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Ensuring equitable access to health care: Strategies for governments, health system planners, and the medical profession

https://policybase.cma.ca/en/permalink/policy11062

Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
Ensuring equitable access to effective and appropriate health care services is one strategy which can help to mitigate health inequities resulting from differences in the social and economic conditions of Canadians. Equitable access can be defined as the opportunity of patients to obtain appropriate health care services based on their perceived need for care. This necessitates consideration of not only availability of services but quality of care as well.1 There is far ranging evidence indicating that access to care is not equitable in Canada. Those with higher socio-economic status have increased access for almost every health service available, despite having a generally higher health status and therefore a decreased need for health care. This includes insured services (such as surgery), as well as un-insured services such as pharmaceuticals and long-term care. Those from disadvantaged groups are less likely to receive appropriate health care even if access to the system is available. They are more likely to report trouble getting appointments, less testing and monitoring of chronic health conditions, and more hospitalizations for conditions that could be avoided with appropriate primary care. There is a financial cost to this disparity in equitable care. Reducing the differences in avoidable hospitalizations alone could save the system millions of dollars. Barriers to equitable access occur on both the patient and health care system or supply side. Common barriers include: (see pdf for correct display of table) Demand Side or Patient Barriers Supply Side or System Barriers Health literacy Services not located in areas of need Cultural beliefs and norms Patients lack family physicians Language Lack of management of chronic disease Cost of transportation Long waits for service Time off work for appointments Payment models which don't account for complexity of patients Access to child care Coordination between primary care and speciality care and between health care and community services Payment for medications or other medical devices/treatments Standardization of referral and access to specialists and social services Immobility- due to physical disabilities, and/or mental health barriers Lack of needs based planning to ensure that population has necessary services Cognitive issues, ie. Dementia, that adversely affect ability to access and comply with care Attitudes of health care workers To tackle barriers on the patient side there is a need to reduce barriers such as transportation and the prohibitive cost of some medically necessary services. Further, there is a need to increase the health literacy of patients and their families/caregivers as well as providing support to health care providers to ensure that all patients are able to be active participants in the management of their care. On the system side the strategies for action fall into four main categories: patient-centred primary care which focuses on chronic disease management; better care coordination and access to necessary medical services along the continuum of care; quality improvement initiatives which incorporate considerations of equity as part of their mandate; and health system planning and assessment which prioritizes equitable access to care. Recommendations are provided for CMA and national level initiatives; health care planners; and physicians in practice. Despite a commitment to equal access to health care for all Canadians there are differences in access and quality of care for many groups. By removing barriers on both the patient and system side it is hoped that greater access to appropriate care will follow. Introduction: In Canada as in many countries around the world there are major inequities in health status across the population. Those lower on the socio-economic scale face higher burdens of disease, greater disability and even shorter life expectancies.2 Many of these disparities are caused by differences in social and economic factors such as income and education known as the social determinants of health.3,1 While many of these factors are outside of the direct control of the health care system, ensuring equitable access to effective and appropriate health care services can help to mitigate some of these disparities. The alternative can also be true. In health systems where access to care and appropriateness are unequal and skewed in favour of those of higher socio-economic status, the health system itself can create further inequities and add greater burden to those already at an increased risk of poor health. Physicians as leaders in the health care system can play a role in ensuring equitable access to care for all Canadians. Equitable Access to Health Care in Canada: Equitable access can be defined as the opportunity for patients to obtain appropriate health care services based on their perceived need for care. This necessitates consideration of not only availability of services but quality of care as well.4 Due to burden of disease and therefore need, those with lower socio-economic status should be utilizing more services along the continuum.5 That, however, is not the case. Individuals living in lower income neighbourhoods, younger adults and men are less likely to have primary care physicians than their counterparts.6 Primary care physicians deliver the majority of mental illness treatment and they are the main source of referrals to psychiatrists or other specialists. However, much of the care for people with mental illnesses, especially on the lower socio-economic end of the scale, is delivered in emergency rooms, which is both costly and episodic. This is due not only to a lack of primary care access but to a lack of community mental health services.7 Those with higher socio-economic status are much more likely to have access to and utilize specialist services.8 Examples include greater likelihood of catheterization and shorter waits for angiography for patients with myocardial infarction9; and greater access to in-hospital physiotherapy, occupational therapy, and speech language therapy for those hospitalized with acute stroke10. Low income men and women with diabetes were just as likely to visit a specialist for treatment as high income individuals despite a significantly greater need for care.11 There is a correlation between higher income and access to day surgery.12 A Toronto study found that inpatient surgery patients were of much higher income than medical inpatients.13 Additionally, utilization of diagnostic imaging services is greater among those in higher socio-economic groups.14 Access to preventive and screening programs such as pap smears and mammography are lower among disadvantaged groups.15 Geography can cause barriers to access. In general rural Canadians have higher health care needs but less access to care.16 People in northern and rural communities typically have to travel great distances to obtain health services as many, especially specialist services, cannot be obtained in their home community.17 Those living in the most rural communities in Canada are the least likely to have a regular family doctor, or to have had a specialist physician visit.18 According to data from the Society of Rural Physicians of Canada, 21% of the Canadian population is rural while only 9.4% of family physicians and 3% of specialists are considered rural.19 This lack of access to specialists and other medically necessary services can lead to delays in treatment and harm to health including unnecessary pain and permanent disability.20 Further, travel for necessary treatment often comes with a significant financial cost.21 It is not just access to insured services that is a problem in Canada. Many Canadians do not have access to needed pharmaceuticals. Researchers have reported that those in the lowest income groups are three times less likely to fill prescriptions, and 60% less able to get needed tests because of cost.22 The use of appropriate diabetes preventative services, medication, and blood glucose testing, has been shown to be dependent on out of pocket expenditures.23 Rehabilitation services are difficult for some Canadians to access as well. Services such as physiotherapy and occupational therapy are often not covered unless they are provided in-hospital or to people on certain disability support programs. This leads to long wait times for services that are covered or no access at all.24 Adding to these inequities is the fact that different programs are covered in different provinces and territories.25 Access to mental health services is a major challenge for Canadians. According to data from Statistics Canada, more than half a million Canadians who had a perceived need for mental health care services, reported that their needs were unmet. Access to counselling services was the most frequent unmet need reported.26 A number of important mental health professionals - notably psychologists and counsellors - are not funded through provincial health budgets, or are funded only on a very limited basis. Access to psychologists is largely limited to people who can pay for them, through private insurance or out of their own pockets.27,2 Access to subsidized residential care, long-term care, home care and end-of-life care is problematic as well. Those with means can access high quality long-term care services within their community, while those with inadequate resources are placed in lower quality facilities sometimes hours away from family and friends.28 Even with expansions promised by governments, home care will not be able to meet the needs of underserved groups such as those living in rural and remote areas.29 Finally, only a fraction of patients have access to or receive palliative and end-of-life care. Those living in rural or remote areas or living with disabilities have severely limited access to formal palliative care.30 Difficulties in access are particularly acute for Canada's Aboriginal peoples. Many live in communities with limited access to health care services, sometimes having to travel hundreds of miles to access care.31 Additionally, there are jurisdictional challenges; many fall through the cracks between the provincial and federal health systems. While geography is a significant barrier for Aboriginal peoples, it is not the only one. Aboriginals living in Canada's urban centres also face difficulties. Poverty, social exclusion and discrimination can be barriers to needed health care. Of all federal spending on Aboriginal programs and services only 10% is allocated to urban Aboriginals. This means that Aboriginals living in urban areas are unable to access programs such as Aboriginal head start, or alcohol and drug services, which would be available if they were living on reserve.32 Further, even when care is available it may not be culturally appropriate. Finally, Canada's Aboriginal peoples tend to be over-represented in populations most at risk and with the greatest need for care, making the lack of access a much greater issue for their health status.33 However, these examples are only part of the story as accessing care which is inappropriate cannot be considered equitable access.34 Those of lower socio-economic status are more likely to use inpatient services; show an increased use of family physician services once initial contact is made;35 and have consistently higher hospitalization rates; 36 This could be due to the higher burden of need or could demonstrate that the services that are received are not addressing the health care needs of those lower on the socio-economic scale.37 Women and men from low-income neighbourhoods are more likely to report difficulties making appointments with their family doctors for urgent non-emergent health problems. They were also more likely to report unmet health care needs.38 In terms of hospitalizations, people with lower socio-economic status were much more likely to be hospitalized for ambulatory care sensitive conditions (ACSC) and mental health39; admissions which could potentially be avoided with appropriate primary care.40 They were also found to have on average longer lengths of stay.41 According to a study of hospitals in the Toronto Central Local Health Integration Network, patients considered to be Alternate Level of Care were more likely to have a low-income profile.42 Further, people with ACSC in low-income groups, those living in rural areas, or those with multiple chronic conditions were twice as likely to report the use of emergency department services for care that could have been provided by a primary care provider.43 There is a financial cost to this disparity. According to a 2011 report, low-income residents in Saskatoon alone consume an additional $179 million in health care costs than middle income earners.44 A 2010 study by CIHI found increased costs for avoidable hospitalizations for ambulatory care sensitive conditions were $89 million for males and $71 million for females with an additional $248 million in extra costs related to excess hospitalizations for mental health reasons.45 Areas for Action: As the background suggests, equitable access is about more than just utilization of services. There are patient characteristics as well as complex factors within the health system which determine whether equitable access is achieved. Recent work has categorized access as having considerations on the supply of services and demand of patients for care. On the demand or patient side we must consider: ability to perceive; ability to seek, ability to reach, ability to pay, and ability to engage. On the supply side or health system considerations include: approachability; acceptability, availability and accommodation, affordability, and appropriateness. 46 The following table highlights some of the current barriers to equitable access. (See PDF for correct display of table) Demand Side or Patient Barriers Supply Side or System Barriers Health literacy Services not located in areas of need Cultural beliefs and norms Patients lack family physicians Language Lack of management of chronic disease Cost of transportation Long waits for service Time off work for appointments Payment models which don't account for complexity of patients Access to child care Coordination between primary care and speciality care and between health care and community services Payment for medications or other medical devices/treatments Standardization of referral and access to specialists and social services Immobility- due to physical disabilities, and/or mental health barriers Lack of needs based planning to ensure that population has necessary services Cognitive issues, ie. Dementia, that adversely affect ability to access and comply with care Attitudes of health care workers Patient based actions for improving equitable access: Low health literacy can lead to difficulties for some Canadians in perceiving a need for care.47 Evidence suggests that more than half of Canadian adults (60%), lack the capacity to obtain, understand and act upon health information and services in order to make health decisions on their own.48 Many physicians are undertaking strategies to minimize this lack of health literacy among their patients. Examples include plain language resources as well as teach-back exercises which allow physicians to determine whether patients have fully understood the information provided.49 These efforts should continue to be supported. Understanding how the health system works and where to access services can be a problem for some individuals.50 Beliefs about the need and value for certain services can also undermine the ability of patients in seeking care.51 Work needs to be done to ensure that disadvantaged groups are aware of the services that are available to them and the benefits of taking preventative steps in their health. Low-income Canadians are ten times more likely to report unmet needs of health care due to the cost of transportation.52 Other barriers include a lack of child care, and ability to get time off work to attend necessary health appointments.53 Strategies that provide patients with transportation to appointments or subsidies for such travel have seen some success. Extended office hours and evening appointments can increase access for those unable to take time off work. Additionally, programs that provide patients with home visits from health care providers can help to eliminate this barrier. Further support and expansion of these programs should be explored. There is also the inability to pay for services not covered by provincial plans such as pharmaceuticals, physiotherapy and other rehabilitation services.54 According to a 2005 report on diabetes in Canada, affordability and access to medical supplies was the biggest challenge for those Canadians living with diabetes.55 Access to services such as mental health counselling, subsidized residential care, and long-term care are also hindered by the inability to pay. Even if patients are able to obtain care they may not be able to fully engage. Language difficulties, low health literacy, cognitive challenges (ie. Dementia), cultural mores and norms, and discrimination or insensitivity of health care workers, may all act as barriers to full participation in care.56 Efforts should be made to develop teaching methods to improve engagement of patients and their families/caregivers from disadvantaged groups.57 Strategies to remove or minimize the barriers created by a lack of health literacy should be developed and shared with physicians and other health care providers. Further, programs which facilitate access to services including interpretation and translation of key health information should be supported.58 Finally, an understanding of a patient's cultural and social context is important. The Royal College of Physicians and Surgeons of Canada and the Association of Faculties of Medicine of Canada have developed training modules for physicians who will be working with Canada's Aboriginal peoples.59 Similar programs have been developed by the Canadian Paediatric Society, and the Society of Obstetricians and Gynaecologists of Canada. More of this training is needed and should focus on groups who are likely to experience disadvantage in health care access and appropriateness. Recommendations for action: CMA and National Level Initiatives The CMA recommends that: 1. Governments develop a national strategy for improving the health literacy of Canadians which takes into account the special needs of different cultures. 2. Governments provide accessible and affordable transportation options for patients requiring medical services when such services are unavailable locally. 3. Governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. 4. Governments examine methods to ensure that low-income and other disadvantaged Canadians have greater access to needed medical interventions such as rehabilitation services, mental health, home care, and end-of-life care. 5. Governments explore options to provide funding for long-term care services for all Canadians. 6. Governments ensure that necessary interpretation and translation services are provided at all points of care. Physicians in Practice The CMA recommends that 7. Physicians be supported in addressing the health literacy of their patients and their families/caregivers. 8. Physician education programs continue to emphasize the important cultural and social contexts in which their patients live. System based actions for improving equitable access: On the system side there are two main areas that need to be addressed: making sure that people can access the services that they need (approachability, availability and accommodation, and affordability); and ensuring that once they have accessed the system that services are appropriate for their health needs (acceptability and appropriateness). Strategies for action include: patient-centred primary care which focuses on chronic disease management; better care coordination and greater access to necessary medical services along the continuum; quality improvement initiatives which incorporate equity as part of their mandate; and health system planning and assessment which prioritizes equitable access to care. 1. Patient-centred primary care which focuses on chronic disease management and which includes programs to increase access to those most at need. Comprehensive primary care offers the biggest possibility for increasing equitable access and reducing health disparities. Data from a large population study in Ontario indicates that inequities in access to primary care and appropriate chronic disease management are much larger than inequities in the treatment of acute conditions.60 Currently many primary care services are located outside of the neighbourhoods with the greatest need for care. While some are accessible through public transportation, there is still a need for more convenient access for these communities. Community health centres (CHC) offer a good model for addressing this challenge through location in disadvantaged neighbourhoods and the provision of culturally appropriate care.61 Additionally, CHCs offer a number of different health, and sometimes social services, under one roof making access to many different types of care more convenient for patients. More work needs to be done to to reduce barriers in access to Canadians living in rural and remote communities. Telemedicine is one strategy that has increased access for rural Canadians. The Ontario Telemedicine Network is one example of this innovative approach. Patients in rural communities can have access to specialists in urban centres through their local health providers. Examples include cardiac rehab follow-up, tele-homecare to support lifestyle changes, and psychiatric or mental health consultations.62 Programs which encourage recruitment and training of health professionals from rural and disadvantaged populations have been found to increase access as these individuals are more likely to return to their home communities to practice.63 Medical schools have been attempting to increase the diversity in their schools for a number of years. However, work still needs to be done. Data from the 2012 student component of the National Physician Survey shows that 278 of the 2000 students who responded to the survey (13.9%) come from families considered to be in the top 1% of earners in Canada. This is compared to only 46 (2.3%) of students whose family incomes place them in the bottom quintile of earners. 64 One of the suggested strategies for increasing diversity in medical schools is increasing the knowledge about the medical profession among rural and disadvantaged young people. An innovative program in Alberta called Mini Docs allows children between the ages of six and 12 to learn about being a doctor and how to stay healthy. The children get to wear medical scrubs for the day and use harmless medical tools such as stethoscopes and bandages. The day long program is run by medical students.65 Strategies to remove financial barriers to access, such as scholarships, should be expanded. Further, there is a need to modify the admissions process to recognize the differences in access to programs such as MCAT preps and overseas volunteer experiences based on the availability of financial resources as well as the necessity of employment for some students while in medical school. This necessary employment may limit the time available for volunteer and community service.66 Another strategy that can be effective in increasing access is programs that seek to link primary care providers with unattached and underserved patients. Programs such as Health Care Connect in Ontario and the GP and Me program in British Columbia actively seek to link sometimes hard to serve patients to appropriate primary care. The College of Family Physicians of Canada has developed a blueprint for comprehensive primary care for Canadians. The concept, a 'patient's medical home' seeks to link Canadians with a comprehensive health care team led by a family physician. These medical homes will take many forms but will be designed to increase both access and the patient-centredness of care.67 Another barrier to access is timeliness of service. Many patients are forced to use walk in clinics or emergency departments as they cannot receive the required care from their primary care providers. Use of walk-in clinics or emergency departments for primary care may lead to lost opportunities for prevention and health promotion.68 Advanced access programs can help to improve equitable access to care by facilitating timely appointments for all patients.69 The AIM (Access improvement measures) program in Alberta uses a system designed by the Institute for Healthcare Improvement to redesign practice to focus on same day appointments and elimination of unnecessary delays.70 Primary care which prioritizes chronic disease management offers the greatest potential for increasing appropriateness of care and reducing system costs. Those most likely to have chronic diseases are also those who face the biggest barriers to equitable access.71 Currently many people with ACSC do not receive the appropriate tests to monitor their conditions, management of their medications, or supports to self-manage their disease.72 Some programs do exist to encourage more effective management of chronic disease. The Champlain Local Health Integration Network (LHIN) in Ontario has developed a cardiovascular disease prevention network to improve care through the use of evidence based practices and better integration between all areas of the health care continuum.73 Primary Care networks in Alberta have similar goals designed to connect multiple physicians, clinics and regions together to support the health needs of the population.74 Further work is necessary to expand these types of programs and to provide appropriate compensation models for complex patients. Payment models in some jurisdictions undermine access by failing to take morbidity and co-morbidity into consideration in designing rates such as equal capitation.75 Finally, there is a need to encourage greater self-management of disease. Practice support programs in British Columbia are providing training to support physicians in increasing patient self-management and health literacy.76 Additional programs of this nature are necessary in all jurisdictions. 2. Better care coordination and greater access to necessary medical services along the continuum of care. Patient-centred care which integrates care across the continuum and which includes community services will be necessary to ensure not only greater access but greater acceptability of care.77 Innovative programs focused on increasing the coordination in terms of transition from hospital to home have shown some success in preventing readmissions particularly when vulnerable populations are targeted.78 Health Links in Ontario aims to reduce costs, based on the assumption that much of the utilization of high cost services, such as emergency department visits, could be prevented with better coordinated care. One of the pilot sites in Guelph aims to assign one person in primary care, likely a doctor or a nurse, to be the primary contact for patients deemed high need and to intervene on behalf of these patients to ensure better care coordination.79 Further work is needed to ensure greater coordination in speciality care. As the evidence demonstrates, access to specialist services are skewed in favour of high-income patients. To reduce this inequity it may be necessary to standardize the referral process and facilitate the coordination of care from the primary care providers' perspective.80 A new program in British Columbia is designed to reduce some of these barriers by providing funding and support to rapid access programs which allow family physicians to access specialist care through a designated hotline. If no specialist is available immediately there is a commitment that the call will be returned within two hours. Specialists available through this program include cardiology, endocrinology, nephrology, psychiatry, and internal medicine among others.81 Similar programs in other jurisdictions could help to increase coordination between primary and speciality care. Care coordination is only part of the problem, however. There is also a need to increase the access to services that are medically necessary across the care continuum. These include a lifetime prevention schedule82, diagnostic testing, specialty services, and access to appropriate rehabilitation services, mental health, long-term care and end of life care. 3. Quality improvement initiatives which incorporate considerations of equity as part of their mandate. Equity has become a key component of many quality improvement initiatives around the world. The Health Quality Council Ontario identified nine attributes of a high-performing health system: safe, effective, patient-centred, accessible, efficient, equitable, integrated, appropriately resourced, and focused on population health.83 The POWER study, a large study of Ontario residents found that where there were targeted programs for quality improvement fewer inequities were observed. In particular they referred to the actions of Cancer Care Ontario and the Ontario Stroke Network. Both of these groups had undergone large quality improvement initiatives to standardize care and increase coordination of services through evidence-based guidelines and ongoing performance measurement. Considerations of accessibility and equity were specifically included. As a result of these efforts, the POWER study found that acute cancer and stroke care in Ontario were quite equitable.84 Similar efforts are underway in other jurisdictions. The Towards Optimized Practice initiative in Alberta supports efforts in medical offices to increase the use of clinical practice guidelines for care as well as quality improvement initiatives.85 Encouraging more health services and programs to undertake such quality improvement initiatives could help to reduce the inequities in access for all Canadians. 4. Health system planning and assessment which prioritizes equitable access to care Considerations of equity must be built specifically into all planning considerations. Too often services are designed without adequate consideration of the specific needs of disadvantaged groups. Planners need to do a better job of understanding their practice populations and tailoring programs to those most in need of care.86 This planning should be done in consultation with other sectors that play a role in influencing the health of their practice populations. Further, assessments of the equity and use of services is also needed. Some services may be designed in a way that is more appropriate for some than others, resulting in higher utilization among some groups and a lack of access for others.87 Innovative work is taking place in the Saskatoon Health Region to try and understand these barriers. Health care services are undergoing specific health equity assessments to ensure that all services meet the needs of diverse populations. This includes looking at the full spectrum of services from preventative care and education programs to tertiary level care such as dialysis. In Ontario, the local health integration networks (LHIN) have now been tasked with developing equity plans for their services. Clear goals and performance measurements are part of this work.88 One of the tools available to support this work is a health equity impact assessment tool developed by the Ontario Ministry of Health and Long-Term Care. This tool is intended for use by organizations within the health system as well as those outside the system who will impact on the health of Ontarians. The main focus of the tool is to reduce inequities that result from barriers in access to quality health services. Additionally, it is designed to identify unintended health impacts, both positive and negative, before a program or policy is implemented.89 Further work is needed to ensure that equity is included in the deliverables and performance management of health care organizations and provider groups across the country.90 To support these planning programs appropriate data will need to be collected. This data needs to be comprehensive for all services and needs to include specific data points which will allow planners as well as providers to understand the composition of their populations as well as measure and report on considerations of equity.91 Recommendations for action: CMA and National Level Initiatives The CMA recommends that: 9. Governments continue efforts to ensure that all Canadians have access to a family physician. 10. Appropriate compensation and incentive programs be established in all jurisdictions to support better management of chronic disease for all Canadians. 11. Governments provide funding and support to programs which facilitate greater integration between primary and speciality care. 12. With support from government, national medical organizations develop programs to increase standardization of care and the use of appropriate clinical practice guidelines. 13. Appropriate data collection and performance measurement systems be put in place to monitor equitable distribution of health services and greater appropriateness of care. Health System Planners The CMA recommends that: 14. Needs based planning be mandated for all health regions and health system planning. Equity impact assessment should be part of this planning to ensure that services meet the needs of all Canadians. 15. Chronic disease management and other supportive strategies for vulnerable patients at risk of frequent readmission to the acute care system be prioritized in all health systems. 16. Quality improvement initiatives be mandated in all care programs. These programs should include a specific focus on standardization of care and continuous quality improvement and should include equity of access as part of their mandate. Physicians in Practice The CMA recommends that: 17. Physicians be supported in efforts to offer timely access in primary care settings. 18. Physicians be supported in continued efforts to include all patients in decisions about their care and management of their illnesses. 19. Physicians be supported in continued efforts to standardize care and utilize evidence based clinical practice guidelines with a particular emphasis on the management of chronic disease. 20. Physicians be encouraged and adequately supported to participate in community-based interventions that target the social determinants of health. Conclusion: Despite a commitment to equal access to health care for all Canadians there are differences in access and quality of care for many groups. For those that are most vulnerable, this lack of access can serve to further exacerbate their already increased burden of illness and disease. The strategies discussed above offer some opportunities for the health sector and the medical profession to intervene and mitigate this inequity. By removing barriers on both the patient and system side it is hoped that greater access to appropriate care will follow. While these strategies offer some hope, these actions alone will not be sufficient to increase the overall health of the Canadian population. Action is still required to tackle the underlying social and economic factors which lead to the disparities in the health of Canadians. References: 1 This paper represents a focus on equitable access to care. For a more general policy statement on the role of physicians in addressing the social determinants of health please see: Canadian Medical Association. Health Equity and the Social Determinants of Health: A Role for the Medical Profession. Ottawa, ON; 2012. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD13-03.pdf 2 The Canadian Medical Association is currently developing a policy paper on access to mental health services in Canada. It is anticipated that this policy statement will be completed in 2014. 1 Levesque JF, Harris M, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013. Available: http://www.equityhealthj.com/content/12/1/18 (accessed 2013Mar 12) 2 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto (ON); 2010. Available: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf (accessed 2011 Jan 14). 3 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 4 Levesque JF, Harris M, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013. Available: http://www.equityhealthj.com/content/12/1/18 (accessed 2013Mar 12) 5 Oliver A, Mossialos E. Equity of access to health care: outlining the foundations for action. J Epidemiol Community Health 2004; 58: 655-658. 6 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2010. Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter7-AccesstoHealthCareServices.pdf (accessed 2012 Dec 10). 7 Kirby M, Goldbloom D, Bradley L. Changing Directions, Changing Lives: The Mental Health Strategy for Canada.Ottawa (ON): Mental Health Commission of Canada; 2012. Available: http://strategy.mentalhealthcommission.ca/pdf/strategy-text-en.pdf (accessed 2013 Mar 12). 8 Allin S. Does Equity in Healthcare Use Vary...; Frolich N, Fransoo R, Roos N. Health Service Use in the Winnipeg Regional Health Authority: Variations Across Areas in Relation to Health and Socioeconomic status. Winnipeg (MB) Manitoba Centre for Health Policy. Available: http://mchp-appserv.cpe.umanitoba.ca/teaching/pdfs/hcm_forum_nf.pdf (accessed 2013 Feb 6); McGrail K. Income-related inequities: Cross-sectional analyses of the use of medicare services in British Columbia in 1992 and 2002. Open Medicine 2008; 2(4): E3-10; Van Doorslaer E, Masseria C. Income-Related Inequality in the Use... Veugelers PJ, Yip AM. Socioeconomic disparities in health care use: Does universal coverage reduce inequalities in health? 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Available: http://www.stmichaelshospital.com/pdf/crich/hospital-care-for-all-report.pdf (accessed 2012 Dec 10). 13 Murphy K, Glazier R, Wang X, et al. Hospital Care for All... 14 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services...Demeter S, Reed M, Lix L, et al. Socioeconomic status and the utilization of diagnostic imaging in an urban setting. CMAJ 2005; 173(10): 1173-1177. 15 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2010. Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter12-SDOHandPopsatRisk.pdf (accessed 2012 Dec 10); Frolich N, Fransoo R, Roos N. Health Service Use in the Winnipeg... Wang L, Nie JX, Ross EG. Determining use of preventive health care in Ontario. 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Equitable Access to Rehabilitation : Realizing Potential, Promising Practices, and Policy Directions. Toronto (ON) Wellesley Institute; 2012. Available : http://www.wellesleyinstitute.com/wp-content/uploads/2012/06/Equitable-Access-to-Rehabilitation-Discussion-Paper1.pdf (accessed 2013 Feb 6). 25 Bowen, S. Access to Health Services for Underserved Populations in Canada. In Certain Circumstances: Issues in Equity and Responsiveness in Access to Health Care in Canada: A collection of papers and reports prepared for Health Canada. Ottawa (ON) Health Canada; 2000. Available: http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2001-certain-equit-acces/2001-certain-equit-acces-eng.pdf (accessed 2013 Feb 6). 26 Statistics Canada. Canadian Community Health Survey: Mental Health, 2012. Ottawa, ON; 2013. Available: http://www.statcan.gc.ca/daily-quotidien/130918/dq130918a-eng.pdf (accessed 2013 Sep 18). 27 Kirby M, Goldbloom D, Bradley L. Changing Directions, Changing Lives... 28 EMC News. CCAC publishes long-term care waitlists monthly. Brockville (ON); 2013. Available: http://www.emcstlawrence.ca/20130404/news/CCAC+publishes+long-term+care+waitlists+monthly (accessed 2013 Apr 11). 29 Health Charities Coalition of Canada. Position Statement on Access to Home Care Revised for Approval Ottawa (ON); 2011. Available: http://www.healthcharities.ca/media/2720/HomeCarePos_statmnt_Sep22_11_Final_EN.pdf (accessed 2013 Mar 12) 30 Canadian Hospice Palliative Care Association. Fact Sheet: Hospice Palliative Care in Canada. Ottawa(ON); 2012. Available: http://www.chpca.net/media/7622/fact_sheet_hpc_in_canada_may_2012_final.pdf (accessed 2013 Mar 25). 31 Bowen, S. Access to Health Services for Underserved Populations..... 32 Place J. The Health of Aboriginal People Residing in Urban Areas. National Collaborating Centre for Aboriginal Health. Prince George, BC; 2012. Available: http://www.nccah-ccnsa.ca/Publications/Lists/Publications/Attachments/53/Urban_Aboriginal_Health_EN_web.pdf (accessed 2013 Sep 18). 33 National Collaborating Centre for Aboriginal Health. Access to Health Services As A Social Determinant of First Nations, Inuit And Metis Health. Prince George (BC) National Collaborating Centre for Aboriginal Health; 2011. Available: http://www.nccah-ccnsa.ca/docs/fact%20sheets/social%20determinates/Access%20to%20Health%20Services_Eng%202010.pdf (accessed 2013 Feb 6). 34 Levesque JF, Harris M, Russell G. Patient-centred access to health care... 35 Allin S. Does Equity in Healthcare Use Vary...; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 36 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status for Males and Females. Ottawa(ON); 2010. Available: https://secure.cihi.ca/free_products/disparities_in_hospitalization_by_sex2010_e.pdf (accessed 2013 Feb 6); Van Doorslaer E, Masseria C. Income-Related Inequality... 37 Allin S. Does Equity in Healthcare Use Vary... 38 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12...;Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 39 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status... 40 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status... ;Roos LL, Walld R, Uhanova J, et al. Physician Visits, Hospitalizations, and Socioeconomic Status: Ambulatory Care Sensitive Conditions in a Canadian Setting. HSR 2005; 40(4): 1167-1185. 41 Curtis LJ, MacMinn WJ. Health-Care Utilization in Canada: 25 Years of Evidence: SEDAP Research Paper No. 190. Hamilton (ON) Social and Economic Dimensions of an Aging Population Research Program; 2007. Available: http://catalogue.iugm.qc.ca/GEIDEFile/23002.PDF?Archive=102297992047&File=23002_PDF (accessed 2013 Feb 14). 42 Murphy K, Glazier R, Wang X, et al. Hospital Care for All... 43 Canadian Institute for Health Research. Disparities in Primary Health Care Experiences Among Canadians With Ambulatory Care Sensitive Conditions. Ottawa(ON); 2012. Available: https://secure.cihi.ca/free_products/PHC_Experiences_AiB2012_E.pdf (accessed 2013 Feb 14). 44 Saskatoon Poverty Reduction Partnership. From poverty to possibility...and prosperity: A Preview to the Saskatoon Community Action Plan to Reduce Poverty. Saskatoon (SK): Saskatoon Poverty Reduction Partnership; 2011.Available: http://www.saskatoonpoverty2possibility.ca/pdf/SPRP%20Possibilities%20Doc_Nov%202011.pdf (accessed 2012 Mar 13) 45 Canadian Institute for Health Information. Hospitalization Disparities... 46 Levesque JF, Harris M, Russell G. Patient-centred access to health care... 47 Bowen, S. Access to Health Services for Underserved Populations... 48 Canadian Council on Learning. Health Literacy in Canada: Initial Results for the International Adult Literacy and Skills Survey. Ottawa (ON); 2007. Available: http://www.ccl-cca.ca/pdfs/HealthLiteracy/HealthLiteracyinCanada.pdf (accessed 2013 Apr 19). 49 Parnell TA, Turner J. IHI 14th Annual International Summit. Health Literacy: Partnering for Patient-Centred Care. April 9, 2013. 50 Bowen, S. Access to Health Services for Underserved Populations... 51 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7.... 52 Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 53 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7...; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 54 Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 55 Chiu S, Hwang SW. Barriers to healthcare among homeless people with diabetes. Diabetes Voice 2006; 51(4): 9-12. Available: http://www.idf.org/sites/default/files/attachments/article_473_en.pdf (2011 Feb 20), 56 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7.... Willems S, De Maesschalck S, Deveugele M, et al. Socio-economic status of the patient and doctor-patient communication: does it make a difference? Patient Educ Couns 2004; 56: 139-146; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 57 Willems S, De Maesschalck S, Deveugele M, et al. Socio-economic status of the patient... 58 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... 59 Indigenous Physicians of Canada and the Association of Faculties of Medicine Canada, "First Nations, Inuit, Métis Health, Core Competencies: A Curriculum Framework for Undergraduate Medical Education" Updated April 2009, online: http://www.afmc.ca/pdf/CoreCompetenciesEng.pdf (accessed October 20, 2010). 60 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2012.Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter13-AchievingHealthEquityinOntario.pdf (accessed 2013 Feb 6). 61 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... ;Bowen, S. Access to Health Services for Underserved Populations..... 62 Williams, R. Telemedicine in Ontario: Fact not Fiction: How to enhance your practice and enrich the patient experience. Ontario Telemedicine Network: Toronto, ON; 2013. Available: http://otn.ca/sites/default/files/telemedicine_in_ontario-_fact_not_fiction_02-26.pdf (accessed 2013 Sep 19). 63 Bowen, S. Access to Health Services for Underserved Populations... 64 National Physician Survey- 2012 student component 65 Alberta Medical Association. Mini Docs. Edmonton (AB); 2012. Available: https://www.albertadoctors.org/about/awards/health-promo-grant/2011-12-recipients/mini-docs (accessed 2013 Apr 18). 66 Dhalla IA, Kwong JC, Streiner DL et al. Characteristics of first-year students in Canadian... 67 The College of Family Physicians of Canada . A Vision for Canada: Family Practice: The Patient's Medical Home. Toronto, ON; 2011. Available: http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf (accessed 2012 Mar 15). 68 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... 69 Ibid 70 Access Improvement Measures. Edmonton (AB): Alberta Primary Care Initiative. Available at: http://www.albertapci.ca/AboutPCI/RelatedPrograms/AIM/Pages/default.aspx (accessed 2013 Mar 12). 71 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... 72 Canadian Institute for Health Research. Disparities in Primary Health Care Experiences... 73 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13... 74 About Primary Care Networks. Edmonton (AB): Alberta Primary Care Initiative. Available at: http://www.albertapci.ca/AboutPCNs/Pages/default.aspx (accessed 2013 Mar 12). 75 Glazier RH. Balancing Equity Issues in Health Systems: Perspectives of Primary Healthcare. Healthcare Papers 2007; 8(Sp):35-45. 76 General Practice Services Committee. Learning Modules-Practice Management. Vancouver (BC): Government of British Columbia & British Columbia Medical Association. Available: http://www.gpscbc.ca/psp/learning/practice-management (accessed 2013 Mar 12). 77 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... 78 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13... 79 Improving Care for High-Needs Patients: McGuinty Government Linking Health Providers, Offering Patients More Co-ordinated Care. Toronto (ON) Ontario Ministry of Health and Long-Term Care; December 6, 2012. Available: http://news.ontario.ca/mohltc/en/2012/12/improving-care-for-high-needs-patients.html (accessed 2012 Dec 10). 80 Curtis LJ, MacMinn WJ. Health-Care Utilization in Canada: 25 Years of Evidence... 81 Shared Care Partners in Care Annual Report 2011/12. Vancouver (BC): Government of British Columbia & British Columbia Medical Association. Available: https://www.bcma.org/files/SC_annual_report_2011-12.pdf (accessed 2013 Mar 12). 82 British Columbia Medical Association. Partners in Prevention: Implementing a Lifetime Prevention Plan. Vancouver, BC; 2010. Available: https://www.bcma.org/files/Prevention_Jun2010.pdf (accessed 2013 Sep 18). 83 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13... 84 Ibid. 85 Toward Optimized Practice. Edmonton (AB). Available at: http://www.topalbertadoctors.org/index.php (accessed 2013 Mar 12). 86 Ali A, Wright N, Rae M ed. Addressing Health Inequalities: A guide for general practitioners. London (UK); 2008. Available: http://www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z%20policy/Health%20Inequalities%20Text%20FINAL.ashx (accessed 2012 Jan 16); Gardner, B. Health Equity Road Map Overview. Toronto (ON): Wellesley Institute, 2012. Available: http://www.wellesleyinstitute.com/wp-content/uploads/2012/09/HER_Systemic-Health-Inequities_Aug_2012.pdf (accessed 2013 Feb 6). 87 Bowen, S. Access to Health Services for Underserved Populations... 88 Gardner B. Health Equity Into Action: Planning and Other Resources for LHINs. Toronto(ON) Wellesley Institute; 2010. Available: http://www.wellesleyinstitute.com/wp-content/uploads/2010/09/Health_Equity_Resources_for_LHINs_1.pdf (accessed 2013 Feb 6). 89 Ontario Ministry of Health and Long-Term Care. Health Equity Impact Assessment (HEIA) Workbook. Toronto, ON; 2012. Available: http://www.health.gov.on.ca/en/pro/programs/heia/docs/workbook.pdf (accessed 2013 Sep 30). 90 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12...; Gardner, B. Health Equity Road Map...; Glazier RH. Balancing Equity Issues in Health Systems... 91 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13...

