1. The Canadian Healthcare System Lecture 4 Tracey Lynn Koehlmoos, PhD, MHA HSCI 609 Comparative International Health Systems

2. Where are we?

3. Canada: Updated info. 2 nd largest country in the world—10 provinces, 2 territories Population: 31.5 million (2005) Life Expectancy: 78 m/ 82 f (2005) Population over 60: >17% All cause mortality: #1 Cancer, #2 CHD Healthcare 10.4% GDP (2005) $142 billion (Canadian) (2005) $2,931 (US) per capita health exp.

4. Health System Overview Medicare (started in 1968) Single-payer, universal coverage 12 separate provincial programs Funding: personal, sales, corporate taxes and federal transfer payments (<25%) Federal gov’t: only provides to special populations (military, native Canadians, federal prisoners), <2% pop.

5. Birth of a system 1966 National Medical Care Insurance Act Medicare went into effect 1968 Widely supported legislation Eliminated financial barriers to care Patient choice of physician Physician choice of practice location/style Health care is a right, not a privilege Capitalism w/ social responsibility (collectivism)

6. Organization of Healthcare Health Canada department: Federal responsibility for national health programs: –Occupational and Environmental Health –Health Promotion –Indian Health Services –Health Protection Medicare: decentralized, provinces determine the management, delivery and financing of health services

7. Private Market Private insurance exists to cover services NOT covered under Medicare (vision, dental, pharmaceuticals for non-elderly) Private insurance is most often employment based 15% of total health expenditures

8. Economics--Revenue Total: $142 Billion (Canadian) in 2005 Public spending covers 69.9% Private Insurance: 15% Out of Pocket 15% Funding: >25% federal transfer funds Provinces raise money through taxes: corporations, personal income, fuel, lottery Two provinces require a low, monthly flat- rate premium paid by employers

9. Economics--Expenditures Where does the money go? $2,931 (US) per capita health exp. 34% Hospital payments (global) 14% Physician payments (FFS) –Salary Caps – Negotiated rates between province and providers 14% Pharmaceuticals 10% Other institutions (LTC, Mental)

10. Management Provincial level planning –Prevents duplication of technology or services National oversight of pharmaceuticals, emphasis on health protection & promotion, R&D National and provincial controls on physician production and practice Strong nation-wide reliance on health administrators: powerful, make policy, emphasis on leadership, cost efficiency, social responsibility

11. Health Services Workforce ~54,000 physicians (1.8 per 1,000) >50% generalists, FP’s 99% reimbursed by provincial health plans Most fee-for-service, some capitation, some salary (community health centers) Out-migration of MD’s to USA (salary caps) All Canadian medical schools are US accredited, easy transfer, much recruiting

12. More Health Services Workforce Nurses: <300,000 Low salaries, low job satisfaction Little autonomy, little professional development (MD’s discourage use of mid-level practitioners) Much out-migration to the USA

13. Hospitals 95% not-for-profit (community boards) Global Budget negotiated annually with province. Capital expenditures are separate from Operating expenditures, gives province control of facilities and renovation. Hospitals developed based on provincial planning

14. Hospitals Advanced technology is hospital based Waiting time for non-emergency procedures Hospital beds declining due to shift to ambulatory setting for procedures.

15. Delivery of Services Most patient care takes place in the office of the private physician. Increased emphasis on prevention/promotion Close monitoring to not duplicate secondary and tertiary services within a region Rationing via review process and wait lists of expensive services (MRI, CTscan) Cost containment shift from inpatient to ambulatory setting (like USA)

16. Long Term Care Each province has a different program 23% of hospital beds are used for LTC: low intensity, low service needs (cost efficient versus acute care services) Hospital based LTC causes waiting lists Especially for the elderly: no cost pharmaceuticals, special poverty preventing programs

17. Current Concerns Inequity in care across provinces and territories (next slide) Increasing number of elderly citizens System-wide rising costs Citizen dissatisfaction with long waits for some services and procedures Cost-containment efforts and global budgeting will interfere with adoption of new technologies.

18. Illustration of Problems with Rurality Infant Mortality Rates by Province, 1995 Source: Statistics Canada, Births and Deaths, 1995.

19. Compared to US Canada has similar health outcomes—OECD ranked 30 th v. US at 37 th. Considerably lower portion of GDP spent on healthcare system 300% per capita less in Canada on administrative fees A true single payer system All inclusive access Waitlists are bad, but exclusion for 44 million Americans is bad, too.

20. Summary Canadian Healthcare System: Medicare Single-payer insurance based in each province Physicians in private practice Global Budgeting for hospitals Healthcare is a right, not a privledge