Helping physicians care for patients
Aider les médecins à prendre soin des patients
Canada is a nation on the precipice of great change. This change will be driven primarily by the economic and social implications of the major demographic shift already underway. The added uncertainties of the global economy only emphasize the imperative for federal action and leadership.
In this brief, the Canadian Medical Association (CMA) is pleased to present four recommendations to the House of Commons Standing Committee on Finance for meaningful federal action in support of a national seniors strategy; these are essential measures to prepare for an aging population.
Canada's demographic and economic imperative
In 2011 the first of wave of the baby boomer generation turned 65 and Canada's seniors population stood at 5 million.1 By 2036, seniors will represent up to 25% of the population.2 The impacts of Canada's aging population on economic productivity are multi-faceted.
An obvious impact will be fewer workers and a smaller tax base. Finance Canada projects that the number of working-age Canadians for every senior will fall from about 5 today to 2.7 by 2030.3
The projected surge in demand for services for seniors that will coincide with slower economic growth and lower government revenue will add pressure to the budgets of provincial and territorial governments. Consider that while seniors account for about one-sixth of the population, they consume approximately half of public health spending.4 Based on current trends and approaches, seniors' care is forecast to consume almost 62% of provincial/territorial health budgets by 2036.5
The latest fiscal sustainability report of the Parliamentary Budget Officer explains that the demands of Canada's aging population will result in "steadily deteriorating finances" for the provinces and territories and they "cannot meet the challenges of population ageing under current policy."6
Theme 1: Productivity
A) New federal funding to provincial/territorial governments
Canada's provincial and territorial leaders are aware of the challenges ahead. This July, the premiers issued a statement calling for the federal government to increase the Canada Health Transfer to 25% of provincial and territorial health care costs to address the needs of an aging population.
To support the innovation and transformation needed to address these needs, the CMA recommends that the federal government deliver additional funding on an annual basis beginning in 2016-17 to the provinces and territories by means of a demographic-based top-up to the Canada Health Transfer (Table 1). For the fiscal year 2016-17, this top-up would require $1.6 billion in federal investment.
Table 1: Allocation of the federal demographic-based top-up, 2016-20 ($million)7
All of Canada
Newfoundland and Labrador
Prince Edward Island
B) Federal support for catastrophic drug coverage
A major gap in Canada's universal health care system is the lack of universal access to prescription medications, long recognized as the unfinished business of medicare. Canada stands out as the only country with universal health care without universal pharmaceutical coverage.8
According to the Angus Reid Institute, more than one in five Canadians (23%) report that they or someone in their household did not take medication as prescribed because of the cost during the past 12 months.9 Statistics Canada's Survey of Household Spending reveals that households headed by a senior spend $724 per year on prescription medications, the highest among all age groups and over 60% more than the average household.10 Another recent study found that 7% of Canadian seniors reported skipping medication or not filling a prescription because of the cost.11
In addition to the very real harms to individuals, lack of coverage contributes to the inefficient use of Canada's scarce health resources. While there are sparse economic data in Canada on this issue, earlier research indicated that this inefficiency, which includes preventable hospital visits and admissions, represents an added cost of between $1 billion and $9 billion annually.12
As an immediate measure to support the health of Canadians and the productivity of the health care sector, the CMA recommends that the federal government establish a new funding program for catastrophic coverage of prescription medication. The program would cover prescription medication costs above $1,500 or 3% of gross household income on an annual basis. Research commissioned by the CMA estimates this would cost $1.48 billion in 2016-17 (Table 2). This would be a positive step toward comprehensive, universal prescription drug coverage.
Table 2: Projected cost of federal contribution to cover catastrophic prescription medication costs, by age cohort, 2016-2020 ($ million)13
Share of total cost
Under 35 years
35 to 44 years
45 to 54 years
55 to 64 years
65 to 74 years
75 years +
Theme 2: Infrastructure and communities
All jurisdictions across Canada are facing shortages in the continuing care sector. Despite the increased availability of home care, research commissioned for the CMA indicates that demand for continuing care facilities will surge as the demographic shift progresses.14
In 2012, it was reported that wait times for access to a long-term care facility in Canada ranged from 27 to over 230 days. It is estimated that 85% of "alternate level of care" patients in hospitals (i.e., patients who do not require hospital-level care) are in these beds because of the lack of availability of long-term care. Due to the significant difference in the cost of hospital care (approximately $846 per day) versus long-term care ($126 per day), the CMA estimates that the shortages in the long-term care sector represent an increased cost of $2.3 billion.
Despite the recognized need for infrastructure investment in the continuing care sector, to date, this sector has been excluded from the Building Canada Plan. The CMA recommends that the federal government amend the criteria of the Building Canada Plan to include capital investment in continuing care infrastructure, including retrofit and renovation. Based on previous estimates, the CMA recommends that $540 million be allocated for 2016-17 (Table 3).
Table 3: Estimated cost to address forecasted shortage in long-term care beds, 2016-20 ($ million)15
Forecasted shortage in long-term care beds
Estimated cost to address shortage
Federal share to address shortage in long-term care beds (based on 1/3 contribution)
Theme 3: Jobs
As previously mentioned, Canada's aging population will produce significant changes in the labour force. There will be fewer Canadian workers, each with a greater likelihood of having caregiving responsibilities for family and friends.
According to the report of the federal Employer Panel for Caregivers, Canadian employers "were surprised and concerned that it already affects 35% of the Canadian workforce."16 This report highlights key findings of the 2012 General Social Survey: 1.6 million caregivers took leave from work; nearly 600,000 reduced their work hours; 160,000 turned down paid employment; and, 390,000 quit their jobs to provide care. It is estimated that informal caregiving represents $1.3 billion in lost workforce productivity. These costs will only increase as Canada's demographic shift progresses.
