The public health system in Canada lies at the heart of our community values. It is the quintessential “public good” and is central to the continued good health of our population. When the public health system is working well, few are even aware that it is at work! Only when something goes terribly wrong — like the Walkerton tragedy or when we are faced with a new threat like SARS — is the integral, ongoing role of public health really recognized.
The Canadian Medical Association (CMA) has been warning that our public health system is stretched to capacity in dealing with everyday demands, let alone responding to the latest crises. Canada’s physicians have repeatedly called for governments to enhance public health capacity and strengthen the public health infrastructure throughout Canada.
Our public health system is the first — and often the only — line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. As most health threats know no boundaries, our public health armaments must be in a constant state of “battle readiness.” In today’s climate of SARS, West Nile Virus, mad cow disease and monkey pox, even the thought that the public health system may be stretched beyond capacity strikes fear into the hearts of Canadians.
Physicians have always been an integral part of the public health system serving as medical officers of health, community health specialists and other related roles. Indeed public health cannot successfully fulfill its mandate without the cooperation and commitment of front-line clinicians.
In this submission, we reflect on the lessons to be learned from our recent experience with SARS and reflect on the longer-term needs of the public health system as a whole. The objectives of the pan-Canadian Public Health Action Plan proposed by the CMA are, first to realize a clearer alignment of authority and accountability in times of extraordinary health emergencies; and, second, to enhance the system’s capacity to respond to public health threats across the country (see recommendations, below, and Appendix 1).
To achieve these twin objectives, three broad strategies are presented for immediate attention. They are legislative reform; capacity enhancement; and research, surveillance and communications.
Legislative reform (see recommendations 1–3)
The country’s response to SARS has brought into stark relief the urgent need for national leadership and coordination of public health activity across the country, especially during a health crisis. The apparent reluctance to act quickly to institute screening at airports, the delay in unifying the practice community for a concerted response and the appalling communications confusion worked against optimum handling of the outbreak — despite the best efforts of health care professionals.
This is a wake-up call that highlights the need for comprehensive legislative reform to clarify the roles of governments with respect to the management of public health threats. A renewed and enhanced national commitment to public health should be anchored in new federal legislation to be negotiated with the provinces and territories.
Specifically, the CMA recommends an Emergency Health Measures Act, to deal with emergent situations in tandem with the creation of a Canadian public health agency headed by a Chief Public Health Officer of Canada.
Capacity enhancement (see recommendations 4–7)
The SARS crisis has demonstrated the diminished capacity within the public health system. The Greater Toronto Area (GTA), with one of Canada’s most sophisticated public and acute health systems, has not been able to manage the SARS crisis adequately and carry on other health programs. The acute care system virtually ground to a halt in dealing with SARS. There was little or no surge capacity in Canada’s largest city. We should be grateful that SARS did not first strike a smaller centre in a far less-advantaged region of Canada.
A critical element of the public health system is its workforce and the health professionals within the acute care system, such as hospital-based infectious disease specialists and emergency physicians who are the front-line interface. Let there be no doubt that the ongoing efforts of the GTA front-line providers are nothing short of heroic. However, the lack of coordinated contingency planning of hospital and community-based disease control efforts was striking. The overall shortage of critical care professionals and the inability of governments to quickly deploy the required professionals to areas of need contributed to the enormous strain on the public and health care system.
Considering the importance of the public health system and its clearly limited capacity to protect and promote the health of Canadians, it is incomprehensible that we do not know how much is actually spent on the system. It is imperative that public health expenditures and capacity, in terms of both physical and human resources, be tracked and reported publicly.
The CMA recommends a $1-billion, 5-year capacity-enhancement program to be coordinated with and through the new Canadian public health agency.
Research, surveillance and communications (see recommendations 8–10)
Canada’s ability to respond to public health threats and acute events, such as SARS, and to maintain its effective public health planning and program development depends on sound research, surveillance and rapid, real-time communications.
A concerted pan-Canadian effort is required to take full advantage of our capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. New-millennium challenges require moving beyond old-millennium responses. Enhanced surveillance is an overdue and integral part of public health, performing an essential function in early detection and response to threats of infectious diseases. Mandatory national reporting of identified diseases by all provinces and territories is critical for national and international surveillance.
During times of crisis, rapid communication to the public, public health staff and front-line clinicians is of critical importance, but in many jurisdictions impossible. We tested our systems during the SARS outbreak and they came up short.
The CMA recommends a one-time federal investment to enhance technical capacity to allow for real-time communication.
The CMA believes that its proposed three-pronged strategy, as set out in the attached recommendations, will go a long way toward addressing shortfalls of the Canadian public health system. Action now will help to ensure that Canadians can once again be confident that they are protected from any future threat of new infectious diseases. Action now will help Canada regain its position as a leader in public health.
We wish the advisory committee well in its deliberations and offer the CMA’s assistance at any time in clarifying the strategies set out in our submission.
Recommendations to the National Advisory Committee on SARS and Public Health
Legislative reform ($20 million / 5 years*)
1. The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada.
2. The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm’s length from government.
3. The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan.
Capacity enhancement ( $1.2 billion / 5 years*)
4. The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals.
5. The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies.
6. Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the proposed Canadian Office for Disease Surveillance and Control.
7. Federal government funding in the amount of $1 Billion over 5 years to build adequate and consistent surge capacity across Canada and improve coordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions.
Research, surveillance and communications ($310 million / 5 years*)
8. An immediate, sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures.
9. The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and intervention.
10. The one-time infusion of $100 million, with an additional $2 million a year, for a “REAL” (rapid, effective, accessible and linked) Health Communication and Coordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies.
*See Appendix 2: Estimated cost of implementing recommendations.
The CMA prepared this submission in response to an invitation from Dr. Naylor to provide input to the National Advisory Committee on SARS and Public Health.
We applaud this initiative and welcome the opportunity to present the views of Canada’s medical community to the committee. The CMA’s basic message is that our health protection laws are woefully outdated and the public health system is stretched beyond capacity. This submission draws on our long history of engagement in public health in Canada and our experience both post-September 11, 2001 and with SARS. It builds on the knowledge and experience of our members, national specialist affiliated societies and provincial and territorial divisions. (We acknowledge, in particular, the outstanding efforts of the Ontario Medical Association and the Canadian Association of Emergency Physicians in battling SARS.)
In this submission, we examine the lessons to be learned from our experience with the SARS outbreak and reflect on both the immediate and longer-term needs of the public health system as a whole. The objectives of the public health action plan proposed by the CMA are, first, to realize a clearer alignment of authority and accountability in times of extraordinary health emergencies and, second, to enhance the system’s capacity to respond to public health threats across the country, including those posed by preventable chronic disease.
The public health system in Canada lies at the heart of our community values. It is the quintessential “public good” and is central to the continued good health of the population. When the public health system is working well, few are even aware that it is at work! Only when something goes terribly wrong — like the contamination of the blood supply in the 1980s, the Walkerton tragedy or SARS — is the integral, ongoing role of public health recognized.
Our public health system is the first — and often the only — line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. As most health threats know no boundaries, our public health system must be in a constant state of “battle readiness.” We can ill afford any weakness in our public health preparedness. In today’s climate of SARS, West Nile Virus, mad cow disease and monkey pox, the mere thought that the public health system may be stretched beyond capacity strikes fear into the hearts of Canadians.
Physicians have always been an integral part of the public health system serving as medical officers of health, specialists in infectious disease and community medicine (who will not remember the stalwart efforts of Dr. Donald Low on SARS?) and in other related roles. Indeed, public health cannot successfully fulfill its mandate without the cooperation and commitment of front-line clinicians.
The CMA has been warning for some time that our system is stretched to capacity in dealing with everyday demands, let alone responding to crises. Canada’s physicians have repeatedly called for governments to enhance public health capacity and strengthen the public health infrastructure throughout Canada. For example, the CMA’s submission to the House of Commons Standing Committee on Finance’s prebudget consultations on October 22, 2001 called for substantial investments in public health and emergency response as a first step to improve the public health system infrastructure and its surge capacity.
This submission not only reiterates our previous recommendations, but also outlines specific actions that the CMA believes must be taken to ensure a strong public health system in Canada.
The Enduring Impact of Severe Acute Respiratory Syndrome
SARS (Severe Acute Respiratory Syndrome): in February 2003, these four letters sent massive shock waves around the world, causing widespread fear and confusion among health care officials and citizens of many countries. The “fear factor” extended across Canada as people realized the full threat of SARS.
Since SARS was first identified in a patient in Toronto in March 2003, 438 probable or suspected cases have been reported to Health Canada and 38 people have died (as of June 23, 2003). However, these numbers do not reflect the full impact of the outbreak. The number of indirect deaths due to system shutdown will never be known.
Local public health authorities across the country went on high alert. Those in the Greater Toronto Area (GTA) as well as their provincial counterparts diverted almost all of their resources to respond to the crisis.
Acute care services were adversely affected as stringent infection-control and screening measures were put into place to control the spread of SARS. In the GTA, the health system — acute and public — was brought to its knees. Over half of the reported SARS cases involved front-line providers as the outbreak largely affected health care settings. Approximately 20 physicians in Ontario contracted SARS and close to 1000 were quarantined. Thousands of nurses and other health care workers also faced quarantine, some more than once.
Institutions closed their doors, limiting access to emergency departments, clinics and physicians’ offices. Intensive care units were full and surgeries were cancelled. Front-line health care professionals involved in critical care were stretched to their physical and mental limits. Others found themselves underutilized due to the impact of the infection-control measures on their practice settings. Feast and famine co-existed.
Although the outbreak was mainly confined to health care settings, the entire GTA felt the effects. Upwards of 20,000 people entered voluntary quarantine. Businesses were affected. The tourism industry is still reeling. The disruption that SARS caused continues to reverberate through health care systems and economies.
In response to urgent requests from both the Ontario Medical Association and Health Canada, the CMA mobilized its membership and assisted in the country’s response to SARS. Everything that could be done was done to facilitate bringing in qualified personnel to relieve those on the front line and make appropriate information available in real time. The CMA has learned its own lessons, both positive and negative. A full chronology of CMA activity is attached as Appendix 3.
It has become abundantly clear that Canada’s public health system was ill prepared to deal with the SARS outbreak. If not for the heroic efforts of public health officials, health care providers and research scientists, Canada’s experience would have been much worse.
Public health in Canada
Public health is the science and art of protecting and promoting health, preventing disease and injury, and prolonging life. It complements the health care system, which focuses primarily on treatment and rehabilitation, sharing the same goal of maximizing the health of Canadians. However, the public health system is distinct from other parts of the health system in two key respects: its primary emphasis is on preventing disease and disability and its focus is on the health needs of populations rather than those of specific individuals.
Public health is the systematic response to infectious diseases. It also ensures access to clean drinking water, good sanitation and the control of pests and other disease vectors. Further, it is immunization clinics and programs promoting healthy lifestyles. But it is also there to protect Canadians when they face a public health crisis like SARS. If the public health system is fully prepared to carry out essential services, then communities across the country will be better protected from acute health events.
The reality in Canada today is that a strong, consistently and equitably resourced and integrated public health system does not exist. Public health systems across Canada are fragmented — a patchwork of programs, services and resources across the county. In reality, it is a group of multiple systems with varying roles, strengths and linkages.
Each province has its own public health legislation. Most legislation focuses on the control of communicable diseases. Public health services are funded through a variable mix of provincial and municipal funding formulae, with inconsistent overall strategies and results, and with virtually no meaningful role for input from health professionals via organizations such as the CMA, or the federal level, in terms of strategic direction or resources.
Federal legislation is limited to the blunt instrument of the Quarantine Act and a variety of health protection-related acts. (e.g., Food and Drugs Act, Hazardous Products Act, Controlled Drugs and Substances Act, Radiation Emitting Devices Act) Some of the laws, such as the Quarantine Act, date back to the late 19th century. Taken as a whole, the legislation does not clearly identify the public health mandate, roles and responsibilities of the different levels of government. In many cases, the assignment of authorities and accountabilities is anachronistic.
Moreover, there is little information available on the functioning and financing of Canada’s public health system. There is no “one-stop shopping” for authoritative information on public health issues.
In 2001, a working group of the Federal, Provincial and Territorial Advisory Committee on Population Health assessed the capacity of the public health system through a series of key informant interviews and literature reviews. The consistent finding was that public health had experienced a loss of resources and there was concern for the resiliency of the system infrastructure to respond consistently and proactively to the demands placed on it. Significant disparities were observed between “have” and “have-not” provinces and regions in their capacity to address public health issues.
