Helping physicians care for patients
Aider les médecins à prendre soin des patients
Canada is a nation on the precipice of great change. This change will be driven primarily by the economic and social implications of the major demographic shift already underway. The added uncertainties of the global economy only emphasize the imperative for federal action and leadership.
In this brief, the Canadian Medical Association (CMA) is pleased to present four recommendations to the House of Commons Standing Committee on Finance for meaningful federal action in support of a national seniors strategy; these are essential measures to prepare for an aging population.
Canada's demographic and economic imperative
In 2011 the first of wave of the baby boomer generation turned 65 and Canada's seniors population stood at 5 million.1 By 2036, seniors will represent up to 25% of the population.2 The impacts of Canada's aging population on economic productivity are multi-faceted.
An obvious impact will be fewer workers and a smaller tax base. Finance Canada projects that the number of working-age Canadians for every senior will fall from about 5 today to 2.7 by 2030.3
The projected surge in demand for services for seniors that will coincide with slower economic growth and lower government revenue will add pressure to the budgets of provincial and territorial governments. Consider that while seniors account for about one-sixth of the population, they consume approximately half of public health spending.4 Based on current trends and approaches, seniors' care is forecast to consume almost 62% of provincial/territorial health budgets by 2036.5
The latest fiscal sustainability report of the Parliamentary Budget Officer explains that the demands of Canada's aging population will result in "steadily deteriorating finances" for the provinces and territories and they "cannot meet the challenges of population ageing under current policy."6
Theme 1: Productivity
A) New federal funding to provincial/territorial governments
Canada's provincial and territorial leaders are aware of the challenges ahead. This July, the premiers issued a statement calling for the federal government to increase the Canada Health Transfer to 25% of provincial and territorial health care costs to address the needs of an aging population.
To support the innovation and transformation needed to address these needs, the CMA recommends that the federal government deliver additional funding on an annual basis beginning in 2016-17 to the provinces and territories by means of a demographic-based top-up to the Canada Health Transfer (Table 1). For the fiscal year 2016-17, this top-up would require $1.6 billion in federal investment.
Table 1: Allocation of the federal demographic-based top-up, 2016-20 ($million)7
All of Canada
Newfoundland and Labrador
Prince Edward Island
B) Federal support for catastrophic drug coverage
A major gap in Canada's universal health care system is the lack of universal access to prescription medications, long recognized as the unfinished business of medicare. Canada stands out as the only country with universal health care without universal pharmaceutical coverage.8
According to the Angus Reid Institute, more than one in five Canadians (23%) report that they or someone in their household did not take medication as prescribed because of the cost during the past 12 months.9 Statistics Canada's Survey of Household Spending reveals that households headed by a senior spend $724 per year on prescription medications, the highest among all age groups and over 60% more than the average household.10 Another recent study found that 7% of Canadian seniors reported skipping medication or not filling a prescription because of the cost.11
In addition to the very real harms to individuals, lack of coverage contributes to the inefficient use of Canada's scarce health resources. While there are sparse economic data in Canada on this issue, earlier research indicated that this inefficiency, which includes preventable hospital visits and admissions, represents an added cost of between $1 billion and $9 billion annually.12
As an immediate measure to support the health of Canadians and the productivity of the health care sector, the CMA recommends that the federal government establish a new funding program for catastrophic coverage of prescription medication. The program would cover prescription medication costs above $1,500 or 3% of gross household income on an annual basis. Research commissioned by the CMA estimates this would cost $1.48 billion in 2016-17 (Table 2). This would be a positive step toward comprehensive, universal prescription drug coverage.
Table 2: Projected cost of federal contribution to cover catastrophic prescription medication costs, by age cohort, 2016-2020 ($ million)13
Share of total cost
Under 35 years
35 to 44 years
45 to 54 years
55 to 64 years
65 to 74 years
75 years +
Theme 2: Infrastructure and communities
All jurisdictions across Canada are facing shortages in the continuing care sector. Despite the increased availability of home care, research commissioned for the CMA indicates that demand for continuing care facilities will surge as the demographic shift progresses.14
In 2012, it was reported that wait times for access to a long-term care facility in Canada ranged from 27 to over 230 days. It is estimated that 85% of "alternate level of care" patients in hospitals (i.e., patients who do not require hospital-level care) are in these beds because of the lack of availability of long-term care. Due to the significant difference in the cost of hospital care (approximately $846 per day) versus long-term care ($126 per day), the CMA estimates that the shortages in the long-term care sector represent an increased cost of $2.3 billion.
Despite the recognized need for infrastructure investment in the continuing care sector, to date, this sector has been excluded from the Building Canada Plan. The CMA recommends that the federal government amend the criteria of the Building Canada Plan to include capital investment in continuing care infrastructure, including retrofit and renovation. Based on previous estimates, the CMA recommends that $540 million be allocated for 2016-17 (Table 3).
Table 3: Estimated cost to address forecasted shortage in long-term care beds, 2016-20 ($ million)15
Forecasted shortage in long-term care beds
Estimated cost to address shortage
Federal share to address shortage in long-term care beds (based on 1/3 contribution)
Theme 3: Jobs
As previously mentioned, Canada's aging population will produce significant changes in the labour force. There will be fewer Canadian workers, each with a greater likelihood of having caregiving responsibilities for family and friends.
According to the report of the federal Employer Panel for Caregivers, Canadian employers "were surprised and concerned that it already affects 35% of the Canadian workforce."16 This report highlights key findings of the 2012 General Social Survey: 1.6 million caregivers took leave from work; nearly 600,000 reduced their work hours; 160,000 turned down paid employment; and, 390,000 quit their jobs to provide care. It is estimated that informal caregiving represents $1.3 billion in lost workforce productivity. These costs will only increase as Canada's demographic shift progresses.