In parallel to the increasing informal caregiving demands on Canadian workers, Canada's aging population will also increase the demand for personal care workers and geriatric competencies across all health and social care professions.17
Theme 4: Taxation
The above section focused on the economic costs of caregiving on the workforce. The focus of this section will be on the economic value caregivers provide while they take on an increased economic burden.
Statistics Canada's latest research indicates that 8.1 million Canadians are informal caregivers, 39% of whom primarily care for a parent.18 The Conference Board of Canada reports that in 2007 informal caregivers contributed over 1.5 billion hours of home care - more than 10 times the number of paid hours in the same year.19 The economic contribution of informal caregivers was estimated to be about $25 billion in 2009.20 This same study estimated that informal caregivers incurred over $80 million in out-of-pocket expenses related to caregiving in 2009.
Despite their tremendous value and important role, only a small fraction of caregivers caring for a parent received any form of government support.21 Only 5% of caregivers providing care to parents reported receiving financial assistance while 28% reported needing more assistance than they received.22
As a first step to providing increased support for Canada's family caregivers, the CMA recommends that the federal government amend the Caregiver and Family Caregiver Tax Credits to make them refundable. This would provide an increased amount of financial support for family caregivers. It is estimated that this measure will cost $90.8 million in 2016-17.23
The CMA recognizes that in the face of ongoing economic uncertainty the federal government may face pressures to avoid new spending initiatives. The CMA strongly encourages the federal government to adopt the four recommendations outlined in this submission rather than further delay making a meaningful contribution to meeting the future care needs of Canada's aging population. The CMA would welcome the opportunity to provide further information and its rationale for each recommendation.
1 Statistics Canada. Generations in Canada. Cat. No. 98-311-X2011003. Ottawa: Statistics Canada; 2012. Available: www12.statcan.gc.ca/census-recensement/2011/as-sa/98-311-x/98-311-x2011003_2-eng.pdf
2 Statistics Canada. Canada year book 2012, seniors. Available: www.statcan.gc.ca/pub/11-402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm
3 Finance Canada. Economic and fiscal implications of Canada's aging population. Ottawa: Finance Canada; 2012. Available: www.fin.gc.ca/pub/eficap-rebvpc/eficap-rebvpc-eng.pdf
4 Canadian Institute for Health Information. National health expenditure trends, 1975 to 2014. Ottawa: The Institute; 2014. Available: www.cihi.ca/web/resource/en/nhex_2014_report_en.pdf
5 Calculation by the Canadian Medical Association, based on Statistics Canada's M1 population projection and the Canadian Institute for Health Information age-sex profile of provincial-territorial health spending.
6 Office of the Parliamentary Budget Officer. Fiscal sustainability report 2015. Ottawa: The Office; 2015. Available: www.pbo-dpb.gc.ca/files/files/FSR_2015_EN.pdf
7 Conference Board of Canada. Research commissioned for the CMA, July 2015.
8 Morgan SG, Martin D, Gagnon MA, Mintzes B, Daw JR, Lexchin J. Pharmacare 2020: The future of drug coverage in Canada. Vancouver: Pharmaceutical Policy Research Collaboration, University of British Columbia; 2015. Available: http://pharmacare2020.ca/assets/pdf/The_Future_of_Drug_Coverage_in_Canada.pdf
9 Angus Reid Institute. Prescription drug access and affordability an issue for nearly a quarter of Canadian households. Available: http://angusreid.org/wp-content/uploads/2015/07/2015.07.09-Pharma.pdf
10 Statistics Canada. Survey of household spending. Ottawa: Statistics Canada; 2013.
11 Canadian Institute for Health Information. How Canada compares: results From The Commonwealth Fund 2014 International Health Policy Survey of Older Adults. Available: www.cihi.ca/en/health-system-performance/performance-reporting/international/commonwealth-survey-2014
12 British Columbia Pharmacy Association. Clinical service proposal: medication adherence services. Vancouver: The Association; 2013. Available: www.bcpharmacy.ca/uploads/Medication_Adherence.pdf
13 Supra at note 7.
14 Conference Board of Canada. Research commissioned for the CMA, January 2013.
16 Government of Canada. Report from the Employer Panel for Caregivers: when work and caregiving collide, how employers can support their employees who are caregivers. Available: www.esdc.gc.ca/eng/seniors/reports/cec.shtml
17 Stall S, Cummings G, Sullivan T. Caring for Canada's seniors will take our entire health care workforce. Available: http://healthydebate.ca/2013/09/topic/community-long-term-care/non-md-geriatrics
18 Statistics Canada. Family caregivers: What are the consequences? Available: www.statcan.gc.ca/pub/75-006-x/2013001/article/11858-eng.htm
19 Conference Board of Canada. Home and community care in Canada: an economic footprint. Ottawa: The Board; 2012. Available: http://www.conferenceboard.ca/cashc/research/2012/homecommunitycare.aspx
20 Hollander MJ, Liu G, Chappeel NL. Who cares and how much? The imputed economic contribution to the Canadian health care system of middle aged and older unpaid caregivers providing care to the elderly. Healthc Q. 2009;12(2):42-59.
21 Supra at note 16.
23 Supra at note 7.
The Canadian Medical Association (CMA) is pleased to present its brief to the House of Commons Standing Committee on Health for consideration as part of its study of "Best Practices and Federal Barriers: Practice and Training of Health Professionals".
The subject under discussion is relevant to both parts of the CMA's mission. The CMA has undertaken considerable activity on the issue. For example, in 2012 and 2013 we participated, with the Canadian Nurses Association and the Health Action Lobby (HEAL) on the Council of the Federation's (CoF) working group on Team-based Care. For many years, the CMA has conducted the National Physician Survey, which develops comprehensive information on physician demographics and practice patterns.