The report’s findings are consistent with previous assessments by the Krever Commission and the Auditor General of Canada. In 1999, the Auditor General said that Health Canada was unprepared to fulfill its responsibilities in public health; communication between multiple agencies was poor; and weaknesses in the key surveillance system impeded the effective monitoring of injuries and communicable and non-communicable diseases. In 1997, Justice Horace Krever reported that the “public health departments in many parts of Canada do not have sufficient resources to carry out their duties.”
The Challenges Ahead
The 21st century brings with it an awesome array of new public health risks and ancient foes. Not all of them can be identified at the present time. New diseases (e.g., SARS, West Nile Virus) will likely continue to emerge. Dr. Alan Bernstein, President of the Canadian Institutes of Health Research, recently noted that SARS is here to stay. Old threats, such as contamination of a community water supply (e.g., Walkerton), can strike quickly if vigilance is relaxed or delegated to third parties. This century will likely bring greater focus on threats from the physical environment. Our social environment is also a source of illness as shown by the recent epidemic trends in obesity and type 2 diabetes mellitus. A substantial minority of Canadians continue to smoke. In short, there is no lack of public health threats to Canadians.
Although for each of these issues, there is a clear role for clinical care, it is the public health system that will identify and monitor health threats and provide interventions to prevent disease and injury and improve health. The system will also be at the front lines in any response to a biological, chemical or nuclear event. The public health system must have the infrastructure to respond to a range of threats to health, including emergencies. The experience with SARS has reaffirmed that we do not have the system flexibility to respond to these events after they have occurred. It is vital that we take steps now “to embrace not just the essential elements of disease protection and surveillance but also new strategies and tactics capable of addressing global challenges.”<1>
CMA’S PROPOSED PUBLIC HEALTH ACTION PLAN
No one policy instrument can possibly address the multiple factors involved in meeting the public health challenge head on. Similarly, no one level of government or constituency (e.g., community medicine) can or should shoulder all of the responsibilities.
Although we need to restore public confidence quickly, we must also do what it takes to get it right. Accordingly, the CMA is proffering a three-pronged approach to meet the challenge:
* A legislative reform strategy
* A capacity enhancement strategy
* A research, surveillance and communication strategy.
These three broad strategies make up the CMA’s proposed 10-point Public Health Action Plan. Taken together, the CMA believes the Plan, if adopted, will serve us very well in the future.
Our experience with SARS — and the seeming lack of coordination between international, federal, provincial and local system levels — should be a massive wake-up call. It highlights the need for legislative reform to clarify the roles of governments with respect to the management of public health issues and threats.
Four years ago, national consultations on renewing federal health protection legislation<2> resulted in a recommendation that
* “The federal government must be given, either through legislation or through memoranda of understanding among provincial and territorial governments, the authority it needs to effectively address any outbreak of a communicable disease, where the health risk extends beyond provincial borders.
* “Federal health protection legislation should be amended to give Health Canada authority to act quickly and decisively in the event of a national health emergency... if it poses a serious threat to public health; affects particularly vulnerable segments of the population; exceeds the capacity of local authorities to deal with the risk; and involves pathogens that could be rapidly transmitted across national and international borders.”
Such legislative reform is consistent with the federal government’s well-recognized responsibility to act to protect public health and safety. It fits well with Health Minister McLellan’s recently announced plans to act now to review and update health protection legislation. The SARS outbreak has provided further experience to support these, and in our view, even stronger recommendations.
There is ample historical evidence to support the federal government’s role in the management of communicable disease, a role that dates back to the time of confederation. The quarantine power was the initial manifestation of this authority in 1867 under Section 91 of the British North America Act and it gave the federal government the responsibility for ensuring the containment of infectious diseases. The outbreak of the Spanish Flu epidemic in 1918 further highlighted the need for coordinated national efforts and (at the urging of the CMA and others) resulted in the creation of the federal Department of Health in 1919. It would be reasonable to assume that legislators at the time had an expansive view of the need for centralized authority to deal with pan-Canadian health threats.
One hundred and thirty-five years after confederation, we have a highly mobile global community. This mobility and the attendant devastating speed with which diseases can spread demand a national response. Currently, there is tremendous variation in public health system capacity among the various provinces and territories and, more particularly, among municipalities and local authorities. Inconsistencies in provincial approaches to public health matters have resulted in significant disparities between and within the provinces.<3>
Health Canada’s mandate as set out in its enabling legislation states that “[t]he powers, duties and functions of the Minister extend to and include all matters over which Parliament has jurisdiction relating to the promotion and preservation of the health of the people of Canada.” The CMA believes that it is time for the federal government to take responsibility for public health matters that touch the lives of all Canadians.
The legal staffs at CMA, in consultation with external experts, have conducted a detailed review of existing legislation. We have concluded, as Health Minister McLellan recently announced, that there is a long overdue need to consolidate and rationalize current related laws. We also believe there is now public support and a demonstrable need to enhance the powers afforded the federal government. We recognize that the government has put forward Bill C-17, the Public Safety Act and a review of health protection legislation is underway.
We believe that amending and updating existing legislation is necessary but not sufficient to address today’s public health challenges. The CMA is calling for the enhancement of the federal government’s “command and control” powers in times of national health emergencies. Specifically we are recommending a three-pronged legislative approach.
1. The CMA recommends
The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada.
The existing Emergencies Act gives the federal government the authority to become involved in public welfare emergencies when regions of the country are faced with “an emergency that is caused by a real or imminent... disease in human beings... that results or may result in a danger to life or property... so serious as to be a national emergency.” However, to use this power, the federal government must declare a “national emergency,” which itself has political and economic ramifications, particularly from an international perspective, and mitigates against its use. The CMA believes that this all-or-nothing approach is not in the public’s best interest. The concept of emergency in the context of public health requires a different response from governments in the future.
Although we recognize that provincial and municipal governments currently have preplanned sets of responses to health threats, the CMA is proposing new legislation to allow for a rapid federal response to public health emergencies. The proposed Emergency Health Measures Act clarifies the roles and authority of governments and ensures a consistent and appropriate response with sufficient human and financial resources to protect Canadians faced with a public health emergency. Of utmost importance, all Canadians, regardless of their location, can be assured that the response to a health emergency will be delivered systematically by experts who can sustain the effort as needed.
The proposed legislation would be founded on a graduated approach that would give the federal government the powers necessary to deal with a crisis, in an appropriately measured way, as it escalates. As the emergency grows, the government could implement stronger measures as required to meet the challenge — in principle, akin to the Unites States’ homeland security levels, which increase as the level of threat increases (see Appendix 4 for a description of the Canadian Emergency Health Alert System).
The CMA strongly believes that the federal government must have jurisdiction to act when the ability of the provinces to respond to public health emergencies is so disparate. The inability of one province to stop the spread of virulent disease would have serious implications for the health of residents in the rest of the country. The federal government and the provinces must work together to ensure the safety of all our citizens.
2. The CMA recommends
The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm’s length from government.
Although some provinces have established centres of public health expertise, considering the breadth of public health issues, the relative population sizes and differences in wealth, it will never be feasible to have comprehensive centres of public health expertise for each province and territory.
Even if one achieved this, there would increasingly be issues of economies of scale and unnecessary duplication among centres. This issue is not unique to Canada.1 The CMA is proposing the development of a Canadian Office for Disease Surveillance and Control (CODSC) operating at arm’s length from any level of government. CODSC would have overall responsibility for protecting the health of Canadians.
The Office would provide credible information to enhance health decisions and promote health by developing and applying disease prevention and control, environmental health and health promotion and education activities.
CODSC would enable a consistent and coordinated approach to public health emergencies as well as play a key role in the prevention and control of chronic diseases and injuries. It would provide national health surveillance, apolitical scientific expertise, system development including standards and guideline development, development and dissemination of an evidence base for public health interventions, skills training and transfer of expertise (i.e., through secondment of staff) and resources, including funding for core programs, to other levels of the system (e.g., provincial and local).
3. The CMA recommends
The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan.
Many national or federal–provincial–territorial committees play an important role in recommending public health strategies or actions. The National Advisory Committee on Immunization and the Federal, Provincial and Territorial Advisory Committee on Population Health are two excellent examples. But there is currently no single credible public health authority in whom is vested, through legislation or federal–provincial–territorial agreement, the overall responsibility for pan-Canadian public health issues.
Therefore, the CMA is recommending the appointment of a Chief Public Health Officer of Canada. Potential roles for this officer may include:
* Serve as the head of the Canadian Office for Disease Surveillance and Control
* Serve as the national spokesperson for public health with the independence to comment on critical public health issues
* Report annually on the health of the population
* Develop, implement and report independently to parliament on public health system performance measures
* Lead processes to identify and address gaps in the nation’s public health system.
The public health system infrastructure is the foundation that supports the planning, delivery and evaluation of public health activities. In March 2001, the Federal, Provincial and Territorial Advisory Committee on Public Health<3> reported,
In the view of respondents the system ‘is lacking in depth.’ This means that a sustained crisis would seriously compromise other programming. While the research does not indicate that the public health system in Canada is strained beyond capacity, there does appear to be agreement that there is a capacity to manage just one crisis at a time.
However, just 2 years later, the GTA, an area with one of Canada’s most sophisticated public and acute care health systems, was not able to manage the SARS crisis and carry on any other programs. The Ontario government recognized this state of affairs when, on 12 June, Ontario’s Health Minister Tony Clement said, “I was concerned that if we had one additional large-scale crisis, that the system would crash.”
Important public health issues ranging from immunization to suicide prevention went virtually unaddressed, as the public health capacity in Toronto was overwhelmed. In the absence of a mechanism to share resources within the system and a general lack of overall system surge capacity, the city of Toronto and the province competed with each other to recruit trained staff from other health departments. The SARS outbreak has shown there is no surge capacity in Canada’s largest city. The acute care system in Toronto virtually ground to a halt in dealing with SARS. We must ask ourselves what would have happened if SARS had struck first in a smaller centre in a far less-advantaged region of Canada.
Clearly Canada is not fully prepared. We should not have needed a crisis to tell us this. The CMA sees several components to rebuilding the capacity of the public health system.
Public health human resources
For the essential functions of the public health system to be realized, public health agencies need a workforce with appropriate and constantly updated skills. Canada’s public health workforce is extremely thin. There appear to be too few graduate-level public health professionals (i.e., those holding a master’s degree and physicians who are certified specialists in community medicine); those who do exist are not distributed equitably across jurisdictions. The scarcity of hospital-based infection control practitioners and emergency physicians within the acute care system and the lack of integration of hospital and community-based disease control efforts have been particularly striking during the SARS outbreak.
The knowledge and skills required for effective public health practice are not static. They continually evolve as new evidence is identified. However, continuing education programming for public health practitioners is woefully underdeveloped in Canada. Health Canada has made some limited progress in this area, but the issue needs to be addressed much more substantively.
4. The CMA recommends
The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals.
Canada has world-class expertise in public health. However, it does not have the depth of other countries, partly because we do not have a national multidisciplinary school of public health of the calibre of Harvard in Boston, Johns Hopkins in Baltimore and the School of Hygiene and Tropical Medicine in London.
A national school of public health, which might be based on a virtual network of centres nationwide, could
* Develop a plan to assess and address the substantial educational needs of new and existing public health staff
* Address the coordination of the various academic training programs to meet the needs of the field
* Ensure self-sufficiency of our public health workforce.
5. The CMA recommends
The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies.
The SARS outbreak clearly demonstrated the need for a pre-planned approach to supporting and augmenting the public health and acute care workforce during a crisis. When health professionals in the GTA were overwhelmed, we were ill prepared to move health professionals in from other jurisdictions to help. Health professional associations like the CMA took the first steps in investigating and overcoming obstacles regarding licensure and insurance. We were taken aback when we found that the Ontario government had unilaterally awarded an exclusive contract to a for-profit company to arrange for emergency relief. The further delay caused by concerns about privacy, confidentiality and harmonizing fees hampered relief efforts. The deployment of health professionals during health emergencies is too important to be left in the hands of for-profit organizations as it was during the SARS experience.
An established Canadian Public Health Emergency Response Service, operating on a non-profit basis, would
* Maintain a “reserve” of public health professionals who are fully trained and could be deployed to areas of need during times of crisis
* Co-ordinate the logistics of issues such as portable licensing, malpractice and disability insurance
* Identify funding for staff training and a more equitable distribution of numbers and skills among jurisdictions.