In parallel to the increasing informal caregiving demands on Canadian workers, Canada's aging population will also increase the demand for personal care workers and geriatric competencies across all health and social care professions.17
Theme 4: Taxation
The above section focused on the economic costs of caregiving on the workforce. The focus of this section will be on the economic value caregivers provide while they take on an increased economic burden.
Statistics Canada's latest research indicates that 8.1 million Canadians are informal caregivers, 39% of whom primarily care for a parent.18 The Conference Board of Canada reports that in 2007 informal caregivers contributed over 1.5 billion hours of home care - more than 10 times the number of paid hours in the same year.19 The economic contribution of informal caregivers was estimated to be about $25 billion in 2009.20 This same study estimated that informal caregivers incurred over $80 million in out-of-pocket expenses related to caregiving in 2009.
Despite their tremendous value and important role, only a small fraction of caregivers caring for a parent received any form of government support.21 Only 5% of caregivers providing care to parents reported receiving financial assistance while 28% reported needing more assistance than they received.22
As a first step to providing increased support for Canada's family caregivers, the CMA recommends that the federal government amend the Caregiver and Family Caregiver Tax Credits to make them refundable. This would provide an increased amount of financial support for family caregivers. It is estimated that this measure will cost $90.8 million in 2016-17.23
The CMA recognizes that in the face of ongoing economic uncertainty the federal government may face pressures to avoid new spending initiatives. The CMA strongly encourages the federal government to adopt the four recommendations outlined in this submission rather than further delay making a meaningful contribution to meeting the future care needs of Canada's aging population. The CMA would welcome the opportunity to provide further information and its rationale for each recommendation.
1 Statistics Canada. Generations in Canada. Cat. No. 98-311-X2011003. Ottawa: Statistics Canada; 2012. Available: www12.statcan.gc.ca/census-recensement/2011/as-sa/98-311-x/98-311-x2011003_2-eng.pdf
2 Statistics Canada. Canada year book 2012, seniors. Available: www.statcan.gc.ca/pub/11-402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm
3 Finance Canada. Economic and fiscal implications of Canada's aging population. Ottawa: Finance Canada; 2012. Available: www.fin.gc.ca/pub/eficap-rebvpc/eficap-rebvpc-eng.pdf
4 Canadian Institute for Health Information. National health expenditure trends, 1975 to 2014. Ottawa: The Institute; 2014. Available: www.cihi.ca/web/resource/en/nhex_2014_report_en.pdf
5 Calculation by the Canadian Medical Association, based on Statistics Canada's M1 population projection and the Canadian Institute for Health Information age-sex profile of provincial-territorial health spending.
6 Office of the Parliamentary Budget Officer. Fiscal sustainability report 2015. Ottawa: The Office; 2015. Available: www.pbo-dpb.gc.ca/files/files/FSR_2015_EN.pdf
7 Conference Board of Canada. Research commissioned for the CMA, July 2015.
8 Morgan SG, Martin D, Gagnon MA, Mintzes B, Daw JR, Lexchin J. Pharmacare 2020: The future of drug coverage in Canada. Vancouver: Pharmaceutical Policy Research Collaboration, University of British Columbia; 2015. Available: http://pharmacare2020.ca/assets/pdf/The_Future_of_Drug_Coverage_in_Canada.pdf
9 Angus Reid Institute. Prescription drug access and affordability an issue for nearly a quarter of Canadian households. Available: http://angusreid.org/wp-content/uploads/2015/07/2015.07.09-Pharma.pdf
10 Statistics Canada. Survey of household spending. Ottawa: Statistics Canada; 2013.
11 Canadian Institute for Health Information. How Canada compares: results From The Commonwealth Fund 2014 International Health Policy Survey of Older Adults. Available: www.cihi.ca/en/health-system-performance/performance-reporting/international/commonwealth-survey-2014
12 British Columbia Pharmacy Association. Clinical service proposal: medication adherence services. Vancouver: The Association; 2013. Available: www.bcpharmacy.ca/uploads/Medication_Adherence.pdf
13 Supra at note 7.
14 Conference Board of Canada. Research commissioned for the CMA, January 2013.
16 Government of Canada. Report from the Employer Panel for Caregivers: when work and caregiving collide, how employers can support their employees who are caregivers. Available: www.esdc.gc.ca/eng/seniors/reports/cec.shtml
17 Stall S, Cummings G, Sullivan T. Caring for Canada's seniors will take our entire health care workforce. Available: http://healthydebate.ca/2013/09/topic/community-long-term-care/non-md-geriatrics
18 Statistics Canada. Family caregivers: What are the consequences? Available: www.statcan.gc.ca/pub/75-006-x/2013001/article/11858-eng.htm
19 Conference Board of Canada. Home and community care in Canada: an economic footprint. Ottawa: The Board; 2012. Available: http://www.conferenceboard.ca/cashc/research/2012/homecommunitycare.aspx
20 Hollander MJ, Liu G, Chappeel NL. Who cares and how much? The imputed economic contribution to the Canadian health care system of middle aged and older unpaid caregivers providing care to the elderly. Healthc Q. 2009;12(2):42-59.
21 Supra at note 16.
23 Supra at note 7.
The Canadian Medical Association (CMA) is pleased to present this brief to the House of Commons Standing Committee on Finance regarding Bill C-462 Disability Tax Credit Promoters Restrictions Act.
The Canadian Medical Association represents 78,000 physicians in Canada; its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care.
The CMA is pleased that the House of Commons has made Bill C-462 a priority. This bill is an important step toward addressing the unintended consequences that have emerged from the Disability Tax Credit since 2005.