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Health and health care for an aging population

https://policybase.cma.ca/en/permalink/policy11061

Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Health care and patient safety
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2013-12-07
Replaces
PD00-03 - Principles for medical care of older persons
Topics
Health care and patient safety
Health systems, system funding and performance
Text
In 2010, 14% of Canada's population was 65 or older. With the aging of the baby boom generation, this proportion is estimated to rise to about 25% in 2036 (1). The aging of Canada's population is expected to have a major impact on the country's economy, society and health care system over the next 25 to 30 years. Though age does not automatically mean ill health or disability, the risk of both does increase as people age. In 2006, 33% of Canadians aged 65 or older had a disability; the proportion climbed to 44% among people aged 75 or older (2). Nearly three-quarters of Canadians over 65 have at least one chronic health condition (3). Because of increasing rates of disability and chronic disease, the demand for health services is expected to increase as Canada's population ages. Currently Canadians over 65 consume roughly 44% of provincial and territorial health care budgets (4), and governments are concerned about the health care system's capacity to provide quality services in future. The CMA believes that to provide optimal care and support for Canada's aging population, while taking care to minimize pressure on the health-care system as much as possible, governments at all levels should invest in: * programs and supports to promote healthy aging; * a comprehensive continuum of health services to provide optimal care and support to older Canadians; and * an environment and society that is "age friendly." This policy describes specific actions that could be taken to further these three goals. Its recommendations complement those made in other CMA policies, including those on "Funding the Continuum of Care" (2009), Optimal Prescribing (2010) and Medication Use and Seniors (Update 2011). 2) Providing Optimal Health and Health Care for Older Persons: This section discusses in detail the three general areas in which the CMA believes governments should invest: a) Promotion of "Healthy Aging" The Public Health Agency of Canada (PHAC) defines healthy aging as "the process of optimizing opportunities for physical, social and mental health to enable seniors to take an active part in society without discrimination and to enjoy independence and quality of life." It is believed that initiatives to promote healthy aging, and enable older Canadians to maintain their health, will help lower health-care costs by reducing the overall burden of disability and chronic disease. Such initiatives could focus on: Physical activity. Being physically active is considered the most important step that older Canadians can take toward improving health, even if they do not start being active until later in life. However in 2008, 57% of seniors reported being physically inactive (5). Injury prevention. Falls are the primary cause of injury among older Canadians; they account for 40% of admissions to nursing homes, 62% of injury-related hospitalizations, and almost 90% of hip fractures (6). The causes of falls are complex, and both physiology (e.g. effect of illness) and environment (e.g. poorly maintained walkways) can contribute. Most falls can be prevented through a mix of interventions: for the person (such as strength and balance training); and for the person's environment, (such as grab bars and railings, slip-proof floor surfaces, walkways that are cleared of snow and ice in winter.) Nutrition. In 2008, 28% of men and 31% of women over 65 were obese (BMI = 30); this is higher than the population average. Underweight is also a problem among seniors, 17% of whom report a BMI of 20 or less (7). The reasons for nutrition problems among older Canadians are complex; they may be related to insufficient income to purchase healthy foods, or to disabilities that make shopping or preparing meals difficult. Mental health. An estimated 10-15% of seniors report depression, and the rate is higher among those with concomitant physical illness, or those living in long-term care facilities (8). Depression among older people may be under-recognized and under-treated, since it might be dismissed as a normal consequence of aging. Poor mental health is often associated with social isolation, a common problem among seniors. Recommendations: Governments and National Associations The CMA recommends that: 1. Governments at all levels support programs to promote physical activity, nutrition, injury prevention and mental health among older Canadians. Health Service Delivery The CMA recommends that: 2. Older Canadians have access to high-quality, well-funded programs and supports to help them achieve and maintain physical fitness and optimal nutrition. 3. Older Canadians have access to high-quality, well-funded programs aimed at determining the causes and reducing the risk of falls. 4. Older Canadians have access to high-quality, well-funded programs to promote mental health and well-being and reduce social isolation. Physicians and Patients The CMA recommends that: 5. Older Canadians be encouraged to follow current guidelines for healthy living, such as the 2012 Canadian Physical Activity Guidelines for adults 65 and over. 6. Physicians and other health care providers be encouraged to counsel older patients about the importance of maintaining a healthy and balanced life style. 7. All stakeholders assist in developing health literacy tools and resources to support older Canadians and their families in maintaining health. b) A Comprehensive Continuum of Health Services Though, as previously mentioned, age does not automatically mean ill health, utilization of health services does increase with increasing age. Patients over 65 have more family physician visits, more hospital admissions and longer hospital stays than younger Canadians (the overall length of stay in acute inpatient care is about 1.5 times that of non-senior adults) (9). In addition, seniors take more prescription drugs per person than younger adults; 62% of seniors on public drug programs use five or more drug classes, and nearly 30% of those 85 and older have claims for 10 or more prescription drugs (10). Heavy medication use by people over 65 has a number of consequences: * The risk of adverse drug reactions is several-fold higher for seniors than for younger patients. * Medication regimes, particularly for those taking several drugs a day on different dosage schedules, can be confusing and lead to errors or non-adherence. * Patients may receive prescriptions from multiple providers who, if they have not been communicating with each other, may not know what other medications have been prescribed. This increases the risk of harmful drug interactions and medication errors. For seniors who have multiple chronic diseases or disabilities, care needs can be complex and vary greatly from one person to another. This could mean that a number of different physicians, and other health and social-services professionals, may be providing care to the same person. A patient might, for example, be consulting a family physician for primary health care, several medical specialists for different conditions, a pharmacist to monitor a complex medication regime, a physiotherapist to help with mobility difficulties, health care aides to clean house and make sure the patient is eating properly, and a social worker to make sure his or her income is sufficient to cover health care and other needs. Complex care needs demand a flexible and responsive health care system. The CMA believes that quality health care for older Canadians should be delivered on a continuum from community based health care, (e.g. primary health care, chronic disease management programs), to home care (e.g. visiting health care workers to give baths and footcare), to long-term care and palliative care. Ideally, this continuum should be managed so that the patient can remain at home, out of emergency departments, hospitals and long term care unless appropriate, can easily access the level of care he or she needs, and can make a smooth transition from one level of care to another when needed. Care managers are an essential part of this continuum, working with caregivers and the patient to identify the most appropriate form of care from a menu of alternatives. Care managers can co-ordinate the services of the various health professionals who deliver care to a given patient, and facilitate communication among them so that all work to a common care plan. A family physician who has established a long-standing professional relationship with the patient and is familiar with his or her condition, needs and preference is ideally placed to serve as manager of a patient's overall care, supported by geriatric and other specialists as appropriate. Not all of the patient's caregivers may be health professionals; more than 75% of the care of older Canadians is delivered by unpaid informal caregivers, usually relatives. The role of the family caregiver can be demanding financially, physically and emotionally. Though governments have instituted tax credits and other forms of support for caregivers, more may be required. The Special Senate Committee on Aging has called for a National Caregiving Strategy to help put in place the supports that caregivers need. (11) Finally, many of the services required by seniors, in particular home care and long-term care, are not covered by the Canada Health Act. Funding of these services varies widely from province to province. Long-term care beds are in short supply; as a result more than 5,000 hospital beds are occupied by patients waiting for long-term care placement (12), making them unavailable for those with acute-care needs. CMA's Health Care Transformation Framework (2010) makes a number of recommendations aimed at improving access to continuing care in Canada. Recommendations: Governments and National Associations The CMA recommends that: 8. Governments and other stakeholders work together to develop and implement models of integrated, interdisciplinary health service delivery for older Canadians. 9. Governments continue efforts to ensure that older Canadians have access to a family physician, supported by specialized geriatric services as appropriate. 10. Governments and other stakeholders work together to develop and implement a National Caregiver Strategy, and expand the support programs currently offered to informal caregivers. 11. All stakeholders work together to develop and implement a national dementia strategy. 12. Governments and other stakeholders work together to develop and implement a pan-Canadian pharmaceutical strategy that addresses both comprehensive coverage of essential medicines for all Canadians, and programs to encourage optimal prescribing and drug therapy. 13. Governments work with the health and social services sector, and with private insurers, to develop a framework for the funding and delivery of accessible and sustainable home care and long-term care services. Medical Education The CMA recommends that: 14. Medical schools enhance the provision, in undergraduate education and in residency training for all physicians, of programs addressing the clinical needs of older patients. 15. Medical students and residents be exposed to specialty programs in geriatric medicine and other disciplines that address the clinical needs of older patients. 16. Continuing education programs on care for older patients be developed and provided to physicians of all specialties, and to other health care providers, on a continuous basis. Health System Planners The CMA recommends that: 17. Health systems promote collaboration and communication among health care providers, through means such as: a. Interdisciplinary primary health care practice settings, that bring a variety of physicians and other health professionals and their expertise into a seamless network; b. Widespread use of the electronic health record; and c. A smooth process for referral between providers. 18. All stakeholders work toward integration of health care along the continuum by addressing the barriers that separate: a. acute care from the community; b. health services from social services; and c. provincially-funded health care services such as physicians and hospitals, from services funded through other sources, such as pharmacare, home care and long term care. 19. Programs be developed and implemented that promote optimal prescribing and medication management for seniors. 20. Research be conducted on a continuous basis to identify best practices in the care of seniors, and monitor the impact of various interventions on health outcomes and health care costs. Physicians in Practice The CMA recommends that: 21. Continuing education, clinical practice guidelines and decision support tools be developed and disseminated on a continuous basis, to help physicians keep abreast of best practices in elder care. c) An Age-Friendly Environment: One of the primary goals of seniors' policy in Canada is to promote the independence of older Canadians in their own homes and communities, avoiding costly institutionalization for as long as feasible. To help older Canadians successfully maintain their independence, it is important that governments and society ensure that the social determinants of health care addressed when developing policy that affects them. This includes assuring that the following supports are available to older Canadians: * Adequate Income: Poverty among seniors dropped sharply in the 1970s and 1980s. In 2008, 6% of Canada's seniors were living in low income, as opposed to nearly 30% in 1978. However, there has been a slight increase in poverty levels since 2007, and it may be necessary to guard against an upward trend in future (13). Raising the minimum age for collecting Old Age Security, as has been proposed, may weigh heavily on seniors with lower incomes, and make prescription drugs, dental care and other needed health services unaffordable. * Employment Opportunities: it has been recommended that seniors be encouraged to work beyond age 65 as a means of minimizing a future drain on pension plans (14). Many older Canadians who have not contributed to employee pension plans may be dependent on employment income for survival. However, employment may be difficult to find if workplaces are unwilling to hire older workers. * Housing. Nearly all of Canada's seniors live in their own homes; fewer than 10% live in long-term care facilities. Options are available that permit older Canadians to live independently even with disabilities and health care needs, such as: o Home support for services such as shopping and home maintenance; and o Assisted-living facilities that provide both independent living quarters and support services such as nursing assistance, and cafeterias if desired. * An Age-friendly built environment. To enable seniors to live independently, the World Health Organization's "Age-Friendly Communities" initiative recommends that their needs be taken into consideration by those who design and build communities. For example, buildings could be designed with entrance ramps and elevators; sidewalks could have sloping curbs for walkers and wheelchairs; and frequent, accessible public transportation could be provided in neighbourhoods where a large concentration of seniors live. * Protection from Abuse. Elder abuse can take many forms: physical, psychological, financial, or neglect. Often the abuser is a family member, friend, or other person in a position of trust. Researchers estimate that 4 to 10% of Canadian seniors experience abuse or neglect, but that only a small portion of this is reported (15). CMA supports awareness programs to bring the attention of elder abuse to the public, as well as programs to intervene with seniors who are abused, and with their abusers. * A Discrimination-Free society. Efforts to boost income and employment security, health care standards and community support for older Canadians are hampered if the pervasive public attitude is that seniors are second-class citizens. An age-friendly society respects the experience, knowledge and capabilities of its older members, and accords them the same worth and dignity as it does other citizens. Recommendations: Governments and National Associations The CMA recommends that: 22. Governments provide older Canadians with access to adequate income support. 23. Governments devote a portion of national infrastructure funding to providing an adequate supply of accessible and affordable housing for seniors. 24. Older Canadians have access to opportunities for meaningful employment if they desire. 25. Communities take the needs and potential limitations of older Canadians into account when designing buildings, walkways, transportation systems and other aspects of the built environment. Health System Planners The CMA recommends that: 26. The health system offer a range of high-quality, well-funded home care and social support services to enable older Canadians to remain independent in the community for as long as possible. 27. Physicians receive advice and education on optimal community supports and resources to keep seniors independent and/or at home. Physicians in Practice The CMA recommends that: 28. Training and programs be provided to physicians and other care providers to enable them to identify elder abuse, and to intervene with abused people and their abusers. 3) Conclusion: Aging is not a disease, but an integral part of the human condition. To maximize the health and well-being of older Canadians, and ensure their continued functionality and independence for as long as possible, CMA believes that the health care system, governments and society should work with older Canadians to promote healthy aging, provide quality patient-centered health care and support services, and build communities that value Canadians of all ages. 1 Public health Agency of Canada. "Growing Older: Adding Life to Years. Annual report on the state of public health in Canada, 2010." Accessed at http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2010/fr-rc/index-eng.php 2 Statistics Canada: A Portrait of Seniors in Canada (2008). Accessed at http://www.statcan.gc.ca/pub/89-519-x/89-519-x2006001-eng.htm 3 Canadian Institute for Health Information. "Seniors and the health care system: What is the impact of multiple chronic conditions?" (January 2011.) Accessed at https://secure.cihi.ca/free_products/air-chronic_disease_aib_en.pdf 4 Canadian Institute for Health Information. National Health Expenditure Trends, 1975 to 2010. Accessed at http://www.cihi.ca/cihi-ext-portal/internet/en/document/spending+and+health+workforce/spending/release_28oct10 5 PHAC 2010 6 PHAC 2010 7 PHAC 2010 8 Mood Disorders Society of Canada. "Depression in Elderly" (Fact sheet). Accessed at http://www.mooddisorderscanada.ca/documents/Consumer%20and%20Family%20Support/Depression%20in%20Elderly%20edited%20Dec16%202010.pdf 9 Canadian institute for Health Information. Health Care in Canada, 2011: A Focus on Seniors and Aging. Accessed at https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf 10 CIHI 2011 11 Special Senate Committee on Aging. "Canada's Aging Population: Seizing the Opportunity." (April 2009). Accessed at http://www.parl.gc.ca/Content/SEN/Committee/402/agei/rep/AgingFinalReport-e.pdf 12 CIHI 2009 13 PHAC 2010 14 Department of Finance Canada. Economic and fiscal implications of Canada's Aging Population (October 2012). Accessed at http://www.fin.gc.ca/pub/eficap-rebvpc/report-rapport-eng.asp#Toc01. 15 PHAC 2010

