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Building a Comprehensive Post-Market Surveillance System : Canadian Medical Association Response to Health Canada’s Discussion Paper “Designing a Mandatory System for Reporting Serious Adverse Reactions”

https://policybase.cma.ca/en/permalink/policy1951
Last Reviewed
2012-03-03
Date
2005-07-28
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2012-03-03
Date
2005-07-28
Topics
Health systems, system funding and performance
Text
Building a Comprehensive Post-Market Surveillance System Canadian Medical Association Response to Health Canada’s Discussion Paper “Designing a Mandatory System for Reporting Serious Adverse Reactions” Submitted to Health Canada July 28, 2005 Overview The CMA believes that all stakeholders should work together to improve adverse drug reaction (ADR) reporting, in the interests of improving patients’ safety and health. However, we believe that activity in pursuit of this end must be based on two fundamental premises: a) Reporting is only one part of a comprehensive post-market surveillance system. In order to effectively monitor the safety of Canada’s drug supply, this system should include: * a simple, comprehensive and user-friendly reporting process; * rigorous analysis of reports to identify significant threats to drug safety; * a communications system that produces useful information, distributed to health care providers and the public in a timely, easily understood manner. There is no point in enacting a mandatory reporting requirement until all of these elements are in place. We wonder why mandatory reporting has been singled out for discussion when a holistic approach to reforming Canada’s drug safety system is called for. b) Health care providers should be encouraged to participate willingly and voluntarily in the reporting process. To be successful, Canada’s post-market surveillance system will depend on the active participation of physicians and other health professionals. Experience with health system quality and safety improvement efforts over the past several years has demonstrated that meaningful acceptance is most effectively obtained when those involved are willing participants. If you build a comprehensive, efficient and effective post-market surveillance system, physicians will participate actively in it. Forcing them to participate before the system has been built will result in alienation, frustration and failure. Comments on Discussion Paper a) Is Mandatory Reporting Necessary? This is a fundamental question and the discussion paper does not satisfactorily address it. There are two reasons why we question the necessity for imposing an ADR reporting requirement on health professionals. First, as awareness of the drug-safety system’s importance has increased, the number of ADR reports has increased along with it - more than 10% in 2004, as the discussion paper notes - without a mandatory reporting requirement. Given this trend, it is highly probable that time, education, adequate resources and increasing familiarity with the surveillance system will raise reporting rates to the desired level (however defined) without mandatory reporting. Second, as the discussion paper points out, there is no evidence that mandatory reporting has been effective in other jurisdictions where it has been implemented. The paper offers no clear explanation for this lack of success. More importantly, it does not indicate how Health Canada plans to ensure that mandatory reporting will succeed in this country when it has proven ineffective elsewhere. A primary principle of any system change is that we should not repeat the mistakes of others. Before launching a program whose success has not been proven, other viable, and possibly more effective, alternatives should be examined. b) Addressing known barriers to reporting The CMA acknowledges that ADRs are under-reported, in Canada and worldwide. The discussion paper identifies a number of barriers to reporting, and its list mirrors the observations and experiences of our own members. We believe most of these barriers can, and should, be overcome. We also agree that it is necessary to raise health professionals’ awareness of the importance of, and process for, ADR reporting. But we question the curious assertion that “Mandatory reporting could raise awareness of the value of reporting simply by virtue of the public debate.” Surely there are more positive ways to raise awareness than publicly speculating about the punitive consequences of non-compliance. We suggest that instead, Health Canada work with physicians and other health professionals to address the existing barriers to reporting. Specifically, we recommend that Health Canada implement: * a well-funded and targeted awareness-raising campaign focused on provider education and positive messaging, * a user-friendly reporting system, including appropriate forms, efficient processes and adequate fees. These measures are within Health Canada’s purview in the existing policy and legislative environment. We believe they would increase reporting without the need for coercive measures. At a minimum, positive system improvements should be tried first before considering a mandatory-reporting requirement. With regard to specific questions posed in the discussion paper: Question 1: Health professionals should be explicitly protected from any liability as a result of reporting an adverse drug reaction. This should be the case regardless of whether reporting is voluntary or mandatory. Question 2: Professionals should be compensated for all meaningful work including the completion of forms and any follow-up required as a result of the information they have provided. We would be happy to expand further on this issue on request. Question 3: Issues of confidentiality should be covered in legislation. The CMA has developed an extensive and authoritative body of knowledge on privacy issues in health care, which we would be pleased to share with Health Canada. c) Improved report quality We agree that increasing the quality and richness of ADR reports is as important as increasing their number. Perhaps it is even more important, since high-quality reports allow for high-quality analysis. Mandatory reporting will not improve the quality of ADR reports; it will simply increase their quantity. It may even compromise the system’s efficiency and effectiveness by increasing the volume of clinically insignificant reports. Experience elsewhere has taught us that true quality cannot be legislated or imposed; any attempt to do so would be pointless. If ADR reports included the information listed in Table 4, this would improve their usefulness and the effectiveness of the overall surveillance process. However, it is unrealistic to expect all reports to contain this level of information. The treating physician may not be able to provide all of it, especially if he or she is not the patient’s regular primary care provider. Some of this information, particularly about outcomes, may not be available at the time of the reporting, and gathering it would require follow-up by Health Canada. Health Canada should consider measures other than mandatory reporting to improve the quality of ADR reports. The CMA suggests that consideration be given to: * Improving follow-up capacity. We agree that it should be made easier for Health Canada officials to contact reporters and request details on follow-up or outcomes. This should be considered as part of a comprehensive initiative to improve Health Canada’s capacity to analyze ADR reports. * Establishing a sentinel system. Another option for increasing high-quality reports would be to establish a “sentinel” group of practicing physicians who would contract to report all ADRs in detail. These physicians, because of their contractual obligation, would be committed to assiduous reporting. Sentinel systems could be established concurrently with efforts to increase voluntary ADR reporting by the broader health professional community. In addition to the current information provided, consideration should be given to including on reporting forms the option to allow Health Canada officials to act on information the physician provides; for example, in the reporting of sexually transmitted diseases physicians provide certain information and have the option to request that public health officials undertake follow-up and contact tracing. d) Minimize administrative burden We agree that Health Canada should give consideration to making the ADR reporting system user-friendly, non-complex and easy to integrate into the patient-care work stream. These reforms can and should be implemented regardless of whether a mandatory requirement is in place. They do not need mandatory reporting to make them work; in fact, they are more likely to encourage ADR reporting than any form of coercive legislation. Rather than making a mandatory reporting requirement “fit” with the traditional patient-care framework, we invite Health Canada to work with us to increase health professionals’ capacity to report ADRs voluntarily. We are already working with Health Canada to improve physicians’ access to drug safety material. Health Canada’s ADR reporting form can now be downloaded from the cma.ca web site, which also posts the latest drug alerts from Health Canada and from the Food and Drug Administration in the U.S. We have developed an on-line course in partnership with Health Canada, to teach physicians when and how to make ADR reports. We hope to build on this collaboration, with the goal of making it possible for physicians to report ADRs online via cma.ca. This will permit them to fit reporting more conveniently into their daily workflow. (Note: the “MedEffects” Web portal now being developed at Health Canada does not fit well into the workflow and therefore will not make reporting easier for health professionals.) In the future, we hope that ADR reporting can be built directly into the Electronic Medical Record (EMR). We think this will be a critical element in the bi-directional communicating that ADR reporting requires. It will also enable rapid integration of advisories into the EMR so that they can be available to physicians at the time they are writing a prescription. Before electronic ADR reporting can work, a standard for electronic data should be in place (at present it is not) and Health Canada should develop the capacity to accept data electronically. Health Canada’s discussion paper makes reference to cost-benefit analysis. We recommend that you take great care not to over-emphasize cost-benefit when it comes to enhancing patient safety. Meaningful improvements in the post-market surveillance system will be costly whatever solution Health Canada eventually embraces, and it is impossible to measure financially the value of safety. What is an acceptable cost for one life saved? e) Minimize Over-Reporting The discussion paper acknowledges that not all adverse reactions need be reported. We strongly agree that one of the dangers of mandatory reporting is its potential to overwhelm the system with an unmanageable flood of reports. There is no reason to require reports of minor side effects that are already known to be associated with given drugs. We agree that the reactions Health Canada most needs to know about are those which are severe and/or unexpected. If Health Canada insists on implementing a mandatory reporting system, it should be limited to these reactions (possibly with the corollary that well known serious ADRs would not need to be reported). However, the operating definitions may need clarification, and we recommend that Health Canada consult with health professionals and others on operational guidelines for defining “serious adverse reaction.” Health Canada’s desire to encourage reports on drugs approved within the last 5 years is understandable (though some drugs may be on the market for longer than this before their true risks are known). In practice, however, many physicians do not know which drugs these are, and seeking out this information may impose a heavy administrative burden. As we move toward an EMR-based reporting system, a tag on the Drug Identification Number to tell when the drug was approved will allow physicians to identify which medications require special vigilance. Appropriate reporting could be encouraged, and over-reporting discouraged, by clear guidelines as to what should be reported as well as appropriate compensation for reporting. f) Match Assessment Capacities In our opinion, this is one of the most important sections in the document. What happens once the reports have been received is crucial if we want to identify a serious drug risk as quickly as possible. Under the current system, one of the most significant barriers to physicians’ reporting is lack of confidence that anything meaningful will be done with their reports. Enhancements to the analysis function must be made concurrently with efforts to increase ADR reporting. ADR reports are only cyber-bytes or stacks of paper unless we can learn from them. This requires rigorous data analysis that can sort “signal from noise” – in other words, sift through thousands of reports, find the ones that indicate unusual events, investigate their cause, and isolate those that indicate a serious public health risk. This requires substantial resources, including an adequate number of staff with the expertise and sensitivity required for this demanding task. Unless Health Canada has this capacity, increasing the number of reports will only add to the backlog in analysts’ in-boxes. The CMA recommends that Health Canada allocate sufficient resources to enable it to effectively analyze and respond to ADR reports and other post-market surveillance information. g) Respect privacy Privacy of both patient and physician information is a significant concern. Physicians’ ethical obligation to maintain patient confidentially is central to the patient-physician relationship and must be protected. We acknowledge that issues of privacy and confidentiality must be resolved when designing an ADR reporting system, particularly as we work toward electronic communication of drug surveillance data and its incorporation into an EMR. For example, regulations should explicitly state that ADR reports are to be used only for the purpose for which they were submitted, i.e. for post-market drug surveillance. In addition, Health Canada should ensure that any privacy provisions it develops meet the legislative test outlined in Section 3.6 of CMA’s Health Information Privacy Code (Attachment I). Health Canada can be assured that physicians take their privacy obligations seriously. The CMA has been a strong and pro-active player in debate on this issue, and our Privacy Code lays the groundwork on which we believe any privacy policies involving ADR reporting should be based. h) Compliance through sanctions Physicians are motivated to report ADRs by their concern for public health and their patients’ well-being. In addition, they are guided by the CMA Code of Ethics and governed by regulatory authorities in every province. A clear ethical and professional obligation already exists to report anything that poses a serious threat to patient safety. If physicians do not comply with this obligation, sanctions are available to the provincial regulatory authorities. In fact, the most serious threat for physicians is loss of standing with the professional regulatory authority, not the courts or any external judicial system. It would be superfluous to add a second level of regulation or scrutiny when remedies already exist. The discussion paper presents few alternatives to the existing self-regulatory system. As the paper itself acknowledges, it is unrealistic to impose sanctions based on failure to report an ADR, since it is not always easy to determine whether an adverse effect is attributable to a health product. But the only suggested alternatives - requiring physicians to demonstrate knowledge, or to have the required reporting forms in their office - seem intrusive, crude and unreasonable; they are also meaningless since they have no direct relation to a physician’s failure to report. If Health Canada is considering a large outlay of taxpayers’ dollars for post-market surveillance, we suggest they target those funds to education and awareness raising, and to enhancing the system’s ability to generate and communicate meaningful signal data, rather than to enforcing a mandatory reporting system based on weak compliance measures, with no evidence of its effectiveness in other jurisdictions. Physicians who are in serious breach of their ethical and legal responsibility to report are subject to sanctions by provincial regulatory authorities. Most provincial colleges have policies or guidelines regarding timely reporting and appropriate enforcement mechanisms. Medicine’s tradition of self-regulation has served it well, and we recommend that Health Canada respect and support existing regulatory authorities as they maintain the standards for appropriate professional behaviour. As we have said before - the preferred quality improvement tools to enhance performance and encourage compliance are education and positive reinforcement, not legislation and the threat of sanctions. Conclusion In its discussion paper Health Canada has invited stakeholders to provide their input on how best to develop a mandatory system for reporting ADRs. The Canadian Medical Association believes that the best way to do this is not to develop one at all. Instead, we believe stakeholders should concentrate on building a sustainable, robust and effective post-market surveillance system which: * encourages and facilitates voluntary reporting, by designing a simple and efficient process that can be incorporated into a physician’s daily workflow; * effectively uses reporting data to identify major public health risks; * communicates drug safety information to providers and the public in a timely, meaningful and practical way. The CMA is committed to working, in partnership with Health Canada and other stakeholders, toward the ultimate goal of a responsive, efficient and effective post-market drug surveillance system. This is part of our long-standing commitment to optimizing Canadians’ safety and health, and achieving our vision of a healthy population and a vibrant medical profession.