Investment in public health
Considering the importance of the public health system and its capacity to protect and promote the health of Canadians, it is amazing that we have no reliable or comprehensive information about how much money is actually spent on the system or what public health human resources are available across Canada. This is partially due to the lack of uniform definitions, service delivery mechanisms and accounting practices. Even in the absence of reliable data on public health expenditures, there is ample evidence that the public health system continues to operate under serious resource constraints across Canada.
6. The CMA recommends
Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the Canadian Office for Disease Surveillance and Control.
In its latest report on health system expenditures, the CIHI states that 6% of total expenditures in 2000 were spent on “public health and administration.”<4> The inclusion of administrative costs in this figure means that public health funding is substantially less than 6% of health system expenditures.2
Federal Government Estimates report that Health Canada allocated $433 million in 2003–2004 for health promotion and prevention activities with spending scheduled to decrease to $308 million by 2005–2006 or by almost 30%. This decrease in spending exemplifies a decade that has seen tremendous fluctuations in spending on public health activities.
The situation is alarming when looked at from a current-dollar basis; there was an 8.8% decrease in funding of public health activities between 1994–1995 and 1997–1998. In fact, federal spending on public health on a constant dollar basis did not regain its 1994–1995 level until 2000–2001.
Although the late 1990s saw some reinvestment in public health initiatives, the most recent 2003–2004 estimates suggest that, once again, federal investment in public health will decrease dramatically over the next few years. Indeed, public health continues to represent only a small fraction of total federal direct spending on health (9.7% in 2002–2003).
At the provincial level, although we cannot distance public health from administration, we know that it fell victim to the brutal climate of fiscal retrenchment of the 1990s, when in real terms provincial–territorial per capita health spending declined for 5 consecutive years after 1991–1992.
During this period, public health was further destabilized by regionalization. According to the Survey of Public Health Capacity in Canada most provincial and territorial officials reported reductions in programming as a result of the transfer of funding and responsibility to regional structures. Although Ontario did not regionalize, in 1997 public health funding was downloaded to municipalities, which left public health departments scrambling to find funds to meet existing programs as well as new services that were mandated by the provincial Health Protection and Promotion Act.
Whether talking about federal or provincial–territorial jurisdictions, we can no longer afford to have funding for health and safety subject to the vagaries of financial cycles.
However, what perhaps is most alarming is the potentially large economic impact of underinvestment in this area. Although the net cost of the SARS outbreak in Ontario is not yet known, recent estimates suggest that it could be as high as $2.1 billion.3 Given this, the proverbial ounce of prevention that is worth a pound of cure comes to mind suggesting that a relatively modest increase in funding for public health could potentially result in substantial savings in the longer term.
7. The CMA recommends
Federal government funding in the amount of $1 billion over 5 years to build adequate and consistent surge capacity across Canada and improve coordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions.
The best way to ensure that the public health system is capable of addressing the range of public health threats, including emergencies, is to significantly increase investment in its capacity. This investment must assist all levels of the system to fulfill essential public health functions, with particular attention to local and regional agencies. The strategic national leadership that we are calling for includes the development of new mechanisms for federal cost sharing of basic public health services and the guarantee of a basic core set of local programs serving everyone in Canada, regardless of where they live.
The system also needs to receive targeted funds so that it can do its work smarter and more effectively. Priority areas for this targeted funding should include development of an integrated information system and staff training.
Research, surveillance and communications
Canada’s ability to respond to emerging public health threats and acute events, such as the SARS outbreak, and to maintain its effective public health planning and program development depends on sound research, surveillance and rapid, real-time communications.
8. The CMA recommends
An immediate sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures.
Similar to the efforts in clinical care to support the use of evidence-based practices, interventions in public health must be based on research, evidence and best practices. A national effort should be undertaken to develop and make widely available, on an ongoing basis, a comprehensive and up-to-date review of the evidence base for public health programs. This information would support effective practice, enhance public health research capacity and support other infrastructure elements (e.g., minimum programs and services, performance measurement, system funding). It could also reduce unnecessary duplication of efforts by different public health agencies.
We applaud the tremendous work of the unique trans-Canada partnership of 4 CIHR-funded research teams who, in just 11 weeks, discovered the complete DNA sequence of the coronavirus associated with SARS. This is a perfect example of what can be accomplished when our talented research teams work together. The recent announcement by the CIHR of an integrated national strategy for research on SARS reflects the intent of this recommendation for other public health challenges.
9. The CMA recommends
The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and interventions.
Public health surveillance is defined as the ongoing, systematic collection, analysis and interpretation of health data necessary for designing implementing and evaluating public health programs. It is an integral part of the public health system and performs an essential function in early detection and response to threats to human health.
Current surveillance systems for communicable and noncommunicable diseases are inadequate to allow public health professionals to detect and react to major health issues. For effective public health management, surveillance must be a continuous process covering a range of integrated data sources to provide useful and timely information.
10. The CMA recommends
The one-time infusion of $100 million, with an additional $2 million a year, for a “REAL” (rapid, effective, accessible and linked) Health Communication and Coordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies.
In today’s world, international travel, business and migration can move infectious diseases around the world at jet speed. But during the SARS experience, governments and public health authorities were unable to communicate in real time with health professionals on the front lines. Gaps in the basic communication infrastructure prevent public health agencies from talking with each other in real time, and also hinder exchanges between public health staff, private clinicians and other sources of information about emerging new diseases.
In response to requests from both the Ontario Medical Association and Health Canada, the CMA mobilized its communication networks to provide physicians with critical information about public health management of SARS. In less than 48 hours, via email and fax, we reached over 45,000 physicians with authoritative information. Through the good offices of the Canadian Council of Health Services Accreditation, this information was also made available to over 1500 accredited health facilities across Canada.
Although necessity caused the limits of the system to be tested, SARS highlighted the fact that we do not have information systems in place to facilitate real-time communication with health professionals. Information is the key to effective response during times of emergency. Information in real time is also essential for effective day-to-day health care to provide, for example, information on adverse drug reactions.
SARS brought out the best in Canada and Canadians’ commitment to one another. It also turned a bright, sometimes uncomfortable spotlight on the ability of this country’s health care system to respond to a crisis, be it an emerging disease, a terrorist attack, a natural disaster or a large-scale accident. We must learn from the SARS experience and quickly move to rebuild the infrastructure of a strong public health system.
The CMA believes that this 10-point Public Health Action Plan will go a long way toward addressing shortfalls in the Canadian public health system. Action now will help to ensure that Canadians can be confident once again that their governments are doing all they can to protect them from the threat of new infectious diseases.
We wish the advisory committee well in its deliberations and offer the CMA’s assistance at any time in clarifying the strategies set out in our submission.
APPENDIX 1: THE CMA’S PUBLIC HEALTH ACTION PLAN
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APPENDIX 2: ESTIMATED COST OF IMPLEMENTING THE RECOMMENDATIONS
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Estimated cost over 5 years
Legislative and institutional reform
1. Canada Emergency Health Measures Act
2. Canadian Office for Disease Surveillance and Control (CODSC)
3. Chief Public Health Officer of Canada
4. Canadian Centre of Excellence for Public Health
5. Canadian Public Health Emergency Response Service
6. Canadian Institute for Health Information and Statistics Canada
7. Surge capacity
Research, surveillance and communications
8. Canadian Institutes of Health Research
9. Mandatory reporting
Included under 2 and 3 above
10. Enhanced reporting
a. Work is currently underway to break-out public health from the current category of “public health and administration.”
b. This is an incremental investment in addition to funding currently available under Health Canada’s Health Promotion and Prevention Strategic Outcome area.
c. Funding must be sequestered specifically for new initiatives related to public health. Additional money could also be acquired through funding from the Canadian Foundation for Innovation, which received an additional $500 million in 2002–2003 (announced in the 2003 federal budget) to enhance the Foundation’s support of public health infrastructure.
APPENDIX 3: CHRONOLOGY OF THE CMA’S RESPONSE TO SARS
* First known case of atypical pneumonia (SARS) occurs in Guangdong province, China
* World Health Organization (WHO) receives reports from the Chinese Ministry of Health about SARS; 305 persons affected and 5 deaths
* Canadian index case arrives in Hong Kong for a family visit
* Canadian index case is a guest at the Metropole hotel in Kowloon
* A medical doctor from Guangdong checks into Metropole hotel in Kowloon. The physician, who became ill a week before staying at the hotel, is considered to be the original source of the infection
* This leads subsequently to outbreaks in Vietnam, Hong Kong, Singapore and Canada after guests leave the hotel and return home
* Canadian index case returns home to Toronto
* Canadian index patient dies in Toronto, 9 days after the onset of her illness
* WHO issues global alert about SARS
* National and international media reports begin appearing about SARS
* The Canadian index patient’s son, Canada’s second SARS victim, dies 15 days after the onset of his illness
* First reports from Toronto about deaths from SARS
* Health Canada receives notice of SARS patients in Ontario and British Columbia; begins regular updates on SARS on its website
* Health Canada initiates its pan-Canadian communication infrastructure, based on its pandemic influenza contingency plans
* CMA calls Health Canada to offer assistance and request “real time information.” CMA immediately placed on list of participants in daily pan-Canadian teleconferences.
* CMA adds a SARS page to its website home page (cma.ca) with CMA Shortcuts to expert information and daily updates
* CMA alerts all its divisions and affiliates to the Health Canada and CMA SARS web pages
* eCMAJ includes SARS updates on its website
* CMA divisions add a link to SARS information for health professionals to their websites
* Health Canada requests CMA’s assistance to inform physicians of the public health management guidelines for SARS
* CMA sends an email to 33,000 members (copied to divisions and affiliated societies) to alert them to Health Canada’s SARS public health management documents and SARS web page
* CMA CEO initiates cross-directorate task force and deploys dedicated staff resources. Some other CMA programs deferred/delayed. Task force begins daily staff SARS Working Group meetings
* CMA communicates with the Ontario Medical Association on a daily basis
* CMA holds teleconference with divisional communication directors re: SARS
* CMA contacts the British Medical Association to establish whether we can secure a supply of masks from European sources
* CMA organizes a teleconference among national health care organizations to discuss SARS developments
* CMA posts electronic grand rounds on SARS for clinicians on cma.ca;
* CMA sends email and fax communication to physicians to raise awareness of SARS e-grand rounds on cma.ca
* Working with the Mental Health Support Network of Canada, CMA prepares and posts on cma.ca, fact sheets for health professionals and the public on coping with the stress caused by SARS
* CMA hosts second teleconference among national health care organizations to discuss SARS developments
* Electronic grand rounds on SARS updated and promoted through cma.ca
* CMA sends email to membership requesting volunteers for the CMA Volunteer Emergency SARS Relief Network
* CMA consults with the American Medical Association regarding the possibility of US physicians volunteering for the relief network
* CMA CEO sends letter to deputy minister of health about the urgent need to create a national ministerial SARS task force
April 30-May 1
* CMA participates in Health Canada-sponsored international SARS conference in Toronto
* Health Canada announces the National Advisory Group on SARS and Public Health, headed by Dr. David Naylor
* Opinion editorial by Dr. Dana Hanson, CMA president, on SARS and public health surge capacity published in The Ottawa Citizen;
* CMA organizes a meeting of national health care organizations to discuss lessons learned from SARS
* CMA receives an invitation to submit a brief to the National Advisory Group on SARS and Public Health
* CMA sends e-mail to targeted segment of its membership (community medicine, public health, infectious disease and medical microbiology) requesting volunteers for the CMA Volunteer Emergency SARS Relief Network
* CMA president outlines the CMA’s Public Health Action Plan during a speech at the Canadian Club in Toronto
* CMA submission to the National Advisory Committee on SARS and public health
APPENDIX 4: CMA’S PROPOSED HEALTH EMERGENCY ALERT SYSTEM
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Health alert may be declared in:
* Any area under federal jurisdiction
* Any community or province/territory with a risk of transmission to other provinces/territories or countries
* Any community or province/territory with insufficient resources to manage the public health emergency within the capacity of the local public health authorities
Definition of the area of concern
Voluntary quarantine for individuals or property
Chief public health officer takes the lead in coordinating the response
Regulation or prohibition of travel
Reviewing and updating health emergency procedures
Determination of local capacity to lead and respond
Coordinating necessary response efforts with national disaster relief agencies, armed forces or law enforcement agencies at the federal–provinical–territorial level
Medium to significant limitations of civil rights and freedoms
Assessing future resource requirements
Deployment of a national response team
Medium to significant limitations of civil rights and freedoms
Evacuation of persons and the removal of personal property
Providing the public with necessary information.