In the past decade a number of health professions have expanded their scopes of practice. In most provinces, for example, pharmacists can now renew prescriptions or provide emergency prescription refills. Ontario has established nurse-practitioner-led primary health care clinics which collaborate with family physicians and others in the community. Nova Scotia has experimented with using paramedics as first-contact primary caregivers in rural or remote areas. Governments expand scopes of practice for a number of possible reasons: cost-effectiveness (i.e. replacing one health professional with a less expensive one); improving access, particularly in areas underserviced by physicians; increasing convenience for patients (for example, allowing a neighbourhood pharmacist to give a flu shot may save the patient from taking time off work for a doctor's appointment): or responding to lobbying by health provider groups.
The CMA believes that ideally, every health care provider should have a scope of practice that is consistent with his or her education and training, and that the health care system should enable them to practice to the fullest extent of this scope. More importantly, the scope of practice of every health professional should enable them to contribute optimally to providing high quality patient-centered care without compromising patient safety. Indeed, the primary reason for expanding the scope of practice of a health professional should be to improve Canadians' health and health care.
In the following pages we will discuss several specific topics related to the Scope of Practice issue, and make recommendations for a possible federal role in supporting best practices among health professionals.
1. A Canada-Wide Approach to Scopes of Practice
Scopes of practice are determined largely by provincial and territorial governments, and each jurisdiction has developed its own regulations regarding what health professional groups may do and under what circumstances. This has led to inconsistency across the country. For example, about half the jurisdictions in Canada allow pharmacists to order laboratory tests and prescribe for minor ailments; provinces vary in the degree to which they fund nurse
practitioner positions; and there is wide variation in how, and even if, physician assistants are regulated.
While recognizing that the authority to determine scopes of practice rests with provincial/territorial governments, CMA believes that it is desirable to work toward consistency in access to health services across Canada.
Recommendation 1: that the federal government work with provincial/territorial governments and with health professional associations to promote a consistent national approach to scope-of-practice expansions
2. Promoting and Facilitating Team-Based Care
The scopes-of-practice issue is closely related to the development of models for team-based care, a development that CMA supports. When Canadians seek health care today, it is mainly to help them maintain their health or to manage chronic diseases. This trend is expected to continue as the population ages and the rate of chronic disease rises correspondingly. For patients who have multiple chronic diseases or disabilities, care needs can be complex and a number of different health and social-services professionals may be providing care to the same person. A patient might, for example, be consulting a family physician for primary health care, several medical specialists for different conditions, a pharmacist to monitor a complex medication regime, a physiotherapist to help with mobility difficulties, health care aides to make sure the patient is eating properly or attending to personal hygiene, and a social worker to make sure his or her income is sufficient to cover health care and other needs.
The complexity of today's health care requires that the system move away from the traditional "silo" method of delivering care and encourage health professionals to work collaboratively to effectively meet patients' needs. The CMA believes that the following factors contribute to the success of inter-professional care:
Patient access to a primary care provider who is familiar with the patient's needs and preferences, and has responsibility for the overall care of the patient, co-ordinating the various providers involved in this care. For more than 30 million Canadians, that primary care provider is a family physician. The College of Family Physicians of Canada believes that family practices can serve as patient's "medical home," in which care is anchored and co-ordinated by a family physician, with access to other health care providers as required.
Mechanisms that encourage collaboration and communication among providers. These include:
o Interdisciplinary primary care practices, such as Family Health Networks in Ontario, which permit patients to access a variety of different health professionals and their expertise from one practice setting;
Widespread use of the electronic health record, which can facilitate information sharing and communication among providers.
A smooth, seamless process for referral from one provider to another.
Role clarity and mutual trust. Each health professional on a care team should have a clear understanding of their own roles and the roles of other team members.
The CoF's Team-Based Care Working Group investigated the critical factors for successful team based care, and identified models in certain provinces that it believed should be considered for rollout across Canada. This rollout could be enhanced if it were encouraged by all governments, including the Government of Canada. In the past, Health Canada has supported demonstration projects in health system reform through the National Primary Care Research Group. The CMA believes that the federal government could take a similar role in future, in supporting and disseminating promising models of inter-professional practice. The dissemination process should be accompanied by a process to rigorously evaluate the effect of such models on health outcomes, quality of patient care, and health care costs.
Recommendation 2: that the Government of Canada support research into and evaluation of innovative models of team-based care, and actively promote the dissemination of successful models nationwide.
Recommendation 3: that Canada Health Infoway work with provinces and territories to increase the adoption of electronic medical records at the point of care and build connectivity among points of care.
3. A Health-Care System That Supports Best Practices in Team-Based Care
We have already discussed the part that governments could play in identifying, disseminating and evaluating models of inter-professional practice. The health care system's planners, funders and managers can also foster team-based care in other ways, such as:
Promoting education in inter-professional care. As the Committee has heard, the Association of Faculties of Medicine of Canada's guiding principles for medical education include valuing inter-professionalism and incorporating it into residency learning and practice. CMA encourages the development of programs to help new physicians and other health professionals acquire the skills needed to function optimally an in inter-professional setting.
Improving access to health services not funded under the Canada Health Act. At present, patients who do not have private health care coverage must pay out of pocket for physiotherapy, dietitian services, mental health care and most social services. This works against the principles of inter-professional care by hindering access to necessary services; this could compromise patient health and safety.
Undertaking an open and meaningful consultation process when changes to scopes of practice are proposed. CMA's experience has been that physicians are more accepting of changes in other professions' scopes of practice if their medical associations have been involved in negotiation on these changes.
Ensuring that the supply of health professionals in Canada is sufficient to the needs of Canadian patients, by developing, implementing and monitoring human resource plans for all major health professions.