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Building bridges: the link between health policy and economic policy in Canada : A Document prepared by the Canadian Medical Association (CMA)

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

https://policybase.cma.ca/en/permalink/policy10441
Date
2012-05-31
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2012-05-31
Topics
Health systems, system funding and performance
Text
Thank you for this opportunity to appear before this committee on behalf of the CMA and its 76,000 members. Canadians believe that transforming our health care system to meet the needs of 21st century Canada must be among the highest priorities for all levels of government, including the federal government. I would like to begin by commenting on the health transfer framework announced by the Minister of Finance in December. This announcement provided some predictability for the years ahead. However, with the federal government reducing its involvement in several areas affecting health or health care, added costs will end up in the laps of the provinces and territories. So while this budget may enhance the federal government's fiscal prospects, it will do so to the detriment of the provinces and territories. But there's more to this debate than funding. We believe that Canadians would be better served if federal health care transfers came with specific guidelines ensuring that the system provides care of comparable access and quality to Canadians across the country, regardless of their circumstances. We are encouraged that the Minister of Health has indicated she wants to collaborate with the provinces and territories on developing accountability measures to ensure value for money and better patient care. We look forward to the minister's plan for accountability. This budget is notable for other missed opportunities. For many years, groups across the political spectrum have called for a pharmaceutical strategy to reduce national disparities. In fact, such a strategy was committed to by governments under the 2004 Health Accord. Minister Kenney referred to this issue indirectly when he said the recent cancellation of supplemental health benefits for refugee claimants is justified because refugees should not have access to drug coverage that Canadians do not have. Rather than cutting off those desperately vulnerable people, Canada's physicians urge the federal government to work with the provinces and territories to develop a plan that ensures all Canadians have a basic level of drug coverage. Indeed, we now appear to be in a race to the bottom in the way we treat vulnerable groups - by, for example, deferring Old Age Security for two years; and changing service delivery to veterans, mental health programs for our military and the Employment Insurance program. Significant policy changes have been announced since the budget, with little opportunity for debate and little evidence provided. We note, as well, the lack of open consultation with Canadians on matters of great import to their lives. Successful policy requires buy-in, which is best achieved when those interested are able to participate in the policy-making process. This brings me to a wider concern shared by our members - that policy-makers are not paying adequate attention to the social determinants of health, factors such as income and housing that have a major impact on health outcomes. We remind the government that every action that has a negative effect on health will lead to more costs to society down the road. The federal government is the key to change that benefits all Canadians. While there are costs and jurisdictions to consider, the CMA believes the best way to address this is to make the impact on health a key consideration in every policy decision that's made. The federal government has used this approach in the past, in considering rural Canadians, for example. We therefore call for a new requirement for a health impact assessment to be carried out prior to any decision made by cabinet. This would require that, based on evidence, all cabinet decisions take into account possible impacts on health and health care, and whether they contribute to our country's overall health objectives. A similar model is in use in New Zealand and some European countries. For instance, what health impact will cuts in funding to the tobacco strategy have? Such an assessment would in particular have a dramatic impact with regard to poverty. Poverty hinders both human potential and our country's economic growth - and needlessly so as there are many ways to address it effectively. The National Council on Welfare - which will disappear as a result of this budget - reported last fall that the amount it would have taken in 2007 for every Canadian to have an income over the poverty line was $12.6 billion, whereas the consequences of poverty that year added up to almost double that figure. Close to 10 per cent of Canadians were living in poverty in 2009, many of them children, as UNICEF underlined yesterday. This is a huge challenge for our country. In closing, as this budget cycle ends and as you begin to prepare for the next, please bear in mind that as prosperous as our country is, if we do nothing for the most vulnerable in our society - children, the elderly, the mentally ill, Aboriginal peoples - we will have failed. Thank you.
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CMA's Response to Questionnaire From the House of Commons Standing Committee on Finance: 2012-2013 Pre-Budget Consultation

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

https://policybase.cma.ca/en/permalink/policy10350
Date
2012-01-12
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2012-01-12
Topics
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) appreciates the opportunity to provide additional comments and recommendations as part of Finance Canada's 2012 pre-budget consultations. The health sector provides essential services and high value jobs supporting communities across Canada. Statistics Canada reports that employment in the health sector accounts for 10% of the Canadian labour force.i In considering possible additional economic stimulus measures that build on the success of Canada's Economic Action Plan, the CMA encourages the federal government to consider investments that target efficiency improvements in the health sector. Efficiency improvements in the health sector yield benefits to all orders of government and Canadians. The following recommendations are advanced for Finance Canada's consideration: * In order to improve the delivery of better care, better health, and better value, the CMA recommends that the federal government work with the provinces, territories and health sector stakeholders to develop a model for accountability and patient-centred care. The CMA encourages the federal government to adopt the Principles to Guide Health Care Transformation, developed by the CMA together with the Canadian Nurses Association and since endorsed by over 60 organizations, as the basis of a pan-Canadian model for accountability and patient-centred care. * Recognizing the significance of nationally comparable metrics on health outcomes and the health care system together with the effectiveness of national public reporting in demonstrating accountability, the CMA recommends that the federal government undertake efforts towards identifying pan-Canadian metrics and measurement that will link health care expenditures to comparable health outcomes. * As the federal government prepares to engage with the provinces and territories to further map out improvements to Canada's health system, the CMA strongly encourages consideration be given to the federal role in coordinating the development of pan-Canadian clinical practice guidelines (CPGs). * While, as previously indicated, the CMA supports the federal government's proposal to expand access to pensions, specifically by developing pooled registered retirement plans (PRPPs), the limitations to PRPPs should be addressed to ensure that they provide value to self-employed Canadians, including physicians. Specifically, addressing the limitations would include: (1) expanding the PRPP framework to include defined benefit and targeted benefit pension plans; (2) increasing the retirement savings capacity of self-employed individuals by either raising the RRSP limit or providing a distinct limit for PRPPs; and, (3) ensuring the PRPP framework expands the eligibility of administrators beyond financial institutions. Introduction The Canadian Medical Association (CMA) appreciates the opportunity to provide additional recommendations to the Government of Canada as part of its 2012 Pre-Budget consultation. Building upon the CMA's recommendations to the House of Commons' Finance Committee, this submission focuses on three issues: (1) improving accountability and patient-centred care in the delivery of new federal health care funding; (2) coordinating the development of pan-Canadian clinical practice guidelines; and (3) addressing limitations in the federal framework for pension reform. 1. Accountability and patient-centred care "Raising sufficient money for health is imperative, but just having the money will not ensure universal coverage. Nor will removing financial barriers to access through prepayment and pooling. The final requirement is to ensure resources are used efficiently." World Health Organization (2010) As the federal government finalizes the Strategic and Operating Review and considers other measures to eliminate the deficit, including scaling down the Economic Action Plan, it must be recognized that improved health systems and the resultant improved productivity pay economic dividends for the country; and, further, that "health" by today's standards is not just the assessment and treatment of illness, but also the prevention of illness, and the creation and support of social factors that contribute to health should also be considered. With the recent announcement by Minister Flaherty with respect to the Canada Health Transfer (CHT) and Canada Social Transfer (CST), the financial parameters for future health care funding have been established. Consistent with previous public opinion research, recent polling by Ekos Research Associates shows that 76% of Canadians identify improving health care as the leading priority for the federal government, ahead of reducing the national debt and deficit.ii However, as we have learned with the 2004 Health Accord, funding alone is not sufficient to ensure Canadian taxpayers benefit from improvements in health care, health outcomes, and value for money. Despite laying out laudable objectives, progress to improve our health care system has been slow following the 2003 and 2004 agreements. There is a general agreement that Canada's health care system is no longer a strong performer when compared to similar nations. The OECD's Health Data, 2011 ranks Canada eighth highest of 34 member states in per capita health care spending, the second highest in hospital spending per discharge, and the seventh lowest in the number of physicians per capita. While Canada outperforms the U.S. on most measures, we fall below the median performance of the OECD on common health quality and system measures. With the new health care funding commitment to 2024, it is now time to plan how to transform the health care system. Principles-based approach is required The CMA is advocating built-in accountability mechanisms to ensure Canada's health care system is focused on delivering improved patient outcomes. Developing a system that is accountable and patient-centred depends on continuously striving to achieve the Institute for Healthcare Improvement's (IHI) Triple Aim objectives of better care, better health and better value. Launched in 2007, the IHI Triple Aim initiative was designed to direct the improvement of the patients' experience of care (including quality, access, and reliability) while lowering the per capita cost of care. It was with the Triple Aim objectives in mind that the CMA jointly developed Principles to Guide Health Care Transformation in Canada with the Canadian Nurses Association (CNA). It is our strong belief that discussions about the future of health care in Canada must be guided by these principles. The CMA-CNA principles are summarized as follows: * Patient-centred: Patients must be at the centre of health care, with seamless access to the continuum of care based on their needs. * Quality: Canadians deserve quality services that are appropriate for patient needs, respect individual choice and are delivered in a manner that is timely, safe, effective and according to the most currently available scientific knowledge. * Health promotion and illness prevention: The health system must support Canadians in the prevention of illness and the enhancement of their well-being, with attention paid to broader social determinants of health. * Equitable: The health care system has a duty to Canadians to provide and advocate for equitable access to quality care and commonly adopted policies to address the social determinants of health. * Sustainable: Sustainable health care requires universal access to quality health services that are adequately resourced and delivered across the board in a timely and cost-effective manner. * Accountable: The public, patients, families, providers and funders all have a responsibility for ensuring the system is effective and accountable. In order to ensure that future federal funding delivers on the Triple Aim objectives of better care, better health and better value, a model for accountability and patient-centred care is required. Such a model would expand upon the CMA-CNA Principles through the development of a set of measurable indicators related to each principle that can be used for setting national standards, monitoring progress and demonstrating accountability to Canadians. The CMA therefore urges the federal government to facilitate discussions with the provinces and territories to identify how resources will be used to improve patient care and health outcomes across the country. To this end, the CMA has urged the Minister of Health to move quickly to engage the provincial and territorial health ministers on transforming the health care system. The CMA recommends that the federal government work with provinces and territories, in consultation with national health sector stakeholders, to develop a model for accountability and patient-centred care. The CMA encourages the federal government to adopt the CMA-CNA Principles to Guide Health Care Transformation as the basis of a pan-Canadian model for accountability and patient-centred care. Improving public reporting: The cornerstone of accountability The federal government has a