The Canadian Medical Association is pleased to present this submission to the House of Commons Standing Committee on Health regarding Bill C-422, National Lyme disease strategy.
The Canadian Medical Association (CMA) is the national organization representing over 80,000 physicians in Canada; its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care.
Lyme disease is a growing problem in Canada. According to the Public Health Agency of Canada (PHAC) there were 315 cases of Lyme disease reported in Canada in 2012 -two and one-half times more cases than the 128 reported in 2009, the year that it became a reportable disease. In the Ottawa area, cases have increased almost 8 fold from 6 in 2009 to 47 in 2013. The PHAC surveillance indicates that established populations of blacklegged ticks are spreading their geographic scope, and are increasing in number, in much of southern Canada. In 2013 the US Center for Disease Control and Prevention released new estimates of Lyme disease that was 10 times higher than the previous yearly reported number of 30,000 reported cases.1 This highlights the difficulty in establishing the true burden of illness from Lyme disease.
Why this matters to Canada's physicians
The Canadian Medical Association supports the implementation of a national strategy that can address the breath of public health and medical issues surrounding the spread of Lyme disease in Canada. As with any new infectious disease threat, Canada needs to ensure that we are prepared to address the impact of Lyme disease on Canadians.
CMA's policy on climate change and human health notes that changes in the range of some infectious disease vectors such as blacklegged ticks, are a possible consequence of climate change in Canada. Research has suggested that the tick vector of Lyme disease has been expanding into southeastern Canada which can lead to increased disease risk for those living in areas with tick populations.2
In this policy, CMA recommends that the federal government report diseases that emerge in relation to global climate change, and participate in field investigations, as with outbreaks of infectious diseases like Lyme disease, and develop and expand surveillance systems to include diseases caused by global climate change.
The World Medical Association Declaration of Delhi on Health and Climate Change urges colleges and universities to develop locally appropriate continuing medical and public health education on the clinical signs, diagnosis and treatment of new diseases that are introduced into communities as a result of climate change. Diagnosis of Lyme disease can be difficult, as signs and symptoms can be non-specific and found in other conditions. 3 If Lyme disease is not recognized during the early stages, patients may suffer seriously debilitating disease, which may be more difficult to treat.4 Given the increasing incidence of Lyme disease in Canada, continuing education for health care and public health professionals and a national standard of care would improve identification, treatment and management of Lyme disease. Greater awareness of where blacklegged ticks are endemic in Canada, as well as information on the disease and prevention measures, can help Canadians protect themselves from infection.
The CMA supports a national Lyme disease strategy which includes the federal, provincial and territorial governments and the medical and patient communities. This strategy must address concerns around research, surveillance, diagnosis, treatment and management of the disease and public health prevention measures will advance our current knowledge base, and improve the care and treatment of those suffering from Lyme disease.
Once again, CMA is pleased to provide this brief to the Standing Committee on Health as part of its study on this important issue. Canada's physicians recognize the importance of monitoring all emerging infectious diseases in Canada. In addition, Canada's physicians recognize the importance of developing strategies to treat, manage, and prevent Lyme disease in Canada.
1 CDC provides estimate of Americans diagnosed with Lyme disease each year, media release August 19, 2013 Accessed at http://www.cdc.gov/media/releases/2013/p0819-lyme-disease.html on Feb 21, 2014.
2 Ogden, N., L. Lindsay, and P. Leighton. 2013. Predicting the rate of invasion of the agent of Lyme disease Borrelia burgdorferi. Journal of Applied Ecology. April, 2013. 50(2):510-518.
3 Mayo Clinic, accessed at http://www.mayoclinic.org/diseases-conditions/lyme-disease/basics/tests-diagnosis/con-20019701 on Feb 21, 2014.
4 Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006;43: 1089-134.
The Canadian Medical Association (CMA) is pleased to provide this submission in response to Health Canada's Notice of proposed order to amend the schedule to the Tobacco Act1, from October 14, 2014, on the restriction of the use of additives.
Canada's physicians have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use.
Flavoured tobacco products include candy or fruit flavoured products including cigarillos, water pipe tobacco, smokeless tobacco and blunt wraps. They come in flavours that are appealing to youth such as chocolate, mint, cherry, peach, or strawberry. Flavouring makes the tobacco products more palatable to youth and young adult smokers because they have a lower tolerance for irritation and an underdeveloped taste for tobacco smoke.2 Menthol is a long standing and common flavour used in cigarettes and is used to reduce the harshness of cigarette smoke. It is the most popular flavour among youth. Almost three out of 10 Canadian youth who smoked cigarettes in the last 30 days (29 per cent) reported smoking menthol cigarettes.3
Tobacco Use and Youth
While tobacco use has declined in Canada we must remain vigilant in our efforts to reduce smoking rates. Today 16 per cent of Canadians continue to smoke on a regular basis and physicians are particularly concerned about the smoking prevalence among young adults and youth with 20 per cent of those aged 20-24, and 11 per cent of youth aged 15-19 currently smoking on a regular basis. 4
Flavoured tobacco products, with their appeal to young Canadians are a major threat to the health and well-being of our youth. A recent report, Flavoured Tobacco Use: Evidence from Canadian Youth based on the 2012/13 Youth Smoking Survey, shows that young people are using flavoured tobacco products at high levels. Results show that 50 per cent of high school students in Canada who used tobacco products in the previous 30 days used flavoured tobacco products.5
Previous Amendments Regarding Flavouring Agents
The CMA supported efforts of the federal government in 2009 to limit the addition of flavouring agents to tobacco products through the 2010 Act to Amend the Tobacco Act. But the Act did not cover all tobacco products and it excluded menthol as a flavouring agent. Manufacturers have been able to modify the weight and packaging of their products to technically comply with the Act while they continue to market flavoured products.
It is the CMA's position that the federal government has an important role in smoking cessation and prevention among youth. The CMA supports the proposed extension of the prohibitions on the use of certain flavouring additives in relation to the manufacture and sale of little cigars to cigars weighing more than 1.4 g but less than 6 g.
The CMA remains very concerned that these amendments do not ban menthol flavouring in tobacco products. To that end, the CMA recommends that Health Canada extend its prohibition on flavouring additives to include a ban on the addition of menthol in all tobacco products.
1 Health Canada. Notice of proposed order to amend the schedule to the Tobacco Act. October 14, 2014. Accessed at: http://www.hc-sc.gc.ca/hc-ps/consult/_2014/tobacco-act-loi-tabac/index-eng.php
2 Carpenter CM, Wayne GF, Pauly JL, Koh HK, Connolly GN. New cigarette brands with flavors that appeal to youth: Tobacco marketing strategies: Tobacco industry documents reveal a deliberate strategy to add flavors known to appeal to younger people. Health Affairs 2005;24(6):1601-1610.
3 Manske SR, Rynard VL, Minaker LM. 2014 (September). Flavoured Tobacco Use among Canadian Youth: Evidence from Canada's 2012/2013 Youth Smoking Survey. Waterloo: Propel Centre for Population Health Impact, 1-18. cstads.ca/reports.
4 Canadian Tobacco Use Monitoring Survey 2012 , accessed at http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/ctums-esutc_2012-eng.php.
5 Manske SR, Rynard VL, Minaker LM. 2014 (September). Flavoured Tobacco Use among Canadian Youth: Evidence from Canada's 2012/2013 Youth Smoking Survey. Waterloo: Propel Centre for Population Health Impact, 1-18. cstads.ca/reports.
Minaker L, Manske S, Rynard VL, Reid JL & Hammond D. Tobacco Use in Canada: Patterns and Trends, 2014 Edition - Special Supplement: Flavoured Tobacco Use. Waterloo, ON: Propel Centre for Population Health Impact, University of Waterloo.