Documents

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Health Care Transformation in Canada: Change that Works, Care that Lasts

https://policybase.cma.ca/en/permalink/policy9837

Last Reviewed
2018-03-03
Date
2010-07-13
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2010-07-13
Topics
Health systems, system funding and performance
Text
Canada's prized Medicare system is facing serious challenges on two key fronts: in meeting the legitimate health care needs of Canadians and in being affordable for the public purse. The founding principles of Medicare are not being met today either in letter or in spirit. Canadians are not receiving the value they deserve from the health care system. In both 2008 and 2009, the Euro-Canada Health Consumer Index ranked Canada 30th of 30 countries (the U.S. was not included in the sample) in terms of value for money spent on health care. Canadians deserve better. Canada cannot continue on this path. The system needs to be massively transformed, a task that demands political courage and leadership, flexibility from within the health care professions and far-sightedness on the part of the public. It is a lot to demand, but nothing less than one of Canada's most cherished national institutions is at stake. Unwillingness to confront the challenges is not an option. With this report, "Health Care Transformation in Canada: Change that Works, Care That Lasts" the Canadian Medical Association (CMA) declares its readiness to take a leadership position in confronting the hard choices required to make health care work better for Canadians. The focus of reform must better serve the patient. The system must adjust to changing needs for care and do so without crowding out other societal needs; many of them determinants of health themselves, such as education and sanitation, and the challenges posed by Canada's geographic, cultural, economic and emerging demographic realities. This report sets out an ambitious but realizable roadmap to ready the system for the future. Its triple aim is to improve the health of the population at large, to improve the health care experiences of patients, and to improve the value for money spent on health and health care. The CMA seeks to spark a spirited discussion among physicians, other health care providers, governments and the public at large so that an urgent effort can be undertaken to put an improved system on a path to sustainability by the time the federal-provincial/territorial Health Accord expires on March 31, 2014. By so doing, a renewed Health Accord will be enabled to maximize value for patients and sustain a strong health care system for future generations. This report is divided into three parts: The Problem; Our Vision; and The Framework for Transformation. It is in this last section that the CMA puts forth a five-pillar transformational plan, including a Charter for Patient-Centred Care, for securing Canada's public health care future. These policy directions have been influenced by our consultations with patients, patient advocacy groups and the public. These initiatives are necessary to support the important work already underway in illness prevention and health promotion, in enhancing capabilities for diagnosis and treatment, and in monitoring system performance. They also represent directions we must take towards preparing for the needs of future generations of Canadians. The CMA, our partner provincial/territorial medical associations and the physicians of Canada are committed to the changes that will allow us to fulfill our objective to provide patients with optimal care within an effective, accountable and sustainable system today and for generations to come. EXECUTIVE SUMMARY Medicare has enjoyed the resounding support of Canadians for nearly half a century. But new times bring new challenges to the health care system and so it has been forced from time to time to adapt and evolve. This document is predicated on the belief of the CMA that new demands for adaptation must be addressed starting now, and in a manner consistent with the spirit and principles that have guided Medicare from the beginning. This report is divided into three Parts. The first lays out the underlying problem confronting the system; the second outlines a vision for Canada's health system by modernizing the guiding principles of Medicare, and the third provides the CMA's prescription for improving the system within and beyond the five original principles that are set out in the Canada Health Act (universality, accessibility, comprehensiveness, portability and public administration). Following the main report, Appendix A addresses the issue of health care funding and sustainability. This is meant to inform readers regarding the complexities inherent in the challenge of sustaining health care provision and funding for current and future populations. Part 1: The Problem Canada's health care system is valued by its citizens. At the same time, it is increasingly recognized that the system is inadequate to meet 21st Century needs and is in urgent need of reform. Canadians wait too long for care. Care providers feel overworked and discouraged. There are insufficient mechanisms to monitor system performance. Technical support needs modernizing. Closer examination of how the five Medicare principles are being met reveals a number of concerns. While there is universal coverage for a narrow range of medically-necessary services, access to other essential health care services is inconsistent, both within and across jurisdictions. Exceedingly long waits for necessary medical care is prevalent. Efficiencies in the management of our health care system must also be found as Canada has recently been ranked last out of 30 countries in terms of value for money spent. Part 2: Our Vision There are numerous steps required to transform Canada's health care system so that it becomes highly effective and meets the health needs of Canadians. A first step is to re-examine the five principles of the Canada Health Act and modernize them as they are no longer sufficient to meet current and evolving needs. All Canadians must have timely access to an appropriate array of medically-necessary services across the full continuum of care, independent of their ability to pay. All health care must be patient-centred. Care must be delivered effectively and must be well-coordinated among all care providers. The health care system must be properly resourced to deliver care in a sustainable way that can accommodate our ever-changing health care needs. Part 3: The Framework for Transformation The CMA's Health Care Transformation Plan has three core goals: improving population health, improving the patient experience of health care, and improving the value for money spent on health care. The CMA has created a Framework for Transformation listing the actions needed for change - organized under five pillars: 1. Building a culture of patient-centred care * Creation of a Charter for Patient-centred Care 2. Incentives for enhancing access and improving quality of care * Changing incentives to enhance timely access * Changing incentives to support quality care 3. Enhancing patient access along the continuum of care * Universal access to prescription drugs * Continuing care outside acute care facilities 4. Helping providers help patients * Ensuring Canada has an adequate supply of health human resources * More effective adoption of health information technologies 5. Building accountability/responsibility at all levels * Need for system accountability * Need for system stewardship The CMA recognizes that none of these directions, taken separately, will transform our health care system. Nor do they represent an exhaustive list of steps, as there are many other directions that can be taken to support our vision. This framework does, however, contain the necessary directions toward the more efficient, high-functioning, patient-focused system that Canadians deserve. Summary of CMA Recommended Directions Implementation of these recommendations will require the collaboration of all levels of government and medical and other health organizations. 1. Gain government and public support for the CMA's Charter for Patient-Centred Care. 2. Implement partial activity-based funding for hospitals, whereby facilities are funded based on the number of patients they treat and the types of illnesses they have, to improve timely access to facility-based care. 3. Implement appropriate pay-for-performance systems to encourage quality of care at both the clinician and facility level. 4. Establish an approach to comprehensive prescription drug coverage to ensure that all Canadians have access to medically necessary drug therapies. 5. Begin construction immediately on additional long-term care facilities. 6. Create national standards, with input from both federal and provincial/territorial governments, for continuing care provision in terms of eligibility criteria, care delivery and accommodation expenses. 7. Develop options to facilitate pre-funding long-term care needs. 8. Initiate a national dialogue on the Canada Health Act in relation to the continuum of care. 9. Explore ways to support informal caregivers and long-term care patients. 10. Develop a long-term health human resources plan through a national body using the best available evidence to support its deliberations. Within this plan: a) Increase medical school and residency training positions. b) Invest in recruitment and retention strategies for physicians, nurses and other health care workers. c) Ease the process of integration into our health care workforce for international medical graduates and Canadian physicians returning from abroad. d) Introduce new providers such as physician assistants to the health care workforce and enhance collaborative, team-based care where appropriate. 11. Adopt the CMA's five-year plan to set out clear targets for accelerating the adoption of Health Information Technology (HIT) in Canada. 12. Accelerate the introduction of e-prescribing in Canada to make it the main method of prescribing by 2012. 13. Require public reporting on the performance of the system, including outcomes. 14. Establish an arm's-length mechanism to monitor the financing of health care programs at the federal and provincial/territorial levels. PART 1: THE PROBLEM Summary: Canada's health care system is valued by its citizens. However, not only is our Medicare system failing to meet the five principles - universality, accessibility, portability, comprehensiveness and public administration - originally laid out in the 1984 Canada Heath Act, but those five principles, while still relevant, need to be expanded in scope to serve the current and future health needs of Canadians. Canadians believe that the relief of suffering and the promotion of health and human dignity are vitally important - for philosophical as well as pragmatic reasons. Simply stated, there is a broad recognition that health is a valued "good" allowing all Canadians to flourish as individuals and groups. Notwithstanding this fundamental belief, neither of the imperatives of our health care system - optimizing function and the compassionate relief of suffering and promotion of dignity - is being met for many people. Our population and our health providers encounter these failures on a daily basis. Polls show that most Canadians unwaveringly support the five principles laid out in the 1984 Canada Health Act - universality, accessibility, portability, comprehensiveness and public administration.1 In fact, since Medicare was first introduced - in Saskatchewan in 1962 and throughout the rest of Canada soon afterward - the idea of universal health care has become central to our national identity. Nearly half a century after Medicare was first introduced, however, Canada's health care system is falling short of the demands being placed on it from patients and providers. Canadians well understand that universal health care requires significant public resources to maintain. While the escalating costs of health care are often perceived as the overriding problem, there are other factors contributing to the crisis. Surveys have repeatedly shown that Canadians are highly satisfied with the care they receive once it is delivered. However, the general view among most Canadians is that their health care system is not as well managed as it must be. They are increasingly concerned about the lack of timely access to see their family physician, the long wait times for diagnostic testing, a widespread lack of access to specialists and specialized treatment, and the compromised quality of care in overburdened emergency rooms, or the unavailability of nearby ER facilities altogether. With our aging population, end of life issues are becoming increasingly important, yet many do not have access to expert palliative care. The founding principles of Medicare are not being met today either in letter or in spirit. Canadians are not receiving the value they deserve from the health care system. Issues such as quality of care, accountability and sustainability are now recognized as key aspects of a high-performing health system. "Health" by today's standards is not just the assessment and treatment of illness, but also the prevention of illness, and the creation and support of social factors that contribute to health. Also missing from our current system, but vitally important to proper care, is health information technology (HIT). In this area, Canada is woefully lacking in both resources and coordinated efforts toward a plan of HIT implementation. Before addressing the missing elements in Canada's health care system, a proper diagnosis of the current system requires a closer look at how the health care system fails to deliver on all five founding principles of Medicare. 1. Universality Studies have consistently shown that poorer, marginalized populations do not access necessary care. Wealthier populations use health care services more frequently than lower-income populations despite higher illness rates in low-income populations. Poorer communities have fewer services to support good health. The most vulnerable populations are least able to access and navigate the health care system. At the same time, these are the people most likely to need health care because the essential determinants of health - housing, education and food security - are often not available to them. Canada's system of universality resonates strongly with Canadians. However, while there is universal first-dollar coverage for insured hospital and medical services, there is uneven coverage of other services also essential to health and quality of life (e.g., prescription drugs and home care). 2. Accessibility The principle of accessibility in the Canada Health Act does not define "timely access" to necessary care. For many patients, the months of waiting for necessary treatment amount to a complete lack of "accessibility." While wait times have been reduced for a limited number of surgical procedures, many Canadians are still waiting far too long to receive necessary medical care for a wide variety of conditions. For many types of treatments, Canadians wait longer than citizens in most other industrialized countries that have similar universal health systems. Approximately five million Canadians do not have a family doctor, severely restricting access to adequate primary medical care. 3. Comprehensiveness Provincial/territorial health insurance plans must insure all "medically necessary" hospital and physician services. Canadians are entitled to all medically necessary (evidence-informed) services to the greatest extent possible. However, since Medicare was established in the 1960s, care patterns have shifted dramatically - away from being primarily acute care in nature, to broader health needs including prevention, treatment and long-term management of chronic illnesses. In addition, new technologies, treatments and medications that were not foreseen by the original planners of Medicare have been developed to diagnose and treat illnesses. At the time the Canada Health Act was passed, physician and hospital services represented 57% of total health spending; this has declined to 41% in 2008.2 Notwithstanding these changes, there is significant public spending beyond services covered by the Act (in excess of 25% of total spending) for programs such as seniors' drug coverage and home care; however, these programs are not subject to the Act's program criteria and are often subject to arbitrary cutbacks. While a majority of the working-age population and their families are covered by private health insurance, those with lower incomes are less likely to enjoy such benefits. Furthermore, the proportion of Canadians working in non-standard employment conditions (e.g., part-time, temporary or contract work) is increasing and these workers are less likely to have supplementary benefits.3 In addition, while most jurisdictions provide some form of seniors' drug coverage, access to other supplementary benefits post-retirement is most likely highly variable. Some of the more severe gaps in coverage include: * the lack of access to prescription medications for those without private health insurance or who are ineligible for government drug benefit programs; this problem is particularly significant for many residents in Atlantic Canada * the lack of continuing care, including both support for people to stay in their home (home care) or appropriate residential care (e.g., facility-based long-term care) * a lack of adequate mental health services. Mental illness is one of the leading burdens of illness in Canada. Access to mental health services for both children and adults is poor. Psychiatric hospitals are not covered under the Canada Health Act. Many essential services, such as psychological services or out-of-hospital drug therapies, are not covered under provincial/territorial health insurance plans. 4. Portability Canadians should receive coverage while travelling outside of their home province or territory. Portability under the Canada Health Act does not cover citizens who seek non-urgent and non-emergency care outside their home province or territory. Canadians who obtain such care in another province or territory are not covered by their health insurance program unless they receive prior approval (usually for services not available in their home province or territory). This principle is honoured by some jurisdictions but has never been fully implemented in Québec. Québec did not sign bilateral reciprocal billing agreements with the other provinces and territories stipulating that providers would be reimbursed at host-province rates. Consequently, Québec patients who receive medical care outside of their province must often pay cash for medical services received and then apply to recoup a portion of their costs from the Québec health insurance program. 5. Public administration Health care insurance plans must be administered and operated on a non-profit basis. The principle of public administration is often misinterpreted to mean public financing of publicly delivered services. In fact, while Medicare services (medically necessary hospital and physician services) are overwhelmingly publicly financed, most services are privately delivered. Most physicians are independent contractors while most hospitals are private organizations governed by community boards. This misconception of what constitutes public administration has inhibited the development of innovative models for publicly funded, privately delivered services. While Canada's system of Medicare is administered publicly, a case can certainly be made that Canada's health care system is not delivering value for the money spent: Canada is one of the highest spenders of health care when compared to other industrialized countries that offer universal care - Canada is the fifth-highest spender per capita on health care and sixth-highest in terms of spending on health as a percentage of GDP. Canadians spent an estimated $183 billion on health care in 2009, or $5452 per person.2 Of this amount, $3829, or 70%, is spent through the publicly funded system. Health care spending in Canada has increased by 6.8 annually over the past five years and has been increasing faster than the growth in the economy and more importantly faster than revenues at the federal and provincial/territorial levels. Canada's health care system is under-performing on several key measures, such as timely access, despite the large amounts we spend on health care. Experts agree that Canada's current health care system is not delivering the level of care that other industrialized countries now enjoy. The Conference Board of Canada4, the World Health Organization5, the Commonwealth Fund6 and the Frontier Centre for Public Policy7 have all rated Canada's health care system poorly in terms of "value for money" and efficiency. New governance models should be considered to improve both system effectiveness and accountability. FISCAL SUSTAINABILITY In addition to the need for improving the performance of our health system is the issue of fiscal sustainability. In 1998, the Auditor General of Canada, Denis Desautels, was among the first to sound an alarm about sustainability with a report on the implications of the aging population. His report projected that government spending on health as a share of GDP; if increases continued apace at an annual rate of 2% of real growth; could as much as double from its 1996 level of 6.4% to 12.5% by 2031.8 According to the most recent estimates from the Canadian Institute for Health Information (CIHI), government health spending as a percentage of GDP reached 8.4% in 2009i - a level which has already exceeded the 8.1% estimate for 2011 set out in the high-growth scenario of the 1998 report.2 Most recently, Parliamentary Budget Officer Kevin Page has again sounded the alarm in his February 2010 Fiscal Sustainability report.9 He projects that total provincial-territorial government health expenditure could rise to over 14% of GDP by 2040-41. This report presents estimates of the fiscal gap (which is defined as the increase in taxes and/or reduction in spending, measured relative to GDP) that is required to achieve sustainability over the long term. Under their baseline scenario, the government would need to increase revenue and/or reduce spending by $15.5 billion annually, starting immediately. Given that most commentators expect the demand for health care services to increase, reduced spending seems unlikely; hence the need to increase revenue is the most likely option. If there is no political appetite or public support for increasing public revenues for health on the basis of universality and risk pooling then we will be faced with choosing among options for raising funds from private sources. A more detailed analysis of health care funding and sustainability is contained in Appendix A. PART 2: OUR VISION Summary: There are numerous steps required to transform Canada's health care system so that it becomes highly effective and meets the health needs of Canadians. A first step is to re-examine the five principles of the Canada Health Act - universality, accessibility, comprehensiveness, portability, and public administration - and modernize them to meet current and evolving needs. MODERNIZING THE PRINCIPLES OF MEDICARE Change must be undertaken with the patients' interests at the centre. To the CMA, this means meaningful implementation and modernization of the Canada Health Act. Transformational change will refocus our system so that serves the patient - not the other way around as is so often the case today. Canada must follow the lead of other developed countries with universal health care systems that have succeeded in this fundamental objective. Below are the modernized principles for Canada's health system recommended by the CMA: 1. Universality All Canadians must have access to the full range of necessary (evidence-informed) health care services using a variety of funding options as necessary to ensure universal coverage regardless of ability to pay. This includes meeting the needs of vulnerable populations who may not be able to access services due to a variety of barriers (e.g., geographical, socio-economic and demographic). 2. Accessibility All Canadians must have timely access to the full array of health care services over their life span, from primary care (including health promotion and illness prevention) through institutionally based secondary and tertiary care, to community and home-based services that promote rehabilitation and health maintenance, and to palliation at the end of life. There should be clear, measurable wait-time targets/benchmarks for access to necessary care, with publicly funded alternatives available in situations where timely care is not locally available to patients in need. 3. Comprehensiveness All Canadians must have access to the full complement of health services, with incentives in the system to encourage the prevention of illness and to promote optimum health while addressing the complex causative pathways affecting health and disease (i.e., social determinants of health). A defined set of nationally comparable, publicly funded core services should be available to all Canadians chosen through an evidence-informed and transparent manner. There should be an ongoing monitoring of the comparability of access to a full range of medically necessary health services across the country. 4. Portability All Canadians must be eligible for coverage while travelling within Canada, outside of their home province/territory. This principle must be honored in all jurisdictions, and apply to all levels of necessary care. 5. Public administration Services must be appropriately, efficiently and effectively delivered, with providers and patients working together to determine how that is done. The system must ensure that care is integrated and coordinated among providers and services to maintain continuity of care. From the patients' perspective, care must be well-coordinated among providers and between levels (i.e., physician to hospital, hospital back to home, etc.), supported by a functional and secure electronic health information system. The system should be guided by properly structured incentives to reward efficient provision of timely, high-quality patient care. This would include incentives such as activity-based funding of hospitals (i.e., paying on the basis of services provided), and pay-for-performance measures for health care providers, with competition based on valid measures of quality and efficiency. The system would utilize both public and private service providers, and put uniform requirements and regulations in place for measuring quality.ii The system must be able to demonstrate good value for money. There must be accountability mechanisms and performance measurements in place to ensure responsibility for monitoring and managing system performance (e.g., efficiency and effectiveness) at all levels. Regular public reporting on system performance will be required. Societal health goals and targets focused on outcomes will be set and monitored. Health care providers and the community will be actively involved in system decision-making. 6. Patient-centred The system needs to be patient-centred. Patient-centred care is seamless access to the continuum of care in a timely manner, based on need and not the ability to pay, that takes into consideration the individual needs and preferences of the patient and his/her family, and treats the patient with respect and dignity. 7. Sustainability The system must be properly resourced in a sustainable manner. Funding must be sufficient to meet ongoing health care needs. The system must be resilient; that is, capable of withstanding or accommodating demand surges and fiscal pressures. It must have the capacity to innovate and improve and be able to anticipate emerging health needs. Prospective monitoring and documentation of emerging health needs and the burden of illness must be undertaken on an ongoing basis. Strategies must be developed and implemented to meet those needs properly. PART 3: THE FRAMEWORK FOR TRANSFORMATION Summary: The CMA's Health Care Transformation Plan has three core goals: improving population health, improving the patient experience of health care, and improving the value of money spent on health care. There are numerous steps required to transform Canada's health care system so that it becomes highly effective and meets the health needs of Canadians. The next steps are contained in a Framework for Transformation, organized under five pillars, with specific recommendations for action. 1. Building a culture of patient-centred care * Creation of a Charter for Patient-centred Care 2. Incentives for enhancing access and improving quality of care * Changing incentives to enhance timely access * Changing incentives to support quality care 3. Enhancing patient access along the continuum of care * Universal access to prescription drugs * Continuing care outside acute care facilities 4. Helping providers help patients * Ensuring Canada has an adequate supply of health human resources * More effective adoption of health information technologies 5. Building accountability/responsibility at all levels * Need for system accountability * Need for system stewardship The CMA recognizes that none of these directions, taken separately, will transform our health care system. Nor do they represent an exhaustive list of steps, as there are many other directions that can be taken to support our vision. This framework does, however, contain the necessary directions toward the more efficient, high-functioning, patient-focused system that Canadians deserve. For the transformation plan to succeed, the following key enablers must be in place: * leadership at all levels including strong political leadership * well-informed Canadians who understand the need for, and characteristics of, a high-performing health system * patients, physicians and other providers actively involved in the reform and management of the system * a commitment to sustainability with adequate levels of resources to ensure that services are in place * health information technology in place to improve service delivery, manage care within and between services, and monitor and evaluate organization and system performance * incentives properly aligned to support a variety of funding and delivery models that can meet system goals (e.g., to improve access, to improve quality) * co-ordinated health human resources planning at the provincial/territorial and national levels * a commitment to support continuous quality improvement and evidence-informed decision-making at both the policy and clinical levels. These five pillars contain the directions which the CMA believes are necessary to successfully transform our health care system. Many other reforms have been proposed in Canada and elsewhere but based on international experience, these should receive priority attention. 