significant stake in national public reporting on the health of Canadians and on the performance of the health care system. As required by the Canada Health Act, the Minister of Health must publicly report administration, operation and adherence to the Act each year. Further, as the largest contributor to the single-payer system, the federal government has a unique role in demonstrating value for money and reporting on strategies to improve the quality, effectiveness and sustainability of the health care system. To facilitate public reporting, in addition to Statistics Canada, the federal government is supported by the Health Council of Canada and the Canadian Institute for Health Information, both established as government-funded non-profits, however, with distinct mandates. Despite pan-Canadian efforts such as provincial health quality councils and federal and non-governmental reporting, there remains significant room for improvement in the area of monitoring and reporting, both on health outcomes and system performance. As noted in the Commonwealth Fund's report on international health care systems, "reporting on health system performance [in Canada] varies widely across the provinces and territories...there is so far little connection between financial rewards and public reporting of performance." Not surprising, this issue was also identified by the Health Council of Canada in its Progress Report 2011. It highlights the challenges in reporting progress and explains the difficulties inherent to the current patchwork, "[w]here provinces and territories had set and publicized targets, it was easier for us to track progress. Where we could not find targets, assessing progress was more difficult." The CMA has long supported improved pan-Canadian public reporting on health and health care. Most recently, the CMA hosted a symposium with health reporting stakeholders to discuss the current status of national reporting and the need for the development of a pan-Canadian reporting framework. As recognized by the symposium's participants, there is a great deal of excellent data collection work occurring across the country. However, these efforts are largely uncoordinated and do not tell the full story of the health of Canadians or adequately assess the performance of the health care system. Indeed, despite an abundance of metrics and measurement, in many cases, data is not necessarily usable by the public or decision-makers and, unfortunately, is not necessarily comparable between jurisdictions. The CMA recommends that the federal government recognize the significance of nationally comparable metrics on health and the health care system and national public reporting in demonstrating accountability (i.e. better health, better care, and better value). In achieving these objectives, the CMA recommends that the federal government mandate an appropriate national organization, such as the Health Council of Canada, to undertake a consultative process with the aim of identifying pan-Canadian metrics and measurement that will link health expenditures and comparable health outcomes. 2. Coordinate the development of pan-Canadian Clinical Practice Guidelines As the federal government prepares to engage with the provinces and territories to further map out improvements to Canada's health system, the CMA strongly encourages consideration be given to the federal role in coordinating the development of pan-Canadian clinical practice guidelines (CPGs). Such a role would build upon the commitment made by the provinces and territories under the auspices of the Council of the Federation to collaborate on the development of three to five CPGs over the coming year. CPGs are systematically developed, evidence- or consensus-based statements to assist health care providers in making decisions about the most appropriate health care to be provided in specific clinical circumstances. There is compelling evidence in the literature, supported by the experience of other countries, that well-designed and disseminated CPGs can enhance the clinical behaviour of providers and provide a positive impact on patient outcomes. The principle argument in support of CPGs is their ability to enhance quality of care and patient outcomes. In addition, CPGs have been found to: * Provide publicly accessible descriptions of appropriate care by which to gauge health care performance; * Help to reduce inappropriate variations in care across diverse geographical and clinical settings; * Offer the potential of empowering patients as to appropriate care expectations; and, * Contribute to public policy goals, such as cost containment, through encouraging more appropriate provider use of resources. However, in the absence of a pan-Canadian approach, CPGs across Canada are of uneven quality and even excellent guidelines may not be effectively disseminated or implemented. In contrast to Canada, peer-nations such as the United Kingdom, the United States and Australia have committed at a national level to support the development and dissemination of CPGs. In November 2011, the CMA, together with leading national medical and health sector stakeholders, convened a Canadian Clinical Practice Guidelines Summit, attended by representatives of the federal and most provincial and territorial governments, to explore key components of a pan-Canadian strategy on CPGs. Emerging from this summit was a clear consensus that it was the federal role to provide the infrastructure support necessary to facilitate the development and dissemination of high-quality CPGs, customizable to the needs of all jurisdictions in Canada. Guideline development and implementation is a complex, lengthy and resource-intensive process. In the absence of federal coordination in Canada, guidelines are produced by disparate, disease-specific groups, often funded by the pharmaceutical industry. This creates an obvious potential for conflict of interest where the guideline development process is far from transparent. Many guidelines are published without disclosure on conflict of interest or methodology applied. Concern over the quality of guidelines presents one the most persistent barriers to adoption by physicians of the recommended practice. The resulting underutilization of CPGs in Canada is widely documented. Clearly, the development and dissemination of pan-Canadian CGPs present a unique and significant opportunity for improvement in Canada's health care system. The CMA recommends that as part of further discussions with the provinces and territories, the federal government commit to working with the provinces, territories and health sector stakeholders towards the development of a pan-Canadian clinical practice guideline initiative. In particular, the CMA recommends that the federal government commit support for the infrastructure necessary for the development, maintenance, and active dissemination of relevant, high-quality clinical practice guidelines. 3. Address the limitations proposed under the pension reform framework As previously indicated in the August 2011 submission to Finance Canada by the Retirement Income Improvement Coalition (RIIC), the CMA supports the federal government's proposal to expand access to pensions, specifically by developing pooled registered retirement plans (PRPPs). While we are currently assessing the package of proposed Income Tax Act amendments and will provide more detailed comments as part of the legislative process, the CMA is concerned that the framework, as proposed, limits the potential for PRPPs to expand physician access to, and investment in, pensions. Based on preliminary analysis, it is our understanding that the core benefit of the PRPP framework is in providing small businesses access to low-cost pension plans, thereby providing a vehicle to encourage employers to establish, and contribute to, pensions for their employees. Given that a significant proportion of physicians are self-employed, they would not benefit from employer contributions to a PRPP. Further, as proposed, the contribution limit to PRPPs would be calculated as an element of the current RRSP and pension contribution limit. Finally, further clarification is required on the type of organization that may qualify as a PRPP administrator. Well-governed organizations that represent a particular membership should be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members. While the CMA supports the proposed PRPP framework in principle, the limitations to PRPPs should be addressed to ensure that they provide value to self-employed Canadians, including physicians. The CMA recommends that Finance Canada consider amendments to the proposed Income Tax Act amendments to address limitations to PRPPs, specifically: (1) expanding the PRPP framework to include defined benefit and targeted benefit pension plans; (2) increasing the retirement savings capacity of self-employed individuals by either raising the RRSP limit or providing a distinct limit for PRPPs; and, (3) ensuring the PRPP framework expands the eligibility of administrators beyond financial institutions. Conclusion The comments and recommendations provided herein represent the CMA's priority recommendations for targeted federal funding towards the achievement of efficiency improvements in Canada's health sector. It is the CMA's position that these measures will contribute to a healthy, more productive and innovative economy by contributing to better care, better health and better value in the health care system. Once again, the CMA appreciates the opportunity to provide these additional comments and recommendations. i 2006 Census data ii http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/2011/Dec-Poll_en.pdf
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A More Robust Economy through a Healthier Population: Canadian Medical Association 2012-2013 pre-budget submission

https://policybase.cma.ca/en/permalink/policy10635
Date
2012-11-01
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2012-11-01
Topics
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) submission to the House of Commons Standing Committee on Finance discusses the important role of the federal government in ensuring Canada's health care system is cost-effective, accountable and accessible across the country in order to support the country's economic advantage. Investing in health and health care is required to generate wealth. As in other leading industrialized countries, the federal government needs to play a stewardship role in the effective allocation of health-related resources to foster a productive workforce and a strong economy. The purpose of this brief is to provide decision-makers with information on areas in which the federal government can contribute to improving the health of Canadians and the health care system - an issue Canadians consistently rank as their top concern. The CMA recommends that: Recommendation # 1 The federal government endorse the Principles to Guide Health Care Transformation, developed by the CMA together with the Canadian Nurses Association and since endorsed by over 120 national organizations. Recommendation #2 The federal government engage the provinces and territories in a consultative process to identify pan-Canadian metrics and measurement that link health expenditures to nationally comparable health outcomes. The purpose of which is to demonstrate accountability to Canadians. Recommendation # 3 The federal government recognize the implications of the social determinants of health on the demands on the health care system. Recommendation # 4 The federal government require that the federal cabinet's decision-making process include a Health Impact Assessment. Recommendation # 5 The federal government, in consultation with provincial and territorial governments and other stakeholders, establish a program of comprehensive prescription drug coverage to be administered through provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drugs. Recommendation # 6 The federal government, together with the provinces and territories, develop and implement a pan-Canadian strategy for continuing care, which would integrate home care and facility-based long-term, respite and palliative care services fully within health care systems. Recommendation # 7 A targeted health infrastructure fund be established as part of the federal government's long-term plan for public infrastructure. The purpose of this fund would be to address infrastructure shortages in the health sector that prevent the optimization of health human resources and exacerbate wait times. Recommendation # 8 The federal government expand the relief programs for informal caregivers to provide guaranteed access to respite services for people dealing with emergency situations, as well as increase the Family Caregiver Tax Credit to better reflect the annual cost of family caregivers' time at market rates. Recommendation # 9 The federal government establish programs to encourage Canadians to save for their long-term care needs by pre-funding long-term care through for example, private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance, such as an RESP-type savings vehicle. Recommendation # 10 The federal government develop and implement a national dementia strategy. Such a strategy will contribute to addressing the alternative level of care crisis impacting the efficiency of the overall health care system. Introduction Despite significant investments in health care and improvements in medical treatment and technologies, health outcomes in Canada are not improving. The incidence of chronic disease, such as diabetes and the corresponding risk factors, among them obesity, continues to rise. These negative outcomes can have a significant impact on the prosperity of the country as health is necessary for individuals to lead a prosperous and autonomous life. While the federal government's investment in the sector has continually increased, it is generally agreed that, in terms of its health care system, Canada is no longer a strong performer compared to similar nations. As in other leading industrialized countries, the Government of Canada needs to play a stewardship role in the effective allocation of health-related resources, which in turn will foster a productive workforce and a strong economy. The federal government also has a role in addressing the social and economic factors that affect the health of Canadians. These factors are often referred to as the social determinants of health and were a central theme at the CMA's annual General Council meeting this year. This brief provides tangible recommendations on how the federal government can contribute to the transformation of Canada's health care system and to improving the health of Canadians. 