Part 2: Issues to be addressed
In 2005, the Disability Tax Credit was expanded to allow individuals to back-file for up to 10 years. While this was a welcome tax measure for individuals with disabilities, the CMA has been urging the Canada Revenue Agency to address the numerous unintended consequences that have emerged. Central among these has been the emergence of a “cottage industry” of third-party companies engaged in a number of over-reaching tactics. The practices of these companies have included aggressive promotional activities to seek and encourage individuals to file the Disability Tax Credit. The primary driver behind these tactics is profit; some companies are charging fees of up to 40 per cent of an individual’s refund when the tax credit is approved.
Further to targeting a vulnerable population, these activities have yielded an increase in the quantity of Disability Tax Credit forms in physician offices and contributed to red tape in the health sector. In some cases, third parties have placed physicians in an adversarial position with their patients. We are pleased that this bill attempts to address the concerns we have raised.
The CMA supports Bill C-462 as a necessary measure to address the issues that have emerged since the changes to the Disability Tax Credit in 2005. However, to avoid additional unintended consequences, the CMA recommends that the Finance Committee address three issues prior to advancing Bill C-462.
First, as currently written, Bill C-462 proposes to apply the same requirements to physicians as to third-party companies if physicians apply a fee for form completion, a typical practice for uninsured physician services. Such fees are subject to guidelines and oversight by provincial and territorial medical regulatory colleges (see Appendix 1: CMA Policy on Third Party Forms: The Physician Role).
The CMA recommends that the Finance Committee:
Amend the definition of “promoters” under section 2 to exclude “a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment.”
. If the committee imports the term “person” from the Income Tax Act, then the applicable section of Bill C-462 should be amended to specify that, for the purposes of the act, “Person does not include a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment.”
Second, the CMA is concerned that one of the reasons individuals may be engaging the services of third-party companies is a lack of awareness of the purpose and benefits of the Disability Tax Credit. Additional efforts are required to ensure that the Disability Tax Credit form (Form T2201) be more informative and user-friendly for patients. Form T2201 should explain more clearly to patients the reason behind the tax credit, and explicitly indicate there is no need to use third-party companies to submit the claim to the CRA.
The CMA recommends that the Finance Committee:
. Recommend that the Canada Revenue Agency undertake additional efforts to ensure that the Disability Tax Credit form is more informative, accessible and user-friendly for patients.
Finally, the CMA recommends that a privacy assessment be undertaken before the bill moves forward in the legislative process. It appears that, as written, Bill C-462 would authorize the inter-departmental sharing of personal information. The CMA raises this issue for consideration because protecting the privacy of patient information is a key duty of a physician under the CMA Code of Ethics.
Part 3: Closing
The CMA encourages the Finance Committee to address these issues to ensure that Bill C-462 resolves existing problems with the Disability Tax Credit while not introducing new ones. The CMA appreciates the opportunity to provide input to the Finance Committee’s study of this bill and, with the amendments outlined herein, supports its passage.
Summary of Recommendations
The definition of “promoters” under section 2 of Bill C-462 should be amended to exclude “a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment.”
If the Committee imports the definition of “persons” from the Income Tax Act, the applicable section of Bill C-462 should be amended to specify that, for the purposes of the act, “Person does not include a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment.”
The Canada Revenue Agency should undertake additional efforts to ensure that the Disability Tax Credit form is informative, accessible and user-friendly.
Prior to advancing in the legislative process, Bill C-462 should undergo a privacy assessment.
Re: Future Mandate of the Health Care Innovation Working Group (the Council of the Federation)
On behalf of the Canadian Nurses Association (CNA) and the Canadian Medical Association (CMA), I am writing in advance of the meeting of the Council of the Federation later this month regarding the future mandate of the Health Care Innovation Working Group with respect to seniors care.
The CNA and CMA welcomed the Council of the Federation's prioritization of seniors care as an area of focus of the Health Care Innovation Working Group. Already, seniors and their families in communities across Canada face significant challenges accessing social supports and health services. These challenges will only intensify as the demographic shift progresses. Based on current trends and approaches, the proportion of provincial/territorial health spending associated with seniors care is forecast to grow by over 15% to almost 62% of health budgets by 2036.
Recognizing the significant pressure this will present for health care systems and provincial/territorial budgets moving forward, it is critical that the Council of the Federation maintain its prioritization of seniors care and meeting the needs of an aging population. As such, we respectfully encourage you in your capacity as Co-Chairs of the Health Care Innovation Working Group to ensure the future mandate of the working group on seniors care be included as part of the agenda at the January 30, 2015 meeting of the Council of the Federation.
The CNA and CMA are actively engaged on this issue and welcome the opportunity to meet with each of you to discuss how we may collaborate to ensure improved health outcomes for seniors, now and in the future.
Christopher S. Simpson, MD, FRCPC, FACC, FHRS
Karima Velji, RN, PhD, CHE
The Canadian Medical Association (CMA) welcomes the opportunity to appear before the Sub-Committee on the Status of Persons with Disabilities to discuss issues related to the Disability Tax Credit (DTC). This tax measure, which is recognition by the federal government that persons with a severe disability may be affected by having reduced incomes, increased expenses or both, compared to those who are not disabled i, helps to account for the intangible costs associated with a severe and prolonged impairment. It also takes into account disability-related expenses that are not listed in the medical expense deduction or which are excluded by the 3% threshold in the Medical Expense Tax Credit.
Physicians are a key point of contact for applicants of the DTC and, given the way the program is structured, a vital participant in its administration. It is for these reasons that we come before you today to address specific concerns related to the program’s performance. In addition, we would like to discuss the broader issue of developing a coherent set of tax policies in support of health and social policy.