1. BUILDING A CULTURE OF PATIENT-CENTRED CARE The concept of "patient-centred care" is taking hold in other developed countries which are also in the process of reforming their health care systems. The essential principle is that health care services are provided in a manner that works best for patients. Health care providers partner with patients and their families to identify and satisfy the range of needs and preferences. Health providers, governments and patients each have their own specific roles in creating and moving toward a patient-centred system. Patients have consistently emphasized the importance of being respected, having open communication and confidentiality of personal information, in addition to quality medical care. While building a patient-centred system is clearly better for patients, it is also better for physicians and all health care providers and administrators. In a patient-centred system, physicians are provided the optimal environment to give the best possible medical care. From the perspective of health administrators, recruitment and retention of providers who are satisfied with their work and their environment can have many tangible benefits. For instance, hospitals employing patient-centred care principles have found improvements in patient outcomes in areas ranging from decreased length of stay and fewer medication errors to enhanced staff recruitment.10 It is recognized that health care providers strive to practise patient-centred care. Often the issue is that the system - intended to serve as a network of services - is where patient-centred care breaks down. CHARTER FOR PATIENT-CENTRED CARE An important first step in building a culture of patient-centred care is to establish a Charter for Patient-centred Care. As a vision statement, the Charter is built on a foundation of reasonableness and fairness, while acknowledging resource constraints. Notwithstanding resource constraints, governments have the duty to ensure availability of the resources required to provide high quality care. This Charter is a mutually reciprocal covenant among patients, physicians, other health care providers, funders and organizers of care. Dignity and respect * All persons are treated with compassion, dignity and respect. * Health care is provided in an environment that is free from discrimination and/or stigma of any kind. * Health care services respond to individual needs and give consideration to personal preferences. Access to care (timeliness, continuity, comprehensiveness) * Access to and timeliness of appropriate medical and psychiatric services is determined by health need. * Access to appropriate services is not limited by the patient's ability to pay. * Care is continuous between health care providers and across settings. Safety and appropriateness * Care is provided in accordance with the applicable professional standard of care, by appropriately qualified health care providers, regardless of the location of service. * Care is based upon the best available evidence and is provided in the safest possible environment. * The quality of all health care services is evaluated, monitored and improved proactively. * Care is informed and influenced by lessons learned from any critical incident or adverse event and by patient experiences. Privacy and security of information * Personal health information is collected, stored, accessed, used, disclosed and accessible to patients in accordance with applicable law and professional codes of ethics. * Providers and recipients of care share responsibility for the accuracy and completeness of information in personal health records. Decision-making * Patients participate actively with providers in decisions about their medical care and treatment. * Personal support and assistance with communication is available when required. * Patients may appoint another person (proxy decision-maker) to act on their behalf and to be aware of their personal health information. * Decisions for care are made with full disclosure of all relevant information. * Patients may consent to or refuse any examination, intervention or treatment, and may change or vary their decisions without prejudice. * Individuals may decline to participate in research without prejudice. Insurability and Planning of health services * All parties use health care resources appropriately. * Recipients and providers are informed and are able to be involved directly, or through representatives, in the planning, organization, delivery and evaluation of health care services. * Decisions about the provision and insurability of drugs and all other treatments or services are made in accordance with evidence and best practices. * Government decision-making with respect to the planning, regulation and delivery of health care products and services is transparent. Concerns and complaints * Patients may comment on any aspect of their personal health care and have concerns investigated and addressed without repercussions. * Patients receive timely information and an expression of regret and sympathy if there is any adverse event during their care, regardless of the reason for such event. * Providers speak publicly and advocate on behalf of Canadians for the provision of high quality care. Direction The creation of a Charter for Patient-centred Care, as presented above, is a solid foundation on which to build a culture of patient-centred care. In order for the Charter to work, it needs to have supporting mechanisms to ensure accountability. Metrics must be identified to track the elements of the Charter. The Charter needs to be accepted by governments, providers and patients to have an impact on the health system culture and care. Other examples of activities to promote a culture of patient-centred care may include: * increasing availability of programs to prevent illness * increasing involvement of patients and their families in the delivery of care when desired (e.g., if preferred by the patient, family and friends may be trained to help provide care for patients while in the hospital or community) * soliciting patients' feedback on health care services received, and readiness to make changes based on that feedback * establishing patient and family advisory councils for hospitals or health regions * establishing a process for patients or their family members to quickly and efficiently raise a concern about care * providing patients with information about how to access medical records while in the hospital or in the community Progress to date/Next steps The final report of Saskatchewan's Patient First Review, For Patients' Sake (2009),11 devoted considerable attention to the need to re-orient health care to a more patient-centred system. As Commissioner Tony Dagnone stated in his report, "patient-first must be embedded as a core value in health care and be ingrained in the 'DNA' of all health care organizations". The report recommended the adoption of a Charter of Patient Rights and Responsibilities for that province. More recently, an advisory committee to the Alberta Minister of Health has also recommended the creation of a Patient Charter for that province.12 Lessons can be learned from the effects of patient charters in other developed countries. The National Health Service in England recently adopted a constitution which establishes its principles and values: sets out the rights to which patients, public and staff are entitled; includes pledges that the National Health Service is committed to achieve; delineates the responsibilities which the public, patients and staff owe to one another to ensure that the National Health Service operates fairly and effectively.13 The Australian Charter of Healthcare Rights describes seven charter rights to which patients, consumers, carers and families are entitled and the ways they can contribute to ensuring their rights are upheld.14 Those rights are: access, safety, respect, communication, participation, privacy and a right to comment on care and have concerns addressed. 2. PROVIDING INCENTIVES TO ENHANCE ACCESS AND IMPROVE QUALITY OF CARE Canadians have consistently identified timely access as Canada's most pressing health issue. Many other health systems around the world have been successful in dealing with timely access and now are examining the quality of care being delivered. This direction looks at changing incentives to accomplish two related objectives: improving timely access and supporting quality care. A. Enhance timely access Most provinces have taken steps to improve timely access to certain components of their health system. For instance, the Saskatchewan Surgical Initiative has set a target for specialty wait times to be no longer than three months within the next four years.15 At the physician level, several initiatives are underway across Canada. In late 2009, the Primary Care Wait Time Partnership involving the College of Family Physicians of Canada (CFPC) and the CMA released its final report entitled, The Wait Starts Here.16 The report identifies several strategies for improving timely access to primary care. Efforts are also underway in some jurisdictions, such as in Manitoba, to improve the referral process from family physician to specialist (i.e., the timeliness and the appropriateness of referrals). Activity-based funding - an idea raised in the Kirby Commission's final report17 - is another strategy to improve timely access at the facility level. Activity-based funding is a reimbursement mechanism that pays hospitals for each patient treated on the basis of the complexity of their case. A reimbursement level is set for each type of case then applies to all hospitals within the jurisdiction. It is also known as service-based funding, case-mix funding or patient-focused funding. As such, funding is viewed as "following the patient" since the hospital is paid only if the service is provided, resulting in increased productivity and in some instances, competition among hospitals to treat patients. Financing of hospital services in most industrialized countries involves some portion of activity-based funding. Canada, although it has been a pioneer in the methodology that underlies activity-based funding, has had limited application for funding purposes. Most hospitals in Canada receive their funding in the form of a global budget that is usually based on historical funding levels. As a result, a well-performing hospital emergency room does not receive any additional funding for seeing more patients. Direction Canada should move toward partial activity-based funding for hospitals to improve hospital productivity. It is almost impossible to decrease wait times and reward productivity without this change in funding. While some countries have implemented 100% activity-based funding, other countries have shown that productivity can increase when even 25% of hospital funding is allocated in this manner. Progress to date/Next steps A number of provinces have taken steps to introduce activity-based funding for facility-based care. The government of British Columbia announced that it will provide "patient-focused funding" for the province's 23 largest hospitals.18 Ontario already has some limited activity-based funding for its hospitals and the government has announced that it will introduce patient-based payment for hospitals on April 1, 2011 as part of a multi-year implementation plan.19 Alberta announced in 2009 that it would be adopting a form of activity-based funding for long-term care facilities that started April 1, 2010 and for hospitals the year after.20 While not yet in place in Québec, the adoption of activity-based funding was recommended in the 2008 Castonguay report.21 Much of the work involved in supporting the adoption of partial activity-based funding has already been undertaken by CIHI and its well-developed Case Mix Group program supported by case-costing data from BC, Alberta and Ontario. B. Support quality care Timely access is one dimension of quality. But there are many other dimensions of quality including safety, effectiveness, appropriateness and acceptability. More recently in Canada, attention is now focused on incentives to improve quality in the processes of care to achieve better outcomes. Incentives for providers Pay-for-performance involves the use of an incentive payment to reward a hospital or physician provider for achieving a target for the quality of patient care. This may be linked to processes or outcomes of care and could be related to the attainment of a specified threshold and/or percentage improvement. Performance incentives may also be linked to the structure of health care delivery as well as the process of that delivery. 22 It is important to note that pay-for-performance, which refers to incentive payments for achieving quality targets, is not the same as activity-based funding, which is a reimbursement mechanism that pays hospitals for each patient treated on the basis of the complexity of their case. Performance incentives can be targeted at both group output provided by a team of providers (nurses, physical therapists, physicians, etc.) as well as individual members of the team. The incentives may also be targeted at measuring the process involved in delivering the desired health care output. Canada will likely follow the lead of other countries in increasing the focus on the outputs and outcomes of the health care system. The promise of pay-for-performance programs is that they can improve access, quality and accountability. Pink et al. 23 have tried to synthesize the international experience with pay-for-performance and its implications for Canada. Based on this assessment they offer four key considerations: 1. Pay-for-performance could potentially be used to target individual providers, provider groups/organizations, or health regions. 2. The selection of quality measures should consider provincial/territorial health goals and objectives, measures included in existing report cards, evidence and the ability to risk-adjust and the extent of provider acceptance. 3. Development of pay for performance should consider factors that are within the scope of control of providers, use positive incentives over disincentives and consider size/timing and perceived fairness of awards. 4. Program evaluation should consider the impact on patients and providers, quality measurement and how payments are used to improve quality. In addition, they cite the need to address enablers/barriers including information technology, consultation, implementation costs and resistance. Direction Implement appropriate pay-for-performance systems. Adopt principles that secure equity and efficiency in pay-for-performance programs in Canada that will ensure the best outcomes for patients, physicians and the health care system at large. Progress to date/Next steps Pay-for-performance has already started in a number of provinces as seen in the table below. Examples of pay-for-performance programs already in effect in Canada [SEE PDF FOR CORRECT DISPLAY OF TABLE INFORMATION] Province Type of program Nova Scotia Family Physician Chronic Disease Management Incentive Program Ontario Cumulative Preventive Care Bonuses for achieving specified thresholds of preventive care for their patients in five areas: influenza vaccine, pap smear, mammography, childhood immunizations and colorectal cancer screening Manitoba Physician Integrated Network has a Quality Based Incentive component24 Alberta Performance and Diligence Indicator (PDI) Fund for Family Physicians: The PDI Fund provides payments to family physicians who meet specific indicators in the care of their patients. The PDI program "will provide payments to individual family physicians, in and out of primary care networks, who meet specific performance and/or diligence indicators that deliver substantive clinical value"25 British Columbia Full Service Family Practice Incentive Program: this includes an obstetrical care bonus payment and an expansion of the Full Service Family Practice Condition Payments that were introduced in 2003. The condition-based bonus payments are related to the monitoring patients' course of care according to BC Clinical Guidelines for diabetes, congestive heart failure and hypertension26 Pay-for-performance programs will continue to expand in Canada. Governments and insurance companies are introducing pay-for-performance incentive programs throughout the industrialized world with the goal of improving health care delivery efficiencies and especially to improve patient care. These are lofty goals because measuring improvements in patient care is complicated. It is vital that physicians, patients and the health care system establish principles that can guide them to make the best decisions concerning pay-for-performance. The scope of the program and what is measured will surely evolve. Full-scale adoption requires an electronic medical record (EMR) to be in place. Incentives for patients At a macro level, public policies can be instituted to encourage healthy behaviours and environmental improvements (e.g., water quality standards). At the individual level, consideration should be given to empowering patients through the use of patient incentives. A rapidly emerging dimension of pay-for-performance is the use of incentives directed at the patient for health maintenance and healthy behaviours. Hall has reported that a number of US employers are offering tangible rewards to employees such as cash, merchandise, vacation days, and reductions in health care premiums or deductibles.27 These incentives are targeted variously at: * activity (e.g., completing a health risk assessment) * achievement (e.g., quitting smoking, lowering Body Mass Index) * adherence (e.g., remaining tobacco-free for 12 months) Positive incentives are used to promote healthy behaviours by transferring funds or alternate benefits to an individual. They work by providing immediate rewards for behaviours that usually provide only long-term health gains. Positive incentives have been shown to be effective in promoting singular, discrete behaviours, such as vaccinations, screening programs, and attending follow-up appointments. An example of an existing Canadian federal government incentive is the children's fitness tax credit. This credit is intended to promote physical activity among children by off-setting some of the cost incurred by families for sports and leisure programs. In Germany, bonuses for healthy behaviours are integrated into the health system. They are offered for both primary and secondary prevention, including check-up programs, achieving healthy weights, smoking cessation, memberships in sports clubs, and other health-promoting activities. The bonuses take the form of points that can be redeemed for items, including sports equipment, health books or reduction in insurance premiums, or in some cases cash. There are also bonuses, in the form of a reduction in co-payments, for adhering to the treatment plan and participating in special care plans.28 Negative incentives or disincentives by governments largely involve the use of regulation and taxation in order to change individual behaviour. This helps to create an environment in which healthy choices are easier to make. For example, the taxation of tobacco, alcohol or unhealthy foods (such as those high in fat, salt or sugar) are commonly cited interventions. Taxes on tobacco products have been highly effective in reducing use. Studies linking cost to consumption of high-sugar content beverages demonstrate a strong link between higher prices and reduced consumption.29 3. ENHANCING PATIENT ACCESS ALONG THE CONTINUUM OF CARE The continuum of care may be defined as the array of health services, regardless of the age of the recipient, ranging from primary care (including health promotion and illness prevention), through institutionally based secondary and tertiary care for acute medical situations, to community- and home-based services that promote health maintenance and rehabilitation for people with chronic problems, and finally to palliation at the end of life. There is a strong realization that Canada's Medicare system covers a decreasing portion of this continuum. An example of where deficits exist is mental health. The CMA's 2008 annual meeting (General Council) tackled the issue of improving access to mental health services as part of a greater effort led by the Mental Health Commission of Canada. The CMA is currently working toward the several resolutions that were adopted, but there are two other areas that are in urgent need of attention. Crucial to improved care is (A) universal access to comprehensive prescription drug coverage and; (B) improving access to continuing care (long-term care, home care and palliative care/hospice). Physicians currently spend a significant amount of time assisting patients to obtain access to necessary prescription drugs. Physicians and families are also heavily engaged in time-consuming efforts to place patients in long-term care facilities or secure assistance in the home. Improving access for Canadians in these two areas would help create a more patient-centred health care system, and enhance efficiency for providers. CMA approved a new policy on Funding the Continuum of Care in December 2009 that identifies a number of overall principles to enhance the continuum of care: * optimal management of the continuum of care requires that patients take an active part in developing their care and treatment plan, and in monitoring their health status * the issue of the continuum of care must go beyond the question of financing and address questions related to the organization of the delivery of care and to the shared and joint responsibilities of individuals, communities and governments in matters of health care and promotion, prevention and rehabilitation * support systems should be established to allow elderly and disabled Canadians to optimize their ability to live in the community * strategies should be implemented to reduce wait times for accessing publicly funded home and community care services * integrated service delivery systems should be created for home and community care services * any request for expanding the public plan coverage of health services, in particular for home care services and the cost of prescription drugs, must include a comprehensive analysis of the projected cost and potential sources of financing for this expansion A. Universal access to prescription drugs Prescription drugs represent the fastest-growing item in the health budget, and the second-largest category of health expenditure. It is estimated that less than one-half of prescription drug costs were publicly paid for in 2008.2 Moreover, Canada does not have a nationally coordinated policy in the area of very costly drugs that are used to treat rare diseases. The term "catastrophic" has been used by First Ministers and in the National Pharmaceutical Strategy to describe their vision of national pharmaceutical coverage. As defined by the World Health Organization, catastrophic expenditure reflects a level of out-of-pocket health expenditures so high that households have to cut down on necessities such as food and clothing and items related to children's education. From the CMA's perspective, the goal is comprehensive coverage for the whole population, pooling risk across individuals and public and private plans in various jurisdictions. Direction Governments, in consultation with the life and health insurance industry and the public, should establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. Such a program should include the following elements: * a mandate for all Canadians to have either private or public coverage for prescription drugs * uniform income-based ceiling (between public and private plans and across provinces/territories) on out-of-pocket expenditures on drug plan premiums and/or prescription drugs (e.g., 5% of after-tax income) * federal/provincial/territorial cost-sharing of prescription drug expenditures above a household income ceiling, subject to capping the total federal and/or provincial/territorial contributions either by adjusting the federal/provincial/territorial sharing of reimbursement or by scaling the household income ceiling or both * group insurance plans and administrators of employee benefit plans to pool risk above a threshold linked to group size * a continued strong role for private supplementary insurance plans and public drug plans on a level playing field (i.e., premiums and co-payments to cover plan costs) Furthermore the federal government should: * establish a program for access to expensive drugs for rare diseases where those drugs have been demonstrated to be effective * assess the options for risk pooling to cover the inclusion of expensive drugs in public and private drug plan formularies * provide adequate financial compensation to the provincial and territorial governments that have developed, implemented and funded their own public prescription drug insurance plans * provide comprehensive coverage of prescription drugs and immunization for all children in Canada * mandate the CIHI and Statistics Canada to conduct a detailed study of the socio-economic profile of Canadians who have out-of-pocket prescription drug expenses, in order to assess barriers to access and to design strategies that could be built into a comprehensive prescription drug coverage program Progress to date/Next steps Provinces and territories have begun to establish public programs of income-based prescription drug coverage. Québec was the first, starting in 1997, and it remains the only province to mandate universal coverage - that is, citizens must have either public or private coverage. Alberta is the most recent to move in this direction, with a seven-point pharmaceutical strategy that was introduced in 2009.30 Overall, however, there is significant variation between the coverage levels of the various plans across Canada. For example, the Manitoba Pharmacare Program is based on adjusted total income (line 150 of the Income Tax return). For families with incomes above $75,000 the deductible is set at 6.08% of total family income.31 In Newfoundland and Labrador, the ceiling on drug costs is set at 10% of net family income (line 236 of the Income Tax return).32 There is wide variation in the burden of out-of-pocket expenditure on prescription drugs in Canada. In 2006 there was almost five-fold variation in the percentage of households spending more than 5% of net income on prescription drugs between PEI (10.1%) and Ontario (2.2%).33 There is some concern about access to cancer drugs, particularly those that are administered outside of hospital. The Canadian Cancer Society has recently reported that of the 12 cancer drugs approved since 2000 that are administered outside a hospital or clinic, three-quarters cost $20,000 or more annually.34 In 2009, Ontario Ombudsman André Morin issued a report critical of the Ministry of Health's decision to limit public funding of the colorectal cancer drug Avastin to 16 cycles.35 Subsequently the government announced that it would cover the cost beyond the 16 cycles if medical evidence from a physician indicates that there has been no disease progression.36 Most, if not all, key national health stakeholders (hospitals,37 pharmacists,38 nurses,39 brand name pharmaceuticals,40 life and health insurance industry41 plus the health charities) have adopted policy statements on catastrophic coverage. There seems to be an unprecedented consensus among health stakeholders on this issue. The most likely window of opportunity to urge the federal government to take action in this area will be the renegotiation of the Health Accord that is set to expire on March 31, 2014. B. Continuing care Continuing care includes services to the aging and to the disabled of all ages provided by long-term care, home care and home support.42 Because continuing care services are excluded from the Canada Health Act, they are, for the most part, not provided on a first-dollar coverage basis. As this kind of care moves away from hospitals and into the home, the community or into long-term care facilities, the financial burden has shifted from governments to the general public. Furthermore, there is tremendous variation across the country in the accessibility criteria for both placement in long-term care facilities and for home care services. According to Statistics Canada's most recent population projections, the proportion of seniors in the population (65+) is expected to almost double from its present level of 13% to between 23% and 25% by 2031.43 While the impact of an aging population on our health care system must not be overlooked, the continuing care needs of the disabled population at all ages must also be appropriately addressed. In the 2004 Health Accord, the provinces and territories agreed to publicly fund two weeks of acute home care after hospital discharge, two weeks of acute community mental health care and end-of-life care.44 Outside of these areas, the types of services offered and funding models vary widely. Continuing care in Canada faces three key challenges: 1. Lack of capacity and access: There is tremendous variation among regions in the levels of public funding for facility-based long-term care. Part of the reason is the lack of national standards for home care services, which results in a wide range of the types of services available, their accessibility, wait times and eligibility for funding. The widespread scarcity of long-term care facilities and home care services has had deleterious consequences: emergency departments are being used as holding stations while admitted patients wait for a bed to become available, surgeries are being postponed, and the care for Alternate Levels of Care patientsiii is compromised in areas that may not suit each patient's specific needs. Major investment is required in community and institutionally based care. 2. Lack of support for informal caregivers: Much of the burden of continuing care falls on informal (unpaid) caregivers. More than one million employed people aged 45-64 provide informal care to seniors with long-term conditions or disabilities45 and 80% of home care to seniors is provided by unpaid informal caregivers.46 3. Lack of funding for long-term care: It is impractical to expect future requirements for long-term care to be funded on the same "pay-as-you-go" basis as other health expenditures. While there is general agreement that, wherever possible, residents should contribute at least a partial payment toward the cost of accommodation at a long-term care facility, the calculation for these charges is inconsistent across the country. Direction Ensure that all Canadians have affordable and timely access to all elements of any continuing care they require. The CMA recommends the following actions: * Construction should begin immediately on additional long-term care facilities. With the senior population projected to increase to around 24% of the population by 2031, and with 3.5% of seniors currently living in these facilities, in order to simply maintain the same occupancy rates, we will need roughly 2,500 additional homes by then. The Building Canada Fund is an ideal source of initial infrastructure funding. * The federal government should work with the provinces and territories to create national standards for continuing care provision in terms of eligibility criteria, care delivery and accommodation expenses, using the Veterans Independence Plan as a starting point. * The federal government should make long-term care insurance premiums tax deductible, introduce a Registered Long-term Care Plan and/or consider adding a third special provision for the Registered Retirement Savings Plan (RRSP) that is similar to the Lifelong Learning Plan and the Home Buyers' Plan, which will allow working adults to draw from their RRSP, without penalty, to pay for their long-term care or home care needs; and consider adding a third payroll tax for continuing care purposes. * Governments initiate a national dialogue on the Canada Health Act in relation to the continuum of care. * Governments should adopt a policy framework and design principles for access to publicly funded medically necessary services in the home and community setting that can become the basis of a "Canada Extended Health Services Act". * Governments and provincial/territorial medical associations review physician remuneration for home- and community-based services. * Governments undertake pilot studies to support informal caregivers and long-term care patients, including those that a) explore tax credits and/or direct compensation to compensate informal caregivers for their work b) expand relief programs for informal caregivers that provide guaranteed access to respite services in emergency situations c) expand income and asset testing for residents requiring assisted living and long-term care d) promote information on advance directives and representation agreements for patients Progress to date/Next steps Many other groups have released reports on this issue, including the Canadian Healthcare Association's 2009 reports on home care and long-term care. Among many other recommendations, both of these reports call for the introduction of national minimum standards for care and additional support for caregivers.47, 48 New Brunswick announced an ambitious long-term care strategy in early 2008 and the province has invested $167 million in long-term care facilities since 2007. There are plans to open 318 nursing home beds over the next three years, with plans to open a total of 700 in the next 10 years.49 The federal government should use New Brunswick as an example to encourage all other provinces and territories to follow suit. In its final report released in April 2009, the Special Senate Committee on Aging made 32 recommendations; eight of them specifically address health care for seniors in terms of care provision, accommodation and affordability.50 As with improving access to prescription drugs, the most likely window of opportunity to press the federal government to take action in the area of continuing care will be the renegotiation of the 2004 Health Accord that is set to expire on March 31, 2014. 