are attributable to the social determinants of health (e.g., injuries or illnesses caused by lack of affordable housing or poverty). Furthermore, these factors can negatively affect the effectiveness of any treatment provided by the health care system.21
Governments and health administrators should focus on improving efficiencies where there is the highest volume of services as new models of efficiency do not always show results in low volume areas.
2.3 Administrative inefficiencies
Health programs can be funded and administered at a variety of levels: local, regional, provincial and federal, as well as through employers. According to CIHI, administration accounted for $6.3 billion, or 3.1%, of health care costs in Canada in 2011-roughly middle of the pack among OECD countries22-but this is only the cost of providing public and private health insurance programs and the costs associated with health departments'operations.11 Generally, differences in the level of health administration can be explained in part by the type of health system and financing used such as whether multiple insurance providers exist or the extent that complex funding and billing procedures are in place.23 1
In terms of other administrative costs, we do not know how Canada has evolved over time in comparison to other sectors of the economy or how we compare internationally with respect to the effectiveness of administration expenditures.1 There have been questions about the expansion and contraction of regional health authorities in Canada over the past two decades. However, Canada does not have a detailed set of health accounts that would permit such analysis. CIHI has recently begun to report the percentage of administrative services expenses (general administration, finances, human resources and communications) as a percentage of total expenses for over 600 hospitals as part of its Canadian Hospital Reporting Project (CHRP).24
One source of administrative waste is the cost of duplicate collection and recording of health information. The health sector has been slow in adopting health information technology to help reduce this form of administrative waste.
Another cause of inefficiency is the increase in administrative burden faced by Canadian physicians and their patients. A major contributor is the rise in requests for physicians to complete third party forms from insurance companies and governments (see Appendix B for a list of examples of federal health programs and related medical forms). Different definitions of concepts are frequently used in these forms, but in many instances they are asking for similar information about the same patient. Physicians are also frequently requested to complete sick notes-the CMA believes such an absence does not require physician confirmation of illness and represents an inefficient use of scarce health care resources.25
The cumulative effect of a physician being requested to complete several forms each day can result in significant administrative burden and take away time that physicians can spend providing direct patient care. Standardizing definitions and wording on third-party forms can save time and reduce administrative errors. Physicians fully support any efforts by the private insurance industry and governments to standardize their medical forms. In addition, consideration should be given to instances where other designated providers can be tasked with completing particular forms. Where suitable, electronic medical records (EMRs) can improve the completion and timely submission of third-party forms to the benefit of patients, providers and third-parties.
To address these administrative inefficiencies, the following actions have been recommended by CMA:
9. Federal and provincial auditors general design and implement a protocol for detailed enumeration of administrative costs within their health care systems, including tracking of these costs over time, and issue an annual public report.
10. CIHI conduct a detailed study of administrative costs of Canadian hospitals and regional health authorities and report the findings.
11. Harmonize and centralize, in electronic and written format, all administrative forms that physicians must fill out on behalf of their patients.
3. Innovating for efficiency
Since the late 1990s, the federal, provincial, and territorial governments, and other granting bodies have provided considerable funding for applied health services research to aid the implementation of pilot projects to improve the quality of care delivered in Canada. However, Canada is frequently criticized for its inability to move beyond pilot projects to full implementation. One often-cited reason is the lack of communication about promising innovations from one jurisdiction to another. Other reasons include regulatory barriers such as funding silos, and pilot project funding for a limited duration to prevent meaningful outcome evaluation. Physician input is a necessary condition for meaningful and sustained system innovation.26
The CMA supports:
12. Developing and testing innovative structures or programs to demonstrate clear evidence of improvement in health care outcomes and fiscal sustainability before wide-spread adoption into the Canadian health delivery system.
13. Developing policy tools that provide criteria for identifying barriers to quality, efficiency and equity in emerging models of health care delivery.
14. Creating a registry of physician-managed health care transformation projects. This registry should outline the challenges and lessons learned associated with each project for those interested in adopting similar projects.
Addressing efficiency challenges in the Canadian health care system can improve the quality, continuity, and comprehensiveness of care, while making the system more cost-effective and sustainable. Many components of the health care inefficiencies set out by Bentley et al are now being considered by governments. Physician input is a necessary condition for meaningful system improvement and innovation. Physicians should practice high quality, evidence-informed health care, and advocate for cost-effective allocation of scarce resources. Canada's physicians are taking a leading role on this matter through such initiatives as Choosing Wisely Canada.