The Integration of Tax Policy with Health Policy and Social Policy
The federal government, through a variety of policy levers such as taxation, spending, regulation and information, has played a key role in the development of our health care and social systems. To date however, discussion about the federal role in these areas has centered largely on federal transfers to the provinces and territories and the Canada Health Act.
However, in looking at how to renew Canada’s health and social programs, we should not limit ourselves to these traditional instruments. Today we have a health system that is facing a number of pressures that will challenge its sustainability. These pressures range from an aging and more demanding population in terms of the specialty care services and technology they will seek; the cry for expanding the scope of medicare coverage to include homecare and pharmacare; and a shortage of health personnel. These are only some of the more immediate reasons alternative avenues of funding health care, and thus ensuring the health and well-being of our citizens, must be explored.
In our pre-budget consultation document to the Standing Committee on Finance ii, the CMA recommended that the federal government establish a blue ribbon National Task Force to study the development of innovative tax-based mechanisms to synchronize tax policy with health policy. Such a review has not been undertaken in over 25 years since the Royal Commission on Taxation in 1966 (Carter Commission).
The CMA is echoing its call for a National Task Force to develop new and innovative ways to synchronize tax policy with health policy and social policy. A study of this nature would look at all aspects of the taxation system, including the personal income tax system, in which the DTC is a component.
The remainder of our brief addresses issues specific to the DTC.
Physician Involvement in the DTC Program
The CMA has in the past provided input with respect to the DTC program. Our working relationship on the DTC program with the Canada Customs and Revenue Agency (CCRA) has been issue-specific, time-limited and constructive.
Our first substantive contact in regard to the DTC program was in 1993 when the CMA provided Revenue Canada with a brief review of the program and the T2201form. It is interesting to note what our observations were in 1993 with regard to this program because many of them still hold true today.
Here are just some of the issues raised by the CMA in 1993 during our initial review of the program:
* The tax credit program may not address the needs of the disabled, it is too hit and miss. The DTC program should be evaluated in a comprehensive way to measure its overall effectiveness in meeting the needs of persons with disabilities.
* The program should be called the “Severe Disability Tax Credit Program” – or something equivalent to indicate that not everyone with a disability is eligible.
* The program puts physicians in a potential conflict with patients—the responsibility of the physician to advocate for the patient vs. gate-keeper need for Revenue Canada. The physician role should be to attest to legitimate claims on the patients’ behalf.
* Revenue Canada should clarify the multiplicity of programs. There are numerous different federal programs and all appear to have varying processes and forms. These overlapping efforts are difficult for patients and professionals.
* A major education effort for potential claimants, tax advisers and physicians should be introduced.
* A suitable evaluation of claimant and medical components of the process should be undertaken.
The CMA does not have a standardized consultative relationship with the CCRA in regard to this program. An example of this spotty relationship is the recent letter sent by the CCRA Minister asking current DTC recipients to re-qualify for the credit. The CMA was not advised or consulted about this letter. If we had been advised we would have highlighted the financial and time implications of sending 75 to 100 thousand individuals to their family physician for re-certification. We also would have worked with the CCRA on alternative options for updating DTC records. Unfortunately, we cannot change what has happened, but we can learn from it. This clearly speaks to the need to establish open and ongoing dialogue between our two organizations.
Policy Measure: The CMA would like established a senior level advisory group to continually monitor and appraise the performance of the DTC program to ensure it is meeting its stated purpose and objectives. Representation on this advisory group would include, at a minimum, senior program officials preferably at the ADM level; those professional groups qualified to complete the T2201 Certificate; various disability organizations; and patients’ advocacy groups.
We would now like to draw the Sub-committee’s attention to three areas that, at present, negatively impact on the medical profession participation in the program, namely program integrity, program standardization (e.g., consistency in terminology and out-of-pocket costs faced by persons with disabilities) and tax advisor referrals to health care providers.
A primary concern and irritation for physicians working with this program is that it puts an undue strain on the patient-physician relationship. This strain may also have another possible side effect, a failure in the integrity of the DTC program process.
Under the current structure of the DTC program, physicians evaluate the patient, provide this evaluation back to the patient and then ask the patient for remuneration. This process is problematic for two reasons. First, since the patient will receive the form back immediately following the evaluation, physicians might receive the blame for denying their patient the tax credit—not the DTC program adjudicators. Second, physicians do not feel comfortable asking for payment when he or she knows the applicant will not qualify for the tax credit.
For the integrity of the DTC program, physicians need to be free to reach independent assessment of the patient’s condition. However, due to the pressure placed by this program on the patient-physician relationship, the physician’s moral and legal obligation to provide an objective assessment may conflict with the physician’s ethical duty to “Consider first the well-being of the patient.
There is a solution to this problem it’s a model already in use by government, the Canadian Pension Plan (CPP) Disability Program. Under the CPP Disability Program, the evaluation from the physician is not given to the patient but, it is sent to the government and the cost to have the eligibility form completed by a physician is subsumed under the program itself. Under this system, the integrity of patient-physician relationship is maintained and the integrity of the program is not compromised.
Policy Measure: The CMA recommends that the CCRA take the necessary steps to separate the evaluation process from the determination process. The CMA recommends the CPP Disability Program model to achieve this result.
Fairness and Equity
The federal government has several programs for people with disabilities. Some deal with income security (e.g., Canada Pension Plan Disability Benefits), some with employment issues (e.g., Employability Assistance for People with Disabilities), and some through tax measures (e.g., Disability Tax Credit). These government transfers and tax benefits help to provide the means for persons with disabilities to become active members in Canadian society.