4. HELPING PROVIDERS HELP PATIENTS The fourth pillar of health care transformation speaks to creating necessary resources to support patient-centred care. Two areas that are absolutely essential are: (A) an adequate supply of health human resources; and (B) health information technology at the level in which care is provided or point of care. A. Health human resources Every high-performing health system begins with a strong primary care system in place. Yet roughly 5 million Canadians do not have a regular family physician, and once Canadians do access primary care, they often face long waits to see consulting specialists, and further waits for advanced diagnostics and ultimately treatment. Part of the reason for these delays is the shortage of health care professionals in Canada. An Organization for Economic Co-operation and Development (OECD) study of countries with wait times shows that the availability of physicians has the strongest association with lower wait times than any other factor.51 Notably, Canada's physician supply relative to the population is far below the OECD average. Statistics indicate that in 2006 Canada had only 2.15 practising physicians per 1,000 population compared to the OECD average of 3.07.52 With the number of medical graduates similarly low in comparison to the OECD average, Canada cannot expect to make up the difference without some new sources for physicians. Nurses and other health professionals are also in short supply, in Canada and across the globe. The Canadian Nurses Association is projecting a shortage of 60,000 full-time equivalent nurses in Canada by 2022 if no new policies are adopted,53 and Western Europe is also experiencing a significant nursing shortage. The global shortage of health professionals compounds the problem - while Canadian training programs still lack sufficient seats to produce enough new providers to meet current and future demands, Canadian-educated physicians, nurses, technicians, etc, are being lured away by ample opportunities to train and work outside of Canada. Initiatives such as the Nursing Sector Study,54 Task Force Two,55 the 2004 Federal/Provincial/ Territorial 10-year Plan to Strengthen Health Care44 and the 2005 Framework for Collaborative Pan-Canadian Health Human Resources Planning56 have all yielded abundant information and recommendations, yet Canada still seems unable to maintain a stable supply of physicians, nurses, technicians or other health care professionals to provide the care and treatment patients need. In its 2008 election platform, the federal government announced that it would contribute funds to the provinces and territories to create 50 new residency positions ($10 million/year for four years), ease repatriation of Canadian physicians living abroad ($5 million/year for four years) and help fund the development of nursing recruitment and retention pilot projects ($5 million over three years). On May 10, 2010, Health Minister Leona Aglukkaq announced funding of $6.9 million for 15 additional family medicine residents in the University of Manitoba's Northern and Remote Family Medicine Program. This is a promising start.57 Collaborative care models - whereby health professionals work together with, and in the best interests of, the patient - can help address some of the gaps in health human resources. Over the past decade there have been three key trends pertinent to collaboration in health care: * the contention/recognition that collaboration is an important element of quality patient-centred care * the growing interest in inter-professional education among health professions * the sustained efforts by governments to foster multidisciplinary teams by creating competitive conditions in primary care through expanding the scope of other non-physician providers Physicians recognize the value of collaboration. The Royal College of Physicians and Surgeons of Canada (RCPSC), the CFPC and the CMA have all released policy documents that identified collaboration with other health professionals as a key role of the physician.58,59,60 The RCPSC has since been working to incorporate these roles and competencies in postgraduate medical training programs across Canada. In 2006, the national boards of ten health professional organizations including CMA and CFPC each ratified the principles and framework for interdisciplinary collaboration in primary health care that were developed by a consortium of staff of these organizations, sponsored by the federal Primary Health Care Transition Fund.61 In an effort to find ways to better distribute the workload and improve access to care, much attention has been turned to the role of physician extenders such as physician assistants. Physician assistants can be trained to work autonomously to evaluate, diagnose and treat patients in a partnership and with the supervision of a licensed physician. In Canada, four programs exist to train physician assistants. The Canadian Forces Medical Services School at the Canadian Forces Base Borden in Ontario trains Canadian Forces members while civilian physician assistants can train at McMaster University, the University of Toronto and the University of Manitoba. After the CMA Board approved the inclusion of the physician assistant profession as a designated health science profession within the accreditation process in 2003, its Conjoint Accreditation Services accredited the Canadian Forces' Physician Assistant Program in 2004. Although this program is currently the only one accredited, the other three schools are undergoing the process. Working smarter, Canada needs to be more systematic about innovations and adoption of health sector resources. There is no national body in Canada equivalent to the Institute for Healthcare Improvement in the US, or the National Health Service's Institute for Innovation and Improvement in England, that is charged with promoting innovation in the delivery of health services. In Canada, the $800-million 2000 Primary Health Care Transition Fund and its fore-runner the $150-million 1997 Health Transition Fund were intended to buy transformation in areas linked to primary care. For the most part, this resulted in short-term pilot demonstration projects that ended when the money ran out. Arguably only Ontario and Alberta have achieved lasting results through the development and proliferation of new models of primary care delivery. Direction Ensure Canada's health care system has an adequate supply of human resources. Addressing health human resource shortages is critical to ensuring a sustainable, accessible and patient-centred health care system. The evaluation of and long-term planning for health human resources needs to be performed by a national body using the best available evidence to support its deliberations. Based on the defined need, there are four main mechanisms to address the shortage of health human resources in the Canadian health care system. These are: 1. increase medical school and residency positions to replenish and increase our physician supply for the future 2. invest in recruitment and retention strategies for physicians, nurses and other health care workers 3. ease the process of integration into our health care workforce for international medical graduates and Canadian physicians returning from abroad 4. introduce new providers such as physician assistants to the health care workforce Progress to date/Next steps Immediate specific steps for increasing Canada's supply of health human resources are as follows: 1. Urge the federal government to honour the remainder of its 2008 commitment to fund residency positions, repatriation of Canadian physicians abroad and pilot projects to recruit and retain nurses. 2. Secure comprehensive funding plans for physician assistant compensation. 3. Continue to work with the Federation of Medical Regulatory Authorities of Canada and provincial/territorial medical associations to monitor the impact of the new labour mobility provision of the Agreement on Internal Trade on the distribution and mobility of physicians. 4. Work with provincial/territorial medical associations to carry out an inventory and assessment of the payment arrangements across Canada that foster the emergence of new practice models based on an interdisciplinary approach and the use of new information technologies. 5. Work with other stakeholders to promote the idea of a national locus for innovation in the delivery of health care. Since it can take ten years or longer to train a new physician depending on specialty, the results of increasing medical school placements and residency positions will not be immediate. However, this plan would ultimately increase the future supply of physicians, and serve as a step toward becoming more self-sufficient in the future. As medical education and postgraduate training extend beyond academic health science centres to the community, and as inter-professional education takes on greater emphasis, educational programs need to ensure quality training experiences. Physicians-in-training require adequate human, clinical and physical resources to train appropriately. Programs must ensure that all new teaching sites are properly equipped to take learners. Training new providers, such as physician assistants, is a medium-term option since it takes fewer years (as few as two depending on the program) to train them. Increasing their numbers within the health workforce and permitting them to share some tasks will allow physicians to devote more one-on-one time with patients. Similarly, integrating international medical graduates and repatriating Canadian physicians currently practising outside the country could be a quicker method of increasing physician numbers than training new physicians, provided that appropriate immigration policies and licensure processes are in place. Removing certain constrains, such as limited operating room times, and providing support for collaborative models of care would allow the health human resources currently available to optimize their ability to practise. These options could see results in the shorter term. B. More effective adoption of health information technologies (HIT) Over the past decade, Canada's ministers and deputy ministers of health have been developing strategies to relieve mounting pressures within the health care sector. In all of these strategies, HIT has been viewed as a foundational component. Five main reasons for implementing HIT have been identified: improved health outcomes (patient safety, wait time reduction), increased accessibility, better integration of health care "silos," cost efficiencies and improved patient-provider satisfaction. Multi-billion dollar investments made in Canada on HIT, however, have not yet resulted in significant benefits to providers or patients. In large measure this is due to the fact that all jurisdictions have taken a top-down approach to their HIT strategies and focused their investment on large-scale HIT systems and architecture, with very little investment being made at the points of care where the actual benefits of HIT will be realized. The majority of health care occurs at the local level. Some 400 million patient encounters take place in Canada each year with most occurring in primary care settings with physicians, clinical teams, in home care and long-term care facilities.62 Patient-physician office interactions outnumber patient-hospital interactions by a ratio of 18 to 1. In Ontario (Diagram 1), just 3,000 out of an average of 247,000 patient visits per day - or 1.2% - are made in hospitals. Diagram 1. Patient visits per day in Ontario (Canada Health Infoway) Compared to a select group of other industrialized countries, Canada ranks last in terms of "health information practice capacity" (i.e., the use of EMRs in primary care practice). According to the most recent Commonwealth Fund study (Figure 1) conducted in 2009, only 37% of Canadian primary care physicians use some form of EMR. That compares to 99% in the Netherlands, 97% in New Zealand, 96% in the UK and 95% in Australia. 63 Direction We need to move from a top-down approach to one that gives all providers, and in particular physicians, the lead role in determining how best to use HIT to improve care, improve safety, improve access and help alleviate our growing health human resource issue. HIT adoption needs to be accelerated, but in a way that focuses on the individual patient and where he or she interacts with the health care delivery system, with the intent of improving quality of care and patient safety. An important priority must be a clear, target-driven plan that meets the needs of Canadian physicians and their patients. The CMA and provincial/territorial medical associations will develop a five-year plan with clear targets for accelerating the adoption of HIT in Canada. This includes working with governments to accelerate the introduction of e-prescribing in Canada to make it the main method of prescribing by 2012. Progress to date/Next steps In February 2009, the federal government announced a $500 million investment in HIT, with specific focus on EMRs and point of care integration, as part of their Economic Stimulus package. Transfer of these funds to Canada Health Infoway was delayed due to concerns over accountability and lack of progress on the electronic health record (EHR) agenda on the part of Infoway and most jurisdictions. The Office of the Auditor General's report on Infoway, and six provincial audits on jurisdictional EHR progress addressed these concerns and the funds were finally transferred in spring 2010. CMA is working to ensure that the bulk of this investment is allocated to physician EMRs, as well as local interoperability solutions and applied research on EMR use and patient tools. How to achieve this goal will be described in detail in the CMA's upcoming five-year strategy for HIT investment in Canada, a plan to connect the delivery points at the front lines of care. Provincially, BC, Alberta, Saskatchewan, Ontario and Nova Scotia have established EMR funding programs and are the most likely to meet targets and realize the value of HIT. The addition of $500 million federal stimulus funding to this environment will allow the remaining provinces and territories to implement similar programs. The key will be to focus HIT efforts and investment directly at the point of care. The CMA five-year HIT plan takes a grassroots, bottom-up approach and identifies ways to quickly implement local and regional solutions that will deliver short-term, tangible benefits without building un-scalable, expensive point-to-point solutions. The five-year HIT plan in and of itself is not the goal of this undertaking. The key to effectiveness lies in ensuring any HIT plan sets clear benchmarks and targets for reporting progress and demonstrating value of accelerated HIT adoption in terms of patient care - access, quality and safety. The CMA five-year HIT strategy will set out clear targets and metrics for benchmarking progress and demonstrating value. Tracking and reporting on progress against these targets would occur over the following three to five years, with a final report card to be released at the end of this period. 5. BUILDING ACCOUNTABILITY/RESPONSIBILITY AT ALL LEVELS Two key issues confronting the Canadian health care system are (A) the lack of accountability for system quality of care and performance, and (B) the lack of stewardship for the integrity of the public health insurance program and its long-term financial sustainability. A. Need for system accountability The past decade has seen growing demand for accountability for performance and outcomes at all levels of the health care system, which has been impossible to deliver due to a lack of direction, resources or accountability. As a result, Canada's ability to report publicly on the performance of the Canadian health care system has been piecemeal at best. A main stumbling block is the federal/provincial/territorial dynamic, with provinces and territories being primarily responsible for health care. In 2000, First Ministers made a commitment to develop common indicators to report to their citizens and in 2003 they set out some 40 indicators in the areas of timely access, quality, sustainability and health status and wellness. Subsequently, the Health Council of Canada was set up to monitor the 2003 Health Accord, but since 2004 only the federal government has honoured its commitment to produce indicators, and Québec and Alberta do not participate on the Health Council. The December 2008 report of the federal Auditor General criticized Health Canada for a lack of interpretation in its report and on the limited number of indicators specific to the First Nations and Inuit Health, for which Health Canada is responsible.64 Some national organizations and private organizations are reporting on health system performance at the macro level. CIHI has been producing annual wait time reports in the past years. Think tanks that have also reported on health system performance include: the Commonwealth Fund, the Conference Board of Canada (which has ranked Canada as a middle-of-the-pack performer) and the Euro-Canada Health Consumer Index, which has ranked Canada 30th out of 30 countries in terms of value for money spent on health care in both 2008 and 2009 (the US was not included).7 The Wait Time Alliance65 has produced five report cards on wait times, assessing national and provincial/territorial performance on access to elective care. The CMA has been releasing an annual report card as part of the General Council meetings for the past nine years. At the provincial/territorial level, reporting on health system performance varies widely. All provinces and territories have been reporting wait times, albeit in varying degrees and quality, for some elective surgical care. Several provinces have quality health councils which are producing reports on the quality of care being received. The Ontario Health Quality Council has released several reports on the performance of Ontario's health system, reporting on nine attributes of a high-performing health system.66 Many of these reports call for the need to accelerate the adoption of electronic health records to acquire better data and properly assess health system performance. Ontario has been a leader in health care reporting within Canada. Since the early 1990s, the Ontario Cardiac Care Network has been the gold standard for the comparison of cardiac centres on the basis of wait time and crude and risk adjusted mortality and length of stay data.67 In 1997, a research team at the University of Toronto, funded by the Ontario Hospital Association, began developing a hospital report that focused on key areas of hospital activity including patient perceptions of hospitals.68 In 2007, CIHI released Canada-wide Hospital Standardized Mortality Ratios (HSMR) for the first time. The HSMR is the ratio of actual (observed) deaths to expected deaths, and is adjusted for several factors that affect in-hospital mortality.69 Most recently, the Saskatchewan Health Quality Council issued its first Quality Insight report which reports at the health region (and, in some cases, hospital) level on 121 indicators in the areas of chronic diseases (asthma, diabetes, post heart attack), drug management and patient experience.70 The quest to improve quality of care is a dominant issue in European health systems. The UK, Denmark and the Netherlands have all implemented mechanisms to monitor the performance of their health system. Accountability and monitoring instruments in place in these three countries include: ratings of hospitals, ratings of doctors and system performance reports. In addition, the UK has organizations devoted to monitoring and improving the quality of its health care system. Public reporting on health system performance enjoys high public acceptability. This was the finding of CMA's consultation process for its health care transformation project. Seventy percent of the public surveyed by Ipsos Reid supported independent reviews of hospitals on quality and performance. National Health Goals were developed by the Government of Canada and approved in a broad consensus by all of the provinces and territories in 2005.71 While there was universal acceptance of these goals at the time, there has been limited action on developing a framework and indicators for monitoring achievements. Comprehensive approaches to population health require coordinated action across governments, supported by a common vision, such as national health goals. The CMA strongly supports the advancement of the National Health Goals agenda and believes that public reporting of supporting indicators reflecting the determinants of health as well as health services and outcomes are an important component of improving the health status of Canadians.72 Direction Improve the accountability of the Canadian health care system by reporting publicly on the performance of the system including outcomes. What is needed is a systemic approach to public reporting that shifts the focus from "blame and shame" to quality improvement. Progress to date/Next steps Based on the foregoing, the most likely opportunity for advancing the idea of increased public reporting in the short term will be to work with existing national and provincial/territorial organizations involved in acquiring and analyzing data related to health system performance. At the federal level, the renegotiation of the Health Accord in the lead-up to March 31, 2014 is the best opportunity to see a heightened commitment to improve public reporting at a coordinated federal-provincial-territorial level. Provincially, Québec's recent budget devoted considerable attention to the issue of system accountability. That government announced the annual publication of health accounts to improve transparency and public awareness on health care spending. The accounts, released with the budget, list health and social services spending and revenues. It also includes a breakdown of health sector resources including the number of physicians and nurses and hospitalization days. B. Need for system stewardship To ensure accountability and responsibility, it will be necessary to establish an arm's-length, independent body to monitor, in a transparent manner, the medium to longer-term prospects of the comparability and financing of health care programs for Canada and the provinces and territories. Since its establishment, Canada's national Medicare program has been a funding partnership between the federal and provincial/territorial governments. Since the mid-1990s, this partnership has been beset by problems, due in part to the exclusive jurisdiction of the provinces/territories to administer health programs and to the federal government's unilateral cut to cash transfers of some $6 billion with the implementation of the Canada Health and Social Transfer in 1996. Three broad concerns have been expressed: 1. Lack of accountability of the provincial/territorial governments for use of health transfer funds: at the provincial level, the reports of both the Ménard (2005)73 and Castonguay (2008)21 commissions in Québec called for the establishment of a health account which would provide accountability for how revenues collected for health are used and to inform the public about issues such as financial sustainability of health programs. 2. Canada is a "patchwork quilt" in terms of the continuum of care: there is increasing concern about the wide variation in the level of services provided across the country. The Canada Health Act program criteria only apply to hospital and medical services, and those represent just 41% of total health spending. There is roughly a further 25% of health spending that is public but there is wide variability across jurisdictions with respect to coverage of broader continuum care, such as home care and prescription drugs. For example, Statistics Canada estimates that there was almost five-fold variation in the proportion of households spending more than 5% of net income on prescription drugs in 2006, ranging from 2.2% in Ontario to 10.1% in PEI.33 3. Canada may not be able to sustain Medicare on a "pay-as-you-go" basis: in 1998 the Auditor General of Canada published a report on the implications of the aging population which projected that government spending on health as a share of GDP could as much as double from its 1996 level of 6.4% to 12.5% by 2031 if it increased at an annual rate of 2% real growth.8 In 1998 the Auditor General recommended that the government produce long range financial projections on the basis of status quo policies and alternatives that would be presented to Parliament. In its response, the government indicated that it would continue its fiscal planning on the basis of setting and meeting short-run targets. Clearly we need to be able to look beyond year-over-year budgeting and reporting. The Parliamentary Budget Officer has recently published a report on Canada's emerging "structural deficit" that estimated this shortfall will reach a level of $19 billion in 2013-14.74 The Parliamentary Budget Officer's mandate does not extend to the provincial/territorial governments. While a number of agencies and organizations are doing work related to long-term system sustainability, each is constrained in some manner from carrying out the forward looking cross-jurisdictional analyses that are required. Direction Establish an arm's-length mechanism to monitor the financing of health care programs for the federal and provincial/territorial levels, to assess the comparability of coverage across jurisdictions, to assess value for money and to make recommendations to governments on the sustainability of the current Medicare program and mechanisms to fund additional programs that cover the continuum of care. Progress to date/Next steps At the federal level, the renegotiation of the Health Accord in the lead-up to March 31, 2014 is the best opportunity to see if such a concept could be acceptable at the federal/provincial/territorial level. The CMA met with federal and provincial auditors general on March 16, 2010 to discuss system accountability and sustainability. The auditors general were very interested in this issue and some anticipate examining the matter in the coming months. PART 4: AN ACTION PLAN FOR 2010-2014 With the CMA's ambitious triple aim of improving the health of the population at large, patients' health care experience and value for money spent, the transformation of health care will inevitably be a multi-year and multi-pronged initiative. The first priority has been the release of this document, with its emphasis on adopting a Charter for Patient-centred Care. The final goal is to ensure that the First Ministers' Agreement in 2014 addresses longer-term fundamental issues, such as providing appropriate access to comprehensive pharmaceuticals and continuing care for all Canadians, and implementing a proper accountability framework. As a multi-year initiative, the CMA will pursue the actions described under the health care transformation directions between now and 2013, in time for the negotiation of the next potential Health Accord expected to take effect after the current 2004 agreement expires. As previously mentioned, the directions listed do not represent an exhaustive list. Rather, they are intended to serve as a foundation for change that will build momentum for health care transformation leading to better care. It will be important to demonstrate tangible results - early wins - so that the public, health care providers and system funders can sense the move toward a more patient-focused system and become energized to implement subsequent actions. Summary timeline of key health care transformation deliverables Release of Framework and Charter for Patient-centred Care Summer 2010 IT: Federal support for EMRs 2010 Partial Activity-Based Funding Beginning 2010 Interoperability/e-prescribing 2011-2012 Health human resources - new funding models (physician assistants) 2011 Comprehensive pharmacare/long-term care 2014 Accord Accountability Framework 2014 Accord PART 5: CONCLUSION The policy directions contained in this document, while fundamental, do not represent the entire array of possible choices. This document focuses on the "what" of health care transformation. The "how to" of implementation will require considerable further work, tailored to the needs and circumstances of the various jurisdictions and their populations. Some of the directions in this document are meant to be carried out by government, some by providers, and some by patients. Many, but not all, of the ideas set out