Discretionary deployment of the national response team or on request of local authorities
Quarantine of individuals and/or property with enforcement by law
Implementing interventions, as appropriate, and emergency response actions
Regulation of the distribution and availability of essential goods, services and resources
Assessing further refinement of actions
Restricting access to the area of concern
Requisition, use or disposition of property
Required consent of governor in council
Lead response team
1. Garrett, L. Betrayal of trust: the collapse of global public health. New York: Hyperion; 2000.
2. Health Canada. National consultations, summary report: renewal of the federal health protection legislation. Ottawa: Health Canada; 1999.
3. Federal, Provincial and Territorial Advisory Committee on Population Health. Survey of public health capacity in Canada: highlights. Ottawa: The Committee; 2001.
4. Canadian Institutes for Health Information. National health expenditure trends: 1975–2002. Ottawa: CIHI; 2002.
5. Lévesque M. The economic impact of SARS. TD Economics Topic Paper. TD Bank Financial Group; 6 May 2003. Available: http://www.td.com/economics/topic/ml0503_sars.html (viewed: 20 June 2003).
1 Many countries (e.g., United States, United Kingdom, Norway and the Netherlands) have developed critical masses of public health expertise at the national level. The Centers for Disease Control and Prevention in the United States, which has a critical mass, great depth of scientific expertise and the tools and fiscal resources to fund public health programs at both state and local levels through demonstration projects, is a sterling example of the effectiveness of such a central agency.
2 A review by the Canadian Institute for Health Information recognizes the problem with current expenditure tracking systems and has recommended separating public health from government administrative costs and prepayment administration in future health system cost estimates.
3 On 6 May, the TD Bank released a paper<5> suggesting that the cost of SARS to the Canadian economy may be between $1.5 and $2.1 billion.
That the government create a one-time Health Care and Innovation Fund to resume health care services, bolster public health capacity and expand primary care teams, allowing Canadians wide-ranging access to health care.
That the government recognize and support the continued adoption of virtual care and address the inequitable access to digital health services by creating a Digi-Health Knowledge Bank and by expediting broadband access to all Canadians.
That the government act on our collective learned lessons regarding our approach to seniors care and create a national demographic top-up to the Canada Health Transfer and establish a Seniors Care Benefit.
That the government recognize the unique risks and financial burden experienced by physicians and front line health care workers by implementing the Frontline Gratitude Tax Deduction, by extending eligibility of the Memorial Grant and by addressing remaining administrative barriers to physician practices accessing critical federal economic relief programs.
Five months ago COVID-19 hit our shores. We were unprepared and unprotected. We were fallible and vulnerable. But, we responded swiftly.
The federal government initiated Canadians into a new routine rooted in public health guidance.
It struggled to outfit the front line workers. It anchored quick measures to ensure some financial stability.
Canadians tuned in to daily updates on the health crisis and the battle against its wrath.
Together, we flattened the curve… For now.
We have experienced the impact of the first wave of the pandemic. The initial wake has left Canadians, and those who care for them, feeling the insecurities in our health care system.
While the economy is opening in varied phases – an exhaustive list including patios, stores, office spaces, and schools – the health care system that struggled to care for those most impacted by the pandemic remains feeble, susceptible not only to the insurgence of the virus, but ill-prepared to equally defend the daily health needs of our citizens.
The window to maintain momentum and to accelerate solutions to existing systemic ailments that have challenged us for years is short. We cannot allow it to pass. The urgency is written on the faces of tomorrow’s patients.
Before the onset of the pandemic, the government announced intentions to ensure all Canadians would be able to access a primary care family doctor. We knew then that the health care system was failing.
The pandemic has highlighted the criticality of these recommendations brought forward by the Canadian Medical Association. They bolster our collective efforts to ensure that Canadians get timely access to the care and services they need. Too many patients are succumbing to the gaps in our abilities to care for them. Patients have signaled their thirst for a model of virtual care. The magnitude of our failure to meet the needs of our aging population is now blindingly obvious. Many of the front line health care workers, the very individuals who put themselves and their families at risk to care for the nation, are being stretched to the breaking point to compensate for a crumbling system.
The health of the country’s economy cannot exist without the health of Canadians.
Long wait times have strangled our nation’s health care system for too long. It was chronic before COVID-19. Now, for far too many, it has turned tragic.
At the beginning of the pandemic, a significant proportion of health care services came to a halt. As health services are resuming, health care systems are left to grapple with a significant spike in wait times. Facilities will need to adopt new guidance to adhere to physical distancing, increasing staff levels, and planning and executing infrastructure changes. Canada’s already financially atrophied health systems will face significant funding challenges at a time when provincial/territorial governments are concerned with resuscitating economies.
The CMA is strongly supportive of new federal funding to ensure Canada’s health systems are resourced to meet the care needs of Canadians as the pandemic and life continues. We need to invigorate our health care system’s fitness to ensure that all Canadians are confident that it can and will serve them.
Creating a new Health Care and Innovation Fund would focus on resuming the health care system, addressing the backlog, and bringing primary care, the backbone of our health care system, back to centre stage.
The CMA will provide the budget costing in follow-up as an addendum to this submission.
RECOMMENDATION 1 Creating a one-time Health Care and Innovation Fund
It took a global pandemic to accelerate a digital economy and spark a digital health revolution in Canada. In our efforts to seek medical advice while in isolation, Canadians prompted a punctuated shift in how we can access care, regardless of our location or socio-economic situation. We redefined the need for virtual care.
During the pandemic, nearly half of Canadians have used virtual care. An incredible 91% were satisfied with their experience. The CMA has learned that 43% of Canadians would prefer that their first point of medical contact be virtual.
The CMA welcomes the $240 million federal investment in virtual care and encourages the government to ensure it is linked to a model that ensures equitable access.
A gaping deficit remains in using virtual care. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify digital opportunities to improve health care delivery, including what regulatory changes are required across provincial/territorial boundaries. To take full advantage of digital health capabilities, it will be essential for the entire population, to have a functional level of digital health literacy and access to the internet.
The continued adoption of virtual care is reliant on our ability to educate patients on how to access it. It will be further contingent on consistent and equitable access to broadband internet service.
Create a Digi-Health Knowledge Bank
Virtual care can’t just happen. It requires knowledge on how to access and effectively deliver it, from patients and health care providers respectively. It is crucial to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy, with the appointment of the Financial Literacy Leader within the Financial Consumer Agency of Canada, can serve as a template for digital health literacy.
We recommend that the federal government establish a Digi-Health Knowledge Bank to develop indicators and measure the digital health of Canadians, create tools patients and health care providers can use to enhance digital health literacy, continually monitor the changing digital divide that exists among some population segments.
Pan-Canadian broadband expansion
It is critical to bridge the broadband divide by ensuring all those in Canada have equitable access to affordable, reliable and sustainable internet connectivity. Those in rural, remote, Northern and Indigenous communities are presently seriously disadvantaged in this way. With the rise in virtual care, a lack of access to broadband exacerbates inequalities in access to care. This issue needs to be expedited before we can have pride in any other achievement.
RECOMMENDATION 2 Embedding virtual care in our nation’s health care system
Some groups have been disproportionately affected by the COVID-19 crisis. Woefully inadequate care of seniors and residents of long-term care homes has left a shameful and intensely painful mark on our record. Our health care system has failed to meet the needs of our aging population for too long.
The following two recommendations, combined with a focus on improving access to health care services, will make a critical difference for Canadian seniors.
A demographic top-up to the Canada Health Transfer
The Canada Health Transfer (CHT) is the single largest federal transfer to the provinces and territories. It is critical in supporting provincial and territorial health programs in Canada. As an equal per-capita-based transfer, it does not currently address the imbalance in population segments like seniors.
The CMA, hand-in-hand with the Organizations for Health Action (HEAL), recommends that a demographic top-up be transferred to provinces and territories based on the projected increase in health care spending associated with an aging population, with the federal contribution set to the current share of the CHT as a percentage of provincial-territorial health spending. A top-up has been calculated at 1.7 billion for 2021. Additional funding would be worth a total of $21.1 billion to the provinces and territories over the next decade.
Seniors care benefit
Rising out-of-pocket expenses associated with seniors care could extend from 9 billion to 23 billion by 2035. A Seniors Care Benefits program would directly support seniors and those who care for them. Like the Child Care Benefit program, it would offset the high out-of-pocket health costs that burden caregivers and patients.
RECOMMENDATION 3 Ensuring that better care is secured for our seniors
The federal government has made great strides to mitigate the health and economic impacts of COVID-19. Amidst the task of providing stability, there has been a grand oversight: measures to support our front line health care workers and their financial burden have fallen short.
The CMA recommends the following measures:
1. Despite the significant contribution of physicians’ offices to Canada’s GDP, many physician practices have not been eligible for critical economic programs. The CMA welcomes the remedies implemented by Bill C-20 and recommends the federal government address remaining administrative barriers to physicians accessing federal economic relief program.
2. We recommend that the government implement the Frontline Gratitude Tax Deduction, an income tax deduction for frontline health care workers put at risk during the COVID-19 pandemic. In person patient care providers would be eligible to deduct a predetermined amount against income earned during the pandemic. The Canadian Armed Forces already employs this model for its members serving in hazardous missions.
3. It is a devastating reality that front line health care workers have died as a result of COVID-19. Extending eligibility for the Memorial Grant to families of front line health care workers who mourn the loss of a family member because of COVID-19, as a direct result of responding to the pandemic or as a result of an occupational illness or psychological impairment related to their work will relieve any unnecessary additional hardship experienced. The same grant should extend to cases in which their work contributes to the death of a family member.
RECOMMENDATION 4 Cementing financial stabilization measures for our front line health care workers
Those impacted by COVID-19 deserve our care. The health of our nation’s economy is contingent on the health standards for its people. We must assert the right to decent quality of life for those who are most vulnerable: those whose incomes have been dramatically impacted by the pandemic, those living in poverty, those living in marginalized communities, and those doubly plagued by experiencing racism and the pandemic. We are not speaking solely for physicians. This is about equitable care for every Canadian impacted by the pandemic.
Public awareness and support have never been stronger. We are not facing the end of the pandemic; we are confronting an ebb in our journey. Hope and optimism will remain elusive until we can be confident in our health care system.
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 firstname.lastname@example.org
2 CMA’s Code of Ethics may be accessed here: https://www.cma.ca/Assets/assetslibrary/
The CMA appreciates the opportunity to appear before this committee as part of your review of the 10-Year Plan to Strengthen Health Care. An understanding of what has worked and what hasn't since 2004 is critical to ensuring the next accord brings about necessary change to the system.
Overview of 2004 Accord
On the positive side of the ledger, the 2004 accord provided the health care system with stable, predictable funding for a decade - something that had been sorely lacking. It also showed that a focused commitment, in this case on wait times, can lead to improvements.
However, little has been done on several other important commitments in the Accord, such as the pledge that was also made in 2003 to address the significant inequity among Canadians in accessing prescription drugs.
Along with the lack of long-term, community and home-based care services, this accounts for a major gap in patient access along the continuum of care.
We also know that accountability provisions in past accords have been lacking in several ways. For instance, there has been little progress in developing common performance indicators set out in previous accord. i The 2004 accord has no clear terms of reference on accountability for overseeing its provisions.
Vision and principles for 2014
What the 2004 accord lacked was a clear vision. Without a destination, and a commitment to getting there, our health care system cannot be transformed and will never become a truly integrated, high performing health system.
The 2014 Accord is the perfect opportunity to begin this journey, if it is set up in a way that fosters the innovation and improvements that are necessary. By clearly defining the objectives and securing stable, incremental funding, we will know what changes we need to get us there.
Now is the time to articulate the vision- to say loudly and clearly that at the end of the 10-year funding arrangement, by 2025, Canadians will have the best health and health care in the world. With a clear commitment from providers, administrators and governments, this vision can become our destination.
As a first step to begin this long and difficult journey, the CMA has partnered with the Canadian Nurses Association, and together we have solicited support from over 60 health care organizations for a series of "Principles to Guide Health Care Transformation in Canada."
These principles define a system that would provide equitable access to health care based on clinical need; care that is high quality and patient-centred; and that focuses on empowering patients to attain and maintain wellness.