Recommendation 4: that the federal government work with provincial/territorial government and national health professional associations to develop and implement a health human resources plan that ensures Canadians' access to all appropriate health care providers.
In conclusion, the Canadian Medical Association recognizes that the great majority of decisions regarding scopes of practice are made at the provincial/territorial level. But we believe that in order to encourage a Canadian health-care system in which all providers work together, contributing their unique skills and expertise to providing patient-centered, seamless, cost-effective care, the support and encouragement of the federal government will be extremely beneficial.
Re: Future Mandate of the Health Care Innovation Working Group (the Council of the Federation)
On behalf of the Canadian Nurses Association (CNA) and the Canadian Medical Association (CMA), I am writing in advance of the meeting of the Council of the Federation later this month regarding the future mandate of the Health Care Innovation Working Group with respect to seniors care.
The CNA and CMA welcomed the Council of the Federation's prioritization of seniors care as an area of focus of the Health Care Innovation Working Group. Already, seniors and their families in communities across Canada face significant challenges accessing social supports and health services. These challenges will only intensify as the demographic shift progresses. Based on current trends and approaches, the proportion of provincial/territorial health spending associated with seniors care is forecast to grow by over 15% to almost 62% of health budgets by 2036.
Recognizing the significant pressure this will present for health care systems and provincial/territorial budgets moving forward, it is critical that the Council of the Federation maintain its prioritization of seniors care and meeting the needs of an aging population. As such, we respectfully encourage you in your capacity as Co-Chairs of the Health Care Innovation Working Group to ensure the future mandate of the working group on seniors care be included as part of the agenda at the January 30, 2015 meeting of the Council of the Federation.
The CNA and CMA are actively engaged on this issue and welcome the opportunity to meet with each of you to discuss how we may collaborate to ensure improved health outcomes for seniors, now and in the future.
Christopher S. Simpson, MD, FRCPC, FACC, FHRS
Karima Velji, RN, PhD, CHE
The CMA brief contains seven recommendations to address pressing needs in the health care system.
Before I get to those, I'd like to highlight why, from my perspective, our health care system is in need of the federal government's attention.
Yesterday, at the Ottawa Hospital, where I am Chief of Staff:
* Our occupancy was 100 per cent.
* 30 patients who came to the emergency department were admitted to the hospital, but we had beds for only four of them.
* 10 are still waiting on gurneys in examining rooms within the emergency department.
* Six patients were admitted to wards and are receiving care in hallways.
* Three surgeries were cancelled - bringing the number of cancellations this year to 480.
* But while all this was happening, we had 158 patients waiting for a bed in a long-term-care facility.
Equally, a few blocks from here and in communities across the country, the health status of our poorest and most vulnerable populations is comparable to countries that have a fraction of our GDP - despite very significant investments in their health.
This is just my perspective. Health care providers of all types experience the failings of our system on a daily basis.
We as a country can do better and Canadians deserve better value for their money.
Canada's physicians are calling for transformative change to build a health care system based on the principles of accessibility, high quality, cost effectiveness, accountability and sustainability.
Through new efficiencies, better integration and sound stewardship, governments can reposition health care as an economic driver, an agent of productivity and a competitive advantage for Canada in today's global marketplace.
The Health Accord expires in March 2014, and we strongly urge that the federal government begin discussions now with the provinces and territories on how to transform our health care system so that it meets patients' needs and is sustainable into the future.
Canadians themselves also need to be part of the conversation.
To help position the system for this transformative change, the CMA brief identifies a number of issues that the federal government should address in the short term:
First, our system needs investments in health human resources to retain and recruit more doctors and nurses.
Although we welcome measures in the last budget to increase the number of residency positions, we urge the government to fulfill the balance of its election promise by further investing in residencies, and to invest in programs to repatriate Canadian-trained physicians living abroad.
Second, we need to bolster our public health e-infrastructure so that it can provide efficient, quality care that responds more effectively to pandemics.
We recommend increased investment:
* to improve data collection and analysis between local public health authorities and primary care practices,
* for local health emergency preparedness, and
* for the creation of a pan-Canadian strategy for responding to potential health crises.
Third, issues related to our aging population also call for action.
As continuing care moves from hospitals into the home, the community, or long-term care facilities, the financial burden shifts from governments to individuals.
We recommend that the federal government study options for pre-funding long-term care - including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance - to help Canadians prepare for their future home care and long-term care needs.
And, as much of the burden of continuing care for seniors also falls on informal, unpaid caregivers, the CMA recommends that pilot studies be undertaken to explore tax credit and/or direct compensation for informal caregivers for their work, and to expand programs for informal caregivers that provide guaranteed access to respite services in emergency situations.
Finally, the government should increase RRSP limits and explore opportunities to provide pension vehicles for self-employed Canadians.
Mr. Chair, a fuller set of recommendations is contained in our report -- Health Care Transformation in Canada: Change that Works. Care that Lasts.
These include universal access to prescription drugs; greater use of health information technology; and the immediate construction of long-term care facilities.
We urge the Committee to consider both our short-term recommendations - and our longer term vision for transforming Canada's health care system.
I look forward to your questions. Thank you.
Thank you Madame Chair and Committee members for the opportunity to speak to you today.
As mentioned, I am Briane Scharfstein, Associate Secretary General at the Canadian Medical Association (CMA). I am a family physician by training and a member of the Ad Hoc Working Group on Medical Isotopes.
The working group was created to advise the Minister of Health in 2008 when the first major sustained shutdown of the Chalk River occurred. When I agreed to join the group, I certainly didn't expect it to still be going over two years later. And, while I am a member of the working group, I want to be clear, that today I am speaking on behalf of the CMA and our more than 72,000 physician members across the country.
My comments are a reflection of the Working Group's June 2008 Lessons Learned report and I regret to say that a good portion of our observations are still true today.