in this document will require additional investment by governments. It will not be possible to implement all of these policy directions at the same time. Much of what is outlined here will be put in place at the provincial/territorial level and will be phased in as each jurisdiction deems fit. Provinces and territories must be encouraged to share the lessons they learn as changes are made so that other jurisdictions can build on their successes. Provision must be made for evaluation and mid-course correction to ensure that the proposed directions achieve their intended objectives. The CMA, our partner provincial/territorial medical associations and the physicians of Canada are committed to inspiring change, for the benefit of the patients we serve and in the interests of our members. The aspirations embodied in this document will foster transformation that allows us to accomplish our goals as physicians - to serve the public, provide for our patients' health needs optimally, and to make our health care system more effective, accountable and sustainable now and for the generations to come. APPENDIX A - HEALTH CARE FUNDING AND THE SUSTAINABILITY CHALLENGE Highlights: The ability to pay for health care, which is in competition with all the other legitimate uses for public funds, and the ability to maintain a health workforce are both central to the concept of sustainability. While there is ample evidence that health spending continues to outpace other areas of public expenditure and the growth of government revenue, there is no consensus that we need to act on it. The section notes the necessity of raising funds from private sources if there is no political appetite or public support for increasing public revenues for health. Other key points in this section: * Appropriate investments in health care result in improved health, which reduces health care demand in the future by decreasing the burden of illness in the population. Better health and the resultant improved productivity of the population pays economic dividends for the country. * Given our changing population demographics, governments in Canada will face challenges finding new revenue streams to fund appropriate initiatives such as long-term care, home care or enhanced pharmaceutical coverage over the next two decades. * A large unfunded liability will be created as a consequence of the need to address our growing, aging population that is increasingly burdened with multiple chronic illnesses. Only recently have a few jurisdictions recognized the unfairness of saddling this economic burden on future generations. * Overall health spending is consuming a rising proportion of total government program spending. It also is rising faster than the growth in our GDP, so our ability to pay for health care is increasingly in question. Other important societal programs will be increasingly jeopardized in order to pay for health care programs. * Methods to manage the gap between current levels of expenditure and what will be required to maintain and respond to future health care demands include, a) reducing services and therefore reducing expenditures, b) raising taxes and c) developing new sources of revenue (such as patient co-payments, population health premiums and private insurance). * Our system and culture relies on the principle of collective risk-pooling so as to lessen individual burden. To sustain health care for current and future Canadians and to expand the basket of required coverage, given our changing demographic reality, creative approaches to managing and funding our health system are necessary. The ability to pay for health care is increasingly in question. The challenge of sustaining our health care system is what makes it imperative to move forward now with health care transformation. Sustainability in health care may be defined as the ability to deliver universal publicly funded health care services without compromising other government programs or the ability of future generations to pay. In 2001 the Honourable Roy Romanow was tasked by the federal government to study and make recommendations in order to "ensure over the long-term the sustainability of a universally accessible, publicly funded health system." The Romanow Commission put forward 47 recommendations in 2002 with a view to "buying change".75 Similarly, the Kirby Commission in its review of the Canadian health care system recommended an additional $5 billion of federal funding per year to restructure and renew Medicare.17 These reports were followed by additional federal funding in the amounts of $34.8 billion and $41.3 billion in the 200376 and 200444 First Ministers' Accords respectively. Eight years later it is evident that, for the most part, these Accords bought time, not change. The directions set out in Part 3 of this report rest on two critical assumptions with respect to sustainability. The first is that there is a business case for quality. That is to say, investments in quality today will pay off in improved health that, in turn, will reduce health care demand and expenditures down the road. The resultant improved productivity from the reduction of illness in the population will generate economic dividends for the country. A second assumption is that timely and appropriate interventions will relieve access bottlenecks currently generating unproductive costs. A study conducted for the CMA in 2008 makes the case: it estimated the cost of excess waiting for four procedures at almost $15 billion.77 Hence, the introduction of activity-based funding for hospitals might not reduce hospital costs in total, but if it increases throughput and timely access there will be offsets in improved quality of life and productivity of the population. Clearly, the gains resulting from these assumptions will not be realized in the short term. All the numbers on sustainability, including the projections by Desautels and Page (highlighted in Part 1), assume the status quo in terms of publicly funded programs. But the current system is hardly sustainable on a quality of care basis, particularly given the demographic changes that will see fewer working-age Canadians supporting more and more elderly citizens weighed down by drug costs and the need, over time, for nursing home care. Given our changing population demographics, governments in Canada cannot avoid the challenge of finding new revenue streams to fund appropriate initiatives, such as long-term care, home care or enhanced pharmaceutical coverage over the next two decades. Since the 1990s, there have been repeated recommendations for expanded public coverage of prescription drugs and home care. Health ministers have estimated it would cost $5 billion for governments to provide "catastrophic" pharmaceutical coverage, meaning no household has to spend more than 5% of net income on prescription drugs.78 In contrast, there has been no national policy discussion about the funding of long-term care. Alberta made an exploratory move in this direction in 2005 when it commissioned Aon Consulting to develop health insurance models for continuing care.79 Aon estimated that in order to pre-fund projected costs to 2050, a flat dollar charge of $779 per capita, indexed at 4% per year, would be required for all Albertans aged 16 or over.80 Similarly, the Organization for Economic Co-operation and Development (OECD) has estimated that long-term care accounted for 1.2% GDP in Canada in 2005 and that, at a minimum, the burden will double to 2.4% by 2050.81 A significant amount of this share will almost certainly be publicly funded. Canada will soon have to grapple with how to finance a more comprehensive - and expensive - system of health and continuing care. This, in turn, raises issues about intergenerational equity, that is to say the fairness with which the costs of the system are distributed between generations. If these escalating costs are not addressed now, future generations will be unfairly, and possibly untenably, saddled with the burden flowing from today's growing elderly population. Academics have developed a technique called generational accounting to measure this effect.82 Hagist has applied generational accounting to estimate the revenue gap for health expenditures in six countries. The revenue gap is the percentage increase in taxes that would have to be applied immediately for both living and future generations to bring current fiscal policy on a sustainable track. The same study also estimated a delayed revenue gap, which is the percentage increase that will be required if increases are postponed until 2050. The results for the six countries are shown in Table 1. [SEE PDF FOR CORRECT DISPLAY OF TABLE INFORMATION] Table 1 Estimates of current and delayed revenue gap for health expenditures Selected countries (% increase) Country Switzerland Austria France Germany UK US Revenue Gap 27.1 13.2 9.0 25.9 23.6 27.0 Delayed Revenue Gap 63.1 28.0 17.4 60.7 47.7 46.9 Source: Hagist, C. Demography and Social Health Insurance. Baden-Baden:Nomos, 2008. As one can see, significant immediate increases in revenues are required in all six countries and much more drastic increases will be required if action is delayed. Klumpes and Tang have also applied generational accounting to the funding of the UK National Health Service. They found that under the base assumption of a 2% real interest rate, future tax payers will need to contribute about ten-fold what 2005 new tax payers did.83 In Canada, Robson has applied similar methods to estimate the "unfunded liability" that will result from an aging population. He estimates that between 2007 and 2050, provincial and territorial health budgets will experience an aggregate liability of almost $1.9 trillion if things continue along as they are.84 Total health spending in Canada reached an historic high of 11.9% of GDP in 2009. While this reflects, in part, the effect of the recession in lowering GDP, health spending grew by 5.5% in nominal terms and 3.3% in real terms over 2008. Table 2 shows the average percentage increases in health and total program spending from 1999 to 2008 and the most recent experience of the provinces and territories as presented in their 2010-11 budgets. Table 2? Health and Program Spending 1999-2008 and Selected Indicators 2010 Provincial Territorial Budgets Province / Territory 1999-2008 Average Annual % Increase in Health Spendinga 1999-2008 Average Annual % Increase in Program Spendinga Health as % Program Spending 2010-11 % Increase in Health Spending 2010-11 over 2009-10 % Increase in Program Spending 2010-11 over 2009-10 % Increase in Revenue 2010-11 over 2009-10 NL 6.2 6.9 37.8 12.4 8.4 3.8 PE 8.4 5.9 37.3 3.9 0.3 2.9 NS 7.2 5.9 46.4 6.8 -0.3 3.5 NB 7.0 4.5 36.7 3.5 1.2 1.8 QC 6.4 5.4 44.7 3.7 2.9 2.9 ONb 7.7 6.0 39.8 6.0 6.5 10.8 MB 6.7 5.4 45.1 5.0 0.8 1.8 SK 7.2 6.6 43.4 6.4 0.6 -0.8 AB 10.2 10.2 44.7 16.6 5.6 1.3 BCc 6.4 3.6 45.6 5.1 4.8 5.8 NT 5.2 4.9 25.2 0.3 5.7 5.0 YT 8.1 7.4 21.9 -7.6 -0.8 8.0 NU 9.3 9.1 24.3 -3.7 1.9 5.9 Average 7.4 6.3 37.9 4.5 2.9 4.1 Data sources available upon request a Source: Canadian Institute for Health Information b Note the budget also contains an estimate that health is 45% of program spending in 2010-11 c Total health spending by function is estimated at 42.1% of all government spending The evidence is incontrovertible that health spending has continuously outpaced other areas of public expenditure. All provinces are expecting further health spending increases in 2010-11 - ranging from 3.7% in Québec to 16.6% in Alberta. In eight out of ten provinces, increases in health spending exceed increases in both total program spending and provincial/territorial revenue. As a percentage of program spending, health stands near or just over 45% in six provinces. Aside from Québec (which is discussed below), few measures have been taken to address the problem. It may well require a province or territory to exceed the psychological barrier of 50% to incite a concerted response. This is suggested by a February 2010 poll done for CMA by Ipsos Reid in which respondents were also asked to estimate the actual, appropriate and maximum proportions of their provincial/territorial budget that are or should be devoted to health. The averages estimated by the public are as follows: * actual current percentage - 38% * appropriate percentage - 47% * maximum percentage - 52%. The prospect of going beyond the 50% threshold of the share of government program spending on health might be likened to the proverbial "crossing the Rubicon," which means following a course of action on which there is no turning back. To follow the 50%+ trajectory under the current parameters of Medicare, taxes will surely have to increase, either through general taxation or a dedicated health premium or some variant thereof. Another option that would still pool risk would be the establishment of a contributory social insurance fund. If, however, there is no political appetite or public support for increasing public revenues for health on the basis of universality and risk pooling then we will be faced with options for raising funds from private sources. These could include co-payments for publicly insured services, private insurance or out-of-pocket payment for uninsured/deinsured services, and deductibles linked to utilization. Québec has been the first among the provinces and territories to acknowledge that the current approach to funding health care is neither sustainable in the long term nor fair to future generations - and to announce measures to address the problem. It has taken three major task forces over the past decade to get to this point. In 2001 the Clair Commission recommended a capitalized (pre-funded) insurance plan to cover loss of autonomy.85 Clair also put forward the idea of the creation of a provincial health insurance corporation apart from the Health Ministry. In 2005 the Ménard Committee again recommended the establishment of an insurance scheme for persons experiencing loss of autonomy, as well as the creation of a health and social services account that would provide transparency and accountability for the sources and uses of funds.73 In 2008 the Castonguay Task Force recommended a dedicated "health stabilization fund" that would be funded in part by a deductible linked to medical visits that would be collected at year-end through the income tax system. Castonguay also recommended a health account.21 In response to these studies, the 2010-11 Québec budget contained the following measures: * starting July 1, 2010 a health contribution (premium) will be introduced, to be collected through the tax system; starting at $25 per adult, this will increase to $200 by 2012 at which time it is expected to raise $945 million * further study of the introduction of a health deductible as proposed by Castonguay * the introduction of an annual health account86 Other jurisdictions will also need to give consideration to options for at least partially pre-funding future health care expenditures. The findings of the February 2010 survey conducted for CMA by Ipsos Reid suggest that Canadians would prefer an option that would assure that funds raised would be dedicated to health care over an option that would simply add additional funds to the consolidated revenue account (Figure 2). In considering such options, however, one must be mindful of the current experience with existing mechanisms that are available to Canadians to accumulate savings. According to Canada Revenue Agency Statistics for the 2007 tax year, one in four (26.4%) Canadians with a taxable return reported making a RRSP contribution.87 The likelihood of making RRSP contributions was strongly correlated with income - 15% or fewer with those with incomes less than $25,000 reported one, rising to greater then 60% among those with incomes of $80,000 or greater. There may be greater uptake with the Tax-free Savings Account (TFSA) that was introduced in 2009. A poll done by Ipsos Reid in June 2009 found that 21% of households had opened a TFSA.88 No research has been done on the salience of saving for future health needs as compared to RRSPs and TFSAs. The CMA's 2006 discussion paper It's About Access: Informing the Debate on Public and Private Health Care provides a comprehensive overview and discussion of the international application and pros and cons of a range of public and private funding options. It also sets out ten policy principles to guide policy decision-making related to the public-private interface. In brief, these are: 1. Timely Access 6. Quality 2. Equity 7. Professional Responsibility 3. Choice 8. Transparency 4. Comprehensiveness 9. Accountability 5. Clinical Autonomy 10. Efficiency89 We believe that these principles will serve to guide a national debate. REFERENCES i Derived as the .7023 public share of the estimate of 11.9% of GDP going to total health expenditure. ii The CMA's 2007 policy statement 'It's still about access! Medicare Plus' sets out comprehensive recommendations for the public-private interface in the delivery and funding of health care. iii Patients who remain in hospital while waiting for placement in long-term care facilities or for home care arrangements to be made. 1 Department of Justice Canada. Canada Health Act (R.S., 1985, c. C-6). www.laws.justice.gc.ca/PDF/Statute/C/C-6.pdf. Accessed 06/28/2010. 2 Canadian Institute for Health Information. National health expenditure trends 1975 to 2009. Ottawa, 2009. 3 Bowlby G. Studies in "non-standard" employment in Canada. www.wiego.org/reports/statistics/nov-2008/bowlby_presentation_2008.pdf. Accessed 06/28/2010. 4 Conference Board of Canada. How Canada performs 2009: A report card on Canada. www.conferenceboard.ca/HCP/Details/Health.aspx. Accessed 06/27/2010. 5 World Health Organization. World health report 2000. Health systems: Improving performance. Geneva, 2000. 6 Commonwealth Fund. Mirror, mirror on the wall. How the performance of the U.S. health care system compares internationally. 2010 update. www.commonwealthfund.org/~/media/files/Publications/Fund%20Report/2010/Jun/1400_Davis_Mirror_Mirror_on_the_wall_2010.pdf 7 Eriksson D, Björnberg A. Euro-Canada Health Consumer Index 2009. Winnipeg: Frontier Centre for Public Policy, 2009. 8 Auditor General of Canada. April 1998 Report. Chapter 6 population aging and information for Parliament: understanding the choices. www.oag-bvg.gc.ca/internet/English/parl_oag_199804_06_e_9312.html. Accessed 01/26/10. 9 Parliamentary Budget Officer. Fiscal sustainability report. February 18, 2020. www2.parl.gc.ca/sites/pbo-dpb/documents/FSR_2010.pdf. Accessed 04/27/10. 10 Stone S. A Retrospective Evaluation of the Planetree Patient-Centred Model of Care on Inpatient Quality Outcomes. Health Environments Research and Design Journal. 2008;1(4):55-69. 11 Dagnone T. For patients' sake. www.health.gov.sk.ca/patient-first-commissioners-report. Accessed 06/28/2010. 12 Minister's Advisory Committee on Health. A foundation for Alberta's health system. www.health.alberta.ca/documents/MACH-Final-Report-2010-01-20.pdf. Accessed 06/28/2010. 13 Department of Health. The NHS Constitution. www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113645.pdf. Accessed 06/28/2010. 14 Australian Commission on Safety and Quality in Healthcare. Australian charter of healthcare rights. www.health.gov.au/internet/safety/publishing.nsf/content/com-pubs_ACHR-roles/$file/17537-charter.pdf. Accessed 06/28/2010. 15 Saskatchewan Health. Sooner, safer, smarter: A plan to transform the surgical patient experience. www.health.gov.sk.ca/Default.aspx?DN=545d9e1d-6cfe-447d-ac42-3b35f0dc8f5d&l=English. Accessed 06/28/2010. 16 Canadian Medical Association, College of Family Physicians of Canada. The wait starts here. The Primary Care Wait Time Partnership. 2 Dec 2009. www.cfpc.ca/.../PCWTP%20FINAL%20-%20FINAL%20ENGLISH%20(DEC%202009).pdf 17 Standing Senate Committee on Social Affairs, Science and Technology. The health of Canadians - the federal role. Volume six: Recommendations for reform. Ottawa, 2002. 18 British Columbia Ministry of Health Services. B.C. launches patient-focused funding provincewide. News release April 12, 2010. www2.news.gov.bc.ca/news_releases_2009-2013/2010HSERV0020-000403.pdf. Accessed 06/28/2010. 19 Ontario Ministry of Health and Long Term Care. Patient-based payment for hospitals. Backgrounder May 3,2010. www.health.gov.on.ca/en/news/release/2010/may/bg_20100503.pdf.Accesed 06/06/2010 20 Duckett S. "Thinking Economically in the health Sector". Presented to the Economics Society of Northern Alberta. 13 Nov 2009. 21 Task Force on the Funding of the Health System. Getting our money's worth. Québec: Gouvernement du Québec, 2008. 22 Donabedian A.Evaluating the quality of medical care. Milbank Quarterly 1966; 44:166-203. 23 Pink GH, Brown AD, Studer ML, Reiter KL, Leatt P. Pay-for-Performance in publicly financed healthcare: Some international experience and considerations for Canada. Healthcare Papers 2006; 6(4):8-26. 24 PIN is a Manitoba Health and Healthy Living primary care renewal initiative that focuses on fee-for-service (FFS) physician groups. Its goal is to facilitate systemic improvements in the delivery of primary care. See: www.gov.mb.ca/health/phc/pin/index.html 25 Alberta Medical Association President's Letter September 16, 2009. See: www.albertadoctors.org/bcm/ama/ama-website.nsf/AllDoc/4C2E247349659BD58725763300532A11/$File/preslet_sept16_09.pdf 26 British Columbia Medical Association. Full service family practice incentive program: frequently asked questions. Vancouver, 2006. 27 Hall B. Health incentives: the science and art of motivating healthy behaviours. Benefits Quarterly 2008; 24(2):12-22. 28 Schmidt H. Bonuses as incentives and rewards for healthy responsibility: A good thing? Journal of Medicine and Philosophy 2008; 33: 198-220. 29 Andreyeva T, Long M, Brownell K. The impact of food prices on consumption: a systematic review of research on the price elasticity of demand for food. Am J Public Health. 2010 Feb; 100(2):216-22. 30 Alberta Health and Wellness. Alberta Pharmaceutical Strategy. www.health.alberta.ca/documents/Pharmaceutical-Strategy-2009.pdf Accessed 11/02/09. 31 Manitoba Health. Manitoba Pharmacare Program. www.gov.mb.ca/health/pharmacare/index.html Accessed 11/02/09. 32 Newfoundland and Labrador Health and Community Services. Enhancements to program make drugs more affordable. April 23, 2007. www.releases.gov.nl.ca/releases/2007/health/0423n01.htm Accessed 11/02/09. 33 Statistics Canada. CANSIM Table 109-5012 Household spending on prescription drugs as a percentage of after-tax income, Canada and provinces. 2008. 34 Canadian Cancer Society. Cancer drug access for Canadians. Toronto, 2009. 35 Marin A. A vast injustice. Toronto, 2009. 36 Ontario Ministry of Health and Long-Term Care. Ontario expands access to cancer drug. News release November 29, 2009. www.health.gov.on.ca/en/news/release/2009/nov/nr_20091129.pdf. Accessed 06/06/2010. 37 Canadian Healthcare Association. Catastrophic pharmaceutical coverage. Ottawa, 2006. 38 Canadian Pharmacists Association. Catastrophic drug coverage - CphA position statement. Ottawa, 2008. 39 Canadian Nurses Association. CNA Presentation to House of Commons Standing Committee on Health Study on Prescription Drugs. September, 2003. 40 Canada's Research Based Pharmaceutical Companies (Rx&D). Catastrophic drug coverage. Ottawa, 2006. 41 Canadian Life and Health Insurance Association. Towards a sustainable, accessible, quality public health care system. Ottawa, 2009. 42 Canadian Institute for Health Information. Development of National Indicators and a Reporting System for Continuing Care (Long Term Care Facilities). Ottawa, 2000. 43 Statistics Canada. Population projections: Canada, the province and territories, 2009 to 2036. The Daily, Wednesday, May 26, 2010. 44 Canadian Intergovernmental Conference Centre. A 10-year plan to strengthen health care. Available from: scics.gc.ca/cinfo04/800042005_e.pdf Accessed 06/07/2010. 45 Pyper W. Balancing career and care. Perspectives on Labour and Income 2006;7(11):5-15. 46 National Advisory Council on Aging. 1999 and beyond: Challenges of an aging Canadian society. Ottawa, 1999. dsp-psd.pwgsc.gc.ca/Collection/H88-3-28-1999E.pdf. Accessed 02/29/2010. 47 Canadian Healthcare Association. Home Care in Canada: From the margins to the mainstream. Available from: www.cha.ca/documents/Home_Care_in_Canada_From_the_Margins_to_the_Mainstream_web.pdf. Accessed 06/04/2010 48 Canadian Healthcare Association. New Directions for Facility-Based Long Term Care. Available from: www.cha.ca/documents/CHA_LTC_9-22-09_eng.pdf. Accessed 06/04/2010. 49 Smith L. There is nothing for nothing any longer, especially for seniors. The Daily Gleaner. 21 Oct 2009. Available from: dailygleaner.canadaeast.com/rss/article/830881. Accessed 11/10/2009. 50 Special Senate Committee on Aging. Is Canada ready for an aging population? Senate Special Committee on Aging Identifies Serious Gaps for Older Canadians in Canada's Aging Population: Seizing the Opportunity. Available from: www.parl.gc.ca/40/2/parlbus/commbus/senate/com-e/agei-e/subsite-e/Aging_Report_Home-e.htm. Accessed 06/07/2010 51 Siciliani L, Hurst J. Explaining waiting times for elective surgery across OECD countries. OECD Health Working Papers No 7. Paris, 2003. 52 OECD Health Data 2009, June 2009. 53 Canadian Nurses Association. Tested solutions for eliminating Canada's registered nursing shortage. Ottawa, 2009 54 Nursing Sector Study Corporation (May 2006). Building the Future: An integrated strategy for nursing human resources in Canada, retrieved from www.cna-aiic.ca/CNA/documents/pdf/publications/Phase_II_Final_Report_e.pdf. Accessed 06/09/09. 55 Task Force Two. A physician human resource strategy for Canada: final report. Ottawa, 2006 56 Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources (2005, revised 2007). Framework for Collaborative Pan-Canadian Health Human Resources Planning, retrieved from www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/hhr/2007-frame-cadre/2007-frame-cadre-eng.pdf. Accessed 06/04/2010 57 Health Canada. Government of Canada announces funding to support 15 new family medicine positions for Canada's north. News release. May 10, 2009. http://www.hc-sc.gc.ca/ahc-asc/media/nr-cp/_2010/2010_72-eng.php. Accessed 06/29/2010. 58 Frank J (ed.) The CanMEDS 2005 Physician Competency Framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 59 College of Family Physicians of Canada. Four principles of family medicine. www.cfpc.ca/English/cfpc/about%20us/principles/default.asp?s=1. Accessed 06/07/2010 60 Canadian Medical Association. CMA Policy on Scopes of Practice. Ottawa, 2001. 61 Enhancing Interdisciplinary Collaboration in Primary Health Care. The principles and framework for interdisciplinary collaboration in primary health care. www.eicp.ca/en/principles/march/EICP-Principles-and-Framework-March.pdf. Accessed 04/28/10. 62 Sources: CIHI Reports for Physician visits: Physicians in Canada: Fee-for-Service Utilization 2005-2006. Table 1-21. Hospital contacts: Trends in Acute Inpatient Hospitalizations and Day surgery Visits in Canada 1995-1996 to 2005-2006 and National Ambulatory Care Reporting System: Visit Disposition by Triage Level for All Emergency Visits - 2005-2006. 63 Schoen C, Osborn R, Doty MM, Squires D, Peugh J, Applebaum S. A survey of primary care physicians in eleven countries, 2009: Perspectives on care, costs and experiences. Health Affairs 2009; 28(6):1179-83. 64 Auditor General of Canada. 2008 December report of the Auditor General of Canada. Chapter 8 - reporting on health indicators - Health Canada. www.oag-bvg.gc.ca/internet/docs/parl_oag_200812_08_e.pdf. Accessed 06/27/2010. 65 www.waittimealliance.ca 66 www.ohqc.ca 67 www.ccn.on.ca 68 www.hospitalreport.ca 69 Canadian Institute for Health Information. HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada. secure.cihi.ca/cihiweb/products/HSMR_hospital_mortality_trends_in_canada.pdf. Accessed 06/09/09. 70 Saskatchewan Health Quality Council. Quality Insight, 2008. www.hqc.sk.ca/download.jsp?oLYnotVGsC60FgKBEcq12DBIzBf0QfLQkUwK4QBZaJtXhmSAKqZibA==. Accessed 06/07/10 71 Public Health Agency of Canada. Health goals for Canada. www.phac-aspc.gc.ca/hgc-osc/pdf/goals-e.pdf. Accessed 06/20/2010. 72 Canadian Medical Association. National Health Goals for Canada: A Review of Successes, Challenges, and Opportunities for the Canadian Medical Association. Ottawa 2010 73 Comité de travail sur la pérennité du système de santé et des services sociaux du Québec. Pour sortir de l'impasse : la solidarité entre nos générations. Québec : Ministère de la santé et des services sociaux du Québec, 2005. 74 Parliamentary Budget Officer. Estimating potential GDP and the government's structural budget balance. www2.parl.gc.ca/Sites/PBO-DPB/documents/Potential_CABB_EN.pdf. Accessed 01/26/10. 75 Romanow, R. Building on values: the future of health care in Canada. Ottawa: Commission on the Future of Health Care in Canada, 2002. 76 Canadian Intergovernmental Conference Centre. 2003 First Ministers' Accord on Health Care Renewal. February 5, 2003. www.scics.gc.ca/pdf/800039001_e.pdf. Accessed 04/27/10. 77 The Centre for Spatial Economics. The economic cost of wait times in Canada 2008. www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/pdf/2008/EconomicReport.pdf Accessed 07/06/2010. 78 Canadian Intergovernmental Conference Centre. National Pharmaceutical Strategy decision points. http://www.scics.gc.ca/cinfo08/860556005_e.html. Accessed 04/27/10. 79 Aon Consulting. Health benefit design options for Alberta Health & Wellness: Executive summary 29 March 2006. http://www.health.alberta.ca/documents/Options-Aon-2006-summary.pdf. Accessed 04/27/10. 80 Aon Consulting. Continuing care. http://www.health.alberta.ca/documents/Options-Aon-2006-Care.pdf. Accessed 04/27/10. 81 Organization for Economic Cooperation and Development. Projecting OECD health and long-term care expenditures: what are the main drivers? Economics Department Working Papers No. 477. http://www.oecd.org/dataoecd/57/7/36085940.pdf. Accessed 04/28/10 82 Auerbach A., Gokhale J., Kotlikoff L. Generational accounts: a meaningful alternative to deficit acccounting. Tax Policy and the Economy 5. Cambridge, MA: MIT Press and the NBER, 1991. 83 Klumpes P, Tang L. The cost incidence of the UK's National Health Service system. Geneva Papers 2008;33:744-67. 84 Robson W. Boomer bulge: dealing with the stress of demographic change on government budgets in Canada. www.cdhowe.org/pdf/ebrief_71.pdf. Accessed 04/28/10. 85 Commission d'étude sur les services de santé et les services sociaux. Emerging solutions : report and recommendations. Québec : Gouvernement du Québec, 2001. 86 Finances Québec. For a more efficient and better funded health-care system. www.budget.finances.gouv.qc.ca/Budget/2010-2011/en/documents/MoreEfficient.pdf. Accessed 04/27/10. 87 Canada Revenue Agency. Income Statistics 2009 - 2007 tax year. Interim Table 2 - Universe data. www.cra-arc.gc.ca/gncy/stts/gb07/pst/ntrm/pdf/table2-eng.pdf. Accessed 04/28/10. 88 Ipsos Reid. Canadians embracing tax-free savings accounts. October 20, 2009. www.ipsos-na.com/news-polls/pressrelease.aspx?id=4557. Accessed 04/28/10. 89 Canadian Medical Association. It's about access: informing the debate on public and private health care. Ottawa, 2006.