However, these programs are not consistent in terms of their terminology, eligibility criteria, reimbursement protocols, benefits, etc. CMA recommends that standards of fairness and equity be applied across federal disability benefit programs, particularly in two areas: the definition of the concept of “disability”, and standards for remuneration to the physician. These are discussed in greater detail below.
1) Defining “disability”
One of the problems with assessing disability is that the concept itself is difficult to define. In most standard definitions the word “disability” is defined in very general and subjective terms. One widely used definition comes from the World Health Organization’s International Classification of Impairments, Disabilities and Handicaps (ICIDH) which defines disability as “any restriction or inability (resulting from an impairment) to perform an activity in the manner or within the range considered normal for a human being.”
The DTC and other disability program application forms do not use a standard definition of “disability”. In addition to the inconsistency in terminology, the criteria for qualification for these programs differ because they are targeted to meet the different needs of those persons with disabilities. To qualify for DTC, a disability must be “prolonged” (over a period of at least 12 months) and “severe” i.e. “markedly (restrict) any of the basic activities of daily living” which are defined. Though CPP criteria use the same words “severe” and “prolonged” they are defined differently (i.e., “severe” means “prevents applicant from working regularly at any job” and “prolonged” means “long term or may result in death”). Other programs, such as the Veterans Affairs Canada, have entirely different criteria.
This is confusing for physicians, patients and others (e.g., tax preparers/advisors) involved in the application process. This can lead to physicians spending more time than is necessary completing the form because of the need to verify terms. As a result if the terms, criteria and the information about the programs are not as clear as possible this could result in errors on the part of physicians when completing the forms. This could then inadvertently disadvantage those who, in fact, qualify for benefits.
Policy Measures: The CMA would like to see some consistency in definitions across the various government programs. This does not mean that eligibility criteria must become uniform.
In addition, the CMA would like to see the development of a comprehensive information package for health care providers that provides a description of each program, its eligibility criteria, the full range of benefits available, copies of sample forms, physical assessment and form completion payment information, etc.
The remuneration for assessment and form completion is another area where standardization among the various government programs would eliminate the difficulties that some individuals with disabilities currently face. For example, applicants who present the DTC Certificate Form T2201 to their physicians must bear any costs associated with its completion out of their own pockets. On the other hand, if an individual is applying to the CPP Disability Program, the cost to have the eligibility form completed by a physician is subsumed under the program itself.
Assessing a patient’s disabilities is a complex and time-consuming endeavour on the part of any health professional. Our members tell us that the DTC Certificate Form T2201 can take as much time and effort to complete as the information requested for CPP Disability Program forms depending, of course, on the patient and the nature of the disability. In spite of this fact, some programs acknowledge the time and expertise needed to conduct a proper assessment while other programs do not.
Although physicians have the option of approaching the applicant for remuneration for the completion of the DTC form, they are reluctant to do so because these individuals are usually of limited means and in very complex cases, the cost for a physician’s time for completing the DTC Form T2201 can reach as much as $150. In addition, physicians do not feel comfortable asking for payment when he/she knows the applicant will not qualify for the tax credit. Synchronizing funding between all programs would be of substantial benefit to all persons with disabilities, those professionals completing the forms and the programs’ administrators.
Policy Measure: We strongly urge the federal government to place disability tax credit programs on the same footing when it comes to reimbursement of the examining health care provider.
Tax Advisor Referrals
With the complexity of the income tax system today, many individuals seek out the assistance of professional tax advisors to ensure the forms are properly completed and they have received all the benefits they are entitled to. Tax advisors will very often refer individuals to health professionals so that they can be assessed for potential eligibility for the DTC. The intention of the tax advisors may be laudable, but often, inappropriate referrals are made to health professionals. This not only wastes the valuable time of health care professionals, already in short supply, but may create unrealistic expectations on the part of the patient seeking the tax credit.
The first principle of the CMA’s Code of Ethics is “consider first the well-being of the patient.” One of the key roles of the physician is to act as a patient’s advocate and support within the health care system. The DTC application form makes the physician a mediator between the patient and a third party with whom the patient is applying for financial support.
This “policing” role can place a strain on the physician-patient relationship – particularly if the patient is denied a disability tax credit as a result a third-party adjudicator’s interpretation of the physician’s recommendations contained within the medical report. Physicians and other health professionals are not only left with having to tell the patient that they are not eligible but in addition advising the patient that there may be a personal financial cost for the physician providing this assessment.
Policy Measure: Better preparation of tax advisors would be a benefit to both patients and their health care providers. The CMA would like CCRA to develop, in co-operation with the community of health care providers, a detailed guide for tax preparers and their clients outlining program eligibility criteria and preliminary steps towards undertaking a personal assessment of disability. This would provide some guidance as to whether it is worth the time, effort and expense to see a health professional for a professional assessment.
As raised in a previous meeting with CCRA, the CMA is once again making available a physician representative to accompany DTC representatives when they meet the various tax preparation agencies, prior to each tax season, to review the detailed guide on program eligibility criteria and initial assessment, and to highlight the implications of inappropriate referral.
The DTC is a deserving benefit to those Canadians living with a disability. However, there needs to be some standardization among the various programs to ensure that they are effective and meet their stated purpose. Namely, the CMA would like to make the following suggestions:
1. The CMA would like established a senior level advisory group to continually monitor and appraise the performance of the DTC program to ensure it is meeting its stated purpose and objectives. Representation on this advisory group would include, at a minimum, senior program officials preferably at the ADM level; those professional groups qualified to complete the T2201 Certificate; various disability organizations; and patient advocacy groups.