I congratulate the Senate for looking specifically at the AECL proposals and for looking at implications for patients. While the CMA is not taking a specific position on the proposal in
Bill C-9 for Atomic Energy Canada Ltd (AECL), in whole or in part, to be sold off to the private sector, we do believe that it is in the best interests of our patients that Canada remains a leader in the sector.
As well, Canada's doctors strongly believe that the impact on individual patient care must be considered and factored into any decisions that might result in disruptions of the supply of medical isotopes.
The CMA acknowledges that the federal budget did include $48 million over two years for research, development and application of medical isotopes and alternatives. Further, there was another allocation of $300 million on a cash basis for AECL's operations in 2010/11 to cover anticipated commercial losses and support the corporation's operations to ensuring a secure supply of medical isotopes and maintaining safe and reliable operations at the Chalk River Laboratory.
However, the CMA remains preoccupied with Canada's ability to ensure a long-term, stable and predictable supply of medically necessary isotopes. That is why we are uneasy about the federal government's exit strategy from the isotope production sector.
The report of the federal government's Expert Panel on the Production of Medical Isotopes, (December 2009) and the federal government's response to that report, (March 2010) appears to focus on the viability of this specific sector of the nuclear industry and has not alleviated our concerns. The government's response to the Panel Report was disappointing to the medical community. The government's decision to abandon Canada's long-standing international leadership in this sector is disheartening.
Of particular concern is the absence of both immediate and medium-term solutions to address the current and impending challenges facing nuclear medicine. This is simply unacceptable.
The CMA, along with our colleagues in the medical community, continues to assert that ensuring access to safe and reliable medical procedures and the provision of high-quality patient care must be the fundamental consideration of government decisions. While the production cost of isotopes cannot be ignored, particularly in times of global fiscal challenges, the medical application and benefits received are of paramount importance and must be neither discounted nor dismissed.
Early diagnosis and treatment are key factors in successful outcomes in cardiac and cancer cases. Without early diagnosis and treatment, patients have an increased risk of needing greater medical intervention later on. With more intensive treatment comes a corresponding increase in costs to the health care system and, most importantly, poorer outcomes for patients.
Specific concerns identified by the CMA and the medical community include, but are not limited to the following:
* Canada's current dependence on international reactors, without a practical back-up plan should these reactors experience difficulties, or shutdown for routine maintenance.
This is especially worrisome as the international agency, the Association of Imaging Producers & Equipment Suppliers (AIPES) warns of the unprecedented level of shortages, in a large part due to the Canada's Chalk River nuclear reactor remaining off line until August 2010 or beyond. In a recent Supply Crisis Update, AIPES points out that with a number of international reactors off-line for scheduled maintenance, the remaining reactors -the OPAL (Australia), Maria (Poland) and REZ (Czech Republic) reactors-are producing Mo99, but their combined output is limited to 15 - 20 % of the world requirements.
* The abandonment of Canada's international responsibilities and world leadership in this sector is counter to the government's own innovation and productivity agenda.
* A growing reliance on emerging technology, cyclotrons and liner accelerators that have yet to be proven as a suitable secure alternative source of radiopharmaceutical.
* A projected future supply chain that is reliant on external sources, rather than domestic production, in times of domestic supply shortages. As well, we are concerned that the federal government is leaving it to the marketplace, solely relying on current distributors to identify external sources supply, rather than searching to identify alternative safe sources of supply.
* Basing Canada's supply strategy on relicensing of the Chalk River reactor five years past its current license with no current guarantees that the plant will return and remain in production, let alone meet relicensing standards.
* The apparent lack of a federal contingency plan if, in 2016, alternative sources of supply and alternative emerging technology does not meet clinical needs.
* An analysis of the overall costs to the health care system as a result of the increased costs incurred during the prolonged period of shortages of isotopes supply and the rising costs as the demand for the alternative diagnostic and treatment models is not apparent.
* Initiatives to help mitigate increased costs for governments and particularly for nuclear medicine facilities do not exist.
The just released survey by the Canadian Institute for Health Information found that two-thirds of nuclear medicine facilities reported that they experienced an increase in the cost of isotopes and that they were managing but exceeding their budget due to vendor surcharges. Only 2% reported that the isotope supply disruptions had no economic impact.
Canada's medical community therefore strongly urges that consideration be given to:
* investing in a mixed-use reactor for research and isotope production, as per the recommendation of the Expert Panel on Isotopes Production report of December, 2009;
* putting in place appropriate strategies and contingency plans to meet the health needs of Canadians; in particular consider a national deployment of PET technology for cancer detection and follow up.
* enhancing transparency by the government that provides more information on the short and medium-tern detailed plans to address isotope shortages;
* increasing the direct consultation with the official representatives of the nuclear medicine and medical community;
* making a public commitment to keep the Chalk River NRU reactor operational beyond the arbitrary date of 2016, as long as necessary and until secure alternative supplies of isotopes or alternative radiopharmaceuticals are proven and are in place; and,
* ensuring that the CNSC resurrects the external medical advisory council to facilitate communication between the medical community and the commission. Prior to 2001, members of the council provided CNSC staff with insight into how operational and policy decisions would affect patient care across the country.
Canada's doctors believe that the federal government must maintain a leadership role in this sector and must not compromise the medical needs of Canadians.
The Canadian Medical Association (CMA) is pleased to provide the information below in
response to questions by the Canada Revenue Agency (CRA) for consideration as part of the
development of regulations following the enactment of the Disability Tax Credit Promoters
Restriction Act. This information is in follow up to CMA’s submission to the CRA dated
December 19, 2014, attached for reference.
As explained in the CMA’s submission attached, the CMA strongly encourages the CRA to
include an exemption for “a health care practitioner duly licensed under the applicable
regulatory authority who provides health care and treatment” from the reporting requirements
in the forthcoming regulations enabled by the Disability Tax Credit Promoters Restriction Act.