1. The Role of the Federal Government Issue: The federal government has the levers to foster a healthy, productive workforce. This section discusses opportunities for the federal government to address the challenges facing Canada's overall health care system. Even though the fiscal arrangement for the future Canada Health Transfers has been established, the federal government has other significant responsibilities with respect to the health of Canadians and the overall health care system. This view is shared by a majority of Canadians. Recent polling found that: 75 per cent of Canadians believe health care should be the federal government's top priority; 87 per cent believe that the federal government should pay more attention to health care, and 85 per cent believe the federal government should play a leading role in protecting and strengthening the health care system. An important role to be fulfilled by the federal government is to ensure Canada's health care system is cost-effective, accountable and accessible across the country. Health expenditures account for an increasing proportion of provincial and territorial budgets, and many warn of increasing future demands on health care. In his Economic and Fiscal Outlook Report of May 17, 2012, the Parliamentary Budget Officer stated that "the provincial-territorial long-term fiscal situation has deteriorated." Measures that transfer costs from one level of government to another do not improve Canada's overall fiscal situation. Despite the importance of the health care sector to Canada's economy and quality of life, it is generally agreed that in health care, Canada is no longer a strong performer relative to similar nations. For instance, OECD Health Data 2012 ranks Canada seventh highest of 34 member states in per capita health care spending,1 while Canada's health care system continues to rank below most of our comparator countries in terms of performance. In addition, recent projections indicate that the overall spending on health as a percentage of GDP will continue to increase.2 However, the health sector has an important role in sustaining Canada's economic recovery and enhancing economic growth. In fact, the health sector supports a healthy and productive workforce by providing over one million high-value jobs, representing about 10 per cent of Canada's labour force. The contribution of Canada's health care system to the international competitiveness of our economy has been repeatedly demonstrated in KPMG's Competitive Alternatives report.3 Taken together, these issues highlight significant potential for the health sector, through efficiency improvements gained by health care transformation, to support long-term economic recovery and growth in Canada. Finally, while the provinces and territories have initiated positive steps to collaborate on the sharing of best practices in health care, federal leadership could contribute to these efforts by addressing the overall performance of the health care system in Canada. The federal government should collaborate with the provinces and territories to introduce a pan-Canadian framework for reporting to Canadians on performance, outcomes and expenditures, including on whether national standards of quality and timeliness have been met. The federal government would also fall under this framework, as it is responsible for the delivery of health care services to a large population. In fact, in health care delivery, it is the fifth-largest jurisdiction in Canada. The CMA recommends that: * The federal government engage the provinces and territories in a consultative process to identify pan-Canadian metrics and measurement that link health expenditures to nationally comparable health outcomes. The purpose of which is to demonstrate accountability to Canadians. 2. The need for a Health Impact Assessment (HIA) Issue: All federal government decisions need to be viewed through the lens of their possible impact on health, health care and Canada's overall health objectives. While a strong health care system is vital, improvements to it alone will not improve health outcomes or reduce the disparities that currently exist in disease burden and health risks. Research suggests that 50 per cent of population health is determined by our social and economic environment.4 What is needed is a process to address the social determinants that can be barriers or enablers to health and to ensure healthy public policy for all Canadians. A Health Impact Assessment (HIA) is a systematic process for making evidence-based judgments on the health impacts of any given policy and to identify and recommend strategies to protect and promote health. The HIA is used in several countries, including Australia, New Zealand, Norway, the Netherlands and the United States. The HIA can ensure that all government departments are able to consider the health impacts of their programs and policies by anticipating possible unintended health consequences or impacts on health care spending. The implementation of an evidence-based HIA is one way in which the federal government can play a leadership role in health care and strengthen accountability to Canadians. The CMA recommends that: * The federal government recognize the implications of the social determinants of health on the demands on the health care system; and that, * The federal government require that the federal cabinet's decision-making process include a Health Impact Assessment to ensure that the health of Canadians is a key factor in every policy decision it makes and unintended consequences are avoided. 3. Contribute to Health Care Transformation (HCT) Issue: A transformed health care system will be more effective and comprehensive and will strengthen Canada's competitive advantage. In 2010, as part of its Health Care Transformation (HCT) initiative, the CMA broadly consulted Canadians across the country on their views on health care. Canadians said they do not believe they are getting good value from their health care system, a feeling borne out by studies comparing Canada's health care system to those in leading countries in Europe. Following this consultation, in partnership with the Canadian Nurses Association, the CMA developed Principles to Guide Health Care Transformation in Canada to guide the transformation of Canada's health care system. To date, over 120 national medical, health and organizations have endorsed these principles. During the HCT consultation, we also heard that Canadians are concerned about inequities in access to care beyond the basic medicare basket, particularly in the area of prescription drugs. In fact, reports in 2002 by the Senate Standing Committee on Social Affairs, Science and Technology (Kirby) and the Commission on the Future of Health Care in Canada (Romanow) forged a consensus on the need for "catastrophic" pharmaceutical coverage, which may be defined as out-of-pocket prescription drug expenditures that exceed a certain threshold of household income. Under the National Pharmaceuticals Strategy (NPS), cost projections of catastrophic pharmaceutical coverage were explored and seemed to favour the use of a variable percentage threshold linked to income. However, there has been no public reporting on progress since 2006.5 Moreover, there is also an issue of expensive drugs that may be used for common diseases. Finally, as highlighted by recent experiences, Canada does not have a monitoring and early notification system for drug shortages nor a systematic mechanism to prevent interruptions in the provision of medically necessary medications. Thus far, the term "catastrophic" has been used by First Ministers and the NPS to describe their vision of national pharmaceutical coverage. As defined by the World Health Organization, catastrophic expenditure reflects a level of out-of-pocket health expenditures so high that households have to cut down on necessities such as food and clothing and items related to children's education.6 In the CMA's view, this does not go far enough and what Canada must strive for is "comprehensive" coverage that covers the whole population and effectively pools risk across individuals, public and private plans, and jurisdictions. There are several indicators that show health care services and coverage are not keeping up with Canadians' needs and vary depending on where one lives in Canada. Wide variation in access to pharmaceutical treatments remains the most glaring example of inequity in our health care system - all Canadians should have a basic level of drug coverage. Further, long wait times for medical care can be found in smaller provinces and drug coverage and services for seniors are particularly poor in Atlantic Canada. The fact remains that one in 10 Canadians cannot afford the medications they are prescribed.7 For this reason, ensuring access by all Canadians to needed prescription drugs is an essential element in the CMA's proposed framework for Health Care Transformation. By working to establish comprehensive prescription coverage, the federal government would not only uphold its commitment to ensure the best health for Canadians, but also contribute to the transformation of our country's most cherished social program. The CMA recommends that: * The federal government endorse the Principles to Guide Health Care Transformation, developed by the CMA together with the Canadian Nurses Association and since endorsed by over 120 organizations. * The federal government, in consultation with provincial, territorial and other stakeholders, establish a program of comprehensive prescription drug coverage to be administered through provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drugs. 4. Meeting the health and health care needs of Canadians Issue: Measures should be taken to prepare for the looming demographic change and address the needs of Canada's aging population Steps need to be taken to ensure that Canada is prepared to handle the growing long-term care needs of its citizens. These should include funding for much-needed infrastructure and additional support for both health care providers and informal caregivers. In its most recent report, the Wait Time Alliance noted a link between the rise in diagnosis of dementia and the rise in alternate-levels-of-care (ALC) patient stays in hospitals. These are patients who are in hospital while they await an alternative level of care in a more appropriate setting, often a long-term facility. The shortage of long-term care facilities is a major impediment to achieving efficiency in the health care system and yet another issue for which the federal government is well positioned to collaborate and coordinate on a pan-Canadian strategy. Under its next long-term infrastructure program, the federal government should include a targeted health sector infrastructure fund for long-term care facilities. This should be part of a pan-Canadian strategy to redirect care from hospitals to homes, communities and long-term care facilities, where patients can receive more appropriate care at a lower cost. We can expect that many more facilities will be required to meet the long-term care needs of Canadians. The most recent census data shows that over the last decade there has been a 38 per cent increase in the number of seniors living in special care facilities.8 Based on residency rates of the present population, Canada will need over 800,000 long-term care beds by 2047. Considering the average size of existing long-term care facilities it is estimated that meeting this future demand will require construction of almost 6,000 additional long-term care facilities over the next 35 years, almost 170 a year.9 Another related issue that has the potential to affect productivity is the burden of providing care to family members. Without adequate long-term care resources and support for home care, Canada's labour force may experience a productivity drag as a result of increased leave and absenteeism to care for elderly relatives. The 2011 federal budget took a first step at providing tax relief for informal caregivers with the introduction of the Family Caregiver Tax Credit. However, this credit of up to $300 a year by no means provides sufficient support for informal caregivers. A 2004 Canadian study estimated that the annual cost of a caregiver's time at market rates for moderately to severely disabled home care clients ranged from $5,221 to $13,374, depending on the community in which they reside.10 Expanding the Family Caregiver Tax Credit would help, but the CMA believes that additional support for informal caregivers will also be needed in the coming years. Also, according to a 2012 World Health Organization (WHO) report on dementia,11 Canada is one of the few members of the G7 without a national strategy on dementia. There is a lack of awareness and understanding of dementia, which results in stigmatization and barriers to diagnosis and care, and has an impact on caregivers, families and societies - physically, psychologically and economically. Canada's aging population, and the projected rise in Alzheimer's disease and related dementias, pose an emerging health crisis that require federal leadership. The CMA recommends that: * The federal government, in partnership with the provinces and territories, develop and implement an integrated, pan-Canadian strategy for continuing care, which would integrate home care and facility-based long-term, respite and palliative care services fully within health care systems. Such a strategy would help prepare for the looming demographic change and the address the needs of Canada's aging population. * A targeted health infrastructure fund be established as part of the federal government's next long-term plan for public infrastructure. The purpose of this fund would be to support communities across Canada in addressing infrastructure shortages in the health sector that prevent the optimization of health human resources and exacerbate wait times. * The federal government expand the relief programs for informal caregivers to provide guaranteed access to respite services for people dealing with emergency situations, as well as increase the Family Caregiver Tax Credit to better reflect the annual cost of family caregivers' time at market rates. * The federal government establish programs to encourage Canadians to save for their long-term care needs by pre-funding long-term care through for example, private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance, such as an RESP-type savings vehicle. * The federal government develop and implement a national dementia strategy. Such a strategy will contribute to addressing the alternative level of care crisis impacting the efficiency of the overall health care system. 1 OECD Health Data 2012 - http://www.oecd.org/health/healthgrowthinhealthspendinggrindstoahalt.htm 2 CD Howe Commentary Chronic healthcare spending disease: a macro diagnosis and prognosis and Livio Di Matteo and ROSANNA DI MATTEO, The Fiscal Sustainability of Canadian Publicly Funded Healthcare Systems and the Policy Response to the Fiscal Gap CHSRF series of reports on financing models: Paper 5, January 2012. http://www.chsrf.ca/Libraries/Commissioned_Research_Reports/Dimatteo-Fiscal-E.sflb.ashx 3 KPMG. Competitive Alternatives: KPMG's Guide to International Business Location Costs. 2012 edition 4 The Standing Senate Committee on Social Affairs, Science and Technology Final Report of Senate Subcommittee on Population Health. June 2009. 5 Federal/Provincial/Territorial Ministerial Task Force on the National Pharmaceutical Strategy Progress Report. June 2006. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2006-nps-snpp/2006-nps-snpp-eng.pdf. Accessed 08-05-08. 6 Xu K, Evans D, Carrin G, Aguillar-Riviera A. Designing health financing systems to reduce catastrophic health expenditure. Geneva: World Health Organization, 2005. 7 Law MR, Cheng L, Dhalla IA et al. The effect of cost on adherence to prescription medications in Canada. CMAJ February 21, 2012 vol. 184 no. 3 8 Statistics Canada. September 19, 2012. Living arrangements of seniors: Families, households and marital status Structural type of dwelling and collectives, 2011 Census of Population. 9 According to the Canadian Healthcare Association (New Directions for Facility-Based Long-Term care), in 2007 there were 2,577 long-term care facilities in Canada and 217,969 beds. We used the average number of beds per facility to calculate the number of facilities required to meet expected future demand. 10 Chappell, N.L., B.H. Dlitt, M.J. Hollander, J.A. Miller and C. McWilliam. 2004. "Comparative Costs of Home Care and Residential Care." The Gerontologist 44(3): 389-400 11 http://www.who.int/mental_health/publications/dementia_report_2012/en/