2. The CMA recommends that the CCRA take the necessary steps to separate the evaluation process from the determination process. The CMA recommends the CPP Disability Program model to achieve this result.
3. That there be some consistency in definitions across the various government programs. This does not circumvent differences in eligibility criteria.
4. That a comprehensive information package be developed, for health care providers, that provides a description of each program, its eligibility criteria, the full range of benefits available, copies of sample forms, physical assessment and form completion payment information, etc.
5. That the federal government applies these social programs on the same footing when it comes to their funding and administration.
6. That CCRA develop, in co-operation with the community of health care providers, a detailed guide for tax advisors and their clients outlining program eligibility criteria and preliminary steps towards undertaking a personal assessment of disability.
7. That CCRA employ health care providers to accompany CCRA representatives when they meet the various tax preparation agencies to review the detailed guide on program eligibility criteria and personal assessment of disability, and to highlight the implications of inappropriate referral.
These recommendations would certainly be helpful to all involved - the patient, health care providers and the programs’ administrators, in the short term. However what would be truly beneficial in the longer term would be an overall review of the taxation system from a health care perspective. This could provide tangible benefits not only for persons with disabilities but for all Canadians as well as demonstrating the federal government’s leadership towards ensuring the health and well being of our population.
i Health Canada, The Role for the Tax System in Advancing the Health Agenda, Applied Research and Analysis Directorate, Analysis and Connectivity Branch, September 21, 2001
ii Canadian Medical Association, Securing Our Future… Balancing Urgent Health Care Needs of Today With The Important Challenges of Tomorrow”, Presentation to the Standing Committee on Finance Pre-Budget Consultations, November 1, 2001.
The Canadian Medical Association (CMA) would like to thank the Standing Senate Committee on Social Affairs, Science and Technology for the opportunity to provide our views on the causes and consequences of obesity in Canada, and our recommendations for a way forward.
Canada’s physicians have repeatedly expressed their concern about the increasing prevalence of obesity and overweight in this country. Over the past ten years, responding to these expressions of concern, the CMA has developed a number of policy statements, briefs to government, and discussion papers on the issue, which articulate our recommendations for addressing this serious problem. In this brief, we will focus our recommendations on two remedies that we believe should be part of the way forward: the implementation of public policy that supports Canadians in making healthy food choices; and the provision of reliable, user-friendly information to health professionals and to the public.
2) Obesity in Canada: Causes and Consequences
More than half (62%) of Canadian adults are overweight according to the 2013 Canadian Health Measures Survey. A quarter of Canadian adults can be classed as obese (BMI = 30); this is double the obesity rate in 1979.1 The rise in obesity is most pronounced among Canada’s heaviest people; since 1985, the prevalence of extreme obesity (BMI=40) rose from 0.3% to 1.6%, a more than five-fold increase.2 One in ten Canadian children is obese;3 obesity in children and youth has more than doubled since the late 1970s. Prevalence of overweight and obesity is higher among some segments of the Canadian population, particularly Aboriginal peoples and people of lower socio-economic status.
1 Statistics Canada. Body composition of adults, 2012 to 2013. Accessed at http://www.statcan.gc.ca/pub/82-625-x/2014001/article/14104-eng.htm. This survey used actual measurement which is considered more accurate than self-report.
2 Twells LK, Gregory DM, Reddigan J, Midodzi WK. Current and predicted prevalence of obesity in Canada: a trend analysis. CMAJ Open, March 3, 2014. Accessed at http://cmajopen.ca/content/2/1/E18.full
3 Statistics Canada. Body mass index of children and youth, 2012 to 2013. Accessed at http://www.statcan.gc.ca/pub/82-625-x/2014001/article/14105-eng.htm
4 Canadian Diabetes Association. http://www.diabetes.ca/diabetes-and-you/kids-teens-diabetes/children-type-2-diabetes
Obesity is of particular concern to Canada’s physicians because it increases a person’s risk of developing a number of serious health problems: high blood pressure, high blood cholesterol, heart disease and stroke, type 2 diabetes, osteoarthritis, lower back pain and other musculoskeletal disorders, and many types of cancer. Type 2 diabetes, once found only in adults, is now being seen in children4. Health advocates are concerned that because of obesity, today’s generation of children will have a shorter life expectancy than their parents.
In addition to poor physical health, obese people are at greater risk than people with normal weights of suffering from mental health problems such as low self-esteem, depression and anxiety. The stigma attached to obesity is high; obese people are at high risk of being bullied, ostracized socially, and discriminated against in the workplace. Some turn to food to relieve stress or as an escape from their unhappy lives, thereby perpetuating a vicious cycle of unhealthy eating and poor mental health.5
5 Canadian Obesity Network. Obesity and mental illness: addressing a double epidemic. Accessed at http://www.obesitynetwork.ca/de.aspx?id=322
6 Public Health Agency of Canada. Obesity in Canada: Health and economic implications. Accessed at http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/oic-oac/econo-eng.php
7 From the CMA background paper on processed food and health. Original citation: Cohen D a. Obesity and the built environment: changes in environmental cues cause energy imbalances. Int J Obes (Lond). 2008;32 Suppl 7:S137–42. doi:10.1038/ijo.2008.250.
The Public Health Agency of Canada estimates that obesity-related health conditions cost Canada $4.6 billion dollars in 2008, both in direct costs (such as hospitals and health professional services) and indirect ones (e.g. disability claims, psychological damage and lost productivity).6 Other estimates have been even higher.