Canadian Medical Association 2
November 10, 2014
On behalf of its more than 82,000 members and the Canadian public, CMA performs a wide variety of functions. Key functions include advocating for health promotion and disease prevention policies and strategies, advocating for access to quality health care, facilitating change within the medical profession, and providing leadership and guidance to physicians to help them influence, manage and adapt to changes in health care delivery.
The CMA is a voluntary professional organization representing the majority of Canada's physicians and comprising 12 provincial and territorial divisions and 51 national medical organizations.
The Canadian Medical Association (CMA) is pleased to provide this submission to the House of Commons Health Committee for its study on e-cigarettes.
Electronic cigarettes, or e-cigarettes, which replicate the act and taste of smoking, but do not contain tobacco, are growing rapidly in popularity. The tube of an e-cigarette contains heat-producing batteries and a chamber holding liquid, mainly propylene glycol. When heated, the liquid is turned into vapour which is drawn into the lungs. Ingredients vary by brand but many contain nicotine. Flavourings are also added with the intention of boosting their appeal to young people. Issues have been identified with labelling of e-cigarettes, where upon inspection, there have been contaminants, and nicotine has been detected in products labeled without nicotine.1 Users are generally able to modify the contents of e-cigarettes, with the addition of other substances, including marijuana.
Originally most e-cigarette manufacturers were small entrepreneurial companies; now, however, all major transnational tobacco companies are also producing e-cigarettes and competing for a share in the market.
There are little data on Canadian use. In the U.S., one in five adult smokers has tried them, according to the Centers for Disease Control and Prevention2.
Current Regulatory Status
Health Canada issued a warning in 20093 about the potential dangers and the fact that e-cigarettes had not been fully evaluated for safety, quality and efficacy. The sale of e-cigarettes containing nicotine is currently illegal in Canada under the Food and Drugs Act regulations4 though they can still be purchased in the US or over the Internet. However, those that do not make any health claim and do not contain nicotine may legally be sold in Canada under the same regulation. Health Canada is considering additional regulatory measures but none have yet been introduced. Some municipal jurisdictions are also considering regulation changes.
Internationally, regulation of e-cigarettes is just beginning, and approaches vary. A few countries - such as Brazil, Norway and Singapore - have banned them outright. France plans to regulate e-cigarettes in the same way as tobacco products, and the US Food and Drug Administration is considering a similar approach. On the other hand, Britain will regulate e-cigarettes as non-prescription drugs starting in 2016.5
Current evidence is insufficient to estimate the health effects of e-cigarettes. There are both defenders and opponents, though their arguments are based largely on opinion since e-cigarettes are only beginning to undergo rigorous clinical testing.6
Proponents, including some health officials and groups, say they are safer than tobacco cigarettes since they do not contain the tar and other toxic ingredients that are the cause of tobacco related disease.7 Some believe they serve a useful purpose as a harm reduction tool or cessation aid, although marketing them as such is not permitted since that claim has never been approved by Health Canada.
Opponents are concerned that the nicotine delivered via e-cigarettes is addictive and that the e-cigarettes may contain other toxic ingredients such as nitrosamines, a carcinogen. Also, they worry that acceptance of e-cigarettes will undermine efforts to de-normalize smoking, and that they may be a gateway to use of tobacco by people who might otherwise have remained smoke-free.8 The use of flavouring agents and attractive packaging could entice children and youth, and survey data in some countries has shown that teens are increasingly experimenting with e-cigarettes.
There has also been a dramatic increase in cases of nicotine overdose by ingestion or through dermal contact, particularly in children.9 The number of these incidents seems to be rising in countries that monitor poisonings.
The World Health Organization recently released a report on the health impacts of electronic nicotine delivery systems (ENDS) use which incorporates the 2013 deliberations and scientific recommendations by the WHO Study Group on Tobacco Product Regulation. It concludes that "ENDS use poses serious threats to adolescents and fetuses. In addition, it increases exposure of non-smokers and bystanders to nicotine and a number of toxicants." The report says that it is possibly less toxic for the smoker than conventional cigarettes but it is unknown by how much.10 This report suggests that governments should have the following regulatory objectives:
* impede the promotion and uptake of e-cigarettes with nicotine by non-smokers, pregnant women and youth;
* minimize potential health risks to e-cigarette users and non-users;
* prohibit unproven health claims from being made about e-cigarettes; and
* protect existing tobacco-control efforts from commercial and other vested interests of the tobacco industry.11
Given the absence of solid evidence of harms or benefits, CMA recommends that:
1. E-cigarettes containing nicotine should not be authorized for sale in Canada.
2. The sale of all e-cigarettes should be prohibited to Canadians younger than the minimum age for tobacco consumption in their province or territory.
3. Smoke-free policies should be expanded to include a ban on the use of e-cigarettes in areas where smoking is prohibited.
4. Research on the potential harms and benefits of electronic cigarette use should be supported.
1 Institut national de santé publique du Québec (INSPQ). (Mai 2013). La cigarette électronique: état de situation. Available : http://www.inspq.qc.ca/pdf/publications/1691_CigarElectro_EtatSituation.pdf
2 Centers for Disease Control and Prevention. About one in five U.S. adult cigarette smokers have tried an electronic cigarette. Centers for Disease Control and Prevention Press Release. February 28, 2013 Available: http://www.cdc.gov/media/releases/2013/p0228_electronic_cigarettes.html (accessed October 31, 2014)
3 Health Canada. Health Canada Advises Canadians Not to Use Electronic Cigarettes (archived). Available: http://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2009/13373a-eng.php (accessed October 31, 2014)
4 Health Canada. Notice - To All Persons Interested in Importing, Advertising or Selling Electronic Smoking Products in Canada. Available: http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/pol/notice_avis_e-cig-eng.php (accessed October 31, 2014)
5 Kelland, K. & Hirschler, B. Insight - No smoke, plenty of fire fuels e-cigarettes. Reuters. June 13, 2013. http://uk.reuters.com/article/2013/06/13/uk-ecigarettes-insight-idUKBRE95C0F720130613 (accessed October 31, 2014)
6 Non-Smokers Rights Association. Product Regulation: The Buzz on E-Cigarettes. Available: http://www.nsra-adnf.ca/cms/page1385.cfm (accessed October 31, 2014)
7 Weeks, C. Could e-cigarettes save smokers' lives? Some health advocates think so. The Globe and Mail April 29, 2013. Retrieved from http://www.theglobeandmail.com/life/health-and-fitness/health/could-e-cigarettes-save-smokers-lives-some-health-advocates-think-so/article11583353/?cmpid=rss1
8 Toronto Public Health. E-cigarettes in Toronto. Staff report to the Toronto Board of Health. August 1, 2014. Available: http://www.toronto.ca/legdocs/mmis/2014/hl/bgrd/backgroundfile-72510.pdf (accessed October 31, 2014).
9 Centers for Disease Control and Prevention. Notes from the Field: Calls to Poison Centers for Exposures to Electronic Cigarettes - United States, September 2010-February 2014. Morbidity and Mortality Weekly Report, 63(13): 292-293. April 4, 2014. Available: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6313a4.htm?s_cid=mm6313a4_w (accessed October 31, 2014).
10 World Health Organization. Electronic nicotine delivery systems. Conference of the Parties to the WHO Framework Convention on Tobacco Control. Sixth session Moscow, Russian Federation, 13-18 October 2014. Provisional agenda item 4.4.2. Available: http://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6_10-en.pdf?ua=1
"The 2014-15 budget signals the end to a tough but necessary period of fiscal consolidation. Current expectations are for a surplus of $6.4-billion in 2015-16, plus a contingency reserve of $3-billion; there is finally some room to manoeuvre in the years ahead."