This exemption is necessary to ensure CRA does not impose duplicative regulatory oversight
of the medical profession, specific to the provision of this uninsured service. As fully explained
in the CMA’s brief, this exemption would not introduce a potential “loophole”.
Issue 1: Organizations Responsible for Physician Regulatory Oversight
The statutory authority for the regulatory oversight of physicians rests with the provincial and
territorial medical regulatory colleges. As explained on page 4 of the CMA’s submission,
medical regulatory colleges have statutory, comprehensive regulatory authority of physicians;
this authority captures: medical licensure, governing standards of practice, professional
oversight, and disciplinary proceedings. Included in this authority is broad regulatory
oversight for fees that physicians may charge for uninsured services, which would capture the
fee charged for the Disability Tax Credit form. The Federation of Medical Regulatory
Authorities of Canada (FMRAC) is the umbrella organization representing provincial and
territorial medical regulatory authorities in Canada and can address how best to contact
individual regulatory colleges.1
Issue 2: CMA’s Code of Ethics
In addition to policies, guidance and oversight by provincial and territorial regulatory
colleges, charging a fee associated with the delivery of an uninsured service, in this case a
fee associated with completing the form associated with the Disability Tax Credit, is captured
by Section 16 of the CMA’s Code of Ethics. Section 16 states: “In determining professional
fees to patients for non-insured services, consider both the nature of the service provided and
the ability of the patient to pay, and be prepared to discuss the fee with the patient.”2
Issue 3: Fee Structure for Uninsured Services
As the CRA does not provide remuneration to physicians for the completion of the Disability
Tax Credit form, the delivery of this service by physicians is an uninsured service. As an
uninsured service there is no set fee level. While provincial and territorial medical associations
Canadian Medical Association 3
May 15, 2015
may provide guidance to physicians within their jurisdiction on uninsured services, which may
be referenced in policies by regulatory colleges, this guidance does not constitute a set fee
schedule. As captured in the CMA’s Code of Ethics referenced above, physicians may
consider patient-specific and other factors in determining a fee for the delivery of an
uninsured service. The CMA encourages CRA to review relevant policies and guidance of
individual provincial and territorial regulatory colleges for a comprehensive understanding of
the oversight of uninsured services.
Once again, the CMA appreciates the opportunity to provide further information to support
the development of regulations to enable the new authorities of the Disability Tax Credit
Promoters Restriction Act and to ensure that CRA does not impose redundant and duplicative
regulatory oversight of the medical profession.
1 FMRAC’s Executive Director is Dr. Fleur-Ange Lefebvre and can be reached at firstname.lastname@example.org
2 CMA’s Code of Ethics may be accessed here: https://www.cma.ca/Assets/assetslibrary/
The Canadian Medical Association's (CMA) pre-budget submission is based on the premise that healthier Canadians are more productive Canadians. It also recognizes that the delivery of quality health care, in a timely manner, is paramount and is not mutually exclusive of any productivity agenda. With the recent release of its Health Care Transformation in Canada: Change That Works. Care That Lasts. policy document, the CMA declared its readiness to take a leadership position in confronting the hard choices required to make health care work better for Canadians. Physicians are reaching out to the Canadian public, opinion and business leaders, governments, interested parties and stakeholders to find ways to improve our health care system and to make sure that the upcoming reforms will focus on better serving patients.
Canada's health care system cannot continue on its current path, especially as pressure grows from an aging population. 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 one of Canada's most cherished national institutions is at stake. We must work together toward a common vision of what we aspire for our health care system.
The CMA commends the federal government for publicly stating it will honour its previous commitment of a 6% annual increase to the Canada Health Transfer through to 2014. This sustained predictable funding has brought some long-term stability to the publicly financed health care sector. However, the CMA believes that the health care system must be capable of withstanding or accommodating demand surges and fiscal pressure. Capacity and innovation strategies need to be developed and implemented to meet emerging health necessities.
In this brief, the CMA identifies a number of key issues related to health human resources and infrastructure that require immediate attention if the Canadian economy is to retain its competitive position in the global economy. Pressure is mounting on the system and there is a need to move beyond data collection to interdisciplinary collaboration. Including health care providers in the decision-making process would lead to better health public policy decisions, and result in much needed pan-Canadian health human resource planning. By making strategic direct investments in health human resources, public health and retirement savings, the federal government would retain its leadership role and contribute to the sustainability of a patient-centred health care system.
Health care's contribution: A more productive and innovative economy
The health care system in Canada employs over a million people, or 7.5% of the labour force. In 2009, Canada invested $183 billion in health care, representing 11.9% of our GDP. The benefits of health care investments not only contribute to a higher quality of life for all Canadians, but the economic multiplier effect of the initial investment is estimated to create an additional $92 billion in economic activity, such as in the high technology sector, financial services and R&D jobs.i Further federal investments in the health care system contribute to ensuring a more productive and innovative economy.
Better Health, Improved Productivity
The Conference Board of Canadaii, the Organization for Economic Co-operation and Development (OECD) iii, the World Health Organizationiv, the Commonwealth Fundv, and the Frontier Centre for Public Policyvi all rate Canada's health care system poorly in terms of "value for money" as well as efficiency. 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. We know that investments in quality today will pay off in improved health that 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.
Our proposals are informed by regular consultations with our 72,000 physician members and reflect what they believe are the most pressing gaps that exist in our health care system today. These recommendations will also start the process of fostering transformation of the health care system that not only serves the health needs of Canadians, but makes our health care system more effective, accountable and sustainable now and for generations to come.
* Please note that the sum of the following recommendations would add less than 0.5% to the current $25 billion Canada Health Transfer that is committed to the provinces.