The causes of obesity are multifarious and highly complex. There is no one, simple cause. In some cases human biology is responsible, because certain people have a genetic predisposition toward gaining weight. But for the most part, obesity can be attributed to environmental circumstances that contribute to Canadians consuming more calories than they burn through physical activity. These circumstances include:
. The widespread consumption of pre-packaged and processed foods. In the US it is estimated that the percentage of food spending that goes toward foods prepared away from home went up from 24% in 1966 to 42% in 2006.7 Processed foods are more likely than fresh foods to be high in trans fats, sodium, sugar and other ingredients that are risk factors for obesity-related diseases. They are available widely, in fast-food outlets, grocery stores and vending machines, and their manufacturers often promote them heavily. In addition, they are generally lower in price than fresh fruits, vegetables or meats, which may be beyond the means of many low-income Canadians.
. Change in physical activity patterns. Many adults spend their days at sedentary desk jobs, and if they engage in physical activity, they often devote specific time to it (say, an hour at the gym) rather than incorporating it into their daily lives. Where children might once have gone outdoors to play after school, today they are more likely to sit in front of a computer or television set.
The conventional wisdom about addressing obesity is that it is the individual’s responsibility to lose weight through diet and exercise, and to keep it off. However, achieving and maintaining a healthy weight is a complex process, and can be frustratingly hard to manage. For many Canadians, obesity is a lifelong condition, and the environmental conditions discussed above
discourage healthy behaviour. Despite an abundance of diet information and advice (of varying quality and accuracy), most people who lose weight eventually put it on again. Pharmaceutical weight loss drugs are available but are not always recommended because of their side effects8. More aggressive treatments such as surgery are recommended mainly for severely obese people with health complications.
8 Canadian Task Force on Preventive Health Care. Recommendations for prevention of weight gain and use of behavioural and pharmacologic interventions to manage overweight and obesity in adults in primary care. CMAJ 187:3 (February 17, 2015): 184-195.
3) The Way Forward
Just as obesity sparks challenges in our populations and has no single cause, so there is no single way forward that will fully address it. CMA believes that the way forward actually involves a number of separate paths moving in the same direction. Two of these paths are discussed in the following sections.
a) Implementing Public Policy That Helps Canadians Make Healthy Food Choices
Public policy can be a powerful tool to help reduce risks to public health. In the case of tobacco control, measures such as bans on tobacco advertising and on smoking in public places contributed to the decline in smoking in Canada by making it easier for individuals to choose to be smoke-free. In the same way, CMA believes the federal government should implement policies and regulations to help create a supportive environment for people wanting to achieve and maintain a healthy weight. In particular, CMA recommends that the Committee give consideration to the following measures:
i) Improving Access to healthy food
Recommendation: that the Government of Canada support community-based initiatives aimed at reducing Canadians’ barriers to accessing healthy, nutritious food.
If Canadians are to be encouraged to make healthy food choices, then healthy foods should be readily available to them at affordable prices. Unfortunately, for many Canadians, this is not the case. In some neighborhoods, often lower-income neighbourhoods, fast food outlets outnumber grocery stores. Many variety stores, restaurants, schools and workplace cafeterias offer a larger selection of processed foods than of fresh fruits, vegetables and meat.
For some Canadians, financial barriers limit their capacity to make healthy individual choices. As a rule, fresh food tends to be more expensive than processed “fast food”. The difficulty is
compounded in Canada’s remoter areas and in the North, where fresh produce must be transported from far away, and what little is available is very high priced.
Programs to improve access to healthy food exist at all levels of government. The federal Northern Food Program, designed to offset the cost of transporting fresh food to remote areas, has been in existence for several years, though it has been criticized as ineffective9. At the community level, not-for-profit and municipal agencies have collaborated on programs such as the Good Food Markets in Ottawa, which offer fresh, affordable foods in low-income areas.10
9 Woo A. “Critics slam Canada’s northern food program.” The Globe and Mail, November 4, 2014. Accessed at http://www.theglobeandmail.com/news/critics-slam-canadas-northern-food-program/article21451386/
10 Canadian Public Health Association. “Ottawa Public Health partners with community Groups to Increase access to healthy foods.” Accessed at http://www.cpha.ca/en/programs/social-determinants/frontlinehealth/stories/ottawa.aspx
11 “Restricting Marketing of Unhealthy Foods and Beverages to Children and Youth in Canada” a policy paper endorsed by CMA and other health and scientific organizations.
Other measures to improve access to healthy food could include: ensuring that every Canadian is within reach of a grocery store; regulating the number and location of fast-food outlets; and increasing the availability of nutritious foods and restricting that of processed foods in workplaces, schools and recreational facilities.
ii) Controls on Marketing of Processed Foods.
Industry marketing of fast food and processed food, including beverages, is ubiquitous – in television, on the radio, on the Internet, and at point-of-purchase displays and event sponsorships. Unfortunately, many of the advertised foods are high in calories and low in nutrients. Food advertising is aimed at Canadians of all ages, but children, particularly those under the age of 13, have been found to be especially vulnerable to it. Research has shown that the advertising of food and beverages to children influences their food and beverage preferences, purchase requests and consumption patterns.11
At present, Canada relies on voluntary industry codes to govern advertising and marketing practices. However, health groups are skeptical of the effectiveness of such codes, and of manufacturers’ commitment to them. The CMA believes that for maximum efficacy, regulatory measures are required to minimize the negative effect of food marketing on health.
Recommendation: That governments ban the advertising and promotion of high-calorie, nutrient poor foods to children 13 years of age or younger.
Food advertisements often include claims as to the product’s nutrition content and health benefits. Unfortunately, such advertising may be misleading; a product labelled “lower fat” may
still have a relatively high fat content, or contain high levels of other potentially unhealthy ingredients such as sugar and sodium. In general, brand-specific advertising is a less than optimal way to provide health information to consumers. Therefore, CMA believes that the federal government should review and regulate the health claims that manufacturers can make for their products, to ensure that these claims are based on the best available scientific evidence and that they are accurately communicated to consumers.