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Health in all policies

https://policybase.cma.ca/en/permalink/policy11527

Date
2015-05-30
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Date
2015-05-30
Topics
Health systems, system funding and performance
Text
HEALTH IN ALL POLICIES Issue Despite significant investments in health and improvements in medical treatment and technologies, health outcomes in Canada have not been moving in the right direction. Chronic diseases such as diabetes and the corresponding risk factors, among them obesity, continue to rise. This negative health status can undermine not only individual health but the productivity and prosperity of the country as well.1 As noted in the Adelaide Statement on Health in All Policies, "Good health enhances quality of life, improves workforce productivity, increases the capacity for learning, strengthens families and communities, supports sustainable habitats and environments, and contributes to security, poverty reduction and social inclusion."2 Research suggests that 15% of population health is determined by biology and genetics, 10% by physical environments, 25% by the actions of the health care system, with 50% being determined by our social and economic environment.3 Many studies show that people low on the socio-economic scale are likely to carry a higher burden of just about any disease.4 Poverty accounts for 24% of person years of life lost in Canada (second only to 30% for neoplasms).5 These numbers demonstrate a need to rethink the way we work to improve the health of the Canadian population. While a strong health care system is vital, changes to our health system alone will not be sufficient to improve health outcomes or reduce the disparities that currently exist in disease burden and health risks. Using health determinants as a focus means that most health promotion and prevention efforts will take place outside of the health and medical care service.6 Canadians must be supported to make the choices that keep them healthy and reduce their risks of injury and disease. However, many face barriers in their physical, social and economic environments which make these healthy choices difficult. What is necessary is a coordinated effort across government sectors to ensure that all policy decisions serve to increase opportunities for health. As noted by the former Minister of Health and Welfare, Jake Epp, "it is not an overstatement to say that public policy has the power to provide people with the opportunities for health, as well as to deny them such opportunities... All policies having a direct bearing on health need to be coordinated."7 Improving population health and reducing inequities should be an overall objective for all governments in Canada. Not only will it help to reduce costs to the health system, it will also increase economic growth as healthier people lose fewer days of work and contribute to overall economic productivity.8 As laid out in the principles to Guide Health Care Transformation, "Coordinated investments in health promotion and disease and injury prevention, including attention to the role of the social determinants of health, are critical to the future health and wellness of Canadians and to the viability of the health care system.9" Background The utilization of such an approach is not new. Governments from England to Finland to New Zealand have increasingly recognized the importance of the social determinants of health and have developed national strategies accordingly. These strategies, often referred to as 'health in all policies,' call for a whole of government approach where cross-departmental collaboration is established at the highest government level to increase the health of the population and reduce inequalities.10 The World Health Organization defines health in all policies as follows: Health in all Policies (HiAP) is an approach to public policies across sectors that systematically takes into account the health and health systems implications of decisions, seeks synergies, and avoids harmful health impacts, in order to improve population health and health equity. A HiAP approach is founded on health-related rights and obligations. It emphasizes the consequences of public policies on health determinants, and aims to improve the accountability of policy-makers for health impacts at all levels of policy-making.11 This approach looks at all policies that have a health impact not just those in the health sector. Policies are reviewed for their potential impact on population health and health system utilization.12 There are many ways that a HiAP approach can be implemented. Examples include: inter-ministerial and inter-departmental committees; community consultations and Citizens' Juries; cross-sector action teams; partnership platforms; integrated budgets and accounting; Health Lens Analyses; cross-cutting information and evaluation systems; impact assessments; joined-up workforce development; and legislative frameworks.13 A Plan for Canada Role of the Federal Government: While the provinces and territories have constitutional authority for the majority of health system delivery, the federal government has a significant role in health: through system oversight, Canada Health Act; delivery to certain populations, Canada's Aboriginal peoples; as well as accountability and pan-Canadian initiatives for the various health systems. Additionally, the federal government has significant control over areas such as taxation, food security and agriculture, justice, transportation safety and income security (eg child tax benefits, Old- Age Security). All of these can have a marked impact on both individual and population health. As a result of these responsibilities the Canadian government needs to adopt a clear mandate to focus on the health of the population. Actions must be taken to provide Canadians with the ability to make healthy choices. All legislation must be subject to a health lens to determine potential health implications so as to minimize or mitigate any negative consequences and maximize opportunities for health benefits. Given the central coordinating function of Cabinet in policy setting and delivery, this would be an ideal place to incorporate a HiAP approach. 1. CMA recommends that the federal government acknowledge the relationship of the social determinants of health on the health of the population as well as the demands of the health care system and that it implement a Health in All Policies approach for all cabinet decision-making. While Cabinet should serve as the central decision-making body for a HiAP approach, there must be formal and sustainable structures that allow timely analysis of the health consequences of policy decisions, which appropriately engage stakeholders, and which ensure that health impacts are actually considered in policy decision-making.14 Such an approach will require some form of enabling legislation as well as benefits for departments that conduct HiAP analysis. In Quebec, for example, all policies are required to undergo a review of health impacts under Section 54 of the 2002 Quebec Public Health Act.15 In addition, it is likely that a lead agency will need to be appointed to facilitate the necessary data collection/analysis to review policies. In the Netherlands health impact assessments are the responsibility of the Department of Intersectoral Policy at the Netherlands School of Public Health.16 Since 2000, the Swedish National Public Health Institute (SNIPH) has been tasked with developing methodology in strategically important areas and with supporting the application of health assessments on the central, regional and local level.17 In England, the Public Health Observatories play a key role in providing data and analysis for health impact assessments.18 A significant barriers to HiAP in Canada is the existing data infrastructure. Hundreds of major and minor publications speak to the volume of analyses undertaken on health and health systems every year in Canada. Despite this effort, Canadian policy makers and the public do not fully understand how health system vs. non-health factors contribute to the health outcomes observed or the picture of overall health. The available data tends to focus on the health care system, sickness and the measurement of sickness related risks. What is missing is a way of organizing the data which provides greater insight for planners and greater accountability for all Canadians. This capacity will need to be developed in order to properly implement a HiAP approach. 2. CMA recommends that the federal government provide the necessary enabling environment to allow for the application of a health in all policies approach in all new policy development. As the experiences from other countries demonstrate there is some value in selecting a few Ministries to begin the process. Once selected the Ministries should be responsible for starting the process and screening any new policies. If there is a potential health impact they would then contact the centralized resource to conduct the analysis and produce a report with potential impacts and recommendations for change. This report would go back to the originating Ministry for review and modification of the policy as necessary. Changes should be highlighted and the revised policy should be sent with the health analysis report to Cabinet for final decision-making. This will help to improve the policy and will create greater awareness among all Cabinet members of the potential health implications of various policies. 3. CMA recommends that the Federal Minister of Health work with Cabinet to select appropriate Ministries to begin the implementation of the health in all policies approach. Role of Health Care Sector: Government is not the only group with a role in HiAP. The health sector, including Canada's physicians can work to ensure that the policy environment promotes health. By working with governments at all levels, physicians can uses their vast knowledge and expertise to provide evidence regarding potential health implications, and promote the development of evidence-informed decision making. In addition, they can work with partners both within and outside of the health sector to advocate as necessary for policy improvements.19 4. CMA recommends that physicians and other health care providers use their knowledge and expertise to support governments in the development of evidence-informed policy which promotes the health of the population. Conclusion Investments in the health system will only go so far in improving the health of the population. Population health approaches must tackle the wider social determinants of health. To do so the government must consider health in all the policies that it develops. References 1 Reeves, Richard A Liberal Dose? Health and Wellbeing - the Role of the State: An Independent Report. 2010. Available: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_111695.pdf 2 World Health Organizatio. Adelaide Statement on Health in All Policies: moving toward a shared governance for health and well-being. Geneva:The Organization; 2010. Available: www.who.int/social_determinants/hiap_statement_who_sa_final.pdf (accessed 2015 Apr 16). 3 Keon, WJ, Pépin L. (2008) Population Health Policy: Issues and Options. Ottawa: The Senate of Canada; 2008. Available at: www.parl.gc.ca/Content/SEN/Committee/392/soci/rep/rep10apr08-e.pdf 4 Dunn JR. The Health Determinants Partnership Making Connections Project: Are Widening Income Inequalities Making Canada Less Healthy? Toronto :The Health Determinants Partnership; 2002 Available: http://en.healthnexus.ca/sites/en.healthnexus.ca/files/resources/widening_income_equalities.pdf (accessed 2015 Apr 16) 5 Wilkins R, Berthelot J-M, Ng E. Trends in mortality by neighbourhood income in urban Canada from 1971 to 1996. Statistics Canada.Health Rep. 2002:13(Supplement): 10. 6 Knutsson I, Linell A Health impact assessment developments in Sweden. Scand J Public Health. 2010;38:115-120. 7 Epp, J. Achieving health for all: a framework for health promotion. Ottawa: Health and Welfare Canada; 1986. Available: www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/1986-frame-plan-promotion/index-eng.php 8 Munro, D Healthy People, Healthy Performance, Healthy Profits: The Case for Business Action on the Socio-Economic Determinants of Health. Ottawa: Conference Board of Canada; 2008.Available: www.conferenceboard.ca/Libraries/NETWORK_PUBLIC/dec2008_report_healthypeople.sflb 9 Canadian Medical Association, Canadian Nursese Association. Principles for Health Care Transformation in Canada. Ottawa: The Associations; 2011. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-13.pdf 10 St-Pierre L. Governance Tools And Framework For Health In All Policies. Available: www.rvz.net/uploads/docs/Achtergrondstudie_-_Governance_tools_and_framework1.pdf 11 World Health Organization, Government of South Australia. Adapted from WHO Working Definition prepared for the 8Th Global Conference on Health Promotion, Helsinki, 10-14 June 2013. 12 Ollila E, Baum F, Pe ña S. Introduction to health in all policies and the analytical framework of the book. In Leppo K, Ollila E, Pera S, et al., editors. Health in all policies: seizing opportunities, implementing policies. Chap. 1. Finland: Ministry of Social Affairs and Health; 2013. Available: www.euro.who.int/__data/assets/pdf_file/0007/188809/Health-in-All-Policies-final.pdf. 13 World Health Organization, Government of South Australia. Adelaide Statement on Health in All Policies: moving towards a shared governance for health and well-being. Geneva: The Organization; 2010. Available: www.who.int/social_determinants/hiap_statement_who_sa_final.pdf (accessed October 18, 2014) 14 Rudolph, L, Caplan J, Mitchell C, et al. Health in All Policies: Improving Health Through Intersectoral Collaboration. Washington(DC): Institute of Medicine. Available: www.phi.org/uploads/application/files/q79jnmxq5krx9qiu5j6gzdnl6g9s41l65co2ir1kz0lvmx67to.pdf (accessed October 21, 2014). 15 National Collaborating Centre for Healthy Public Policy. Implementation of Sectin 54 of Quebec's Public Health Act. Quebec: The Centre; 2012. Available at: www.ncchpp.ca/docs/Section54English042008.pdf 16 Wright, J, Parry J, Scully EInstitutionalizing policy-level health impact assessment in Europe: Is coupling health impact assessment with strategic environmental assessment the next step forward? Bull World Health Orga. 2005;83(6):472-7 17 Knutsson I, Linell A Health impact assessment developments in Sweden. Scand J Public Health. 2010;38(2):115-20 18 St-Pierre L. Governance Tools And Framework for health in all policies. Available: www.rvz.net/uploads/docs/Achtergrondstudie_-_Governance_tools_and_framework1.pdf 19 Leppo K, Tangcharoensathien V. The health sector's role in HiAP. In Leppo K, Ollila E, Pera S, et al., editors. Health in all policies: seizing opportunities, implementing policies. Chap. 14. Finland: Ministry of Social Affairs and Health; 2013. Available: www.euro.who.int/__data/assets/pdf_file/0007/188809/Health-in-All-Policies-final.pdf. (accessed October 18, 2014)