They call for a system that provides accountability to those who use it and those who fund it; and that is sustainable - by which I mean adequately resourced in terms of financing, infrastructure and human resources, and measured against other high-performing systems, with cost linked to outcomes.
Based on our experience working within the provisions of the 2004 accord, we would like to suggest three strategies to ensure the next accord leads to a sustainable, high-performing health care system.
They are: a focus on quality; support for system innovation; and the establishment of an accountability framework and I will touch briefly on each one.
Focus on quality
First, the crucial need to focus on improving the quality of health care services. The key dimensions of quality, and by extension, the areas that need attention are: safety, effectiveness, patient-centredness, efficiency, timeliness, equitability and appropriateness.
Excellence in quality improvement in these areas will be a crucial step towards sustainability.
To date, six provinces have instituted health quality councils. Their mandates and their effectiveness in actually achieving lasting system-wide improvements vary. What is missing and urgently needed is an integrated, pan-Canadian approach to quality improvement in health care that can begin to chart a course to ensure Canadians ultimately have the best health and health care in the world.
Canadians deserve no less and, with the resources at our disposal, there is no reason why this should not be achievable.
The CMA recommends that the federal government fund the establishment and resource the operations of an arms-length Canadian Health Quality Council, with the mandate to be a catalyst for change, a spark for innovation and a facilitator to disseminate evidence-based quality improvement initiatives so that they become embedded in the fabric of our health systems from coast to coast to coast.
To help expand quality improvement across the country, the Institute for Healthcare Improvement's Triple Aim provides the solid framework. Our health care systems will benefit inordinately from a simultaneous focus on providing better care to individuals and better health to populations, while reducing the per-capita cost. There is ample evidence that quality care is cost effective care. This approach, when adopted and applied as the pan-Canadian framework for any and all structural changes and quality improvement initiatives, will not only serve patients well, but will also enhance the experience of health care providers on the front lines.
The second strategy revolves around system innovation. Innovation and quality improvement initiatives are infinitely more likely to be successful and sustained if they arise out of a commitment by frontline providers and administrators to the achievement of a common goal. We need to shift away from compliance models with negative consequences that have little evidence to support their sustainability.
Innovative improvements in health care in Canada are inadequately supported, poorly recognized, and constrained from being shared and put into use more widely. This needs to change. The 2014 accord, with a focus on improving Canadians' health and health care, can facilitate the transformation we all seek.
Building on the success of the 2004 Wait Times Reduction Fund and the 2000 Health Accord Primary Health Care Transition Fund, the CMA proposes the creation of a Canada Health Innovation Fund that would broadly support the uptake of health system innovation initiatives across the country.
A Working Accountability Framework
And, third, there needs to be a working accountability framework. This would work three ways.
To provide accountability to patients - the system will be patient-centred and, along with its providers, will be accountable for the quality of care and the care experience.
To provide accountability to citizens - the system will provide and, along with its administrators and managers, will be accountable for delivering high quality, integrated services across the full continuum of care.
And to provide accountability to taxpayers - the system will optimize its per-capita costs, and along with those providing public funding and financing, will be accountable for the value derived from the money being spent.
We have done all of this because of our profound belief that meaningful change to our health care system is of the essence, and that such change can and must come about through the next health accord.
Therefore I thank this committee for your efforts on this important area. I would be happy to answer your questions.
Issues identified in 2004 Accord and Current Status
[NOTE: see PDF for correct dispaly of table]
Annual 6% escalator in the CHT to March 31, 2014
Has provided health care system with stable, predictable funding for a decade.
Adoption of wait-time benchmarks by December 2005 for five procedural areas
Largely fulfilled. However, no benchmarks were set for diagnostic imaging. The Wait Time Alliance is calling for benchmarks for all specialty care.
Release of health human resource (HHR) action plans by December 2005
Partially fulfilled. Most jurisdictions issued rudimentary HHR plans by the end of 2005; F/P/T Advisory Committee on Health Delivery and Human Resources issued a paper on a pan-Canadian planning HHR framework in September 2005.
First-dollar coverage for home care by 2006
Most provinces offer first-dollar coverage for post-acute home care but service varies across the country for mental health and palliative home care needs.
An objective of 50% of Canadians having 24/7 access to multidisciplinary primary care teams by 2011
Unfulfilled: Health Council of Canada reported in 2009 that only 32 per cent of Canadians had access to more than one primary health care provider.
A 5-year $150 million Territorial Health Access Fund
Fulfilled: Territorial Health System Sustainability Initiative (THSSI) funding extended until March 31, 2014.
A 9-point National Pharmaceuticals Strategy (NPS)
Largely unfulfilled: A progress report on the NPS was released in 2006 but nothing has been implemented.
Accelerated work on a pan-Canadian Public Health Strategy including goals and targets
F/P/T health ministers (except Quebec) put forward five high-level health goals for Canada in 2005, although they were not accompanied by operational definitions that would lend themselves to setting targets.
Continued federal investments in health innovation
Unknown-no specificity in the 2004 Accord.
Reporting to residents on health system performance and elements of the Accord
P/T governments ceased their public reporting after 2004, and only the federal government has kept its commitment (at least to 2008).
Formalization of the dispute advance/resolution mechanism on the CHA
Done but not yet tested.
i P/T governments ceased their public reporting after 2004, and only the federal government has kept its commitment (at least to 2008).Government of Canada. Healthy Canadians: a federal report on comparable health indicators 2008. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/system-regime/2008-fed-comp-indicat/index-eng.pdf. Accessed 06/21/11.
The Canadian Medical Association (CMA) submits this brief to the Standing Committee on Finance and Economic Affairs for consideration as part of its study on Bill 47, Making Ontario Open for Business Act, 2018.
The CMA unites physicians on national, pan-Canadian health and medical matters. As the national advocacy organization representing physicians and the medical profession, the CMA engages with provincial/territorial governments on pan-Canadian health and health care priorities.
As outlined in this submission, the CMA supports the position of the Ontario Medical Association (OMA) in recommending that Schedule 1 of Bill 47 be amended to strike down the proposed new Section 50(6) of the Employment Standards Act, 2000. This section proposes to reinstate an employer’s ability to require an employee to provide a sick note for short leaves of absence because of personal illness, injury or medical emergency.
Ontario is currently a national leader on sick notes
In 2018, Ontario became the first jurisdiction in Canada to withdraw the ability of employers to require employees to provide sick notes for short medical leaves because of illnesses such as a cold or flu. This legislative change aligned with the CMA’s policy position1 and was strongly supported by the medical and health policy community.
An emerging pan-Canadian concern about the use of sick notes
As health systems across Canada continue to grapple with the need to be more efficient, the use of sick notes for short leaves as a human resources tool to manage employee absenteeism has drawn increasing criticism in recent years. In addition to Ontario’s leadership, here are a few recent cases that demonstrate the emerging concern about the use of sick notes for short leaves:
In 2016, proposed legislation to end the practice was tabled in the Manitoba legislature.2
The Newfoundland and Labrador Medical Association and Doctors Nova Scotia have been vocal opponents of sick notes for short leaves, characterizing them as a strain on the health care system.3,4
The University of Alberta and Queen’s University have both formally adopted “no sick note” policies for exams.5,6
The report of Ontario’s Changing Workplaces Review summarized stakeholder comments about sick notes, describing them as “costly, very often result from a telephone consultation and repeat what the physician is told by the patient, and which are of very little value to the employer.”7
Ontario’s action in 2018 to remove the ability of employers to require sick notes, in response to the real challenges posed by this practice, was meaningful and demonstrated leadership in the national context.
The requirement to obtain sick notes negatively affects patients and the public
By walking back this advancement, Ontario risks reintroducing a needless inefficiency and strain on the health system, health care providers, their patients and families. For patients, having to produce a sick note for an
employer following a short illness-related leave could represent an unfair economic impact. Individuals who do not receive paid sick days may face the added burden of covering the cost of obtaining a sick note as well as related transportation fees in addition to losing their daily wage. This scenario illustrates an unfair socioeconomic impact of the proposal to reinstate employers’ ability to require sick notes.
In representing the voice of Canada’s doctors, the CMA would be remiss not to mention the need for individuals who are ill to stay home, rest and recover. In addition to adding a physical strain on patients who are ill, the requirement for employees who are ill to get a sick note, may also contribute to the spread of viruses and infection. Allowing employers to require sick notes may also contribute to the spread of illness as employees may choose to forego the personal financial impact, and difficulty to secure an appointment, and simply go to work sick.
Reinstating sick notes contradicts the government’s commitment to end hallway medicine
It is important to consider these potential negative consequences in the context of the government’s commitment to “end hallway medicine.” If the proposal to reintroduce the ability of employers to require sick notes for short medical leaves is adopted, the government will be introducing an impediment to meeting its core health care commitment.
Reinstating sick notes would increase the administrative burden on physicians
Finally, as the national organization representing the medical profession in Canada, the CMA is concerned about how this proposal, if implemented, may negatively affect physician health and wellness. The CMA recently released a new baseline survey, CMA National Physician Health Survey: A National Snapshot, that reveals physician health is a growing concern.8 While the survey found that 82% of physicians and residents reported high resilience, a concerning one in four respondents reported experiencing high levels of burnout.
How are these findings relevant to the proposed new Section 50(6) of the Employment Standards Act, 2000? Paperwork and administrative burden are routinely found to rank as a key contributor to physician burnout.9 While a certain level of paperwork and administrative responsibility is to be expected, health system and policy decision-makers must avoid introducing an unnecessary burden in our health care system.
Conclusion: Remove Section 50(6) from Schedule 1 of Bill 47
The CMA appreciates the opportunity to provide this submission for consideration by the committee in its study of Bill 47. The committee has an important opportunity to respond to the real challenges associated with sick notes for short medical leaves by ensuring that Section 50(6) in Schedule 1 is not implemented as part of Bill 47.
1 Canadian Medical Association (CMA). Third-Party Forms (Update 2017). Ottawa: The Association; 2017. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD17-02.pdf (accessed 2019 Nov 13).
2 Bill 202. The Employment Standards Code Amendment Act (Sick Notes). Winnipeg: Queen’s Printer for the Province of Manitoba; 2016. Available: https://web2.gov.mb.ca/bills/40-5/pdf/b202.pdf (accessed 2019 Nov 13).
3 CBC News. Sick notes required by employers a strain on system, says NLMA. 2018 May 30. Available: www.cbc.ca/news/canada/newfoundland-labrador/employer-required-sick-notes-unnecessary-says-nlma-1.4682899
4 CBC News. No more sick notes from workers, pleads Doctors Nova Scotia. 2014 Jan 10. Available: www.cbc.ca/news/canada/nova-scotia/no-more-sick-notes-from-workers-pleads-doctors-nova-scotia-1.2491526 (accessed 2019 Nov 13).
5 University of Alberta University Health Centre. Exam deferrals. Edmonton: University of Alberta; 2018. Available: www.ualberta.ca/services/health-centre/exam-deferrals (accessed 2019 Nov 13).
6 Queen’s University Student Wellness Services. Sick notes. Kingston: Queen’s University; 2018. Available: www.queensu.ca/studentwellness/health-services/services-offered/sick-notes (accessed 2019 Nov 13).
7 Ministry of Labour. The Changing Workplaces Review: An Agenda for Workplace Rights. Final Report. Toronto: Ministry of Labour; 2017 May. Available: https://files.ontario.ca/books/mol_changing_workplace_report_eng_2_0.pdf (accessed 2019 Nov 13).
8 Canadian Medical Association (CMA). One in four Canadian physicians report burnout [media release]. Ottawa: The Association; 2018 Oct 10. Available: www.cma.ca/En/Pages/One-in-four-Canadian-physicians-report-burnout-.aspx (accessed 2019 Nov 13).
9 Leslie C. The burden of paperwork. Med Post 2018 Apr.
It is a pleasure to address the Standing Committee on Finance today as part of your pre-budget consultations.
In keeping with the theme set by the Committee, our presentation - Tax Incentives for Better Living - focuses on changing the tax system to better support the health and well being of all Canadians.
Today I will share with you three recommendations improving the health of Canadians and productivity of the Canadian economy:
First, tax incentives for pre-paid long-term care insurance;
Second, tax incentives to retain and recruit more doctors and nurses;
Third, tax incentives to enhance health system productivity and quality improvements.
1. Long Term Care insurance
Canada's population is ageing fast. Yet, long-term care has received little policy attention in Canada. Unlike other countries like the UK and Germany who have systems in place, Canada is not prepared to address these looming challenges.