Recommendations for the 2011 Federal Budget:
A. Investing in Health Human Resources: $53.1 million over 4 years
1. The federal government should fulfill the balance of its 2008 election promisevii of investing $33.1 million over 4 years to fund 35 new residencies per year; and invest $20 million over 4 years in the repatriation of Canadian physicians working abroad.
B. Investing in pandemic preparedness (post H1N1): $500 million over 5 years
2. The federal government should increase funding ($200 million over 5 years) to enhance disease surveillance by linking public health databases with real-time clinical information through patient Electronic Medical Records in order to facilitate data collection and analysis between local public health authorities and primary care practices.
3. The federal government should increase funding ($200 million over 5 years) for local health emergency preparedness planning to improve collaboration and coordination of clinical care and public health structures at the local level during public health crises and reduce the variation of capacity across the country.
4. The federal government should invest in the creation of a pan-Canadian strategy ($100 million over 5 years) to build a process for a harmonized national clinical response, including vaccine programs in times of potential health crises.
C. Improving retirement savings options for the self-employed: federal taxes to be deferred over time
5. The federal government should increase RRSP limits and explore opportunities to provide pension vehicles for self-employed Canadians.
D. Encourage Canadians to save for long-term care needs: federal taxes to be deferred over time
6. The federal government should study options for pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance.
E. Support for informal caregivers
7. The federal government should undertake pilot studies that explore tax credit and/or direct compensation for informal caregivers for their work and expand relief programs for informal caregivers that provide guaranteed access to respite services for people dealing with emergency situations.
A. Investing in Health Human Resources: $53.1 million over 4 years
Every high-performing health system begins with a strong primary care system. 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 treatment. Part of the reason for these delays is the shortage of health care professionals in Canada and the lack of long-term pan-Canadian planning to ensure needs are met.
Canada ranks 26th of 30 OECD member countries in physician-to-population ratio. The lack of physicians in Canada puts the system under pressure and the impact of this is being felt by patients across the country. A Centre for Spatial Economics studyviiicommissioned by the CMA, found that the Canadian economy is expected to lose $4.7 billion in 2010, as a result of excessive wait times for just four procedures: joint replacements, MRIs, coronary artery bypass surgery and cataract surgery. When people wait too long for care businesses face increased human resource costs to replace lost or affected employees. There is a loss in output and especially productivity. The reduction in output would lower federal and provincial government revenues in 2010 by $1.8 billion. The econometric model in the report used to calculate these costs also estimates that to cut wait times to government recommended benchmarks would require a $586 million investment or just 2% of the current Canada Health Transfer. This investment would boost GDP by $6.2 billion.
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, and other health professionals are being lured away by ample opportunities to train and work outside Canada.
The CMA commends the federal government for recently announcing the Northern and Remote Family Medicine Residency Program in Manitoba, which constitutes an investment of just over $6.9 million. The program will provide extensive medical training for 15 additional family medicine residents over the next four years. We urge the government to build on this announcement and honour its full commitment. Thousands of health care professionals are currently working abroad, including approximately 9,000 Canadian-trained physicians. We know that many of the physicians who do come back to Canada are of relatively young age, meaning that they have significant practice life left. While a minority of these physicians return on their own, many more can be repatriated in the short term through a relatively small but focussed effort by the federal government, led by a secretariat within Health Canada.
Recommendation 1: The federal government should fulfill its 2008 election promiseix of investing $33.1 million over 4 years to fund 35 new residencies per year; and invest $20 million over 4 years in the repatriation of Canadian physicians working abroad.
B. Investing in pandemic preparedness (post H1N1): $500 million over 5 years
The absence of a national communicable disease/immunization monitoring system is an ongoing problem. In 2003, the report of the National Advisory Committee on SARS and Public Health recommended that "the Public Health Agency of Canada should facilitate the long term development of a comprehensive and national public health surveillance system that will collect, analyze, and disseminate laboratory and health care facility data on infectious diseases... to relevant stakeholders." Seven years later, Canada still does not have a comprehensive national surveillance and epidemiological system.
Clinicians' practices are highly influenced by illness patterns that develop regionally and locally within their practice populations; thus, surveillance data are useful in determining appropriate treatment. During the H1N1 outbreak, real-time data were not available to most physicians and when data did become available, they were already several weeks old. Greater adoption of electronic medical records (EMRs) in primary care and better public health electronic health records (EHRs), with the ability to link systems, will augment existing surveillance capacity and are essential to a pan-Canadian system. International strategy and technology consulting firm Booz Allen Hamilton found that the benefits of an interconnected Electronic Health Record (EHR) in Canada could provide annual system-wide savings of $6.1 billion. A pan-Canadian electronic health information system is urgently needed and must become a priority during the inter-pandemic phase, with adequate federal funding and provincial/territorial collaboration.
Recommendation 2: The federal government should increase funding ($200 million over 5 years) to enhance disease surveillance by linking public health databases with real-time clinical information through patient Electronic Medical Records in order to facilitate data collection and analysis between local public health authorities and primary care practices.
Recommendation 3: The federal government should increase funding ($200 million over 5 years) for local health emergency preparedness planning to improve collaboration and coordination of clinical care and public health structures at the local level during public health crises and reduce the variation of capacity across the country.
A key measure to combat pandemic influenza is mass vaccination. On the whole, Canada mounted an effective campaign: 45% of Canadians were vaccinated, and the proportion was even higher in First Nations communities - a first in Canadian history. The outcome was positive, but many public health units were stretched as expectations exceeded their pre-existing constrained resources. Nationally promulgated clinical practice guidelines had great potential to create consistent clinical responses across the country. Instead, the variation and lack of coordination in providing important clinical information during this crises eroded the public's confidence in the federal, provincial and territorial response.