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A Prescription for Productivity: Toward a more efficient, equitable and effective health system : CMA’s 2005 Pre-Budget Submission to the Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy1946
Last Reviewed
2013-03-02
Date
2005-10-24
Topics
Health systems, system funding and performance
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2013-03-02
Date
2005-10-24
Topics
Health systems, system funding and performance
Text
Introduction This pre-budget submission makes the case 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 to any productivity agenda. As Emerson once said, “the first wealth is health.” 1 Last fall, the First Ministers recognized this by agreeing on a plan that will, over the next 10-years, add an additional $41 billion federal dollars into our health care system. The Canadian Medical Association applauds the government for spearheading this renaissance in federal health care funding. But like the human body, that is always evolving, the health care system needs to be monitored and trained for optimal performance. The consequences of under investing in health care in the past are haunting us today. Better health … better Canada Canada, which at one time was the most attractive place on earth to live, is falling behind. According to the Conference Board of Canada, Canada’s overall economic performance has fallen from 3rd best in the world, to 6th and now to 12th. One of the drivers of this precipitous fall is – according to the Conference Board’s analysis – the weakened state of our health care system. For example, our infant mortality rates are rising, not falling, in relative terms. We have tumbled from our top-five ranking in the 1980s — to where we are today in the 22nd spot out of 27 countries of the Organization for Economic Co-operation and Development (OECD). That is why, now more than ever, Canada’s economy is in need of strategic federal direct investments in health care as part of an overall productivity enhancing package. The CMA is not alone in linking health care investments to better economic performance. According to the latest economic research, “There is now strong empirical evidence to suggest a two-way relationship: improved health significantly enhances economic productivity and growth. 2 ” Furthermore, the Royal Institute of International Affairs states that, “…improved health supports labour productivity; by augmenting life expectancy, it encourages savings and private investment. Health expenditures are an investment not a cost. It is crucial that governments develop a long-term perspective.” The health care sector in Canada employs over a million people or 7.5% of the labour force. In 2004, Canada invested $130 billion in health care representing 10% of our GDP. The benefits of the health care investments not only accrue to a higher quality of life for all Canadians, but the economic multiplier effect of the initial investment is estimated to create an additional $65 billion in economic activity. 3 The CMA has identified 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. We will make the case that, by making strategic federal direct investments in health human resources and public health, the federal government can make a great leap forward in reinforcing a critical foundation for a healthier more productive Canadian economy. These initiatives involve investments in physical, human and entrepreneurial capital, which if sustained over the long-term, will pay dividends in terms of improved population health. The competition for world class health care labour is becoming more global and will intensify. Unless Canada can provide excellent training, tools and working conditions international demand threatens to undermine the foundations of our system. For example, if Canada were to move today to cap working hours on physicians to 48 hours per week as the European Union has done, Canada would be short a whopping 12,780 physicians. Not only is there international demand for world class medical professionals, but also the stock of these professionals especially in Canada is aging. The United States is expected to be short by 200,000 physicians by 2020. They have looked to Canada before to fill the gap, and they may again. This is why the federal government must play a leadership role in supporting health human resources (HHR) while at the same time sustaining Canadian health care industries. When investments in health are aligned with technology at the right time, they can, as Federal Reserve Chairman Allan Greenspan suggests, “provide key insights into clinical best practices and substantially reduce administrative costs.” One of the key health infrastructure investments that has to be made is the electronic medical record (EMR). For too long Canada has lagged all major industrialized countries in adopting an EMR. A pan-Canadian EMR would deliver higher quality care, faster and at a higher value. An EMR would also allow Canada’s health care system to dramatically increase communication between jurisdictions. Communication and coordination of resources are keys to dealing with natural disasters such as Hurricane Katrina which devastated New Orleans. We need these investments sooner rather than later to avoid making the mistakes (e.g. in the case of SARS) as pointed out by the Naylor Report 4 . One of the key areas where the federal government can make a difference is the creation of a secure communications network linking up public health authorities and health providers across the country. According to Dr. Klaus Stöhr, project leader of the Global Pandemic Project at the World Health Organization, “Once a pandemic virus emerges, it is too late to begin planning or to begin collaboration.” 5 In spite of the imminent threat of a pandemic influenza, there are $34.3 millions in planned cuts to the Public Health Agency of Canada, over the next two years, as a result of program review. We need only look as far as New Orleans to see what an under-funded federal emergency preparedness system can reap. The loss of life in New Orleans was tragic and many agree unnecessary. In Canada we had SARS. Canada did squelch SARS and learned a lot about our capacities, yet we still have not lived up to the potential of being better prepared. Looking ahead, “In the event of a pandemic, the economic effects could be severe, affecting virtually all sectors and regions,” according to Dr. Sherry Cooper Chief Economist, BMO Nesbitt Burns. Dr. Cooper goes on to say that “Awareness is key to preparedness and proper surveillance, planning and preparation are essential to effective response and containment.” 6 Over the last several years, the CMA raised serious concerns about the ability of Canada’s public health system to respond to disasters and made a number of recommendations to address national preparedness in terms of security, health and capacity of the system. The CMA firmly believes that there remain significant shortcomings in our capacity to respond to health care emergencies. As we look to the future it is critical that the federal government make a stronger commitment to public health. Public health programming is too important to be sacrificed in the short-term expenditure review exercises. The continued application of the GST on physician practices is an unfair tax on health. Because physicians cannot recapture the GST paid on goods and services for their practices in the same way most other businesses can, the GST distorts resource allocation for the provision of medical care. As a result, physicians end up investing less than they otherwise could on goods and services that could improve patient care and enhance health care productivity such as information management and information technology systems. Zero-rating the GST on physician practices would remove an unfair tax on health and allow for greater investment in technologies that would result in better care. Summary The CMA’s pre-budget submission has presented the facts on how investments in physical, human and entrepreneurial capital can enhance our health care system and, in turn, make our economy more productive. As our health care system efficiencies improve, the benefits not only accrue to health care workers, but also the ultimate dividend is better patient care and improved population health. Improvements in the quality of care, and especially speed of care, enable the Canadian labour force to increase its performance and fully reach its potential. These health care investments ultimately translate into a stronger, more competitive and more productive economy. CMA’s 10 point productivity plan (with estimated investment) Efficiency Recommendation #1: That Health Canada, in collaboration with Citizenship and Immigration Canada, provincial and territorial governments and Canada’s medical schools, provide funding for 600 postgraduate training positions to enable qualified international medical graduates who are Canadian citizens or landed immigrants to complete medical training requirements. Investment: $45 million per year for 3 years. [600 x $75k (approximate annual training cost per resident]. Recommendation #2: That Health Canada, in collaboration with Foreign Affairs Canada and provincial and territorial governments, carry out a direct ad campaign in the United States to encourage expatriate Canadian physicians and other health professionals to return to practice in Canada. Investment: A one-time investment of $10 million. Recommendation #3: That the Minister of Finance in collaboration with the Minister of Health allocate $1 billion over 5 years to a Health Human Resource Reinvestment Fund. This fund would be used to implement a needs-based, pan-Canadian, integrated health human resources plan based on the principle of self-sufficiency for Canada. Investment: $1 billion over 5 years. Recommendation #4: That Health Canada, in collaboration with the Department of Human Resources and Skills Development and the provincial and territorial governments, create the Canadian Coordinating Office for Health Human Resources to facilitate pan-Canadian planning of health human resource needs. Investment: $3 million per year. Equity Recommendation #5: That the Minister of Finance introduces legislation to amend the federal Excise Tax Act to zero-rate the Goods and Services Tax (GST) on physician practices. Investment: $84 million per year or 0.27 % of total $31.5 billion GST revenues in 2005/06. Recommendation #6 That the Minister of Finance in collaboration with the Minister of Health provide additional financial support to Canada Health Infoway, to realize the vision of a secure interoperable pan-Canadian electronic medical record, with a targeted investment toward physician office automation. Investment: $1.5 billion over 10 years. Recommendation #7: That the Department of Human Resources and Skills Development introduce changes to the Canada Student Loans Program to extend the interest free status on Canada student loans for medical residents pursuing postgraduate training. Investment: $5 million per year. Recommendation #8: That the Minister of Finance in collaboration with the Minister of Health increase the base budget of the Canadian Institutes of Health Research to enhance research efforts in the area of population health and public health as well as significantly accelerating the pace of knowledge transfer. Investment: $600 million over 3 years. Effectiveness Recommendation #9: In order to ensure that adequate emergency preparedness and public health capacity is built at both federal and provincial levels, the federal government should provide sustained additional funding, to the Public Health Agency of Canada, and exempt it from expenditure review contributions. Investment: $684.3 million over 3 years (details in Appendix 1). Recommendation #10: That Health Canada and the Public Health Agency of Canada provide a one-time infusion of $100 million, to improve technical capacity to communicate with front-line public health providers in real-time during health emergencies. Investment: A one time investment of $ 100 million. The first wealth is health Canada, which at one time was the most attractive place on Earth to live, is falling behind. According to the Conference Board of Canada, Canada’s overall economic performance has fallen from 3rd best in the world, to 6th and now to 12th. One of the drivers of this precipitous fall is – according to the Conference Board’s analysis – the weakened state of our health care system. For example, our infant mortality rates are rising, not falling, in relative and absolute terms. We have tumbled from our top-five ranking in the 1980s — to where we are today; in the 22nd spot out of 27 OECD countries. That is why, now more than ever, Canada’s economy is in need of strategic federal direct investments in health care as part of an overall productivity enhancing package. According to the latest economic research, “There is now strong empirical evidence to suggest a two-way relationship: improved health significantly enhances economic productivity and growth. 