Glen Hodgson, Senior VP and Chief Economist
Conference Board of Canada - February 2014
Having emerged from the global economic downturn, now is the time for the federal government to make strategic investments that will ensure Canada's long-term economic sustainability. The ageing of Canada's population is the most pressing policy imperative of our time. As highlighted in Finance Canada's 2012 report, Economic and Fiscal Implications of Canada's Ageing Population, action to prepare for an ageing population will support the sustainability of Canada's public finances and social programs.
The CMA's recommendations for the 2014-15 federal budget focus on strategic investments in three key areas:
1. Supporting Canadian families and seniors
A) Pan-Canadian Seniors Strategy
The CMA is concerned that Canada is ill-prepared for the demographic shift already underway. By 2036, it is expected that a quarter of Canada's population will be over age 65; almost double the proportion of today. Already, patients aged 65 and older account for nearly half of Canada's health care spending. Seniors also face challenges accessing health services across the continuum of care. These challenges are getting worse, despite growing efforts to provide sustainable, high-quality health care for seniors, and despite most provinces having seniors care strategies in place.
Canadians share our concern. According to an Ipsos Reid poll commissioned by the CMA, a majority of respondents (83%) said they were concerned about their health care in their retirement years. This poll found that nine out of ten Canadians (93%) believe Canada needs a national strategy for seniors health care that integrates home care, hospitals, hospices, and long-term care facilities into the continuum.
Recommendation: The CMA recommends that the federal government provide targeted funding to support the development of a pan-Canadian strategy to address the needs of the aging population.
B) Incenting savings for future continuing care needs
According to the Organization for Economic Cooperation and Development (OECD), long-term care spending in Canada averaged 1.2% of GDP over the 2006-10 period and could more than double to 2.5% by 2060. The Canadian Life and Health Insurance Association estimates there will be an unfunded long-term care liability of $590 billion over and above existing government programs as the boomer generation passes through their old age1.
Of the approaches available to address this unfunded liability, encouraging and incentivizing individuals to save for their future continuing care needs is the least demanding of public finances as compared with increased personal or business income taxes or mandatory contributions.
There has been increasing interest among Canadians with focused savings vehicles established by the federal government. There continues to be increased uptake with Registered Education Savings Plans (RESPs) to support post-secondary education. The growth in RESP assets was significant in 2011 and 2012, representing an average annual rate of 12.6%.2
There has also been increased uptake in the use of tax sheltered individual savings vehicles, such as the Tax Free Savings Account (TFSA). According to a Finance Canada report, as of 2011 there were 8.2 million individuals with a TFSA, representing 31% of tax filers, and they contributed $30.7 billion in that year. The report noted that the greatest proportionate growth in TFSA uptake was observed among those with incomes of less than $20,000, with their participation rate almost doubling from 11% in 2009 to 20% in 20113.
Recommendation: The CMA recommends that the federal government use its economic levers to encourage Canadians to save over their lifetime for future continuing and long-term care needs not covered under the Canada Health Act.
C) Promoting Healthy Ageing
The Public Health Agency of Canada (PHAC) defines healthy ageing as "the process of optimizing opportunities for physical, social and mental health to enable seniors to take an active part in society without discrimination and to enjoy independence and quality of life."
Such initiatives could focus on:
* Physical activity - 57% of seniors in 2008 reported being physically inactive4;
* Injury prevention - 40% of admissions to nursing homes, 62% of injury-related hospitalizations, and almost 90% of hip fractures are due to falls by seniors5;
* Nutrition - 28% of men and 31% of women over 65 were obese (BMI = 30); this is higher than the population average. Underweight is also a problem among seniors, 17% of whom report a BMI of 20 or less6.
The federal government has already undertaken steps to address healthy ageing among Canada's seniors, such as 'Seniors: Active. Engaged. Informed'. In funding over 13,000 projects across Canada, the New Horizons for Seniors Program has demonstrated success in enabling new programs to achieve specific goals; this program can be harnessed to deliver projects focused on promoting healthy ageing.
Recommendation: The CMA recommends that the New Horizons for Seniors program be expanded by $5 million per year to include funding for programs promoting healthy ageing activities for Canadian seniors.
2. Ensuring the availability and access to continuing care
"When we poll CARP members, they call for leadership in helping Canadians save for retirement, get home care when they need it and get access to affordable drug."
Susan Eng, VP, Advocacy for CARP - February 2014
A) Addressing the Continuing Care Infrastructure Crisis
A major issue facing health care systems across the country is the high number of alternate level of care patients (ALC) in acute care hospitals. ALC patients-many of whom are seniors-are those who have completed the acute care phase of their treatment but remain in an acute care bed or who are admitted into a hospital bed due to the lack of more appropriate assisted living settings.
The CMA supports efforts to allow Canadian seniors to remain in the community as long as possible. However, there are increasing pressures on the continuing care sector given the rise in the number of seniors with complex health and social needs. These pressures not only relate to the construction of new facilities, including assisted living units and other innovative residential models for seniors, but apply as well to the need to upgrade and retrofit existing facilities7.
Despite increasing the availability of home care, Canada will face a significant infrastructure shortage in the continuing care sector. The CMA estimates this infrastructure shortage costs the health care system about $2.3 billion a year; this cost is estimated to skyrocket as our population ages.
Recommendation: The CMA recommends the federal government deliver $2.3 billion in funding to leverage provincial/territorial strategic investment in the construction, renovation and retrofitting of assisted living units, other innovative residential models, and long-term care facilities.
B) Supporting Caregivers
The 2011 Budget introduced a new non-refundable Family Caregiver Tax Credit to provide tax relief to those who provide informal care for a dependent relative within their home. However, the credit is limited to 15% of a maximum $2,040 in expenses for 2013 or a maximum sum of $306. While this credit can be added to other tax credits, the total amount is small in relation to the burden experienced by caregivers and it remains non-refundable.
The CMA is concerned that the scarcity of financial support and programs supporting caregivers represents significant risks in relation to economic costs, lower productivity, impacts on the labour market, inefficiencies within the health care system and, most importantly, patient care.
Informal caregivers are the backbone of any health care and social care system. The work of the 1.5 to 2 million caregivers in Canada is estimated at $25-26 billion annually, while incurring $80 million dollars annually in out-of-pocket costs8. The role of informal caregivers will only increase with the move to providing more care at home.
Recommendation: The CMA recommends the federal government make the Family Caregiver Tax Credit a refundable tax credit as part of an effort to better support informal caregivers.
3. Accelerating innovation in health care through enhanced use of electronic medical records (EMRs)
"The need for innovation ..., both in terms of medical technologies and healthcare delivery systems, is one of the most pressing public policy challenges of our times."
Hon. Rona Ambrose, Health Minister - January 2014
The CMA supports prioritizing continuing the development and meaningful use of electronic medical records (EMRs).
A recent report estimates the costs of a pan-Canadian electronic health record (EHR) between $7.9 billion and $16.0 billion9 while total gross savings over a 20-year range were projected at over $82 billion. To date, approximately $2.1 billion in federal funding has been invested. Five national benefit evaluation studies have been commissioned since 2008 and these analyses estimated $7.7 billion in benefits to date as a result of this investment10.
This initial investment has resulted in digitized health care information and paper processes, and created a robust marketplace for innovation by EMR vendors. As such, the value of investments in EMRs is emerging. The 2013 National Physicians Survey11 indicated that:
* Almost 70% of medical general practitioners (GPs) and specialists now use an EMR, up from 56% in 2012 and 37% in 2009.
* 45% of GPs and 40% of specialists report increased or greatly increased efficiency due to the use of EMRs.
* 63% of GPs and 50% of specialists report the quality of patient care they provide is better or much better since they started using an EMR.