Clinical Practice Guidelines (CPGs) recommended by
The Health Care Innovation Working Group of the Council of the Federation
The group recommended each province and territory work with their health authorities to adopt the following CPGs:
* The C-CHANGE guidelines for cardiovascular disease published by the Canadian Cardiovascular Harmonization of National Guidelines Endeavour (C-CHANGE) to reduce guideline variations and confusion among care providers.
* Harmonized guidelines for diagnosis, which include:
o Laboratory testing (e.g., urine analysis, ECGs)
o Risk stratification strategies (e.g., family history, lifestyle choices, and diabetic patients).
* Harmonized guidelines for treatment, which include:
o Establishing treatment targets (e.g., limiting alcohol consumption, healthy body weight, glycemic or glucose targets)
o Health behavior interventions (e.g., balanced heart healthy diet, limiting salt intake, smoking cessation)
o Pharmacological therapy (e.g., assessment of drug and drug interactions, co-morbidities).
Examples of federal health programs and related medical forms
physicians are frequently requested to complete
* Canada Pension Plan Disability
* Disability Tax Credit
* Employment Insurance (Sickness Benefits Claim)
* Non-Insured Health Benefits (for First Nations people and Inuit)
* Veterans Disability Pension
* Compassionate Care Leave
* Exception/Limited Use Drug Request Form (to permit access to drugs not on provincial formularies)
* Interim Federal Health Program
* Canadian Adverse Drug Reaction Monitoring forms
1 Organisation for Economic Co-operation and Development. Health care systems: getting more value for money. OECD Economics Department Policy Note No. 2. Paris: The Organisation; 2010.
2 Canadian Institute for Health Information. Developing a model for measuring the efficiency of the health system in Canada. Ottawa: The Institute; 2012. Available: https://secure.cihi.ca/free_products/HS_Efficiency_Tech_Report_EN-web.pdf (accessed 2013 Apr 30).
3 Organisation for Economic Co-operation and Development. OECD economic surveys: Canada 2012. Paris: OECD Publishing; 2012. Available: http://dx.doi.org/10.1787/eco_surveys-can-2012-enOECD
4 Bentley T, Effros R, Palar K, et al. Waste in the U.S. health care system: a conceptual framework. Milbank Q. 2008;86(4):629-59.
5 Wennberg J, Gittelson A. Small area variations in health care delivery. Science. 1973;182:1102-8.
6 Field MJ, Lohr KN. Clinical practice guidelines: directions for a new program. Washington (DC): National Academy Press; 1990. p. 38.
7 Canadian Medical Association. Handbook on clinical practice guidelines. Ottawa: The Association; 2007.
8 The Canadian Institutes of Health Research (CIHR) has launched a Strategy for Patient Oriented Research and one of its core elements is the improvement of guideline development, dissemination and uptake through support for guideline development and dissemination. Canadian Institutes of Health Research. Canada's strategy for patient-oriented research: improving health outcomes through evidence-informed care. Ottawa: The Institutes; 2011. Available: www.cihr-irsc.gc.ca/e/documents/P-O_Research_Strategy-eng.pdf (accessed 2012 Feb 22).
9 Canadian Medical Association. CMA Infobase: clinical practice guidelines (CPGs). Available: www.cma.ca/En/Pages/clinical-practice-guidelines.aspx (accessed 2012 Feb 22).
10 Council of the Federation Working Group. From innovation to action - the first report of the Health Care Innovation Working Group. Available: www.canadaspremiers.ca/phocadownload/publications/health_innovation_report-e-web.pdf (accessed 2013 Apr 25).
11 Canadian Institute for Health Information. National health expenditure trends, 1975 to 2013. Ottawa: The Institute; 2013. Available: https://secure.cihi.ca/free_products/NHEXTrendsReport_EN.pdf.
12 Canadian Institute for Health Information. Health care in Canada 2010. Ottawa: The Institute; 2010. Available: https://secure.cihi.ca/free_products/HCIC_2010_Web_e.pdf (accessed 2014 Oct 7).
13 Canadian Medical Association. Appropriateness. Ottawa: The Association; 2014. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-05.pdf.
14 Goldberger JJ, Buxton AE. Personalized medicine vs guideline-based medicine. JAMA. 2013;309(24):2559-60.
15 Siwek J. Choosing wisely: top interventions to improve health and reduce harm, while lowering costs. Am Fam Physician. 2012;86(2):128-33.
16 The Good Stewardship Working Group. The "top 5" lists in primary care. Arch Intern Med. 2011;171(15):1385-90.
17 Centre for Spatial Economics. The economic cost of wait times in Canada. Ottawa: The Centre; 2008. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/EconomicReport-e.pdf (accessed 2014 Apr 14).