The first of the baby-boomers will turn 65 in 2011. By 2031, seniors will comprise one quarter of the population - double the current proportion of 13%. The second challenge is the lack of health service labour force that will be able to care for this ageing population.
Long-term care cannot and should not be financed on the same pay-as-you-go basis as medical/hospital insurance. Therefore the CMA urges the Committee to consider either tax-pre-paid or tax-deferred options for funding long-term care. These options are examined in full in the package we have supplied you with today.
2. Improving access to quality care
Canada's physician shortage is a critical issue. Here in Quebec, 1 in 4 people do not have access to a family physician. Overall 3.5 people in Canada do not have a family Physician. Despite this dire shortage, the Canada Student Loans program creates barriers to the training of more physicians.
Medical students routinely begin their postgraduate training with debts of over $120,000. Although still in training, they must begin paying back their medical school loans as they complete their graduate training. This policy affects both the kind of specialty that physicians-in-training choose, and ultimately where they decide to practice.
We urge this Committee to recommend the extension of interest-free status on Canada Student Loans for all eligible health professional students pursuing postgraduate training.
3. Health System IT: increasing productivity and quality of care
The last issue I will address is health system automation. Investment in information technology will lead to better, safer and cheaper patient care. In spite of the recent $400 million transfer to Canada Health Infoway, Canada still ranks at the bottom of the G8 countries in access to health information technologies. We spend just one-third of the OECD average on IT in our hospitals. This is a significant factor with respect to our poor record in avoidable adverse health effects.
An Electronic Health Record (EHR) could provide annual, system-wide savings of $6.1 billion - every year - and reduce wait times and thereby absenteeism. But, the EHR potential can only be realized if physician's offices across Canada are fully automated.
The federal government could invest directly in physician office automation by introducing dedicated tax credits or by accelerating the capital cost allowance related to health information technologies for patients.
Before I conclude, the CMA again urges the Committee to address a long-standing tax issue that costs physicians and the health care system over $65 million a year. When you add hospitals - that cost more than doubles to over $145 million-or the equivalent of 60 MRI machines a year.
The application of the GST on physicians is a consumption tax on a producer of vital services and affects the ability of physicians to provide care to their patients. And now with the emphasis on further sales tax harmonization, the problem will be compounded.
Nearly 20 years ago when the GST was put into place, physician office expenses were relatively low for example: tongue depressors, bandages and small things. There was practically no use computers or information technology. How many of you used computers 20 years ago?
Now Canadian physicians' could be and should be using 21st century equipment that is expensive but powerful. This powerful diagnostic equipment can save lives and save the system millions of dollars in the long run. It provides a clear return on investment.
Yet, physicians still have to pay the GST (and the PST) on diagnostic equipment that costs a minimum of $500,000 that's an extra $30,000 that physicians must pay.
The result of this misalignment of tax policy and health policy is that most Radiologists' diagnostic imaging equipment is over 30-years old. Canadians deserve better.
It's time for the federal government to stop taxing health care. We urge the Committee to recommend the "zero-rating" publicly funded health services or to provide one-hundred percent tax rebates to physicians and hospitals.
In conclusion, we trust the Committee recognizes the benefits of aligning tax policy with health policy in order to create the right incentives for citizens to realize their potential.
1. Tax Incentives for Long-Term Care
2. Tax Incentives to Bolster Health Human Resources and,
3. Tax Incentives to Support Health System Automation.
This committee can respond to immediate access to health care pressures that Canadians are facing. Delaying a response to these pressures will have an impact on the competiveness of our economy now, and with compounding effects in the future.
I appreciate the opportunity of entering into a dialogue with members of the Committee and look forward to your questions.
Dear First Ministers:
Re: Protecting and supporting Canada’s health-care providers during COVID-19
Given the rapidly escalating situation both globally and in our country, we know that the health and safety of all people and health-care providers in Canada is uppermost on your minds. We appreciate the measures that have been taken by all levels of government to minimize the spread of COVID-19. However, we must ensure those working directly with the public, including physicians, nurses, pharmacists, and social workers, are properly protected and supported, so that they can continue to play their role in the response.
First and foremost, we urge all levels of government to put measures in place to ensure the personal protective equipment that point-of-care providers require to deliver care safely throughout this outbreak is immediately deployed and ready to use. Coordinated measures and clear, consistent information and guidelines will ensure the appropriate protection of our health-care workforce.
Given the increased pressure on point-of-care providers, we ask that all governments support them by providing emergency funding and support programs to assist them with childcare needs, wage losses due to falling ill or having to be quarantined, and support of their mental health needs both during and after the crisis has subsided.
We also expect all governments to work together to provide adequate, timely, evidence-based information specifically for health-care providers. Clear, consistent and easily accessible guidance will enable them to do their jobs more efficiently and effectively in times of crisis. This can and should be
done on various easily accessible platforms such as online resources, an app, or through the creation of a hotline.
We know there will be challenges in deploying resources and funding, particularly around the supply of personal protective equipment. We ask that you consider any and all available options to support health-care providers through a coordinated effort both during and following this crisis. Our organizations look forward to continuing to work with you in these difficult times. If there is anything we can do to help your teams, you need only ask.
Claire Betker, RN, MN, PhD, CCHN(C)
President, Canadian Nurses Association
Jan Christianson-Wood, MSW, RSW
President, Canadian Association of Social Workers
kinanâskomitin (I’m grateful to you)
Lea Bill, RN BScN
President, Canadian Indigenous Nurses Association
Sandy Buchman, MD, CCFP(PC), FCFP
President, Canadian Medical Association
The Canadian Medical Association (CMA) submits this response to the Canada Revenue Agency (CRA) as part of its public consultation on the Disability Tax Credit.
The CMA has long-standing and significant concerns pertaining to the Disability Tax Credit. Most notable is the recent legislative development that resulted in physicians being captured in the definition of “promoter”. In light of the significant concern with physicians being captured in the definition of “promoter”, this submission will focus exclusively on the regulatory development following the enactment of the Disability Tax Credit Promoters Restrictions Act. However, the CMA will follow up at a later date with feedback and recommendations to CRA on how the Disability Tax Credit form and process can be improved.
Prior to providing the CMA’s position for consideration as part of the regulatory consultation, relevant background respecting the CMA’s participation and recommendations during the legislative process is reviewed.
2. Background: CMA’s Recommendations during the Legislative Process
The CMA actively monitored and participated in the consultation process during the legislative development of Bill C-462, Disability Tax Credit Promoters Restrictions Act. During its consideration by the House of Commons, the CMA appeared before the House of Commons Finance Committee and formally submitted its recommendations.1 The CMA’s submission to the Finance Committee is attached as an appendix for reference. Throughout this process, the CMA consistently raised its concern that the bill proposed to include
physicians in the definition of “promoter”, to which the response was consistently that physicians would not be captured. The Member of Parliament sponsoring the bill conveyed this message at the second reading stage in the House of Commons:
1 Canada. Parliament. House of Commons. Standing Committee on Finance (2013). Evidence, May 7, 2013. 41st Parliament, 1st Session. Retrieved from www.parl.gc.ca/HousePublications/Publication.aspx?DocId=6138958&Language=E&Mode=1&Parl=41&Ses=1
“Mr. Massimo Pacetti: Mr. Speaker…[in] her bill, she says that the definition of a promoter means a person who directly or indirectly accepts or charges a fee in respect to a disability tax credit. Who is a promoter exactly? Is a doctor, or a lawyer or an accountant considered a promoter?
Mrs. Cheryl Gallant: Mr. Speaker, that is an excellent question from my colleague opposite. We are looking at third party promoters quite apart from the regular tax preparers and accountants. It is a new cottage industry that sprung up once the 10- year retroactive provision was made. It recognizes that there are volunteer organizations and even constituency offices that do this type of work. They help constituents fill out applications for tax credits. There is a provision for exemptions so people who volunteer their time at no charge or doctors do not fall into this.”2
In contradiction to this statement, during the Senate National Finance Committee’s study of Bill C-462, CRA Assistant Commissioner Brian McCauley confirmed the CMA’s concerns,
stating explicitly that physicians would be captured in the definition of “promoter” and explained “they have to be captured because, if they weren't, you leave a significant compliance loophole”.3
As will be explained further below in this submission, this statement reveals a lack of
understanding of the implications of capturing physicians in the definition of “promoter”, in that it has established duplicative regulatory oversight of physicians, specific to the Disability Tax Credit form.
3. Priority Issue: Identify Physicians as an Exempt Profession in Regulation
The CMA has been consistent in our opposition to the approach that resulted in physicians being included in the definition of “promoters”. The definition of “promoter” captures physicians who may charge a fee to complete the disability tax credit form, a typical practice
2 C. Gallant. (2013 Feb. 5) Parliament of Canada. Debates of House of Commons (Hansard). 41st Parliament, 1st Session. Retrieved at www.parl.gc.ca/HousePublications/Publication.aspx?Language=E&Mode=1&DocId=5962192#Int-7872066
3 Canada. Parliament. Senate. Standing Committee on National Finance (2014). Evidence, April 2, 2014. 41st Parliament, 2nd Session. Retrieved at www.parl.gc.ca/Content/SEN/Committee/412/nffn/09ev-51313-e.htm?Language=E&Parl=41&Ses=2&comm_id=13.
for uninsured physician services.
As indicated on page 4 of the CRA’s consultation document, the Disability Tax Credit Promoters Restrictions Act includes the authority to “identify the type of promoter, if any, who is exempt from the reporting requirements under the Act.” Two questions are included on page 7 of the consultation document in relation to this regulatory authority.
It is the CMA’s recommendation in response to Question 12 (“Are there any groups or professions that should be exempt from the reporting requirements of the new Act?”) that physicians licensed to practice are identified in regulation as an exempt profession.
Specifically, the CMA recommends that CRA include an exemption in the regulations for “a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment” from the reporting requirements of the Disability Tax Credit Promoters Restrictions Act.
As explained below, this exemption will not introduce a potential loophole that may be exploited by third party companies to circumvent the new restrictions and will mitigate the legislative development that has introduced duplicative regulatory oversight of physicians.
4. Exemption Required to Avoid Duplicative Regulatory Regime; Not a Loophole
By capturing physicians in the definition of promoters, the Disability Tax Credit Promoters Restrictions Act has introduced a duplicative regulatory body for physicians: a development which the CMA has fundamentally opposed.
As CMA understands it, the CRA’s key concern in capturing physicians in the definition of promoter is with respect to the possibility that third party companies may circumvent these limitations by employing a physician. As previously noted, this issue was raised by CRA’s Assistant Commissioner Brian McCauley in his appearance before the Senate National Finance Committee during its study of Bill C-462.
A) CMA’s Recommendation Respects Existing Regulatory Oversight Regime of Physicians
The CMA’s recommendation and regulatory proposal limits the exemption of physicians as a profession to those currently licensed under the regulatory authority of provincial/territorial medical regulatory colleges. In Canada, medical practice is the regulatory purview of provinces and territories.
Charging a fee for the completion of a form is a typical practice for uninsured services – these are services that fall outside of provincial/territorial health insurance coverage. The practice of charging a fee for an uninsured service by a licensed physician is an activity that is part of medical practice. Such fees are subject to guidelines by provincial and territorial medical associations and oversight by provincial/territorial medical regulatory colleges.
The regulatory oversight, including licensing, of physicians falls under the statutory authority of medical regulatory colleges, as legislated and regulated by provincial and territorial governments. For example, in the Province of Saskatchewan, the Medical Profession Act, 1981 establishes the regulatory authority of the College of Physicians and Surgeons of Saskatchewan. This regulatory authority is comprehensive and captures: medical licensure, governing standards of practice, professional oversight, disciplinary proceedings, and offences. In Ontario, this authority is established by the Regulated Health Professions Act, 1991; in British Columbia, by the Health Professions Act, 1996, and so on.
B) CMA’s Recommendation Does Not Introduce a Loophole
The exemption of physicians as a profession that is “duly licensed under the applicable regulatory authority who provides health care and treatment” would not constitute a loophole. Firstly, any concerns regarding the practices of a physician that is exempted based on this definition could be advanced to the applicable regulatory college for regulatory oversight and if appropriate, discipline.