The next step in the evolution of EMRs is enhanced use. In Canada, federal investment does not extend beyond the equivalent of the first stage of the U.S. framework for Meaningful Use. There remain significant gaps in funding to achieve enhanced use of EMRs by clinicians, regional interoperability, and to structure EMR data to leverage big data analytics.
Recommendation: The CMA recommends the federal government continue to fund Canada Health Infoway (CHI) to administer remaining project funds from the $500 million allocated in 2009, and allocate an additional $500 million, to be administered by CHI, for projects to achieve enhanced use of EMRs.
1 Canadian Life and Health Insurance Association. Helping Canadians prepare for long-term care costs. CLHIA report on long-term care policy. 2014.
2 Employment and Social Development Canada. 2012 CESP Annual Statistical Review. http://www.esdc.gc.ca/eng/jobs/student/reports/statistics/cesp_2012.shtml#h2.4-h3.1
3 There is a detailed analysis of the TFSA in the 2012 Tax Expenditures and Evaluations report by Finance Canada (Pages 31-42 in http://www.fin.gc.ca/taxexp-depfisc/2012/taxexp-depfisc12-eng.pdf).
4 PHAC 2010
5 PHAC 2010
6 PHAC 2010
7 Canadian Medical Association, The Need for Health Infrastructure in Canada. Submitted to Hon. Denis Lebel, PC, MP Minister of Transport, Infrastructure and Communities. March 18, 2013.
8 Hollander, M.J, Liu, G., Chappeell, N.L. (2009). Who cares and how much? The imputed economic contribution to the Canadian health care system of middle aged and older unpaid caregivers providing care to the elderly. Healthcare Quarterly, 12(2), 42-59.
10 Remote Patient Monitoring (RPM) Evaluation; EMR Evaluation; Telehealth evaluation; Drug Information Systems (DIS) evaluation; Diagnostic Imaging (DI) systems evaluation
The Canadian Medical Association (CMA) is pleased to confirm its strong support for the federal government's health and social policy commitments, as identified in the ministerial mandate letters.
In this brief, the CMA outlines seven recommendations for meaningful and essential federal action to ensure Canada is prepared to meet the health care needs of its aging population. The CMA's recommendations are designed to be implemented in the 2016-17 fiscal year in order to deliver immediate support to the provinces and territories and directly to Canadians.
Immediate implementation of these recommendations is essential given the current and increasing shortages being experienced across the continuum of care in jurisdictions across Canada. In 2014, the CMA initiated a broad consultative initiative on the challenges in seniors care, as summarized in the report A Policy Framework to Guide a National Seniors Strategy for Canada. This report highlights the significant challenges currently being experienced in seniors care and emphasizes the need for increased federal engagement.
Finally, if implemented, the CMA's recommendations will contribute to the federal government's strategic commitments in health, notably the commitment to the development of a new Health Accord.
1) Demographic Imperative for Increased Federal Engagement in Health
Canada is a nation on the threshold of great change. This change will be driven primarily by the economic and social implications of the major demographic shift already underway. The added uncertainties of the global economy only emphasize the imperative for federal action and leadership.
In 2015, for the first time in Canada's history, persons aged 65 years and older outnumbered those under the age of 15 years.1 Seniors are projected to represent over 20% of the population by 2024 and up to 25% of the population by 2036.2
It is increasingly being recognized that the projected surge in demand for services for seniors that will coincide with slower economic growth and lower government revenue will add pressure to the budgets of provincial and territorial governments.3 Today, while seniors account for about one-sixth of the population, they consume approximately half of public health spending.4 Based on current trends and approaches, seniors care is forecast to consume almost 62% of provincial/territorial health budgets by 2036.5
The latest National Health Expenditures report by the Canadian Institute of Health Information (CIHI) projects that health spending in 2015 was to exceed $219 billion, or 10.9% of Canada's gross domestic product (GDP).6 To better understand the significance of health spending in the national context, consider that total federal program spending is 13.4% of GDP.7 Finally, health budgets are now averaging 38% of provincial and territorial global budgets.8 Alarmingly, the latest fiscal sustainability report of the Parliamentary Budget Officer explains that the demands of Canada's aging population will result in "steadily deteriorating finances" for the provinces and territories, who "cannot meet the challenges of population aging under current policy."9
Taken together, the indicators summarized above establish a clear imperative and national interest for greater federal engagement, leadership and support for the provision of health care in Canada.
2) Responses to Pre-Budget Consultation Questions
Question 1: How can we better support our middle class?
A) Federal Action to Help Reduce the Cost of Prescription Medication
The CMA strongly encourages the federal government to support measures aimed at reducing the cost of prescription medication in Canada. A key initiative underway is the pan-Canadian Pharmaceutical Alliance led by the provinces and territories. The CMA supports the federal government's recent announcement that it will partner with the provinces and territories as part of the pan-Canadian Pharmaceutical Alliance. In light of the fact that the majority of working age Canadians have coverage for prescription medication through private insurers10, the CMA recommends that the federal government support inviting the private health insurance industry to participate in the work of the pan-Canadian Pharmaceutical Alliance.
Prescription medication has a critical role as part of a high-quality, patient-centred and cost-effective health care system. Canada stands out as the only country with universal health care without universal pharmaceutical coverage.11 It is an unfortunate reality that the affordability of prescription medication has emerged as a key barrier to access to care for many Canadians.
According to the Angus Reid Institute, more than one in five Canadians (23%) report that they or someone in their household did not take medication as prescribed because of the cost during the past 12 months.12 Statistics Canada's Survey of Household Spending reveals that households headed by a senior spend $724 per year on prescription medications, the highest among all age groups and over 60% more than the average household.13 Another recent study found that 7% of Canadian seniors reported skipping medication or not filling a prescription because of the cost.14
The CMA has long called on the federal government to implement a system of catastrophic coverage for prescription medication to ensure Canadians do not experience undue financial harm and to reduce the cost barriers of treatment. As a positive step toward comprehensive, universal coverage for prescription medication, the CMA recommends that the federal government establish a new funding program for catastrophic coverage of prescription medication. The program would cover prescription medication costs above $1,500 or 3% of gross household income on an annual basis. Research commissioned by the CMA estimates this would cost $1.57 billion in 2016-17 (Table 1).
Table 1: Projected cost of federal contribution to cover catastrophic prescription medication costs, by age cohort, 2016-2020 ($ million)15
Share of total cost
Under 35 years
35 to 44 years
45 to 54 years
55 to 64 years
65 to 74 years
75 years +
B) Deliver Immediate Federal Support to Canada's Unpaid Caregivers
There are approximately 8.1 million Canadians serving as informal, unpaid caregivers with a critical role in Canada's health and social sector.16 The Conference Board of Canada reports that in 2007, informal caregivers contributed over 1.5 billion hours of home care - more than 10 times the number of paid hours in the same year.17 The economic contribution of informal caregivers was estimated to be about $25 billion in 2009.18 This same study estimated that informal caregivers incurred over $80 million in out-of-pocket expenses related to caregiving in 2009.
Despite their tremendous value and important role, only a small fraction of caregivers caring for a parent receive any form of government support.19 Only 5% of caregivers providing care to parents reported receiving financial assistance, while 28% reported needing more assistance than they received.20
It is clear that Canadian caregivers require more support. As a first step, the CMA recommends that the federal government amend the Caregiver and Family Caregiver Tax Credits to make them refundable. This would provide an increased amount of financial support for family caregivers. It is estimated that this measure would cost $90.8 million in 2016-17.21
C) Implement a new Home Care Innovation Fund
The CMA strongly supports the federal government's significant commitment to deliver more and better home care services, as released in the mandate letter for the Minister of Health.