18 Knight A. The theory of constraints in health and social care. Aldbury (UK): QFI Consulting; 2011.
19 Canadian Institute for Health Information. Measuring the level and determinants of health system efficiency in Canada. Ottawa: The Institute; 2014 Apr. Available: https://secure.cihi.ca/free_products/HSE_TechnicalReport_EN_web.pdf (accessed 2014 Feb 5).
20 Statistics Canada. Access to a regular medical doctor, 2012. Available: www.statcan.gc.ca/pub/82-625-x/2013001/article/11832-eng.htm (accessed 2014 Jan 5).
21 Canadian Medical Association. Health care in Canada: What makes us sick? Town hall report. Ottawa: The Association; 2013 Jul. Available: www.cma.ca/Assets/assets-library/document/fr/advocacy/What-makes-us-sick_en.pdf.
22 Organisation for Economic Co-operation and Development. Guidelines to improve estimates of expenditure on health administration and health insurance. Paris: The Organisation; 2013 Dec.
23 Himmelstein DU, Jun M, Busse R, et al. A comparison of hospital administrative costs in eight nations: U.S. costs exceed all others by far. Health Aff (Millwood). 2014;33(9):1586-94.
24 Canadian Institute for Health Information. Canadian Hospital Reporting Project (CHRP). Available: www.cihi.ca/CIHI-ext-portal/internet/EN/Home/home/cihi000001 (accessed 2014 Mar 20).
25 Canadian Medical Association. Short-term illness certificate. Ottawa: The Association; 2011. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-06.pdf
26 Lee TH, Cosgrove T. Engaging doctors in the health care revolution. Harv Bus Rev. 2014;92(6):104-11, 138.
HEALTH IN ALL POLICIES
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. This negative health status can undermine not only individual health but the productivity and prosperity of the country as well.1 As noted in the Adelaide Statement on Health in All Policies, "Good health enhances quality of life, improves workforce productivity, increases the capacity for learning, strengthens families and communities, supports sustainable habitats and environments, and contributes to security, poverty reduction and social inclusion."2
Research suggests that 15% of population health is determined by biology and genetics, 10% by physical environments, 25% by the actions of the health care system, with 50% being determined by our social and economic environment.3 Many studies show that people low on the socio-economic scale are likely to carry a higher burden of just about any disease.4 Poverty accounts for 24% of person years of life lost in Canada (second only to 30% for neoplasms).5 These numbers demonstrate a need to rethink the way we work to improve the health of the Canadian population. While a strong health care system is vital, changes to our health system alone will not be sufficient to improve health outcomes or reduce the disparities that currently exist in disease burden and health risks.
Using health determinants as a focus means that most health promotion and prevention efforts will take place outside of the health and medical care service.6 Canadians must be supported to make the choices that keep them healthy and reduce their risks of injury and disease. However, many face barriers in their physical, social and economic environments which make these healthy choices difficult. What is necessary is a coordinated effort across government sectors to ensure that all policy decisions serve to increase opportunities for health. As noted by the former Minister of Health and Welfare, Jake Epp, "it is not an overstatement to say that public policy has the power to provide people with the opportunities for health, as well as to deny them such opportunities... All policies having a direct bearing on health need to be coordinated."7
Improving population health and reducing inequities should be an overall objective for all governments in Canada. Not only will it help to reduce costs to the health system, it will also increase economic growth as healthier people lose fewer days of work and contribute to overall economic productivity.8 As laid out in the principles to Guide Health Care Transformation, "Coordinated investments in health promotion and disease and injury prevention, including attention to the role of the social determinants of health, are critical to the future health and wellness of Canadians and to the viability of the health care system.9"
The utilization of such an approach is not new. Governments from England to Finland to New Zealand have increasingly recognized the importance of the social determinants of health and have developed national strategies accordingly. These strategies, often referred to as 'health in all policies,' call for a whole of government approach where cross-departmental collaboration is established at the highest government level to increase the health of the population and reduce inequalities.10 The World Health Organization defines health in all policies as follows:
Health in all Policies (HiAP) is an approach to public policies across sectors that systematically takes into account the health and health systems implications of decisions, seeks synergies, and avoids harmful health impacts, in order to improve population health and health equity. A HiAP approach is founded on health-related rights and obligations. It emphasizes the consequences of public policies on health determinants, and aims to improve the accountability of policy-makers for health impacts at all levels of policy-making.11
This approach looks at all policies that have a health impact not just those in the health sector. Policies are reviewed for their potential impact on population health and health system utilization.12
There are many ways that a HiAP approach can be implemented. Examples include:
inter-ministerial and inter-departmental committees; community consultations and Citizens' Juries; cross-sector action teams; partnership platforms; integrated budgets and accounting; Health Lens Analyses; cross-cutting information and evaluation systems; impact assessments; joined-up workforce development; and legislative frameworks.13
A Plan for Canada
Role of the Federal Government:
While the provinces and territories have constitutional authority for the majority of health system delivery, the federal government has a significant role in health: through system oversight, Canada Health Act; delivery to certain populations, Canada's Aboriginal peoples; as well as accountability and pan-Canadian initiatives for the various health systems. Additionally, the federal government has significant control over areas such as taxation, food security and agriculture, justice, transportation safety and income security (eg child tax benefits, Old- Age Security). All of these can have a marked impact on both individual and population health.