Recommendation: that the Government of Canada set rigorous standards for the advertising of health claims for food, and strengthen provisions against deceptive advertising in the Food and Drug Act.
iii) Enhancing Nutrition Labelling
Governments at all levels, as well as health organizations, currently provide a variety of programs, educational materials and guidelines to the public. The CMA encourages these initiatives and encourages all levels of government to continue to make overweight and obesity a public health education priority.
Food labels are an important means of health education, providing guidance to shoppers at the point of purchase to help them inform their food choices. Health Canada has made important contributions to public education, through a number of programs including its “Nutrition Facts” package labels. The labels are continually being revised and updated, as research reveals new information about nutrition and about effective means of conveying health messages to the public. As part of its revision process, CMA believes that Health Canada should consider enhancing health messages on the front as well as the back of food packages.
Recommendation: that the Government of Canada implement, and set rigorous standards for, front-of-package food labelling.
The CMA encourages the federal government to build upon the current package labelling system, making labels as user-friendly as possible and helping Canadians to interpret the information they provide. Colour-coded, brief-summary labels, such as the “red-light, green-light” system used in Britain, are intended to provide consumers with an “at a glance” assessment of a food’s nutritional value. While the system has its critics, it has the benefit of being easy to notice and interpret. The CMA has also recommended that food packages and retail displays contain warnings about the health risks associated with an excessive consumption of calorie-high, nutrient poor food and beverages.
b) Information and Support for Physicians and other Health Professionals
For many patients, obesity is a lifelong condition which, like other chronic health conditions, can be managed medically but rarely fully cured. Increasingly, it is being recognized that effective obesity management requires more than short-term weight loss diets; it involves identifying and addressing both the root causes of a patient’s weight gain (physical, psychological or socio-economic) and the barriers the patient experiences in maintaining healthy weight. 12 According to the Canadian Obesity Network, primary care interventions should be evaluated not by how many pounds the patient loses but by improvements in the patient’s health and well-being.
12 Canadian Obesity Network: 5As Guiding Principles. Accessed at http://www.obesitynetwork.ca/5As_core_principles
13 “Weight loss surgeries leap in Canada, study says.” CBC News, May 22, 2014. Accessed at http://www.cbc.ca/news/health/weight-loss-surgeries-leap-in-canada-study-says-1.2651066
Physicians, working with dietitians, nurses, physiotherapists, mental health care providers and other health professionals, have an important role in providing care and support to people who are trying to maintain a healthy weight. Physicians can provide nutrition advice to patients as part of the routine medical examination. In addition, since primary care physicians are generally the patient’s first point of contact with the health care system, they often see patients at “teachable moments” when, because of an associated health condition such as diabetes, they are motivated to change unhealthy behaviours. Physicians can also provide patients with resources to help them live healthy lives. For instance, in British Columbia, physicians are prescribing exercise on specially-designed prescription pads, distributing free pedometers, and hosting free walking events for their patients and the public. In the Edmonton area, Primary Care Networks are prescribing free access passes or a free month of access at local municipal recreation facilities.
The tertiary health care sector also has an important role to play in addressing obesity, since there is a growing number of severely obese patients who are at high risk of serious health problems and may require specialized treatment, possibly bariatric surgery. According to a study by the Canadian Institute for Health Information, the number of bariatric surgeries performed in Canada has jumped four-fold since 2006-07. The study notes that though the health care system has made great strides in meeting the demand,13 access to bariatric surgery varies from one region of Canada to another. Governments have an important role to play in ensuring equitable access to bariatric surgery for patients for whom it is clinically indicated.
Recommendation: That the federal government work with provincial/territorial governments and with researchers, medical educators and others to continually develop and disseminate up-to-date, evidence-based clinical knowledge and
practice tools, to help physicians and other health professionals manage overweight and obesity in their patients.
Clinical guidelines, based on the best current scientific evidence, are available to help health professionals work with their patients to achieve and maintain healthy weights. The Canadian Obesity Network has developed a “5As of Obesity Management” program for primary care. The Canadian Task Force on Preventive Health Care also develops and frequently updates recommendations for primary caregivers on how to manage overweight and obesity in practice. The Task Force’s most recent recommendations were published in the Canadian Medical Association Journal early in 2015. Clinical practice guidelines should be distributed widely and continually updated, and governments could play an important role in supporting the revision and dissemination process.
Thanks to ongoing research our knowledge of the extent and causes of obesity, and the effectiveness of existing programs in addressing it, is continually growing and developing. CMA encourages an ongoing commitment to research, and believes that the Government of Canada has an important role to play in supporting it. Results of this research should be communicated to health professionals and the public as quickly and widely as possible, so that it can be rapidly incorporated into clinical practice.
Recommendation: That the federal government support, and help to disseminate, evidence-based research on obesity in Canada and on the evaluation of strategies to address it.
Obesity and overweight are serious health problems in Canada, and as such are of great concern to the country’s physicians and to the Canadian Medical Association. The causes, CMA believes, are rooted mainly in changes in our environment and their effect on our eating and physical activity habits. The consequences are extremely serious, both for individual Canadians’ health and for the sustainability of Canada’s health care system.
CMA believes that the way forward requires a number of different interventions, on many levels. These should include providing and continually updating research and practice information for health professionals; and implementing policies that support Canadians as they pursue the goal of maintaining healthy weights.
Once again, CMA commends the Senate of Canada on conducting this study. We hope it will help encourage productive and meaningful change in the way Canadians view obesity, and assist in creating a social environment that supports healthy eating and healthy weight.