Accessible, integrated home care has an important role in Canada's health sector, including addressing alternate level of care (ALC) patients waiting in hospital for home care or long-term care. As highlighted by CIHI, the majority of the almost 1 million Canadians receiving home care are aged 65 or older.22 As population aging progresses, demand for home care can be expected to increase.
Despite its importance, it is widely recognized that there are shortages across the home care sector.23 While there are innovations occurring in the sector, financing is a key barrier to scaling up and expanding services. To deliver the federal government's commitment to increasing the availability of home care, the CMA recommends the establishment of a new targeted home care innovation fund. As outlined in the Liberal Party of Canada's election platform, the CMA recommends that the fund deliver $3 billion over four years, including $400 million in the 2016-17 fiscal year.
Question 2: What infrastructure needs can best help grow the economy...and meet your priorities locally?
Deliver Federal Investment to the Long-term Care Sector as part of Social Infrastructure
All jurisdictions across Canada are facing shortages in the continuing care sector. Despite the increased availability of home care, research commissioned for the CMA indicates that demand for continuing care facilities will surge as the demographic shift progresses.24
In 2012, it was reported that wait times for access to a long-term care facility in Canada ranged from 27 to over 230 days. More than 50% of ALC patients are in these hospital beds because of the lack of availability of long-term care beds25. Due to the significant difference in the cost of hospital care (approximately $846 per day) versus long-term care ($126 per day), the CMA estimates that the shortages in the long-term care sector represent an inefficiency cost to the health care system of $2.3 billion a year.26
Despite the recognized need for infrastructure investment in the continuing care sector, to date, this sector has been unduly excluded from federal investment in infrastructure, namely the Building Canada Plan. The CMA recommends that the federal government include capital investment in continuing care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure. Based on previous estimates, the CMA recommends that $540 million be allocated for 2016-17 (Table 2), if implemented on a cost-share basis.
Table 2: Estimated cost to address forecasted shortage in long-term care beds, 2016-20 ($ million)27
Forecasted shortage in long term care beds
Estimated cost to address shortage
Federal share to address shortage in long term care beds (based on 1/3 contribution)
In addition to improved delivery of health care resources, capital investment in the long-term care sector would provide an important contribution to economic growth. According to previous estimates by the Conference Board of Canada, the capital investment needed to meet the gaps from 2013 to 2047 would yield direct economic benefits on an annual basis that include $1.23 billion contribution to GDP and 14,141 high value jobs during the capital investment phase and $637 million contribution to GDP and 11,604 high value jobs during the facility operation phase (based on an average annual capital investment).
Question 3: How can we create economic growth, protect the environment, and meet local priorities while ensuring that the most vulnerable don't get left behind?
Deliver new Funding to Support the Provinces and Territories in Meeting Seniors Care Needs
Canada's provincial and territorial leaders are struggling to meet health care needs in light of the demographic shift. This past July, the premiers issued a statement calling for the federal government to increase the Canada Health Transfer (CHT) to 25% of provincial and territorial health care costs to address the needs of an aging population.
It is recognized that as an equal per-capita based transfer, the CHT does not currently account for population segments with increased health needs, specifically seniors. The CMA was pleased that this issue was recognized by the Prime Minister in his letter last spring to Quebec Premier Philippe Couillard.
However, the CMA is concerned that an approach to modify the transfer formula would potentially delay the delivery of federal support to meet the needs of an aging population. As such, rather than the transfer formula, the CMA has developed an approach that delivers support to jurisdictions endeavoring to meet the needs of their aging populations while respecting the transfer arrangement already in place.
The CMA commissioned the Conference Board of Canada to calculate the amount for the top-up to the CHT using a needs-based projection. The amount of the top-up for each jurisdiction is based on the projected increase in health care spending associated with an aging population.
To support the innovation and transformation needed to address the health needs of the aging population, the CMA recommends that the federal government deliver additional funding on an annual basis beginning in 2016-17 to the provinces and territories by means of a demographic-based top-up to the Canada Health Transfer (Table 3). For the fiscal year 2016-17, this top-up would require $1.6 billion in federal investment.
Table 3: Allocation of the federal demographic-based top-up, 2016-20 ($million)28
All of Canada
Newfoundland and Labrador
Prince Edward Island
Question 4: Are the Government's new priorities and initiatives realistic; will they help grow the economy?
Ensure Tax Equity for Canada's Medical Professionals is Maintained
Among the federal government's commitments is the objective to decrease the small business tax rate from 11% to 9%. The CMA supports this commitment to support small businesses, such as medical practices, in recognition of the significant challenges facing this sector. However, it is not clear whether as part of this commitment the federal government intends to alter the Canadian-Controlled Private Corporation (CCPC) framework. The federal government's framing of this commitment, as released in the mandate letter for the Minister of Small Business and Tourism, has led to confusion and concern.
Canada's physicians are highly skilled professionals, providing an important public service and making a significant contribution to our country's knowledge economy. Canadian physicians are directly or indirectly responsible for hundreds of thousands of jobs across the country, and invest millions of dollars in local communities, ensuring that Canadians are able to access the care they need, as close to their homes as possible.
In light of the design of Canada's health care system, the majority of physicians are self-employed professionals and effectively small business owners. As self-employed small business owners, they typically do not have access to pensions or health benefits. In addition, as employers, they are responsible for these benefits for their employees.
In addition to managing the many costs associated with running a medical practice, Canadian physicians must manage challenges not faced by many other small businesses. As highly-skilled professionals, physicians typically enter the workforce with significant debt levels and at a later stage in life. For some, entering practice after training requires significant investment in a clinic or a practice.
Finally, it is important to recognize that physicians cannot pass on the increased costs introduced by governments, such as changes to the CCPC framework, onto patients, as other businesses would do with clients.
For a significant proportion of Canada's physicians, the CCPC framework represents a measure of tax equity for individuals taking on significant personal financial burden and liability as part of our public health care system. As well, in many cases, practices would not make economic sense if the provisions of the CCPC regime were not in place. Given the importance of the CCPC framework to medical practice, changes to this framework have the potential to yield unintended consequences in health resources, including the possibility of reduced access to much needed care.
The CMA recommends that the federal government maintain tax equity for medical professionals by affirming its commitment to the existing framework governing Canadian-Controlled Private Corporations.
The CMA recognizes that the federal government must grapple with an uncertain economic forecast and is prioritizing measures that will support economic growth. The CMA strongly encourages the federal government to adopt the seven recommendations outlined in this submission as part of these efforts. In addition to making a meaningful contribution to meeting the future care needs of Canada's aging population, these recommendations will mitigate the impacts of economic pressures on individuals as well as jurisdictions. The CMA would welcome the opportunity to provide further information and its rationale for each recommendation.
Summary of Recommendations
1. The CMA recommends that the federal government establish a new funding program for catastrophic coverage of prescription medication; this would be a positive step toward comprehensive, universal coverage for prescription medication.
2. The CMA recommends that the federal government support inviting the private health insurance industry to participate in the work of the pan-Canadian Pharmaceutical Alliance.
3. The CMA recommends that the federal government amend the Caregiver and Family Caregiver Tax Credits to make them refundable.
4. To deliver the federal government's commitment to increasing the availability of home care, the CMA recommends the establishment of a new targeted home care innovation fund.
5. The CMA recommends that the federal government include capital investment in continuing care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure.
6. The CMA recommends that the federal government deliver additional funding on an annual basis beginning in 2016-17 to the provinces and territories by means of a demographic-based top-up to the Canada Health Transfer.
7. The CMA recommends that the federal government maintain tax equity for medical professionals by affirming its commitment to the existing framework governing Canadian-Controlled Private Corporations.