As a result of these responsibilities the Canadian government needs to adopt a clear mandate to focus on the health of the population. Actions must be taken to provide Canadians with the ability to make healthy choices. All legislation must be subject to a health lens to determine potential health implications so as to minimize or mitigate any negative consequences and maximize opportunities for health benefits. Given the central coordinating function of Cabinet in policy setting and delivery, this would be an ideal place to incorporate a HiAP approach.
1. CMA recommends that the federal government acknowledge the relationship of the social determinants of health on the health of the population as well as the demands of the health care system and that it implement a Health in All Policies approach for all cabinet decision-making.
While Cabinet should serve as the central decision-making body for a HiAP approach, there must be formal and sustainable structures that allow timely analysis of the health consequences of policy decisions, which appropriately engage stakeholders, and which ensure that health impacts are actually considered in policy decision-making.14
Such an approach will require some form of enabling legislation as well as benefits for departments that conduct HiAP analysis. In Quebec, for example, all policies are required to undergo a review of health impacts under Section 54 of the 2002 Quebec Public Health Act.15
In addition, it is likely that a lead agency will need to be appointed to facilitate the necessary data collection/analysis to review policies. In the Netherlands health impact assessments are the responsibility of the Department of Intersectoral Policy at the Netherlands School of Public Health.16 Since 2000, the Swedish National Public Health Institute (SNIPH) has been tasked with developing methodology in strategically important areas and with supporting the application of health assessments on the central, regional and local level.17 In England, the Public Health Observatories play a key role in providing data and analysis for health impact assessments.18
A significant barriers to HiAP in Canada is the existing data infrastructure. Hundreds of major and minor publications speak to the volume of analyses undertaken on health and health systems every year in Canada. Despite this effort, Canadian policy makers and the public do not fully understand how health system vs. non-health factors contribute to the health outcomes observed or the picture of overall health. The available data tends to focus on the health care system, sickness and the measurement of sickness related risks. What is missing is a way of organizing the data which provides greater insight for planners and greater accountability for all Canadians. This capacity will need to be developed in order to properly implement a HiAP approach.
2. CMA recommends that the federal government provide the necessary enabling environment to allow for the application of a health in all policies approach in all new policy development.
As the experiences from other countries demonstrate there is some value in selecting a few Ministries to begin the process. Once selected the Ministries should be responsible for starting the process and screening any new policies. If there is a potential health impact they would then contact the centralized resource to conduct the analysis and produce a report with potential impacts and recommendations for change. This report would go back to the originating Ministry for review and modification of the policy as necessary. Changes should be highlighted and the revised policy should be sent with the health analysis report to Cabinet for final decision-making. This will help to improve the policy and will create greater awareness among all Cabinet members of the potential health implications of various policies.
3. CMA recommends that the Federal Minister of Health work with Cabinet to select appropriate Ministries to begin the implementation of the health in all policies approach.
Role of Health Care Sector:
Government is not the only group with a role in HiAP. The health sector, including Canada's physicians can work to ensure that the policy environment promotes health. By working with governments at all levels, physicians can uses their vast knowledge and expertise to provide evidence regarding potential health implications, and promote the development of evidence-informed decision making. In addition, they can work with partners both within and outside of the health sector to advocate as necessary for policy improvements.19
4. CMA recommends that physicians and other health care providers use their knowledge and expertise to support governments in the development of evidence-informed policy which promotes the health of the population.
Investments in the health system will only go so far in improving the health of the population. Population health approaches must tackle the wider social determinants of health. To do so the government must consider health in all the policies that it develops.