The CMA’s proposed regulatory exemption would not be applicable in the case of a physician not licensed to practice; in this case, the individual would not be under the regulatory authority of a medical regulatory college and would fall under the CRA’s regulatory purview,
as established by the Disability Tax Credit Promoters Restrictions Act. With regard to the example raised by CRA’s Assistant Commissioner Brian McCauley in his remarks before the Senate Committee of a retired doctor hired by promoter, retired physicians can retain their licence. If this was the case for this particular physician, as noted above, when CRA had concerns regarding this physician’s actions, his or her regulatory college could have taken appropriate disciplinary action. If, on the other hand, this retired physician’s licence had lapsed, both the individual and the promoter who hired him or her would be potentially liable for fraud (assuming that the term “medical doctor” used in Form T2201 refers to an actively licensed physician) which would convey more serious consequences than those proposed by the Disability Tax Credit Promoters Restrictions Act.
The CMA strongly encourages the CRA to identify physicians as a profession that is exempt from the reporting requirements of the Disability Tax Credit Promoters Restrictions Act. This exemption is critical to ensure that possible unintended consequences, specifically duplicative regulatory oversight of physicians, are avoided.
Submission in Response to the Consultation on the Canada Emergency Wage Subsidy: Keeping Medical Clinic Employees on the Payroll June 5, 2020
Since the outset of the COVID-19 pandemic, the CMA has been actively engaged as part of Canada’s domestic response. In addition to our engagement on key public health issues such as the supply and distribution of personal protective equipment, the CMA has addressed physician practice needs, including releasing a
Virtual Care Playbook to support the rapid conversion of medical practices to virtual care delivery.
In the context of physician practices operating as small businesses, the CMA strongly supports the federal government’s emergency economic relief programs. Access to these programs is critical to the viability of
many physician practices — and the ability of medical clinics across Canada to retain vital front-line health care workers (FLHCWs) and keep their doors open to continue serving the needs of their patient population.
However, despite the dire need for these programs by medical professionals — who constitute a strategic
resource and sector at the best of times, but particularly in a pandemic — presently, the CMA is concerned
that many physicians are experiencing administrative barriers to accessing these critical federal support
programs for their employees.
This submission provides a briefing on physician practices and the need to access the CEWS, an overview of
the technical and administrative factors impeding access, as well as proposed remedies to enable a rapid
Physician Practices and Access to the CEWS
While health care in Canada is predominantly publicly funded, it is primarily privately delivered. In Canada’s health care system, the vast majority of physicians are self-employed professionals operating medical practices as small business owners. Physician-owned and -run medical practices ensure that Canadians are able to access the health care they need, in communities across all jurisdictions. In doing so, Canadian physicians are directly responsible for 167,000 jobs across the country, contributing over $39 billion to Canada’s GDP. Including the expenses and overhead associated with running physician practices, nearly 289,000 jobs indirectly relate to physician practices.
However, as much as physician practices resemble small businesses on the basis of key criteria like employing staff and paying rent, it is imperative to recognize that they are in fact core stewards of a substantial portion of Canada’s health care system and critical health system infrastructure.
It is a national imperative to ensure the viability of such a core component of Canada’s health care system as our medical clinics and the staff they employ. To this end, both federal and provincial/territorial governments have a role in ensuring Canada’s medical clinics are there to serve the health care needs of Canadians, through the pandemic and beyond.
Physician practices have experienced significant impacts related to changing volumes of patient care and delivery models of care in light of public health restrictions since the pandemic was declared on Mar. 11, 2020. The CMA commissioned an economic impact analysis to better understand the impacts across various practice settings. This analysis reveals that across the range of practice settings, the after-tax monthly earnings of physician practices are estimated to decline between 15% and 100% in the low-impact scenario, and between 25% and 267% in the high-impact scenario.
Despite meeting the revenue reduction and employer eligibility factors, the CMA is concerned that many physicians are ineligible for the CEWS because of technical and administrative factors that are inconsistent with other existing federal legislative frameworks.
The CMA conducted a survey of its membership between May 22 and June 1 to better understand physicians’ experiences accessing the federal economic relief programs; 3,730 physicians participated in this survey. Overall, about a third (32%) of physicians polled had attempted to apply to at least one of the federal programs available and 15% of all physicians who responded applied for the CEWS, making it the second most applied-to program.
Of those physicians who applied to the CEWS, 60% were successful, 7% were denied and the remaining 33% were still awaiting response at the time of the survey. Of those who applied but were denied the CEWS, a third (33%) indicated it was because of their cost-sharing structure, 3% responded it was because they worked in a hospital-based setting and a further 22% simply didn’t know. Finally, as part of the survey, physicians shared comments that speak to the issues outlined in this brief. A few excerpts are below:
“We are a group of 4 surgeons and have a cost sharing agreement to pay our office expenses. Our office is outside of the hospital. We tried to apply for the CEWS but have recently received accounting advice supported by legal advice that cost sharing agreements will not be candidates for the CEWS. We are therefore presently exploring other options such as a work share situation or temporary/permanent layoffs.” CMA member, survey respondent
“I work in a group with 11 other OBGYNs. We are still unsure to this point about whether the CEWS applies to our situation. Our revenue is certainly down by ~30% or more. The issue is that our structure doesn't fall into one of the neat categories for CEWS … We are awaiting clarification from our accountant on our status but it seems that the way the rules are currently written, we will not benefit from CEWS, and unfortunately, we are reducing staff hours to cope with our reduction in revenue.” CMA member, survey respondent
“My main frustration is that I can't find a clear answer on whether a clinic made up of multiple doctors with a cost sharing agreement is eligible for CEWS for our employees. I imagine many family practice clinics are set up this way … So as it stands we have not been able to access any financial programs in order to help pay our overhead/staff despite 50% reduction in patient volume.” CMA member, survey respondent
A. Cost-Sharing Arrangements — Front-Line Health Care Workers Employed in Physician Clinics
One of the main types of practices that are unable to access the CEWS because of technical administrative barriers, despite meeting the key eligibility criteria, are physicians operating independently within a cost-sharing business structure.
Like many other independent professionals, physicians operate in group settings. In fact, according to the Canadian Institute for Health Information, in 2019, 65% of family practices operated in a group setting. However, unlike other independent professionals, physicians have been encouraged to operate in a group setting, both by accreditation bodies as well as by provincial health authorities, to meet system delivery goals.
Appendix A provides a case study based on Sudbury Medical Associates (SMA), an illustrative example of three doctors (Dr. Brown, Dr. Lee and Dr. Assadi) who coordinated the operations of their medical practices together to open an integrated health care clinic. While they provide care to their own respective patient rosters, these three physicians share in the clinic space rent and employ 10 employees together. Because
of the way SMA is structured, these physicians are unable to access the CEWS for their proportionate share
of their employees’ salaries. Each physician has met all the CEWS criteria except for the fact that SMA administers the payroll for their 10 employees under its own payroll number.
SMA illustrates a typical family medicine clinic representative of the many medical practices in Canada who employ numerous FLHCWs.
B. Cost-Sharing Arrangements — Front-Line Health Care Workers Employed by Specialist Physicians Practising in a Hospital-Based Environment
Another type of physician structure unable to access the CEWS because of the use of cost-share arrangements are specialist physicians practising in a hospital-based environment or academic health science centre (an “AHSC”). The purpose of an AHSC is to provide specialized health care services, carry out medical research and train the next generation of Canada’s health care professionals.
Provincial funding agreements are designed to align the interest of all parties in an AHSC (clinical care, teaching, research and innovation) and often contain governance and accountability requirements. In order to discharge responsibilities under provincial funding agreements and to run a practice that can meet certain metrics, physicians are required to hire their own staff. Consequently, cost-sharing arrangements are utilized by these physicians to efficiently hire staff while meeting their other responsibilities.
In response to the COVID-19 pandemic, hospitals have implemented strategies designed to protect the health care system from collapsing or being overwhelmed. For example, many hospitals have cancelled elective surgeries; coupled with the fear many patients have of going to the hospital, this has resulted in a decline in patient care volume as hospitals and physician practices adhere with public health guidelines. This has led to a significant decline in revenue, requiring physicians to access the CEWS program in order to continue to employ their staff.
Like all physicians in Canada, specialist physicians practising in a hospital-based health care setting are responsible for significant levels of fixed overhead expenses related to a medical practice. This includes medical insurance, licensing fees, maintaining an office and other professional fees. As a standard practice, employees of physicians who practise in AHSCs are often paid by a third party. In many instances, physicians have established an agency relationship pursuant to which they delegate authority to the hospital to act as their agent with respect to withholding taxes, source deductions and filing T4 returns. The main reason for this agency is to ensure that the physician focuses on teaching, researching and patient care. For clarity,
the administrator (hospital) has no legal authority to conclude on any employment matter such as the determination of a bonus or a wage increase or the payout of any severance. All these matters would
be the responsibility of the physician in his/her capacity as employer.
Anticipating a second wave of COVID-19, many physicians are concerned about maintaining their staff during a future work stoppage given their current inability to apply for the CEWS. As employers, physicians can appreciate that the hospital’s payroll number is creating additional administrative complexity for the
Canada Revenue Agency (CRA). However, as an employer and small business, their ability to access
the CEWS program is an integral part of their strategy to retain and maintain their staff.
C. Technical Analysis — CEWS Legislation and the Principal-Agent Relationship
i) CEWS Legislation — Qualifying Entity
Pursuant to the COVID-19 Emergency Response Act, an entity will qualify for CEWS to the extent that it is a Qualifying Entity under ss. 125.7(1) of the Income Tax Act (ITA). One of the criteria to be a qualifying entity is that the entity had, on Mar. 15, 2020, a business number in respect of which it is registered with the Minister to make remittances required under ITA s. 153. By virtue of how cost-sharing arrangements are structured, the administrator (agent) handles the payroll filings using their own payroll number, which can be different from the employing physician (principal). On the basis of the uniqueness of cost-sharing structures and the definition in the legislation, physicians who employ individuals under these arrangements need to rely on principal-agent concepts in order to qualify
for the CEWS provided all other criteria are met.
Presently, the CEWS application portal does not recognize principal-agent arrangements, which are common among physician practices as they employ FLHCWs. It is recognized that each participant or physician in a cost-sharing arrangement is in fact its own business and that physicians share the costs
of certain overhead expenses, which include wage-related costs for FLHCWs. In these structures, the payroll number for the employee(s) may be associated with one of the independently operating physicians or it may be associated with a separate entity. As such, these physicians are not likely to have a distinct payroll number associated with their eligible employee under the CEWS. The case law and the administrative position of the CRA demonstrate the following:
1. The principals in a cost-sharing arrangement are the employers; and
2. The agent’s payroll number should be considered the payroll number for the principal for the purposes of making a CEWS application.
ii) Case Law
Subsection 9(1) of the ITA provides for the basic rules as they relate to computing the income or loss from business or property. In both Avotus Corporation v The Queen and Fourney v The Queen , the Tax Court of Canada determined that where a person carries on business as agent for another, it is the principal that is carrying on the business and not the agent.
The Fourney case provides for several concepts that extend to the unique nature of cost-sharing arrangements. These concepts should provide clarity about a principal’s ability to make a CEWS claim if it had a payroll agent that had a business number to make remittances before Mar. 15, 2020. The concepts are summarized as follows:
1. Corporations can act as Agent
In Fourney, at paragraphs 41 and 42, it was concluded that a corporation can act as its shareholder’s agent:
It is established, then, that corporations can act as agents, and this concept is not repugnant to the rule that corporations have separate legal personality a matter addressed in the oft-cited Salomon case.
2. Business Activities belong to the Principal
At paragraphs 60 and 65 of Fourney, the Tax Court examined the following activities and ultimately concluded that the activities were in fact the activities of the principal and not the agent. The following conclusions can be drawn from the case:
Payments made to the corporate agent were found to be revenues of the principal.
Contracts entered into by the corporate agent were contracts entered into by the principal.
T4s issued under the corporate agent’s name were deductible expenses to the principal.
Lastly, at paragraph 65, the Tax Court characterized the corporate agent as a mere conduit for the appellant.
iii) Administrative Policy
For GST/HST purposes, the CRA accepts the concept of an agency relationship typically utilized by physicians in cost-sharing practices. In RITS 142436 “Implementation of Cost Sharing Arrangement,” the CRA concluded that GST/HST does not apply to payments made to “Company A” because it was an agent in relation to remuneration paid to the employees of Company B and Company C. In this ruling, Companies A, B and C were all employers with Company A administrating the payroll as agent.
The CRA’s conclusions appear to take the follow matters into account:
Employees are jointly employed by the principals in the cost-sharing arrangement.