1 Statistics Canada. Population projections: Canada, the provinces and territories, 2013 to 2063. The Daily, Wednesday, September 17, 2014. Available: http://www.statcan.gc.ca/daily-quotidien/140917/dq140917a-eng.htm
2 Statistics Canada. Canada year book 2012, seniors. Available: www.statcan.gc.ca/pub/11-402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm
3 Conference Board of Canada. A difficult road ahead: Canada's economic and fiscal prospects. Available: http://canadaspremiers.ca/phocadownload/publications/conf_bd_difficultroadahead_aug_2014.pdf.
4 Canadian Institute for Health Information. National health expenditure trends, 1975 to 2014. Ottawa: The Institute; 2014. Available: www.cihi.ca/web/resource/en/nhex_2014_report_en.pdf
5 Calculation by the Canadian Medical Association, based on Statistics Canada's M1 population projection and the Canadian Institute for Health Information age-sex profile of provincial-territorial health spending.
6 CIHI. National Health Expenditure Trends,1975 to 2015. Available: https://secure.cihi.ca/free_products/nhex_trends_narrative_report_2015_en.pdf.
7 Finance Canada. Update of Economic and Fiscal Projections 2015. http://www.budget.gc.ca/efp-peb/2015/pub/efp-peb-15-en.pdf.
8 CIHI. National Health Expenditure Trends,1975 to 2015. Available: https://secure.cihi.ca/free_products/nhex_trends_narrative_report_2015_en.pdf.
9 Office of the Parliamentary Budget Officer. Fiscal sustainability report 2015. Ottawa: The Office; 2015. Available: www.pbo-dpb.gc.ca/files/files/FSR_2015_EN.pdf
10 IBM for the Pan-Canadian Pharmaceutical Alliance. Pan Canadian Drugs Negotiations Report. Available at: http://canadaspremiers.ca/phocadownload/pcpa/pan_canadian_drugs_negotiations_report_march22_2014.pdf .
11 Morgan SG, Martin D, Gagnon MA, Mintzes B, Daw JR, Lexchin J. Pharmacare 2020: The future of drug coverage in Canada. Vancouver: Pharmaceutical Policy Research Collaboration, University of British Columbia; 2015. Available: http://pharmacare2020.ca/assets/pdf/The_Future_of_Drug_Coverage_in_Canada.pdf
12 Angus Reid Institute. Prescription drug access and affordability an issue for nearly a quarter of Canadian households. Available: http://angusreid.org/wp-content/uploads/2015/07/2015.07.09-Pharma.pdf
13 Statistics Canada. Survey of household spending. Ottawa: Statistics Canada; 2013.
14 Canadian Institute for Health Information. How Canada compares: results From The Commonwealth Fund 2014 International Health Policy Survey of Older Adults. Available: www.cihi.ca/en/health-system-performance/performance-reporting/international/commonwealth-survey-2014
15 Conference Board of Canada. Research commissioned for the CMA, July 2015.
16 Statistics Canada. Family caregivers: What are the consequences? Available: www.statcan.gc.ca/pub/75-006-x/2013001/article/11858-eng.htm
17 Conference Board of Canada. Home and community care in Canada: an economic footprint. Ottawa: The Board; 2012. Available: http://www.conferenceboard.ca/cashc/research/2012/homecommunitycare.aspx
18 Hollander MJ, Liu G, Chappeel NL. Who cares and how much? The imputed economic contribution to the Canadian health care system of middle aged and older unpaid caregivers providing care to the elderly. Healthc Q. 2009;12(2):42-59.
19 Government of Canada. Report from the Employer Panel for Caregivers: when work and caregiving collide, how employers can support their employees who are caregivers. Available: www.esdc.gc.ca/eng/seniors/reports/cec.shtml
21 Conference Board of Canada. Research commissioned for the CMA, July 2015.
22 CIHI. Seniors and alternate level of care: building on our knowledge. Available: https://secure.cihi.ca/free_products/ALC_AIB_EN.pdf.
23 CMA. A policy framework to guide a national seniors strategy for Canada. Available: https://www.cma.ca/Assets/assets-library/document/en/about-us/gc2015/policy-framework-to-guide-seniors_en.pdf.
24 Conference Board of Canada. Research commissioned for the CMA, January 2013.
25 CIHI. Seniors and alternate level of care: building on our knowledge. Available: https://secure.cihi.ca/free_products/ALC_AIB_EN.pdf
26 CMA. CMA Submission: The need for health infrastructure in Canada. Available: https://www.cma.ca/Assets/assets-library/document/en/advocacy/Health-Infrastructure_en.pdf.
28 Conference Board of Canada. Research commissioned for the CMA, July 2015.
Thank you Mr. Chair.
I am Dr. Jeff Blackmer, the Vice-President of Medical Professionalism for the Canadian Medical Association.
On behalf of the CMA, let me first commend the committee for initiating an emergency study on this public health crisis in Canada.
As the national organization representing over 83,000 Canadian physicians, the CMA has an instrumental role in collaborating with other health stakeholders, governments and patient organizations in addressing the opioid crisis in Canada.
On behalf of Canada’s doctors, the CMA is deeply concerned with the escalating public health crisis related to problematic opioid and fentanyl use.
Physicians are on the front lines in many respects.
Doctors are responsible for supporting patients with the management of acute and chronic pain. Policy makers must recognize that prescription opioids are an essential tool in the alleviation of pain and suffering, particularly in palliative and cancer care.
The CMA has long been concerned with the harms associated with opioid use. In fact, we appeared before this committee as part of its 2013 study on the government’s role in addressing prescription drug abuse.
At that time, we made a number of recommendations on the government’s role – some of which I will reiterate today.
Since then, the CMA has taken numerous actions to contribute to Canada’s response to the opioid crisis.
These actions have included advancing the physician perspective in all active government consultations.
In addition to the 2013 study by the health committee, we have also participated in the 2014 ministerial roundtable and recent regulatory consultations led by Health Canada — specifically, on tamper resistant technology for drugs and delisting of naloxone for the prevention of overdose deaths in the community.
Our other actions have included:
· Undertaking physician polling to better understand physician experiences with prescribing opioids;
· Developing and disseminating new policy on addressing the harms associated with opioids;
· Supporting the development of continuing medical education resources and tools for physicians;
· Supporting the national prescription drug drop off days; and,
· Hosting a physician education session as part of our annual meeting in 2015.
Further, I’m pleased to report that the CMA has recently joined the Executive Council of the First Do No Harm strategy, coordinated by the Canadian Centre on Substance Abuse.
In addition, we have joined 7 leading stakeholders as part of a consortium formed this year to collaborate on addressing the issue from a medical standpoint.
I will now turn to the CMA’s recommendations for the committee’s consideration. These are grouped in four major theme areas.
1) Harm Reduction
The first of them is harm reduction.
Addiction should be recognized and treated as a serious, chronic and relapsing medical condition for which there are effective treatments.
Despite the fact that there is broad recognition that we are in a public health crisis, the focus of the federal National Anti-Drug Strategy is heavily skewed towards a criminal justice approach rather than a public health approach.
In its current form, this strategy does not significantly address the determinants of drug use, treat addictions, or reduce the harms associated with drug use.
The CMA strongly recommends that the federal government review the National Anti-Drug Strategy to reinstate harm reduction as a core pillar.
Supervised consumption sites are an important part of a harm reduction program that must be considered in an overall strategy to address harms from opioids. The availability of supervised consumption sites is still highly limited in Canada.
The CMA maintains its concerns that the new criteria established by the Respect for Communities Act are overly burdensome and deter the establishment of new sites.
As such, the CMA continues to recommend that the act be repealed or at the least, significantly amended.
2) Expanding Pain Management and Addiction Treatment
The second theme area I will raise is the need to expand treatment options and services.