1 Reeves, Richard A Liberal Dose? Health and Wellbeing - the Role of the State: An Independent Report. 2010. Available: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_111695.pdf
2 World Health Organizatio. Adelaide Statement on Health in All Policies: moving toward a shared governance for health and well-being. Geneva:The Organization; 2010. Available: www.who.int/social_determinants/hiap_statement_who_sa_final.pdf (accessed 2015 Apr 16).
3 Keon, WJ, Pépin L. (2008) Population Health Policy: Issues and Options. Ottawa: The Senate of Canada; 2008. Available at: www.parl.gc.ca/Content/SEN/Committee/392/soci/rep/rep10apr08-e.pdf
4 Dunn JR. The Health Determinants Partnership Making Connections Project: Are Widening Income Inequalities Making Canada Less Healthy? Toronto :The Health Determinants Partnership; 2002 Available: http://en.healthnexus.ca/sites/en.healthnexus.ca/files/resources/widening_income_equalities.pdf (accessed 2015 Apr 16)
5 Wilkins R, Berthelot J-M, Ng E. Trends in mortality by neighbourhood income in urban Canada from 1971 to 1996. Statistics Canada.Health Rep. 2002:13(Supplement): 10.
6 Knutsson I, Linell A Health impact assessment developments in Sweden. Scand J Public Health. 2010;38:115-120.
7 Epp, J. Achieving health for all: a framework for health promotion. Ottawa: Health and Welfare Canada; 1986. Available: www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/1986-frame-plan-promotion/index-eng.php
8 Munro, D Healthy People, Healthy Performance, Healthy Profits: The Case for Business Action on the Socio-Economic Determinants of Health. Ottawa: Conference Board of Canada; 2008.Available: www.conferenceboard.ca/Libraries/NETWORK_PUBLIC/dec2008_report_healthypeople.sflb
9 Canadian Medical Association, Canadian Nursese Association. Principles for Health Care Transformation in Canada. Ottawa: The Associations; 2011. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-13.pdf
10 St-Pierre L. Governance Tools And Framework For Health In All Policies. Available: www.rvz.net/uploads/docs/Achtergrondstudie_-_Governance_tools_and_framework1.pdf
11 World Health Organization, Government of South Australia. Adapted from WHO Working Definition prepared for the 8Th Global Conference on Health Promotion, Helsinki, 10-14 June 2013.
12 Ollila E, Baum F, Pe ña S. Introduction to health in all policies and the analytical framework of the book. In Leppo K, Ollila E, Pera S, et al., editors. Health in all policies: seizing opportunities, implementing policies. Chap. 1. Finland: Ministry of Social Affairs and Health; 2013. Available: www.euro.who.int/__data/assets/pdf_file/0007/188809/Health-in-All-Policies-final.pdf.
13 World Health Organization, Government of South Australia. Adelaide Statement on Health in All Policies: moving towards a shared governance for health and well-being. Geneva: The Organization; 2010. Available: www.who.int/social_determinants/hiap_statement_who_sa_final.pdf (accessed October 18, 2014)
14 Rudolph, L, Caplan J, Mitchell C, et al. Health in All Policies: Improving Health Through Intersectoral Collaboration. Washington(DC): Institute of Medicine. Available: www.phi.org/uploads/application/files/q79jnmxq5krx9qiu5j6gzdnl6g9s41l65co2ir1kz0lvmx67to.pdf (accessed October 21, 2014).
15 National Collaborating Centre for Healthy Public Policy. Implementation of Sectin 54 of Quebec's Public Health Act. Quebec: The Centre; 2012. Available at: www.ncchpp.ca/docs/Section54English042008.pdf
16 Wright, J, Parry J, Scully EInstitutionalizing policy-level health impact assessment in Europe: Is coupling health impact assessment with strategic environmental assessment the next step forward? Bull World Health Orga. 2005;83(6):472-7
17 Knutsson I, Linell A Health impact assessment developments in Sweden. Scand J Public Health. 2010;38(2):115-20
18 St-Pierre L. Governance Tools And Framework for health in all policies. Available: www.rvz.net/uploads/docs/Achtergrondstudie_-_Governance_tools_and_framework1.pdf
19 Leppo K, Tangcharoensathien V. The health sector's role in HiAP. In Leppo K, Ollila E, Pera S, et al., editors. Health in all policies: seizing opportunities, implementing policies. Chap. 14. Finland: Ministry of Social Affairs and Health; 2013.
Available: www.euro.who.int/__data/assets/pdf_file/0007/188809/Health-in-All-Policies-final.pdf. (accessed October 18, 2014)