Principals have legal responsibility for the employees.
The principals would delegate responsibility or authority to an agent, which could be a corporation or another physician.
That agent would be given discretion to pay the employees, withhold and remit the appropriate amount of taxes, file T4 slips, hire and terminate at the determination of the principals.
Each principal would pay the agent for their proportionate share of payroll and report such payroll on their respective financial statements and tax returns.
The CRA also concluded that the “employment status of a person for GST/HST purposes is the same for income tax purposes.”
The Department of Finance provides that the CEWS helps businesses keep employees on the payroll, encourages employers to rehire workers previously laid off, and better positions businesses to bounce back following the crisis. In keeping with this objective, a payroll number for an agent should extend itself to the principals for the purposes of applying for the CEWS because it is supported by case law and the administrative practices of the CRA. Application of any federally legislated program should be conceptually consistent with historical frameworks already established.
The CMA holds that the legislation as written can remain as currently drafted as it provides for the majority of applicants looking to access the CEWS. However, to address the unintended exclusion of cost-sharing arrangements, the CMA recommends that the CRA provide administrative guidance consistent with and based on existing case law and administrative positions.
The CMA recommends that the Federal Government and the CRA enable physicians to claim their proportionate share of eligible remuneration paid through a cost-sharing arrangement provided all other program eligibility criteria are met.
Administratively, this may be achieved by the following:
a “check-box” on the application denoting the applicant is a participant in a cost sharing arrangement
identification of the cost-sharing arrangement payroll number
a joint election between the agent and employer allowing the employer to utilize the agent’s payroll number and denoting the percentage allocation of salary costs to the particular employer
If this recommendation is not feasible, the CMA recommends that the Federal Government and the CRA implement an alternate approach whereby a cost-share administrator is permitted to make a CEWS claim in their capacity as agent on behalf of each eligible entity (principal). Since period 3 is almost complete, there could be less administration regarding these claims as agents have not made application.
Similar to the preferred remedy above, this may be achieved by the following:
a “check box” on the application indicating that an “agent” is filing the claim on behalf of eligible employers
the applicant could also provide (either initially or upon desk audit) the business numbers to CRA for each employer
a joint election among the agent and the employers allowing the agent to act on behalf of the employers for purposes of the CEWS
This would provide ease of audit for the CRA as the claim can be verified against the T4 and payroll remittances. The election and disclosure requirements would also alleviate any concerns the CRA or Department of Finance may have regarding potential abuse of the program.
In Appendix B we also outline supporting documentation to be retained for a CEWS Claim by a Cost-Sharing Entity, which will ensure cost-sharing entities have the appropriate documentation to submit a claim and also assist the CRA in conducting pre-assessment audits.
The CMA would be pleased to provide further detail on this issue or consider other alternatives to ensure FLHCWs receive wages during these unprecedented times.
Canada’s physicians are important employers. Not only are they responsible for almost 167,000 in direct employment, together with their staff, they are at the front lines of Canada’s response to the COVID-19 pandemic. Our health care system cannot withstand loss of employment or risks to the viability of medical clinics, at this crucial time — and indeed at any time. The CMA strongly encourages the Federal Government to address the issues outlined above in preventing physicians from accessing this critical economic relief program. On behalf
of the doctors of Canada, the CMA stands ready to collaborate in resolving these technical and administrative barriers.
Appendix A: Welcome to Sudbury Medical Associates (SMA)
Dr. Christopher Brown (60) settled in his hometown of Sudbury to practise family medicine about 30 years ago. He operated in his own space, with his own employees until SMA was formed. Dr. Jennifer Lee (45) has been practising in Sudbury for her entire career. Dr. Lee handles all family patients with a special focus on maternity and young family care. Dr. Sarah Assadi (30) recently completed her residency. Dr. Assadi spent time in Sudbury as a locum and enjoyed the strong community feel.
Dr. Brown and Dr. Lee are long-time colleagues and recently approached Dr. Assadi to open an integrated health care clinic. Together they would require 10 employees (comprised of nurse practitioners, medical assistants and receptionists) to effectively operate the clinic. Optically, SMA appears to be one business when in fact it is comprised of three distinct medical practices. Each physician or their professional corporation maintains their own distinct patient list. Upon the advice of professional advisors, the physicians entered into a cost-sharing agreement to realize cost efficiencies related to the integrated health care clinic (administration and lease). This structure will ensure the needs of the community are met by the expansion of operating hours facilitated by a flexible staffing model. Understanding that cost-sharing arrangements are accepted by provincial health authorities and the Canada Revenue Agency (CRA), Dr. Brown, Dr. Lee and Dr. Assadi documented this arrangement, which includes the following details:
Dr. Brown Dr. Lee Dr. Assadi SMA
Legal entity Prof corp Prof corp Sole-proprietor Corp
Proportionate share of costs 20% 40% 40%
Legal employer (10 staff) ü ü ü
Legally responsible — all contracts ü ü ü
Payroll, T4 and remittances ü
Report for income tax purposes:
Proportionate share of costs administered by SMA including payroll ü ü ü
The impact of COVID-19 resulted in a significant slowdown of patient visits between Mar. 15 and May 31 as the residents of Sudbury were social distancing and were only leaving their homes for urgent matters. Dr. Brown, Dr. Lee and Dr. Assadi are concerned about keeping their front-line health care workers employed and at the same time maintaining a sufficient level of family health care in the community. Considering a possible second wave of COVID-19, these physicians need to ensure that their community health clinic remains open and safe so there is no unintended stress on hospitals.
Like many small businesses that have experienced significant revenue declines, these physicians are hopeful to access the Canada Emergency Wage Subsidy (CEWS) to ensure they can retain their specialized employees and pivot to the new environment they need to operate within. Upon further review, only Dr. Lee and Dr. Assadi experienced sufficient revenue declines to access the CEWS, but currently they do not qualify because of how they structured the payroll for these 10 employees. They are concerned that without the CEWS, they will not be able to retain all of their staff or see as many patients. The following table summarizes the CEWS analysis:
CEWS criteria Dr. Brown Dr. Lee Dr. Assadi SMA
Eligible entity ü
Prof corp ü
Prof corp ü
Sole proprietor ü
Revenue decline test: March 2020 Not met ü ü No revenues to report
(eligible remuneration ) ü ü ü
Qualified for the CEWS No
(revenue decline test not met) No
(payroll account number held by SMA, which manages payroll on behalf of Dr. Lee) No
(payroll account number held by SMA, which manages payroll on behalf of Dr. Assadi) No
(has no revenue and is not the legal employer)
As employers, Dr. Lee and Dr. Assadi do not understand why their businesses are unable to access the CEWS for their proportionate share of their employees’ salaries. Each has met all of the CEWS criteria except for the fact that SMA administers the payroll for their 10 employees under its own payroll number.
Appendix B: Illustration of Supporting Documentation to be Retained for a
CEWS Claim by Cost-Sharing Entity
To the extent that employers operating through a cost-sharing structure are permitted to make a CEWS claim, the following documentation could be requested by the CRA to verify the claim upon desk audit.
For illustrative purposes, let’s assume that Dr. Lee and Dr. Assadi both made a CEWS claim.
Supporting Documentation Request
1. The legal documentation establishing the agency relationship pursuant to which Dr. Lee and Dr. Assadi delegated authority to SMA to handle the income tax remittances, source deductions and T4 reporting.
2. The employment contracts, which clearly indicate that each of Dr. Lee, Dr. Assadi (and Dr. Brown) are the employers.
Alternatively, confirmation from the employees that SMA is not the employer and that they are employed
by Drs. Lee, Assadi and Brown.
3. SMA’s accounting records or financial statements, which clearly support its position as an agent. Note: Typically, most cost-share administrators will have NIL revenue and account for all cash inflows and outflows on their balance sheet in a manner similar to a lawyer’s trust account.
4. An analysis demonstrating the revenue decline for the relevant period for Dr. Assadi’s business and Dr. Lee’s business.
5. Calculations supporting the proportionate share of “baseline remuneration” and “eligible remuneration” paid to the employees by Dr. Assadi’s business and Dr. Lee’s business.
6. A reconciliation of the wage subsidy received along with their proportionate share of the wage subsidy so it can be properly accounted for and taxed.
The Canadian Medical Association (CMA) is pleased to present this brief to the House of
Commons Standing Committee on Finance regarding Bill C-462 Disability Tax Credit
Promoters Restrictions Act.
The Canadian Medical Association represents 78,000 physicians in Canada; its mission is to
serve and unite the physicians of Canada and to be the national advocate, in partnership
with the people of Canada, for the highest standards of health and health care.
The CMA is pleased that the House of Commons has made Bill C-462 a priority. This bill is
an important step toward addressing the unintended consequences that have emerged from
the Disability Tax Credit since 2005.
Part 2: Issues to be addressed
In 2005, the Disability Tax Credit was expanded to allow individuals to back-file for up to 10
years. While this was a welcome tax measure for individuals with disabilities, the CMA has
been urging the Canada Revenue Agency to address the numerous unintended consequences
that have emerged. Central among these has been the emergence of a “cottage industry” of
third-party companies engaged in a number of over-reaching tactics. The practices of these
companies have included aggressive promotional activities to seek and encourage individuals
to file the Disability Tax Credit. The primary driver behind these tactics is profit; some
companies are charging fees of up to 40 per cent of an individual’s refund when the tax
credit is approved.
Further to targeting a vulnerable population, these activities have yielded an increase in the
quantity of Disability Tax Credit forms in physician offices and contributed to red tape in the
health sector. In some cases, third parties have placed physicians in an adversarial position
with their patients. We are pleased that this bill attempts to address the concerns we have
The CMA supports Bill C-462 as a necessary measure to address the issues that have
emerged since the changes to the Disability Tax Credit in 2005. However, to avoid additional
unintended consequences, the CMA recommends that the Finance Committee address three
issues prior to advancing Bill C-462.
First, as currently written, Bill C-462 proposes to apply the same requirements to physicians
as to third-party companies if physicians apply a fee for form completion, a typical practice
for uninsured physician services. Such fees are subject to guidelines and oversight by
provincial and territorial medical regulatory colleges (see Appendix 1: CMA Policy on Third
Party Forms: The Physician Role).
The CMA recommends that the Finance Committee:
Amend the definition of “promoters” under section 2 to exclude “a health care
practitioner duly licensed under the applicable regulatory authority who provides
health care and treatment.”
If the committee imports the term “person” from the Income Tax Act, then the
applicable section of Bill C-462 should be amended to specify that, for the purposes
of the act, “Person does not include a health care practitioner duly licensed under the
applicable regulatory authority who provides health care and treatment.”
Second, the CMA is concerned that one of the reasons individuals may be engaging the
services of third-party companies is a lack of awareness of the purpose and benefits of the
Disability Tax Credit. Additional efforts are required to ensure that the Disability Tax Credit
form (Form T2201) be more informative and user-friendly for patients. Form T2201 should
explain more clearly to patients the reason behind the tax credit, and explicitly indicate there
is no need to use third-party companies to submit the claim to the CRA.
The CMA recommends that the Finance Committee:
Recommend that the Canada Revenue Agency undertake additional efforts to ensure
that the Disability Tax Credit form is more informative, accessible and user-friendly for
Finally, the CMA recommends that a privacy assessment be undertaken before the bill moves
forward in the legislative process. It appears that, as written, Bill C-462 would authorize the
inter-departmental sharing of personal information. The CMA raises this issue for
consideration because protecting the privacy of patient information is a key duty of a
physician under the CMA Code of Ethics.
Part 3: Closing
The CMA encourages the Finance Committee to address these issues to ensure that Bill C-
462 resolves existing problems with the Disability Tax Credit while not introducing new ones.
The CMA appreciates the opportunity to provide input to the Finance Committee’s study of
this bill and, with the amendments outlined herein, supports its passage.
Summary of Recommendations
The definition of “promoters” under section 2 of Bill C-462 should be amended to exclude “a
health care practitioner duly licensed under the applicable regulatory authority who provides
health care and treatment.”
If the Committee imports the definition of “persons” from the Income Tax Act, the applicable
section of Bill C-462 should be amended to specify that, for the purposes of the act, “Person
does not include a health care practitioner duly licensed under the applicable regulatory
authority who provides health care and treatment.”
The Canada Revenue Agency should undertake additional efforts to ensure that the Disability
Tax Credit form is informative, accessible and user-friendly.
Prior to advancing in the legislative process, Bill C-462 should undergo a privacy assessment.