7 ” The health care sector in Canada employs over a million people or 7.5% of the labour force. In 2004, Canada invested $130 billion in health care, representing 10% of our GDP. The benefits of the health care investments not only accrue to a higher quality of life for all Canadians, but the economic multiplier effect of the initial investment is estimated to create an additional $65 billion in economic activity. 8 I. Efficiency – providing tools to improve patient care and productivity A healthy and productive health workforce is the key to a well performing health care system and sets the foundation for a productive labour force. That is the ideal. However, there is a shortage of physicians across Canada. This shortage is creating a tremendous amount of pressure on the health care system. As demand for health care increases and the supply of health care workers is fixed, the pressure on these workers to do “more with less” is enormous. That is why Canadian physicians need the federal government’s support to have the tools and time to build on their productivity. Making human capital investments in physicians (value centres) Federal Health Minister Ujjal Dosanjh acknowledged the value of physicians in his speech to the Canadian Medical Association’s General Council this August 2005 by saying, “I want you to know that our government sees physicians … not as cost centres but as value centres”. It is in this spirit that we urge the government to invest in HHR. In order for the First Ministers Meeting (FMM) Agreement to be successful in improving access to care, governments must make the health workforce a major priority. In particular, the $1 billion in HHR funding in the Wait Times Reduction Fund should be made available immediately to address the crisis in health human resources rather than in the last 4 years of the 10-year agreement as currently projected. Given the current shortages in health human resources, action on HHR must begin now — not in 2010. Investing in physicians, or as Minister Dosanjh eloquently put, “value centres” will have real dividends for Canadians and the health care system. Accordingly, the CMA calls upon the federal government to play a key role in improving the availability of health human resources by developing a pan-Canadian HHR strategy that includes the involvement of health care providers. 9 For as Minister Dosanjh acknowledged, "It is clear to me that, if we are going to achieve the kind of solutions that have the support of Canadians, that our physicians must be engaged as active and valued partners.” The cost of under-investing in health human resources The pressures on human capital within the health care system are clear. Since the cutbacks in medical school admissions in the early 1990s, the gap between the growing demand for medical care and physician supply has widened. Canada’s ratio of 2.1 physicians per 1,000 population remains one of the lowest among the Organization for Economic Co-operation and Development (OECD) countries and below the OECD average of 2.9. With this ratio, Canada ranks 24th out of 30 OECD countries. In addition, as more doctors enter retirement age the shortage of physicians is becoming acute. The cost to patients — and their employers — is manifested in wait times, increasing difficulty to access primary care. In spite of these pressures Canada still does not educate enough doctors to replace those about to retire. The status quo threatens capital stock within the health sector, the general labour force, and even the world. “In the face of a global shortage of health care workers … can a country in which 24% of practicing doctors were educated outside its own borders continue to rely on physicians from countries that can least afford to lose them?” — Dr. Peter Barrett, CMA past president, August 2005 CMA annual meeting. Social and economic dividends of investing in HHR The CMA recommends that Canada’s long-term objective should be to increase enrolments in health disciplines to achieve greater self-sufficiency. The dividend of investing in HHR is a better, more efficient health care workforce who will deliver higher quality care in a timely manner. A well funded public health care system makes all Canadians healthier and more productive in their economic and social roles. In addition, becoming HHR self-sufficient also has the potential benefit of eventually exporting made-in-Canada health sector goods and services. But beyond re-stocking the pool of HHR for the future, attention also needs to be paid to the current stock of physicians. The issue of retention, or keeping physicians interested in working, is especially important now considering that a record number of physicians are about to retire. (i) Maximizing our existing health human capital — providing more training opportunities for international medical graduates As noted earlier, Canada ranks at the bottom among OECD countries in physicians per capita. As blunt an indicator as this may be the recent Supreme Court ruling in the Zeliotis case is a poignant reminder that there is an imbalance in the system between supply (HHR) and demand. We need more health care workers to protect, or save from burnout, the health care human capital investments that Canada has made already. We also need to ensure that Canada’s labour force — our macro human capital — has access to quality care without reasonable delays. Since it takes anywhere from 7 to 10 years to train a new physician, there are limits to how much can be done in the short term to address shortages. One short-term response would be to facilitate the training of qualified international medical graduates (IMGs) who are already in Canada. The CMA has welcomed the federal government’s recent investment of $75 million in the 2005 budget for the integration of internationally trained health workers, and notes that federal funding has already produced tangible results as some medical schools have increased the number of postgraduate training positions available to IMGs. However, there is an issue of clinical training capacity at Canada’s medical schools; consequently this initial investment is insufficient to provide training opportunities for over 600 IMGs and countless other qualified internationally trained health workers who are already in Canada. Accordingly, the CMA recommends that the federal government provide sufficient funding to provide additional training positions to train the existing supply of IMGs who would be eligible to begin a post-MD residency training immediately. The capacity to train these Canadian citizens or landed immigrants exists in Canadian medical schools. Currently, Canadian medical schools are providing postgraduate training opportunities to close to 900 visa trainees from abroad, largely from Persian Gulf countries. The federal government helps redeploy some of this capacity by offering medical schools, on a time-limited basis, to purchase some of these visa trainee positions to train IMGs that can then be deployed in Canada’s health care system. Such funding could also provide for the comprehensive assessments of IMGs that have been developed in several jurisdictions. The CMA also strongly supports the initiative of the Medical Council of Canada (MCC) in developing a pilot for the off-shore electronic administration of the MCC’s evaluation exams. Recommendation #1: That Health Canada, in collaboration with Citizenship and Immigration Canada, provincial and territorial governments and Canada’s medical schools, provide funding for 600 postgraduate training positions to enable qualified international medical graduates who are Canadian citizens or landed immigrants to complete medical training requirements. Investment: $45 million per year for 3 years. [600 x $75k (approximate annual training cost per resident]. (ii) Repatriating human capital - getting our Canadian physicians back home from the US Canada has been a net exporter of physicians to the United States for a generation. As government funding for health care fell in the 1990s exports of Canadian physicians to the US rose. Last year was the first year in which Canada gained more physicians than it sent to the US. There is a window of opportunity to repatriate Canadian physicians from the United States. The quality of Canadian life, competitive remuneration packages and a practice commitment that is characterized by greater physician autonomy are many of the chief drawing points for such a campaign. As the Canadian dollar approaches US $0.90 advertising in the US has also become much more affordable. Recommendation #2: That Health Canada, in collaboration with Foreign Affairs Canada and provincial and territorial governments, carry out a direct ad campaign in the United States to encourage expatriate Canadian physicians and other health professionals to return to practice in Canada. Investment: A one-time investment of $10 million. (iii) Diligence on HHR As Canada’s population ages and as health care technology improves, demand for health care will increase. Health care in economic terms is a superior good: as the population’s standard of living improves, so does the demand for superior goods. But will this increased demand be met with an adequate supply of physicians to provide the kind of care Canadians need in a timely manner? Not likely, but we don’t know for sure because Canada does not currently have a way to assess the ability of our medical schools to meet these future needs across the country. An inadequate physician supply has important implications for human, physical and entrepreneurial capital in Canada’s economy. If the physician supply is not properly aligned with the demographic needs of the population the result is a loss (calculations vary and depend on the individual) in potential human capital as patients postpone treatment or wait too long for treatment. Investments in future physical capital investments may also be misallocated or not made at all if the proper health human resources are not in place. In addition, entrepreneurial capital may also very well flow to places where the optimal health human resources are in place. Why we need a Health Human Resources Reinvestment fund Canada lags behind other countries in the education and training of physicians. For example, as of 2002-2003 there were 12.2 first-year medical school places per 100,000 population in England compared with only 6.5 per 100,000 in Canada. It should be added that the United Kingdom has aggressively expanded medical enrolment since the late 1990s by opening 4 new medical schools and increasing medical school intake by some 2,300 places (60%) between 1997 and 2004. The CMA and other major national medical organizations have called on governments to increase medical school capacity to 3,000 first-year training positions per year in order to stabilize Canada’s physician supply. With recent increases in positions at a number of medical schools, current indications suggest that we have reached about 2,300 positions per year. However, given the growing demand for health services and changing patterns of medical practice, it is likely that medical school capacity will have to be increased much more significantly. For example, if Canada were to move today to cap working hours on physicians to 48 hours per week as the European Union has done, Canada would be short a whopping 12,780 physicians. Accordingly, as was done in the 1960s when the federal government introduced the Health Resources Fund, the CMA urges the federal government to create a Health Human Resource Reinvestment Fund in order to implement a needs-based, pan-Canadian, integrated health human resources plan based on the principle of self-sufficiency for Canada. Recommendation #3: That the Minister of Finance in collaboration with the Minister of Health allocate $1 billion over 5 years to a Health Human Resource Reinvestment Fund. This fund would be used to implement a needs-based, pan-Canadian, integrated health human resources plan based on the principle of self-sufficiency for Canada. Investment: $1 billion over 5 years. (iv) Creation of the Canadian Coordinating Office for Health Human Resources At a broader level, there is also a need for continued coordination of pan-Canadian HHR needs for today and the future. Governments are investing very large sums of funding in health care without having the benefit of a national long-term health human resources strategy. Since health human resources are increasingly mobile in the global economy, it is essential that Canada’s 14 provincial, territorial and federal health care systems devise a coordinated approach to training, recruiting and retaining health human resources. The Canadian Coordinating Office for Health Human Resources would be modeled along the same lines as the Canadian Coordinating Office for Health Technology Assessment (CCOHTA) created in 1989. Presently, there is no overall national coordinating body to assist provinces and territories in the planning of health human resources, particularly one that includes all pertinent stakeholders including physicians and other health care professionals. Building on previous federal investments in health sector studies across a number of health disciplines, the CMA urges the federal government to establish a Canadian Coordinating Office for Health Human Resources involving representation from health care professions — something both the Romanow and Senator Kirby reports recommended. Recommendation #4: That Health Canada, in collaboration with the Department of Human Resources and Skills Development and the provincial and territorial governments, create the Canadian Coordinating Office for Health Human Resources to facilitate pan-Canadian planning of health human resource needs. Investment: $3 million per year. II. Equity: improving health infrastructure and technology to provide better care (v) Freeing-up entrepreneurial capital and retaining physicians Why the GST should not apply to physician practices The CMA is calling on the federal government to remove an insidious tax on health by zero-rating (10 ) the GST on physician practices. The introduction of the GST was never intended to fall onto the human and physical capital used to produce goods and services. The GST is a value-added tax on consumption that was put into place to remove the distorting impact that the federal manufacturers sales tax was having on business decisions. However, the GST was applied to physician practices in a way that does exactly the opposite. The federal government must rectify the situation once and for