Treatment options and services for both addiction as well as pain management are woefully under-resourced in Canada.
This includes substitution treatments such as buprenorphine-naloxone as well as services that help patients taper off opioids or counsel them with cognitive behavioural therapy.
Availability and access of these critical resources varies by jurisdiction and region. The federal government should prioritize the expansion of these services.
The CMA recommends that the federal government deliver additional funding on an emergency basis to significantly expand the availability and access to addiction treatment and pain management services.
3) Investing in Prescriber and Patient Education
The third theme I will raise for the committee’s consideration is the need for greater investment in both prescriber as well as patient education resources.
For prescribers, this includes continuing education modules as well as training curricula. We need to ensure the availability of unbiased and evidenced-based educational programs in opioid prescribing, pain management and in the management of addictions.
Further, support for the development of educational tools and resources based on the new clinical guidelines to be released in early 2017 will have an important role.
Finally, patient and public education on the harms associated with opioid usage is critical.
As such, the CMA recommends that the federal government deliver new funding to support the availability and provision of education and training resources for prescribers, patients and the public.
4) Establishing a Real-time Prescription Monitoring Program
Finally, to support optimal prescribing, it is critical that prescribers be provided with access to a real-time prescription monitoring program.
Such a program would allow physicians to review a patient’s prescription history from multiple health services prior to prescribing. Real-time prescription monitoring is currently only available in two jurisdictions in Canada.
Before closing, I must emphasize that the negative impacts associated with prescription opioids represent a complex issue that will require a multi-faceted, multi-stakeholder response.
A key challenge for public policy makers and prescribers is to mitigate the harms associated with prescription opioid use, without negatively affecting patient access to the appropriate treatment for their clinical conditions.
To quote a past CMA president: “the unfortunate reality is that there is no silver bullet solution and no one group or government can address this issue alone”.
The CMA is committed to being part of the solution.
Since 2010, the Canadian Medical Association (CMA) has been calling for health care transformation in Canada to better meet the needs of Canadians. A high performing health care system must be able to respond to the changing nature of its population's health needs.
The CMA believes that seniors care is the paramount health care issue of our time. Our older population will double over the next 20 years, while the 85 and older group is set to quadruple. Currently, we spend almost half of all our health care dollars on seniors. Improving seniors' care will go a long way to fixing our health care system; this is because strategies to address the needs of this population can be leveraged to address the needs of other population groups. That is why CMA has called for the development of a Pan-Canadian Seniors Strategy as a necessary first step.
The CMA welcomes the creation of the Advisory Panel on Healthcare Innovation to better prepare health systems across the country for the above challenges and to contribute toward the sustainability of Canada's public finances and social programs. This brief identifies five important innovations that will not only benefit Canada's growing seniors population but the broader Canadian population as well.
Five Innovations to Improve our Health Care System
1. Supportive living models and palliative care
Canada suffers from a lack of integrated community/residential supports and palliative care models, contributing to poor patient outcomes, significant inappropriate use of health care resources, and higher health care costs. An obvious sign of this gap is the significant number of alternate-level-of care (ALC) patients-most of whom are seniors-languishing in hospitals across Canada. ALC patients are those inpatients that no longer require acute care and are waiting for placement in a more appropriate setting. According to a 2009 Canadian Institute for Health Information (CIHI) report, dementia accounted for almost one-quarter of ALC hospitalizations and more than one-third of ALC days.i Dementia is the leading cause of dependency and disability among older persons. The Wait Time Alliance (WTA) has stated that the most important action to improve timely access to specialty care for all Canadians is by addressing the issue of alternate-level-of-care (ALC) patients.ii
The creation of supportive and integrated living models particularly for the frail elderly and those with dementia would lead to improved health outcomes for these patients as well as savings to the health care system.
* Supportive living models can involve providing technology and human resources to support seniors to stay in their home. It has been estimated that tele-homecare could yield an annual reduction in approximately $540 million in inpatient costs and $23 million in emergency department visit costs.iii
* For others, particularly those with dementia, residential care models are required that can properly support their needs and provide the highest quality of life possible. A few such models are already in existence but more are required. Models include the Bruyère Village in Ottawa (http://www.bruyere.org/bruyere-village) and Saskatoon's Sherbrooke Community Centre (http://www.sherbrookecommunitycentre.ca/). CMA recommends that federal and provincial infrastructure programs allow for innovative residential care options to be eligible for funding.
* Despite the vast majority (96%) of Canadians supporting the use of palliative and hospice care in end-of-life care, only 16-30% of Canadians who are dying have access to or receive hospice, palliative and end-of-life servicesiv. This issue must be addressed immediately across the country. Currently, there is no standard palliative and hospice care model in Canada. However, there are some innovative programs around the country that are leading the way to higher quality palliative care (e.g., West Island Palliative Care Residence in Quebec). The CMA is currently preparing a report to inform health care decision makers including physicians on tools to integrate palliative and hospice care services in their respective communities. But assistance is required to implement innovative practice models across the country.
2. Integrated strategies for high-users of health care and at-risk populations
It is now recognized that a targeted approach is necessary to make substantive change to improve the health status of populations; including reducing health inequities and ensuring more appropriate access to health care resources by those citizens who have a range of socio-economic needs.
Approximately five percent of patients account for two-thirds (66 percent) of provincial health expenditures-many of whom are elderly. This picture is consistent across the country.v This high use is often due to systemic issues, such as poor integration or lack of access, rather than the choices of these patients. There is general agreement that multi-sectoral approaches are necessary that involve the integration of clinical and social care as well as other sectors to best address this population group that often has polymorbidities.
Programs are being implemented in a few provinces at the regional or provider level to try and accommodate the needs of the high-users population by coordinating and integrating care for the benefit of the patient and the family. Examples include Health Links in Ontario and the Regional Integrated Complex Patient Care Planning (RICP2) program at Vancouver Coastal Health Authority. However, funding models-particularly for inter-sectoral approaches-to support the wide-spread adoption of these approaches are rare.
In addition to the high-users are those populations that feature a high burden of illness. Hundreds of research papers have confirmed that people in the lowest socio-economic groups carry the greatest burden of illness.vi Those within the lowest socio-economic status are 1.4 times more likely to have a chronic disease, and 1.9 times more likely to be hospitalized for care of that disease.vii
As with the high-user group, a multi-sectoral approach is required to address the social determinants of health. While it is important for society to strive to eliminate poverty and provide adequate housing and food security, the health care sector can also contribute. Some innovative programs have been put in place such as the Well North program in the United Kingdom that is targeted at improving the health of the poorest fastest, reducing premature mortality and reducing worklessness.viii In Canada, the St. Michael's family health team has an income security specialist on their multi-disciplinary team. This individual helps patients to navigate the government's social services system, will help patients reduce expenses, complete their taxes, set up bank accounts, access free programs, budget and save for emergencies. These patients are identified through screening conducted by family physicians on the team.
There are innovative approaches being developed to address the needs of high-volume users as well as at-risk populations. As many of these innovations involve greater integration between health and the community sector and attention to issues not traditionally funded through health care payment systems, there is a need to provide access to funds to enable these innovations to continue and be spread across the country.
A targeted, integrated approach to identify communities in need is required and this must be based on reliable community data (i.e., meaningful use of patient data) which can be used to integrate resources to improve health status. The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is Canada's first multi-disease electronic medical records (EMR) surveillance and research system that allows family physicians, epidemiologists and researchers from across the country to better understand and manage chronic care conditions for their patients. Health information is collected from EMRs in the offices of participating primary care providers (e.g. family physicians) for the purposes of improving the quality of care for Canadians suffering from chronic and mental health conditions and three neurologic conditions including Alzheimer's and related dementias. CPCSSN makes it possible to securely collect and report on vital information from Canadians' health records to improve the way these chronic diseases and neurologic conditions are managed (http://cpcssn.ca/). Despite this innovative approach to sharing information to better manage chronic care conditions, its five-year federal funding terminates in 2015. The estimated cost of continuing the project is approximately $3 million per year.