Recommendation 4: The federal government should invest in the creation of a pan-Canadian strategy ($100 million over 5 years) to build a process for a harmonized national clinical response, including vaccine programs in times of potential health crisis.
C. Improved retirement savings options for self-employed: federal taxes to be deferred over time
With the aging Canadian population and the decline in the number of Canadians participating in employer-sponsored pension plans, now is the time to explore strengthening the third pillar of Canada's government-supported retirement income system: tax-assisted savings opportunities and vehicles available to help Canadians save to meet future continuing care needs.
Of keen interest to the medical profession are measures to help self-employed Canadians save for their retirement. Physicians represent an aging demographic - 38% of Canada's physicians are 55 or older. Self-employed physicians, like many other self-employed professionals, are unable to participate in workplace registered pension plans (RPPs). This makes them more reliant on Registered Retirement Savings Plans (RRSPs) relative to other retirement savings vehiclesx. The recent economic downturn has shown that volatility of global financial markets can have an enormous impact on the value of RRSPs over the short-and medium-term. This variability is felt most acutely when RRSPs reach maturity during a time of declining market returns and RRSP holders are forced to sell at a low price.
The possibility that higher-earning Canadians, such as physicians, may not be saving enough for retirement was raised by Jack Mintz, Research Director for the Research Working Group on Retirement Income Adequacy of Federal-Provincial-Territorial Ministers of Finance. In his Summary Report, Mr. Mintz wrote that income replacement rates in retirement fall below 60% of after-tax income for about 35% of Canadians in the top income quintile. This is due to the effect of the maximum RPP/RRSP dollar limits and the government should consider raising these limits.
Recommendation 5: The federal government should increase RRSP limits and explore opportunities to provide pension vehicles for self-employed Canadians.
D. Encourage Canadians to save for long-term care needs: federal taxes to be deferred over time
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 2031xi. With Canadians living longer and continuing care falling outside the boundaries of Canada Health Act (CHA) first-dollar coverage, there is a growing need to help Canadians save for their home care and long-term care needs. These needs are an important part of the retirement picture as the federal government considers options for ensuring the ongoing strength of Canada's retirement income system.
Additional information is contained in CMA's submission to the House of Commons Standing Committee on Finance during its study on Retirement Income Security of Canadians (May 13, 2010).
Recommendation 6: The federal government should study options for pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance.
E. Support for informal caregivers
Much of the burden of continuing care falls on informal (unpaid) caregivers. More than a million employed people aged 45-64 provide informal care to seniors with long-term conditions or disabilities, and 80% of home care to seniors is provided by unpaid informal caregivers. Canada lags behind several countries, including the U.K., Australia, Germany, Japan, the Netherlands and the U.S. in terms of supporting informal caregivers.
Recommendation 7: The federal government should undertake pilot studies that explore tax credit and/or direct compensation for informal caregivers for their work and expand relief programs for informal caregivers that provide guaranteed access to respite services for people dealing with emergency situations.
The CMA encourages the federal government to consider the recommendation found in the report entitled; Raising the Bar:A Roadmap for the Future of Palliative Care in Canada supported by the Canadian Hospice Palliative Care Association.
The recommendations contained in the CMA's pre-budget submission represent our priority recommendations for federal investments that will contribute to a healthy, more productive and innovative economy. These recommendations will also start the process of fostering transformation of the health care system that not only serves the health needs of Canadians but makes our health care system more effective, accountable and sustainable now and for generations to come. As the federal government's commitment to the provinces through the 2004 Health Care Accord expires in 2014, it is imperative that investments are made that not only provide better care but are also sustainable for our country's economy.
Appendix Table 1
i The additional economic activity generated by the health care sector is based on a conservative 1.5 multiplier. The CMA is pursuing precise estimates of the benefits of health care investments in Canada. Please see:
Economic Footprint of Health Care Services in Canada Prepared for: Canadian Medical Association by Carl Sonnen
with Natalie Rylska Informetrica limited January 2007 In economics, the multiplier effect or spending multiplier is the idea that an initial amount of spending (usually by the government) leads to increased consumption spending and so results in an increase in national income greater than the initial amount of spending. The existence of a multiplier effect was initially proposed by Richard Kahn in 1930 and published in 1931. http://en.wikipedia.org/wiki/Fiscal_multiplier Snowdon, Brian and Howard R. Vane. Modern macroeconomics: its origins, development and current state. Edward Elgar Publishing, 2005. ISBNS 1845422082, 9781845422080. p. 61.
ii How Canada Performs 2008: A Report Card on Canada, The Conference Board of Canada
iii Organization for Economic Co-operation and Development [OECD] (2007). OECD Health
Data 2007. Version 07/18/2007. CD-ROM. Paris: OECD.
iv World Health Organization [WHO] (2007). World Health Statistics 2007. see: http://www.who.
v Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care May 15, 2007 (updated May 16, 2007)
Authors: Davis, Schoen, Schoenbaum, Doty, Holmgren, Kriss, Shea
vi Euro-Canada Health Consumer Index 2008, Health Consumer Powerhouse, Frontier Centre for Public Policy, FC Policy Series No. 38 see:www.fcpp.org/pdf/ECHCI2008finalJanuary202008.pdf
vii Health Care Certainty for Canadian Families, the Conservative Party of Canada, backgrounder 10/08/08.
viii The economic cost of wait times in Canada, the Centre for Spatial Economics, July 2010.
ix Health Care Certainty for Canadian Families, the Conservative Party of Canada, backgrounder 10/08/08.
x A more detailed outline of the issues surrounding pension reform can e found in CMA's Submission on Pension Reform Backgrounder for the Standing Committee on Finance, May 13, 2010. www.cma/submissions-to-government
xi Statistics Canada. Populations projections. The Daily, Thursday, December 15, 2005.