all. Based on estimates by KPMG, physicians have paid $1.1 billion in GST related to their medical practice. This is $1.1 billion that could have been invested in better technology to increase care and productivity. Re-investing the zero-rating of the GST for physician practices Zero-rating the GST would initially cost the federal government $84 million (11) or 0.27% of total GST revenues for 2005/06. However, as physicians across Canada re-invest the zero-rated GST tax back into their practices — and especially in their patients — there would be considerable dividend back to the federal government in terms of healthier Canadians and a more efficient economy. Zero-rating the GST for physician practices is about properly calibrating the tax system with the health care delivery system, in order to help meet our national health and economic goals. Dispelling the myth of a GST precedent Some bureaucrats and politicians believe that zero-rating the GST for physician practices may set a precedent. In fact, the precedent has already been set: significant elements of publicly-funded health care are already zero-rated or qualify for a rebate on GST. For example, prescription drugs, a significant and growing driver of total health care costs, have been zero-rated since 1996. Hospitals have benefited from an 83% rebate since the inception of the GST, and the 2005 budget extended the reach of this rebate to not-for-profit organizations delivering services that were previously delivered in the hospital setting. In addition to hospitals, rebates have been extended to other public and para-public sectors such as municipalities, universities and schools (the so-called “MUSH” sector). The 2004 federal budget confirmed that municipalities would be able to recover 100% of the GST and the federal component of the harmonized sales tax (HST) immediately. Recommendation #5: That the Minister of Finance introduces legislation to amend the federal Excise Tax Act to zero-rate the Goods and Services Tax (GST) on physician practices. Investment: $84 million per year or 0.27 % of total $31.5 billion GST revenues in 2005/06. (vi) Electronic Medical Record — increasing health and productivity In the words of Finance Minister Goodale, “Top-notch physical infrastructure is essential to a successful economy and a rising quality of life.” To be sure, Canada needs better highways, bridges and sewer systems. We need this basic infrastructure to enjoy a basic quality of life. But we want more than a basic life. To achieve a higher quality of life and to ensure international competitiveness, Canada needs to invest in the infrastructure of the 21st century, this is e-infrastructure. A pan-Canadian Electronic Medical Record (EMR) would deliver higher quality care, faster and at higher value. An EMR will save lives and improve efficiencies When investments in health are aligned with technology at the right time, they can as Federal Reserve Chairman Allan Greenspan suggest, “provide key insights into clinical best practices and substantially reduce administrative costs.” Health care delivery in Canada is a $130 billion industry. It represents more than 10% of our country’s gross domestic product. And it continues to grow. Yet we are managing the system with technology that would have been unacceptable to the banking industry even 20 years ago. Studies show (12) that the sooner we have a pan-Canadian EMR in place, the sooner the quality of health care will improve. For too long Canada has lagged all major industrialized countries in adopting an EMR (see Table 2). [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 2 Canada has fallen behind in EMR investments Percent of physicians using electronic records and prescriptions Country Records Prescriptions Britain 59% 87% New Zealand 52% 52% Australia 25% 44% United States 17% 9% Canada 14% 8% Harris Interactive Survey (2001) conducted for Harvard School of Public Health and the Commonwealth Fund's International Health Care Symposium. [TABLE END] An adequate health information infrastructure with pan-Canadian connectivity With an initial investment of $1.2 billion, Canada Health Infoway (CHI) has been working with provincial and territorial governments to put in place key components of a pan-Canadian health information infrastructure. While significant investments have been made in provincial and territorial health information systems, two key concerns have emerged. First, the $1.2 billion investment in CHI, while significant, is only 15% of the estimated cost of implementing a fully interoperable electronic medical record system in Canada. Second, CHI has made very limited progress in building a common, secure and interoperable platform - the backbone of a pan-Canadian system. Accordingly the CMA endorses the recommendations put forward by the Association of Canadian Academic Healthcare Organizations (ACAHO), the Canadian Nurses Association and the Canadian Healthcare Association to provide CHI with significant funding so that it may fulfill its core mission. Empowering investments in e-entrepreneurship for better health One of the gaps in the pan-Canadian EMR is the lack of attention paid to health information infrastructure on the front lines of health care delivery. While medical services across the country are largely publicly – funded, most physicians run their own practices. As entrepreneurs doctors take on the responsibility and risk of investing in new capital equipment from diagnostics to EMRs. Like any other business, doctors must calculate the return on investment for any capital equipment that they buy. In the case of the EMR, most of the return benefits the government, according to a Center for Information Technology Leadership in the United States 13 . A physical capital investment in an EMR improves care and deepens entrepreneurial capital By making all relevant patient information immediately available at the time of any encounter, and by providing equally rapid access to general medical information that assists in clinical decision-making, an EMR significantly enhances a clinician's ability to make good decisions, which will reduce medical errors and their associated costs. The timeliness of information also means that diagnoses are made more quickly, which significantly reduces the amount of time that patients need to spend using costly hospital beds or emergency room resources. Further cost reductions come from diminished duplication: all too often, time is lost and money is spent repeating diagnostic tests that were recently done but whose results are unavailable. Recovery of health information technology investments is almost immediate A Booz, Allan, Hamilton study on the Canadian health care system estimates that the benefits of an EMR could provide annual system-wide savings of $6.1 billion, due to a reduction in duplicate testing, transcription savings, fewer chart pulls and filing time, reduction in office supplies and reduced expenditures due to fewer adverse drug reactions. The study went on to state that the benefits to health care outcomes would equal or surpass these annual savings. Mobilizing physicians to operationalize a pan-Canadian EMR The physician community can play a pivotal role in helping the federal governments make a connected health care system a realizable goal in the years to come. Through a multi stakeholder process encompassing the entire health care team, the CMA will work toward achieving cooperation and buy-in. This will require a true partnership between provincial medical associations, provincial and territorial governments and CHI. The CMA is urging the federal government to allocate an additional investment of $1.5 billion to Canada Health Infoway. Criteria would be set for the fund that would restrict investment to automating physician offices through an agreement between the medical division and the appropriate province or territory. The $1.5 billion federal investment would be leveraged on the basis of a 75:25 sharing with physicians to generate $1.5 billion in physician office automation investment over the next 10 years. Specific modalities of disbursements of these funds would be set up by agreements with the provincial medical associations. CHI already has stringent financial controls and processes in place and can extend them to manage this program. Recommendation #6: That the Minister of Finance in collaboration with the Minister of Health provides additional financial support to Canada Health Infoway, to realize the vision of a secure interoperable pan-Canadian electronic medical record, with a targeted investment toward physician office automation. Investment: $1.5 billion over 10 years. (vii) Alleviating medical resident debt ? extend the interest relief on Canada student loans for medical residents Medical students are accumulating unprecedented levels of debt as tuition fees for medical school continue to sky rocket. The increase in debt influences the kind of practice young physicians pursue as well as where they practice. The Canadian Medical Association commends the federal government for its commitment to reduce the financial burden on students in health care professions as announced in the 2004 FMM Agreement and encourages it to act on this promise by extending the interest relief on Canada student loans for medical residents. Extending the interest relief on Canada student loans for medical residents would avoid distorting medical students’ career choices and encourage new graduates to stay in Canada. Deregulation of tuition => increased debt burden => drag on entrepreneurship It wasn’t always this way. The deregulation of medical school tuition fees in some provinces dramatically increased the debt burden of medical students. It is important to note that medical residents are in a unique situation not faced by other students who graduate from university programs. Once students graduate from medical school, they earn the right to be called physicians. However, they cannot practice until they complete a residency program. The program, which takes between 2-10 years to complete, certifies them as a specialist in a number of disciplines ranging from family medicine to radiology to rheumatology. During the compulsory residency program they must act as both student and employee. Table 1 includes the annual salary of medical residents and fellow hospital employees. Medical residents are not paid by the hour; otherwise their wages would be higher as there is no limit on the hours (80+) they work. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 1. Medical residents learn a lot but don’t earn a lot Resident stipend versus fully qualified health care employees Status, Ottawa, Ontario Annual Stipend or Fulltime Salary (as applicable) Minimum Postsecondary Education Requirement Minimum Related Experience Requirement Ontario Resident, PGY-1 (national average is $42,862) $ 44,230 7 + years 7+ years related clinical and other experience acquired through undergraduate medical education and pre-professional experiences, including clerkships, electives, etc. Locksmith/Door Mechanic, Ottawa Hospital $44,051 None. High school diploma required and a course or certificate in locksmithing 5-years relevant experience Supervisor of Housekeeping, Ottawa Hospital $ 41,165 - $48,000 2 years OR certified member of the OHHA CAHA, or related 3-years general supervisory experience [TABLE END] The Cost of under-investing in medical residents hits rural Canada hard As medical debt increases more physicians are choosing to go into some specialties (remunerated at a much higher rate) as opposed to family medicine. This has an impact on the accessibility, quality and overall cost of the health care system. Family practitioners are on the front-lines of medical care, and they treat and prevent millions of illnesses across Canada every year. The fall in demand for family practice in general, and rural family practice in particular, is now having a significant impact on health care and economic performance. The lack of a local family physician is often a determining factor in a company’s decision to make a direct investment in a community. For example, a multi-national company would likely not invest in a multi-billion dollar ski hill if there were no doctors available to treat ski related accidents. Improving access to medical education Canada’s future depends on ensuring that all Canadians have access to our medical schools. This sentiment was recently echoed by Finance Minister Ralph Goodale, “...but such skills are still confined to a minority of our population. We must do better. Canada’s future depends upon it.” Extending the interest-free status on Canada student loans would be an important signal to young Canadians from all socio-economic backgrounds that want to become a doctor. Drawing from a smaller portion of the population limits the experience and variety of community contact. Specific knowledge of a patient group allows a future physician adapt their care for that group. Thus, we should be graduating residents from all across the country from diverse socio-economic backgrounds. This is not unlike an entrepreneur who by tailoring services to a clients need that were previously unmet delivers better service and captures market share. Recommendation #7: That the Department of Human Resources and Skills Development introduce changes to the Canada Student Loans Program to extend the interest free status on Canada student loans for medical residents pursuing postgraduate training. Investment: $5 million per year. (viii) Making medical research investments count – supporting knowledge transfer The Canada Institutes of Health Research (CIHR) was created to be Canada's premier health research funding agency. One of the most successful aspects of the CIHR is its promotion of inter-disciplinary research across the four pillars of biomedical, clinical, health systems and services as well as population health. This has made Canada a world leader in new ways of conducting health research. However, with its current level of funding, Canada is significantly lagging other industrialized countries in its commitment to health research. Knowledge transfer is one of the areas where additional resources would be most usefully invested. Knowledge Translation (KT), a prominent and innovative feature of the CIHR mandate, has the potential to: * Significantly increase and accelerate the benefits flowing to Canadians from their investments in health research; and  * Establish Canada as an innovative and authoritative contributor to health-related knowledge translation. Population and public health research is another area where increased funding commitments would yield long-term dividends. For example, “Researchers (and research funders) should create more opportunities for interactions with the potential users of their research. They should consider such activities as part of the 'real' world of research, not a superfluous add-on.”