3. Optimal prescribing
Poor prescribing can lead to poor patient outcomes and unnecessary costs to the health care system (e.g., fractured hips from falls). The evidence is clear that many seniors in Canada are exposed to inappropriate drug therapy. Data from European countries such as Denmark, , show that inappropriate prescribing can be controlled with only 5.8% of elderly patients using an inappropriate medication in a four month period in 2001. In Canada, CIHI studied senior's drug claims from public programs in four provinces from 2000 to 2006 and found that the rate of inappropriate drug use in 2005-06 varied from 25.2% in Manitoba to 31.3% in New Brunswick. The rate of regular use of such medications ranged from 12.9% in Alberta to 18.8 % in New Brunswick.
E-prescribing decreases the likelihood of adverse drug events or interactions, and provides tools to monitor both patient adherence and practitioner prescribing patterns. One component of an optimal prescribing strategy would be to provide support to provincial/territorial ministries of health to complete the implementation of drug information systems and regional e-prescribing solutions, and/or to develop an agenda to accomplish the enhanced use of electronic medical records.
A second component of an optimal prescribing initiative would be the development of a collaboration of content experts and professional associations to raise awareness of inappropriate prescribing among physicians and other health professionals and then to develop online educational courses and practice tools to assist at the point of care. Initially the focus might be on prescribing for seniors, but subsequently could expand to cover other priority topics such as inappropriate antibiotic use or the use of narcotics for non-cancer pain.
4. Choosing Wisely Canada - Reducing the provision of low value care
A disconcerting proportion of health care, estimated in the United States to be as much as 30%, confers little of no benefit on patients and may, through exposure to excess radiation, drug reactions, adverse events during procedures, or the worry associated with false positive tests, actually cause harm. This represents both sub-optimal quality of care and poor stewardship of scarce health care resources.
The provision of unnecessary care is driven by many elements including physician habit, lack of up-to-date clinician knowledge, patient demand, and structural or financial incentives in the health system. To counter these diverse influences the CMA partnered with the University of Toronto to launch Choosing Wisely Canada, a campaign to facilitate evidence-informed conversations between physicians and patients about the necessity of tests and treatment about low-value tests and treatment. As of October 2014, 102 recommendations have been developed by national specialty societies about clinical activities that generally should be avoided. For example, the Canadian Geriatrics Society advises physicians and patients against the use of antipsychotics as a first choice to treat behavioural and psychological symptoms of dementia as well as against the use of benzodiazepines or other sedative-hypnotics in older adults as a first choice for insomnia, agitation or delirium.
Within its first year of operation the campaign enlisted over 30 national specialty societies, the College of Family Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, all provincial and territorial medical associations, and six large citizen groups. To date the campaign has been resourced by seed funding from the Ontario government, direct contribution from the CMA, and a modest contribution agreement from Health Canada.
If the early success of Choosing Wisely Canada is to be sustained, secure long-term funding is essential. Such resources are necessary to support the development and dissemination of materials to raise physician awareness, provide educational opportunities, make available point-of-care tools, assist with implementation at the practice level, and contribute to data collection for evaluation. The medical professional has clearly stepped forward to take ownership of the low value care challenge; they deserve federal support to ensure a successful long-term outcome.
5. National Health Care Guidance Institute
Clinical practice guidelines (CPGs) have a unique ability to enhance quality of care. The peer-reviewed literature provides robust evidence that guideline use is associated with a positive impact on both processes of care and patient outcomes. Additionally, a number of studies have reported that the application of specific CPGs result in cost-effective care, including, for example, those used in the treatment of community-acquired pneumonia, stroke prevention in primary care, traumatic brain injury, and the use of lipid-lowering drugs. Conditions such as these gain particular significance in the face of an aging population: what is the out-patient antibiotic of choice in an elderly patient with pneumonia?; in an older patient with a cardiac arrhythmia what are the comparative risks of treatment with anticoagulants versus possible cerebrovascular accident?; at what age is it no longer helpful to treat hyperlipidemia? CPGs available at the point of care provide evidence-based answers to such questions.
Internationally, national governments have recognized the value of CPGs and taken a leadership role in ensuring their quality and making them available to practitioners. Three among many examples are: United States (Agency for Healthcare Research and Quality, National Guideline Clearinghouse); United Kingdom (National Institute for Health and Clinical Excellence); and Australia (National Health and Medical Research Council, National Institute of Clinical Studies).
The challenge is that CPGs are not uniformly utilized across Canada nor do we possess a national body or systematic approach to CPG development and dissemination. There are various models that can be implemented to execute this function (e.g., full function agency, collaborative virtual agency) to perform such key functions as prioritizing areas for guideline development, maintaining a national repository and driving active dissemination. The key is having a dedicated agency that can oversee the development and dissemination of CPGs at a pan-Canadian level to improve the quality of care that Canadians receive.
Federal mechanisms to support health innovation
All health systems in Canada and elsewhere are facing the challenge to better meet the needs of their seniors' population. National governments can provide necessary direction and support. The federal government must play a leadership role on seniors care and supporting health care innovation in concert with the provinces and territories and as a system manager itself for those patients falling under federal jurisdiction (e.g., armed forces). This can begin with a First Ministers' Conference as part of the development of a Pan-Canadian Seniors Strategy.
CMA recognizes there are elements of transformation already taking place in the country across the continuum of care that are being supported by technological innovation or clinical innovation (e.g., Choosing Wisely Canada). However, in many cases, there is little funding available to fund projects beyond pilot project status or bring them up to scale, and there is very little cross-country awareness of these "pockets of excellence" due to the absence of mechanisms to share best practices.
Accordingly, CMA recommends the establishment of a National Health System Innovation Fund targeted to provinces and territories to support the adoption of health system innovations including those identified in this brief. Funding criteria should be designed to not only support the development of these innovations but to incent their adoption on a scaled-up basis.
Finally, recognizing the relationship of the social determinants of health on the demands of the health care system, the federal government should implement a requirement for all cabinet decision-making to include a health-in-all policies approach whereby all polices from tax, to transportation, to trade would undergo a health lens to ensure that negative health impacts were minimized/eliminated and positive health outcomes were supported or expanded. This would help to minimize the often unintended health consequences that arise from policies outside of the health sector.
This brief identifies five opportunities for innovating Canada's health care system by improving seniors care-the paramount health care issue of our time. Our proposed innovations would not only improve the efficient delivery of health care but more importantly the quality of care provided to all Canadians. These innovation initiatives require medical leadership at the point of care level in tandem with change at the broader system level with federal support. Together, these innovations can further contribute to the transformation of Canada's health care system-one that better meets the needs of Canadians today and into the future.
i Canadian Institute for Health Information. Alternate level of care in Canada. Ottawa (ON): The Institute; 2009. Available: https://secure.cihi.ca/free_products/ALC_AIB_FINAL.pdf
ii Wait Time Alliance, Shedding light on Canadians' total wait for care. Report card on wait times in Canada. June 2012.
iii Telehealth Benefits and Adoption: Connecting People and Providers Across Canada. Praxia and Gartner. May, 30, 2011.
iv Canadian Hospice Palliative Care Association. 2014. Fact sheet: hospice palliative care in Canada. [Accessed 11 November 2014]. Available from http://www.chpca.net/media/330558/Fact_Sheet_HPC_in_Canada%20Spring%202014%20Final.pdf
v Canadian Institute for Health Information. Pan-Canadian forum on high users of health care-Summary report. The Institute: 2014.
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