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Improving efficiency in the Canadian health care system

https://policybase.cma.ca/en/permalink/policy11525

Date
2015-05-30
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Date
2015-05-30
Topics
Health systems, system funding and performance
Text
IMPROVING EFFICIENCY IN THE CANADIAN HEALTH CARE SYSTEM Achieving value in health care systems is an important objective for all nations.1 Health care systems in Canada and elsewhere are examining ways to address inefficiencies to make the system more cost-effective and sustainable while improving the quality, continuity, and comprehensiveness of care. This policy statement puts forth recommendations for system sustainability and improving quality of care. All system stakeholders including providers, funders and patients bear responsibility to ensure the health care system is as efficient as possible. Physician input is a necessary condition for meaningful system improvement and innovation. 1. Introduction Health care systems in Canada and elsewhere are examining ways to address inefficiencies to make the system more cost-effective and sustainable while improving the quality, continuity, and comprehensiveness of care. The concept of efficiency in health care has two applications. The most common is technical efficiency, which is defined as producing maximum output for a given level of inputs, or minimizing input for a given level of output.2 The difference between actual output and the maximum achievable output may be attributed to inefficiency within the system. The second is called allocative efficiency, which refers to optimizing resource allocation to produce maximum outputs that fulfill societal demands. Canadian research suggests that increasing technical and allocative efficiency rather than increasing spending could solve some of the current challenges regarding health care quality and sustainability. Based on a macro system-level approach to estimating efficiency among its member countries, the Organization for Economic Cooperation and Development (OECD) has estimated that all of its member countries could achieve better value from their health care spending-Canada could save 2.5% of Gross Domestic Product in public spending by 2017 if it were to become as efficient as the most efficient OECD countries.3 2. Health care inefficiencies The various inefficiencies in the Canadian health care system may be categorized and visualized using the conceptual framework developed by Bentley et al in 2008 for the U.S. health care system 4 (see Figure 1). In Canada, no such framework exists. The framework of Bentley et al contains three main categories of inefficiencies - clinical, operational, and administrative. Clinical inefficiencies relate to practice variation challenges including, the provision of inappropriate care. Operational inefficiencies include duplication of health care services, inefficient processes, overly expensive inputs, and errors in data collection and processing. Administrative inefficiencies may be generally thought of as excess transaction costs associated with claims payment and excess costs of administration and management over and above what is required to deliver front-line health care. Figure 1. Typology of health care inefficiencies Source: Adapted from Bentley et al, 2008. 2.1 Clinical Inefficiencies Clinical waste and inefficiencies refer to services that provide marginal or no health benefit compared with less costly alternatives. This may include practice variation and the provision of inappropriate and cost-ineffective care, or the underuse of more appropriate care. There is overlap between clinical inefficiencies (e.g., providing the wrong service) with operational inefficiencies (the inefficient production of services). The chief contributor to clinical inefficiencies or waste in the health care field is practice variation-the reduction of unwarranted care variation is the foundation of the quality movement. John Wennberg and colleagues have pioneered the main body of work in this area through their studies on small area variation in care delivery.5 Over the last quarter century, technical studies on clinical practice guidelines (CPGs) have been developed in increasing numbers to address issues of appropriateness of care and care variation. CPGs are defined as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances".6 CPGs should contribute to better health, enhance the quality of care by reducing practice variation, and contribute to better value and lower costs by encouraging more appropriate use of resources by care providers.7 Although there has been no systematic approach in Canada to developing and disseminating CPGs, or to ensuring the quality of the CPGs produced, various organizations have developed initiatives to tackle this issue.8 Since the early 1990s, the Canadian Medical Association (CMA) has developed and maintained a CPG Infobase, which contains roughly 1,200 guidelines.9 The uptake of CPGs is a crucial component and insufficient resources are applied to necessary clinical practice change processes. Moreover, CPGs should be distillable to actionable points-of-care recommendations suited to the intended end user (e.g., family physicians). In January 2012, the Council of the Federation (CoF) established the Health Care Innovation Working Group, which comprises all provincial and territorial health ministers, to determine practical and innovative ways to increase the value and effectiveness of care.10 The group's CPG recommendations focused on cardiovascular disease and diabetes - two of the most prevalent and highest-costing chronic diseases in Canada (see Appendix A for list of CPGs). In accordance with the CoF, the CMA recommends: 1. Developing chronic disease management and other supportive strategies for vulnerable patients at risk of frequent readmission to the acute care system. 2. Integrating clinical practice guidelines with electronic medical records. 3. Implementing a pan-Canadian clinical practice guidelines strategy. 4. Using evidence-informed clinical practice guidelines to evaluate patient outcomes, appropriateness, and cost-effectiveness. 5. Developing deployment strategies to ensure maximum use of clinical practice guidelines by physicians. Clinical practice guidelines need regular updating as new evidence emerges. Therefore, a Pan-Canadian strategy should include a system of regular review and updating using development methods that would exclude the possibility of industry bias. Canada's physicians are taking a leading role on this matter through such initiatives as Choosing Wisely Canada (see below). 2.1.1 Appropriateness There is an increasing trend in health care utilization in areas such as medical procedures, drugs, and physician services.11 Questions remain about whether or not people are receiving care that is appropriate and based on the best available scientific information.12 Inappropriate care, such as the hospitalization of patients who need community-based services or prescribing antibiotics for upper respiratory infections that are likely viral in origin, is another source of clinical inefficiency, using scarce resources for marginal or no health benefit. The CMA recently defined appropriate care as the right care, provided by the right provider, to the right patient, in the right venue, at the right time: * "right care" is based on evidence for effectiveness and efficacy in the clinical literature, and not only implies appropriateness of use, but inappropriateness of failure to use; * "right provider" is based on ensuring the provider's scope of practice adequately meets but does not far exceed the skills and knowledge to deliver the care; * "right patient" acknowledges that care choices must be matched to individual patient characteristics and preferences; * "right venue" emphasizes that some settings are better suited in terms of safety and efficiency to delivering a specific type of care than others; * "right time" indicates care is delivered in a timely manner consistent with agreed upon bench marks. As a corollary to this definition, if all five components are present, high quality care has been delivered with the optimal use of resources, that is, waste has been eliminated and the best value has been obtained. Appropriateness is primarily determined by analyses of the evidence of clinical effectiveness, safety, and other health system impacts.13 The practical application of appropriateness is made when these analyses are qualified by (a) clinician judgment, particularly in atypical circumstances14 and (b) societal and ethical principles and values, including patient preferences. There are a number of perverse incentives that can contribute to the delivery of inappropriate care across the system. These exist at the system level (e.g., patients staying in hospitals longer than needed due to the lack of community services), as well as at the individual encounter level (changes in fee codes for insured medical services such as new consult fees to see a patient every six months). Physicians and payers such as governments need to work together to eliminate perverse incentives based on available medical evidence. Physician incentives should align with system needs. The challenge is getting governments, health authorities and provincial and territorial medical associations, and individual providers agreeing on system goals and objectives. In the U.S., an innovative appropriateness initiative called Choosing Wisely was established in 2011 with the goal of improving care quality and reducing harm to patients by avoiding unnecessary interventions, with the added benefit of possible cost reductions.15 The initiative challenged specialty societies to identify five clinical activities in their field that are generally of little value or are potentially harmful to patients.16 In Canada, CMA's 2013 General Council called for the formation of a collaborative working group to develop specialty-specific lists of clinical tests/interventions and procedures for which benefits have generally not been shown to exceed the risks. Choosing Wisely Canada was launched on April 2, 2014 with the release of eight lists produced by nine specialty societies (one list was released jointly by the CMA's Forum on General and Family Practice Issues (GP Forum) and the College of Family Physicians of Canada (CFPC)). Twelve additional medical specialty societies released lists in October 2014. The Choosing Wisely Canada campaign is endorsed and supported by over 35 national specialty societies representing a broad spectrum of physicians, as well as by all provincial medical associations, patient organizations, accrediting bodies and others (Website: www.choosingwiselycanada.org). Choosing Wisely Canada aims to promote physician-patient communication about unproductive care and conserve resources by eliminating unneeded activities. This initiative also serves as an example of the role of public education campaigns to help improve appropriate care. The development of a Canadian version of the Choosing Wisely initiative assists in operationalizing the Institute for Healthcare Improvement's (IHI) Triple Aim concept of better care, better health, better value. Specific benefits include: * Improving accountability by providing transparent, evidence-informed care; * Facilitating patients to make the right care decisions; * Enhancing physician-patient relationships: improve communication and decision-making between patients and their physician; and * Reducing clinical inefficiencies. The ultimate objective and impetus for adopting a Choosing Wisely initiative must be to improve patient outcomes. Cost savings to the system should occur as a byproduct. Physicians are in the best position to identify which medical services are unnecessary. Both patients and providers need to be aware of the costs associated with each treatment option, recognizing there is a balance to strike between cost and value. To facilitate this process, the CMA recommends: 6. Making available data on the cost and cost-effectiveness of treatment options at the point of care. 7. Collecting information to evaluate cost-effective care. 8. Posting costs generated by requests for diagnostic and laboratory tests in electronic medical records. Evaluation should take place to ensure the posting of costs is targeted to areas where it will be most effective. 2.2 Operational inefficiencies Examples of operational waste include: undertaking tests or procedures more frequently than clinically necessary (e.g., duplication of tests); unnecessary time spent waiting for medical services or time wasted from processes that add little value; using brand drugs for patients who get equal benefit from generics; and health and cost consequences of medical errors or the use of defective medical devices. These system inefficiencies can amount to very significant costs to the health care system, patients and the economy. For instance, lengthy waits can have serious health consequences for patient outcomes and result in the substitution of additional health care services while waiting (e.g., use of pain medication). A 2008 study calculated the economic impact of excessive wait times for five procedures (hip and knee replacement surgery, MRIs, CABG surgery and cataract surgery) in all 10 provinces. It found that, in addition to the obvious emotional, physical and financial toll endured by patients and their families, lengthy waits for these medical treatments cost Canada's economy an estimated $14.8 billion overall in 2007 in reduced economic activity by patients ($16.9 billion in 2014 dollars). This included a $4.4 billion reduction in federal and provincial government revenues.17 Notwithstanding a shortage in health care infrastructure, there is general consensus that not all hospital infrastructure is used to its fullest capacity, contributing to lengthy wait times for many patients. This can include excessive turnover time between cases or limited operating room hours that can result in the last patient of the day being unable to receive their surgery at great cost to the patient and their family. In many instances, urban hospitals must cancel surgeries due to overbooked operating room time when in smaller and rural communities, operating rooms are not fully utilized. Strategies should be explored to enable greater use of health infrastructure resources in smaller community hospitals that will serve to enhance timely access to care for patients. This would also ensure that staff had a level of activity that would maintain their skills. There has been significant uptake of operations research and quality improvement processes to help eliminate operational waste and address unnecessary waiting by patients. To this end, CMA will continue to work with its partners in the Wait Time Alliance to identify strategies to improve timely access to care for patients across the continuum. The CMA will also study the potential health applications of the Theory of Constraints within the Canadian health care system.18 There can also be system-wide inefficiencies in the various health systems operating in the country and in terms of how health systems interact with other systems such as economic and social support systems (e.g., lack of services to address homelessness). Changes in one component of the health care system can negatively affect the efficiency in another component. For instance, cuts made to home care services can lead to a rise in the number of alternate-level-of care (ALC) patients in hospitals, increased wait times in emergency departments, and elective surgery cancelations. A more recent source of system inefficiency has been occurring due to the piecemeal adoption of electronic medical records and information systems (EMR) throughout the country. The multitude of systems adopted by different segments of the health care system has resulted in problems with system inter-operability that often exacerbate administrative and clinical inefficiencies such as preventing the electronic attachment of test results leading to the reordering of tests. The Canadian Institute for Health Information (CIHI) developed a model to measure and evaluate "health system efficiency" within Canada. It measures the average efficiency of health systems in Canada's health regions and the factors that help explain variations in estimates of system efficiency (measured as the reduction in potential years of life lost (PYLL) from treatable causes of death). The study found that equitable access to physician care is positively associated with efficiency.19 Unfortunately, over 4 million Canadians still do not have a regular family physician.20 In addition, the CIHI study found that factors related to the social determinants of health can also affect system efficiency (e.g., missed prevention opportunities). Frequently, the health care system is relied on to address preventable health needs that are attributable to the social determinants of health (e.g., injuries or illnesses caused by lack of affordable housing or poverty). Furthermore, these factors can negatively affect the effectiveness of any treatment provided by the health care system.21 Governments and health administrators should focus on improving efficiencies where there is the highest volume of services as new models of efficiency do not always show results in low volume areas. 2.3 Administrative inefficiencies Health programs can be funded and administered at a variety of levels: local, regional, provincial and federal, as well as through employers. According to CIHI, administration accounted for $6.3 billion, or 3.1%, of health care costs in Canada in 2011-roughly middle of the pack among OECD countries22-but this is only the cost of providing public and private health insurance programs and the costs associated with health departments'operations.11 Generally, differences in the level of health administration can be explained in part by the type of health system and financing used such as whether multiple insurance providers exist or the extent that complex funding and billing procedures are in place.23 1 In terms of other administrative costs, we do not know how Canada has evolved over time in comparison to other sectors of the economy or how we compare internationally with respect to the effectiveness of administration expenditures.1 There have been questions about the expansion and contraction of regional health authorities in Canada over the past two decades. However, Canada does not have a detailed set of health accounts that would permit such analysis. CIHI has recently begun to report the percentage of administrative services expenses (general administration, finances, human resources and communications) as a percentage of total expenses for over 600 hospitals as part of its Canadian Hospital Reporting Project (CHRP).24 One source of administrative waste is the cost of duplicate collection and recording of health information. The health sector has been slow in adopting health information technology to help reduce this form of administrative waste. Another cause of inefficiency is the increase in administrative burden faced by Canadian physicians and their patients. A major contributor is the rise in requests for physicians to complete third party forms from insurance companies and governments (see Appendix B for a list of examples of federal health programs and related medical forms). Different definitions of concepts are frequently used in these forms, but in many instances they are asking for similar information about the same patient. Physicians are also frequently requested to complete sick notes-the CMA believes such an absence does not require physician confirmation of illness and represents an inefficient use of scarce health care resources.25 The cumulative effect of a physician being requested to complete several forms each day can result in significant administrative burden and take away time that physicians can spend providing direct patient care. Standardizing definitions and wording on third-party forms can save time and reduce administrative errors. Physicians fully support any efforts by the private insurance industry and governments to standardize their medical forms. In addition, consideration should be given to instances where other designated providers can be tasked with completing particular forms. Where suitable, electronic medical records (EMRs) can improve the completion and timely submission of third-party forms to the benefit of patients, providers and third-parties. To address these administrative inefficiencies, the following actions have been recommended by CMA: 9. Federal and provincial auditors general design and implement a protocol for detailed enumeration of administrative costs within their health care systems, including tracking of these costs over time, and issue an annual public report. 10. CIHI conduct a detailed study of administrative costs of Canadian hospitals and regional health authorities and report the findings. 11. Harmonize and centralize, in electronic and written format, all administrative forms that physicians must fill out on behalf of their patients. 3. Innovating for efficiency Since the late 1990s, the federal, provincial, and territorial governments, and other granting bodies have provided considerable funding for applied health services research to aid the implementation of pilot projects to improve the quality of care delivered in Canada. However, Canada is frequently criticized for its inability to move beyond pilot projects to full implementation. One often-cited reason is the lack of communication about promising innovations from one jurisdiction to another. Other reasons include regulatory barriers such as funding silos, and pilot project funding for a limited duration to prevent meaningful outcome evaluation. Physician input is a necessary condition for meaningful and sustained system innovation.26 The CMA supports: 12. Developing and testing innovative structures or programs to demonstrate clear evidence of improvement in health care outcomes and fiscal sustainability before wide-spread adoption into the Canadian health delivery system. 13. Developing policy tools that provide criteria for identifying barriers to quality, efficiency and equity in emerging models of health care delivery. 14. Creating a registry of physician-managed health care transformation projects. This registry should outline the challenges and lessons learned associated with each project for those interested in adopting similar projects. 4. Conclusion Addressing efficiency challenges in the Canadian health care system can improve the quality, continuity, and comprehensiveness of care, while making the system more cost-effective and sustainable. Many components of the health care inefficiencies set out by Bentley et al are now being considered by governments. Physician input is a necessary condition for meaningful system improvement and innovation. Physicians should practice high quality, evidence-informed health care, and advocate for cost-effective allocation of scarce resources. Canada's physicians are taking a leading role on this matter through such initiatives as Choosing Wisely Canada. Appendix A Clinical Practice Guidelines (CPGs) recommended by The Health Care Innovation Working Group of the Council of the Federation The group recommended each province and territory work with their health authorities to adopt the following CPGs: * The C-CHANGE guidelines for cardiovascular disease published by the Canadian Cardiovascular Harmonization of National Guidelines Endeavour (C-CHANGE) to reduce guideline variations and confusion among care providers. * Harmonized guidelines for diagnosis, which include: o Laboratory testing (e.g., urine analysis, ECGs) o Risk stratification strategies (e.g., family history, lifestyle choices, and diabetic patients). * Harmonized guidelines for treatment, which include: o Establishing treatment targets (e.g., limiting alcohol consumption, healthy body weight, glycemic or glucose targets) o Health behavior interventions (e.g., balanced heart healthy diet, limiting salt intake, smoking cessation) o Pharmacological therapy (e.g., assessment of drug and drug interactions, co-morbidities). Appendix B Examples of federal health programs and related medical forms physicians are frequently requested to complete * Canada Pension Plan Disability * Disability Tax Credit * Employment Insurance (Sickness Benefits Claim) * Non-Insured Health Benefits (for First Nations people and Inuit) * Veterans Disability Pension * Compassionate Care Leave * Exception/Limited Use Drug Request Form (to permit access to drugs not on provincial formularies) * Interim Federal Health Program * Canadian Adverse Drug Reaction Monitoring forms References 1 Organisation for Economic Co-operation and Development. Health care systems: getting more value for money. OECD Economics Department Policy Note No. 2. Paris: The Organisation; 2010. 2 Canadian Institute for Health Information. Developing a model for measuring the efficiency of the health system in Canada. Ottawa: The Institute; 2012. Available: https://secure.cihi.ca/free_products/HS_Efficiency_Tech_Report_EN-web.pdf (accessed 2013 Apr 30). 3 Organisation for Economic Co-operation and Development. OECD economic surveys: Canada 2012. Paris: OECD Publishing; 2012. Available: http://dx.doi.org/10.1787/eco_surveys-can-2012-enOECD 4 Bentley T, Effros R, Palar K, et al. Waste in the U.S. health care system: a conceptual framework. Milbank Q. 2008;86(4):629-59. 5 Wennberg J, Gittelson A. Small area variations in health care delivery. Science. 1973;182:1102-8. 6 Field MJ, Lohr KN. Clinical practice guidelines: directions for a new program. Washington (DC): National Academy Press; 1990. p. 38. 7 Canadian Medical Association. Handbook on clinical practice guidelines. Ottawa: The Association; 2007. 8 The Canadian Institutes of Health Research (CIHR) has launched a Strategy for Patient Oriented Research and one of its core elements is the improvement of guideline development, dissemination and uptake through support for guideline development and dissemination. Canadian Institutes of Health Research. Canada's strategy for patient-oriented research: improving health outcomes through evidence-informed care. Ottawa: The Institutes; 2011. Available: www.cihr-irsc.gc.ca/e/documents/P-O_Research_Strategy-eng.pdf (accessed 2012 Feb 22). 9 Canadian Medical Association. CMA Infobase: clinical practice guidelines (CPGs). Available: www.cma.ca/En/Pages/clinical-practice-guidelines.aspx (accessed 2012 Feb 22). 10 Council of the Federation Working Group. From innovation to action - the first report of the Health Care Innovation Working Group. Available: www.canadaspremiers.ca/phocadownload/publications/health_innovation_report-e-web.pdf (accessed 2013 Apr 25). 11 Canadian Institute for Health Information. National health expenditure trends, 1975 to 2013. Ottawa: The Institute; 2013. Available: https://secure.cihi.ca/free_products/NHEXTrendsReport_EN.pdf. 12 Canadian Institute for Health Information. Health care in Canada 2010. Ottawa: The Institute; 2010. Available: https://secure.cihi.ca/free_products/HCIC_2010_Web_e.pdf (accessed 2014 Oct 7). 13 Canadian Medical Association. Appropriateness. Ottawa: The Association; 2014. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-05.pdf. 14 Goldberger JJ, Buxton AE. Personalized medicine vs guideline-based medicine. JAMA. 2013;309(24):2559-60. 15 Siwek J. Choosing wisely: top interventions to improve health and reduce harm, while lowering costs. Am Fam Physician. 2012;86(2):128-33. 16 The Good Stewardship Working Group. The "top 5" lists in primary care. Arch Intern Med. 2011;171(15):1385-90. 17 Centre for Spatial Economics. The economic cost of wait times in Canada. Ottawa: The Centre; 2008. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/EconomicReport-e.pdf (accessed 2014 Apr 14). 18 Knight A. The theory of constraints in health and social care. Aldbury (UK): QFI Consulting; 2011. 19 Canadian Institute for Health Information. Measuring the level and determinants of health system efficiency in Canada. Ottawa: The Institute; 2014 Apr. Available: https://secure.cihi.ca/free_products/HSE_TechnicalReport_EN_web.pdf (accessed 2014 Feb 5). 20 Statistics Canada. Access to a regular medical doctor, 2012. Available: www.statcan.gc.ca/pub/82-625-x/2013001/article/11832-eng.htm (accessed 2014 Jan 5). 21 Canadian Medical Association. Health care in Canada: What makes us sick? Town hall report. Ottawa: The Association; 2013 Jul. Available: www.cma.ca/Assets/assets-library/document/fr/advocacy/What-makes-us-sick_en.pdf. 22 Organisation for Economic Co-operation and Development. Guidelines to improve estimates of expenditure on health administration and health insurance. Paris: The Organisation; 2013 Dec. 23 Himmelstein DU, Jun M, Busse R, et al. A comparison of hospital administrative costs in eight nations: U.S. costs exceed all others by far. Health Aff (Millwood). 2014;33(9):1586-94. 24 Canadian Institute for Health Information. Canadian Hospital Reporting Project (CHRP). Available: www.cihi.ca/CIHI-ext-portal/internet/EN/Home/home/cihi000001 (accessed 2014 Mar 20). 25 Canadian Medical Association. Short-term illness certificate. Ottawa: The Association; 2011. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-06.pdf 26 Lee TH, Cosgrove T. Engaging doctors in the health care revolution. Harv Bus Rev. 2014;92(6):104-11, 138. --------------- ------------------------------------------------------------

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