(Lavis et al., 2001) 14 Recommendation #8: That the Minister of Finance in collaboration with the Minister of Health increase the base budget of the Canadian Institutes of Health Research to enhance research efforts in the area of population health and public health as well as significantly accelerating the pace of knowledge transfer. Investment: $600 million over 3 years. III. Effective - an ounce of prevention is worth a pound of cure A little preparation before a crisis occurs is preferable to a lot of fixing up afterward. According to the World Health Organization and the Public Health Agency of Canada (PHAC) an influenza pandemic is inevitable. The consequences of not being adequately prepared will result in more lost lives and a multi-billion dollar hole in our economy, as was the experience in Toronto as a result of SARS in 2003. Looking ahead, PHAC estimates that the impact of pandemic influenza in Canada, if vaccines are not available, is between 11,000 and 58,000 deaths and economic costs of $5 to $38 billion. (ix) Protecting our capital infrastructure through emergency preparedness When SARS hit Canada in the spring of 2003 people got very sick and died. There was public confusion that quickly spilled into the economy. Internal and external trade in Canada was disrupted. According to the Conference Board of Canada the economic impact of the outbreak of SARS in the Greater Toronto Area equaled $1.5 billion. Investments in public health and emergency preparedness will allow the system to function more effectively and alleviate the impact of novel infectious diseases. We have expert advice how to do it – the Naylor Report. Reduce the economic burden of pandemics — close the Naylor Gap The National Advisory Committee on SARS and Public Health (the Naylor Report) estimated that approximately $1 billion in annual funding is required to implement and sustain the public health programming that Canada requires. Although representing an important reinvestment in this country’s public health system, the funding announced in the 2005 budget falls well short of this basic requirement. Dr. Jeffrey Koplan 15 , the past Director of the US Centers for Disease Control and Prevention laid out 7 areas for building capacity and preparedness within a public health system: 1. A well trained, well staffed public health workforce. 2. Laboratory capacity to produce timely and accurate results for diagnosis and investigation. 3. Epidemiology and surveillance to rapidly detect health threats. 4. Secure accessible information systems to help analyze and interpret health data. 5. Solid communication to ensure a secure two-way flow of information. 6. Effective policy evaluation capability. 7. A preparedness and response capability that includes a response plan and testing and maintaining a high state of preparedness. These points apply for both the day-to-day functioning of the public health system and its ability to respond to threats whether it is a new infectious disease, a natural disaster or a terrorist attack. Public health must be ready for all such threats. It is crucial, that the federal government build and maintain its stockpile of supplies for emergency use, its public health laboratories for early detection, its capacity to rapidly train and inform front-line health workers of emerging threats, its ability to assist the provinces and territories, and coordinate provincial responses in the event of overwhelming or multiple simultaneous threats. Vaccination is the most cost-effective health intervention available When a pandemic hits Canada vaccinations are a key component in reducing the impact. According to the Centers for Disease Control and Prevention (CDC) vaccination against childhood diseases is one of the most cost effective health interventions available. For example the measles-mumps-rubella vaccination saves $16.34 in direct medical costs for every dollar spent. The CMA urges the federal government to continue to support the National Immunization Strategy and the consistent availability of National Advisory Committee on Immunization recommended vaccines in all provinces and territories. A clear role for federal leadership – protecting our future The idea that public health is a federal responsibility “is based on the premise that public health matters - particularly emergencies - are so important that the federal government should simply use its powers for ”peace, order and good government” to unilaterally direct how public health matters should be addressed, and to ensure they are fully addressed.” 16 Consequently, the CMA recommends the enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation to allow for a more rapid national response in cooperation with the provinces and territories, based on a graduated systematic approach to emergencies that pose an acute an imminent threat to human health and safety across Canada. Regardless of how well prepared any municipality is, under certain circumstances public health officials will need to turn to the provincial, territorial or the federal government for help. The success of such a multi-jurisdictional approach is contingent upon good planning beforehand between the federal, provincial and territorial and local-level governments. There is an important role for the federal government to urgently improve the coordination among authorities and reduce the variability between various response plans in cooperation with provincial authorities. Public health investments take time Public health must be funded consistently in order to reap the full benefit of the initial investment. Investments in public health will produce healthier Canadians and a more productivity workforce for the Canadian economy. But this takes time. By the same token, neglect of the public health system will cost lives and hit the Canadian economy hard. As the federal government examines ways of achieving efficiencies and cost savings in federal programs through the Cabinet Committee on Expenditure Review it is critical that the Public Health Agency of Canada be protected from any cuts. Recommendation #9: In order to ensure that adequate emergency preparedness and public health capacity is built at both federal and provincial levels, the federal government should provide sustained additional funding, to the Public Health Agency of Canada, and exempt it from expenditure review contributions. Investment: $684.3 million over 3 years (details in Appendix 1). (x) Investments in effective public health communication are crucial The effectiveness of the public health system is dependent, in large part, on its capacity to communicate authoritative information in a timely way. A two-way flow of information between public health experts and the practicing community is necessary at all times. It becomes essential during emergency situations. The rapid, effective, accessible and linked (REAL) health communication and coordination initiative improves the ability of the public health system to communicate in a rapid fashion by: * Providing a focal point for inter-jurisdictional communication and coordination to improve preparedness in times of emergency. * Developing a seamless communication system leveraging formal and informal networks. * Researching the best way to disseminate emergency information and health alerts to targeted health professionals and public health officials in a rapid, effective and accessible fashion. Recommendation #10: That Health Canada and the Public Health Agency of Canada provide a one-time infusion of $100 million, to improve technical capacity to communicate with front-line public health providers in real-time during health emergencies. A one time investment of $100 million. Conclusion — the economic impact of investments in health care The CMA’s pre-budget submission has presented the facts on how investments in physical, human and entrepreneurial capital can enhance our health care system and, in turn, make our economy more productive. Improvements in the quality of care, and especially speed of care, enable the Canadian labour increase their performance and reach their potential. The 2004 First Minister Health Accord is a positive step in renewing the federal government’s commitment to publicly funded health care, more needs to be done. Like the human body, that is always evolving, the health care system needs to be calibrated for optimal performance. Targeted investments in health human resources as well as health care infrastructure will result in an optimal allocation of resources, better health and a stronger economy. Appendix 1 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY]  CMA’s 10 point productivity plan    (in millions of dollars) 3-year 2006/07 2007/08 2008/09 Total   Efficiency i. Improving access -opening-up training positions for International Medical Graduates 45.0 45.0 45.0 135.0   ii. Repatriating our human capital -getting Canadian physicians home from the U.S. 10.0 0.0 0.0 10.0   iii. Health Human Resource Reinvestment Fund* 100.0 200.0 300.0 600.0   iv. Creating the Canadian Coordinating Office for Health Human Resources 3.0 3.1 3.2 9.3   Efficiency total 158.0 248.1 348.2 754.3   Equity v. Freeing-up entrepreneurial capital -zero-rating the GST on physician practices 84.0 86.1 88.3 258.4 vi. Investing in physical and human capital through physician office automation (CHI transfer)** 1,463.7 0.0 0.0 1,463.7   vii. Providing debt-relief to medical residents - an investment in human capital 5.0 5.1 5.3 15.4   viii. Making health research investments count -supporting knowledge transfer 100.0 200.0 300.0 600.0   Equity total 1,652.7 291.2 393.6 2,337.5   Effectiveness ix. Planning for the worst -pandemic preparation 25.0 25.0 25.0 75.0   Closing the Naylor Gap 75.0 150.0 250.0 475.0   Protection from expenditure review committee reductions*** 16.4 17.9 0.0 34.3   x. Ensuring effective public health communication 100.0 0.0 0.0 100.0   Effectiveness total 216.4 192.9 275.0 684.3   Total 2,027.1 732.2 1,016.8 3,776.1 * Note: additional 2 years of funding at $200 million per year. ** Note: the physician office automation financing plan is a 1-time transfer to Canada Health Infoway (CHI). CHI would deliver funding directly. Estimates are based on information from CHI (October 2005). *** Working Group on a Public Health Agency for Canada In Report: A Public Health Agency of Canada Ottawa: Public Health Agency of Canada; Apr 2004. Available: www.phac-aspc.gc.ca/rpp-2005-06/index.html#2b (accessed Oct 2005). [TABLE END] Appendix 2 10 year Costing of the Physician Automation [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [TABLE END] 1. There are approximately 60,000 licensed physicians in Canada. It is estimated that 20% already have an Electronic Medical Record (EMR) in their clinical office. Therefore this costing analysis is to support the other 48,000 physicians to automate their offices. 2. The cost to automate an office is based on the work carried out by the Alberta government and the Alberta Medical Association through the Physician Office Support Program (POSP).They have used a four year cost of $41,000 which covers capital, installation, training and operational costs over the four years. First year costs are $26,000 with $5,000 over the remaining three years. References 1 Ralph Waldo Emerson (1803–1882), essayist, poet, philosopher. “Power,” The Conduct of Life (1860). 2 According to the Royal Institute of International Affairs who also quote two Nobel Laureates in Economics. In, Health Expenditure and Investment Rather than a Cost? International Economics Program, Chatham House. 07/05. Available: www.chathamhouse.org.uk/index.php?id=189&pid=245 (accessed Oct 2005). 3 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. 4 Learning from SARS - Renewal of Public Health in Canada A report of the National Advisory Committee on SARS and Public Health. Ottawa: Health Canada; Oct 2003. Available: www.phac-aspc.gc.ca/publicat/sars-sras/naylor/(accessed October 2005) 5 5 Cooper S. Don’t fear fear or panic panic an economist’s view of pandemic flu Toronto: BMO Nesbitt Burns; October 2005. Avalable www2.bmo.com/news/article/0,1257,contentCode-5047_divId-4_langId-1_navCode-112,00.html 6 ibid 7 According to the Royal Institute of International Affairs who also quote two Nobel Laureates in Economics. In, Health Expenditure and Investment Rather than a Cost? International Economics Program, Chatham House. 07/05. Available: www.chathamhouse.org.uk/index.php?id=189&pid=245 (accessed Oct 2005). 8 The additional economic activity generated by the health care sector is based on a conservative 1.5 multiplier. The CMA is currently pursuing precise economic multiplier estimates of the benefits of health care investments in Canada. 9 The CMA and the Canadian Nurse Association go into greater depth concerning the pressures on a strategy for HHR in, “Planning Framework for Health Human Resources. A Green Paper. June 2005 Available: www.cna-nurses.ca/CNA/documents/ pdf/publications/CMA_CNA_Green_Paper_e.pdf. 10 Zero-rated supplies refer to a limited number of goods and services that are taxable at the rate of 0%. This means there is no GST/HST charged on the supply of these goods and services, but GST/HST registrants can claim an input tax credit (ITC) for the GST/HST they pay or owe on purchases and expenses made to provide them. Available: www.cra-arc.gc.ca/tax/business/topics/gst/glossary-e.html (accessed September 2005) 11 An independent study by KPMG estimated that physicians have “overcontributed” in terms of unclaimed ITCs by approximately $57.2 million in 1992. In 2005, this comes to an inflation adjusted figure of $84 million. 12 Booz, Allan, Hamilton Study, Pan-Canadian Electronic Health Record, Canada’s Health Infoway’s 10-Year Investment Strategy, March 2005-09-06 13 The Center for Information Technology Leadership (www.citl.org) is non-profit research organization established in 2002 to guide the health care community in making more informed strategic IT investment decisions. 14 Lavis, J., Ross, S., Hurley, J., Hohenadel, J., Stoddart, G., Woodward, C., Abelson, J. Reflections on the Role of Health-Services Research in Public Policy-Making. Paper 01-06. 15 Koplan JP. Building Infrastructure to Protect the Public’s Health. Public Health Training Network Broadcast Available: www.phppo.cdc.gov/documents/KoplanASTHO.pdf (accessed Oct 2005). 16 Report: A Public Health Agency for Canada Building a Foundation for Intergovernmental Harmony and Cooperation Available: www.phac-aspc.gc.ca/publicat/phawg-aspgt-noseworthy/2_e.html (accessed Oct 2005)
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