1 About the case summary 12 Font size Times New Roman Average 2-3 pages Name and student number First case summary due on September 26

2 Canadian health care systems: the past and the future Objectives: Understand principles of Canadian health care system Understand its evolution and how the system works Understand the current problems in the system

3 Quiz Testing your knowledge about the Canadian Health Care System 1. The health insurance plan of a province must be administrated and operated on a non-profit basis by a public authority accountable to the provincial government. TrueFalse

4 2. Medically services provided by hospitals and physicians are covered by Medicare. True False

5 3. All people living in Canada are entitled for the insured health services on uniform terms and conditions. True False

6 4. Additional charges to insured patients for insured services are not allowed. True False

7 5. Canadian residents are entitled to coverage when they move to another province within Canada, but not covered when they travel aboard. True False

8 Principles of Medicare Public administration Comprehensiveness Universality Accessibility portability

9 Canadian health care system Publicly financed, privately delivered The responsibility of provincial government - Management and delivery of health care services The responsibility of federal government – Setting and administering of national principles or standards for the health care system assisting in the financing of provincial health care services through fiscal transfers, fulfilling functions for which it is constitutionally Responsible, and responsible for health protection, disease prevention, and health promotion.

10 Rely extensively on primary care physicians Account for 51% of all active physicians in Canada Paid on fee-for-services basis Act as “gatekeeper” of the Canadian health care system

11 95% hospitals are non-profit entities Run by community boards of trustees, voluntary organizations or municipalities. Accountable to the communities they serve, not to the provincial bureaucracy

12 Evolution of universal health insurance Prior to 1940’s, private medicine dominated health care in Canada resulting in access to care being based on ability to pay.

13 Evolution (contd.) 1947 the province of Saskatchewan introduced a public insurance plan for hospital services 1956 federal government, seeking to encourage the development of hospital insurance programs in all provinces, offered to cost-share hospital and diagnostic services on a roughly fifty-fifty basis.

14 Evolution (contd.) By 1961, all ten provinces and the two territories had signed agreements establishing public insurance plans that provided universal coverage for at least in- patient hospital care that qualified for federal cost-sharing.

15 Evolution (contd.) Public medical care insurance began in the province of Saskatchewan, providing coverage for services provided by physicians outside hospitals. By 1972, all of the provincial and territorial plans had been extended to include physicians’ services. The objective to have a national health insurance plan for hospital and medical care in Canada had been realized.

16 How does the system work? Payers Provincial government – Ministry of Health (MOH) Covers insured hospital and physician services Covers costs of certain non-insured services for certain specific population groups Controls the rate of adopting and diffusing expensive medical technology

17 Insurance companies Cover a range of health services that remain outside the national health insurance framework Workplace safety and insurance board Provide insured benefits to workers with work-related injuries or illness

18 Providers Hospitals: teaching hospitals, general/community hospitals, small hospitals and mental health hospitals Physicians: general physicians and specialists nurses

19 Other health care providers Include dentists, chiropractors, opticians, occupational therapists, etc. Voluntary organizations Ontario Gerontology Association (is an incorporated voluntary organization concerned with aging, thereby promoting quality of life for older adults. Its membership provides an inter- disciplinary forum for those involved in the field of gerontology)

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33 Problems in the health care system Emergency overcrowding Doctor shortage One in four Ontario doctors will retire in four years By 2020, 30% of Ontario’s population will be over the age of 55. Waiting time Access to health care providers, diagnostic tests, specialty treatment, hospital beds

34 Waiting time examples: Six months to obtain a hip replacement Five months to get a CAT scan Some patients wait more than a year for cardiac surgery Some cancer patients go to the States for treatment 2/3 Canadian physicians are finding it difficult to get appropriate resources such as diagnostic tests, referrals or operating room time for their patients.

35 Waiting time for the access to health care services Waiting time for unmet need and/or inadequate resources within the health care system

36 Health care crisis or Really?

37 Environmental factors Aging population (30% of Ontario population over 55) Physicians leave outnumber those who have returned ¾ family physicians are unable to accept new patients Funding constraints People demands high quality services

38 Long-term impact Personal life Work Economic development The Canadian health care system is one of the central determinants of our industrial competitiveness and our quality of life. (Conference Board of Canada, 1998)

39 Causes The system Organized around acute care, rather than chronic care (reactive vs. proactive) Task-oriented rather than customer-oriented Lack of integration Lack of cost-saving incentives Hospitals Physicians patients Gatekeeper, is it necessary?

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41 Ourselves Lack of medical knowledge Misuse Healthy life style

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43 Changing paradigm OldNew acute carecontinuum of care treating illnessmaintaining and promoting wellness Individual patientsdefined population Provider similardifferentiation Inpatient admissionpeople health Fill bedsprovide timely care Separate org.Integrated system Run organizationoversee a market Managers as depart.headsoperate across organizations Coordinate servicespurse quality improvement

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48 Reforming the Canadian health care system Reforming primary health services (150 physicians, 220,000 patients, 7 sites) Availability of a nurse practitioner to enhance access to primary care 24-hour access to care No change in the waiting time Quality of care is considered to be good or very good Patients were very satisfied

49 Hospital Services Restructuring Committee (HSRC) Horizontal integration within the hospital sector Result in extensive cost reduction and rationalization of services within the hospital sector But heavier load for hospital personnel

50 Physicians High level of satisfaction except those in Chatman No change in their practice patterns Some found unable to offset the extra costs of information technology Found difficult in providing on-all coverage (since they can’t bill for the telephone advice) Unrealistic expectations from the government Information technology acquisition process (lengthy, resource-intensive, inefficient, and fragmented)

51 The Western Canada Waiting List Project is a consortium of medical associations, regional health authorities, health research centres, and ministries of health, which will develop valid reliable, clinically transparent and useful tools to assist the management of waiting lists in cataract surgery, children's mental health, general surgery, hip and knee replacement, and MRI scanning

52 Sources of information

53 Fully 82% agree with the idea that we need long term, sustainable funding to improve the health care system in Canada. Moreover, almost half (49%) think government spending on health care should be increased even if it means higher income taxes.

54 Health care misuse

55 Privatization Pay for some services Expanding the public health care system (cover all costs)

56 What does the waiting time telling us?

57 What do Canadians think their system? Generally speaking, Canadians assign the overall quality of the health care system a fairly positive rating. At least six in ten give the health care system a B grade or better in terms of overall quality, choice of health services, and their most recent interaction with the system.

58 They are most positive about access to their family doctor, to walk in clinics, and access for children and seniors (at least five in ten assign a B grade or better). Across the other accessibility dimensions tested (e.g., access to medical specialists, diagnostic equipment, and emergency room services) Canadians are less positive in their assessment of the health care system. The majority assign a C grade or worse in terms of accessibility to these health care services.

59 Only 5% give the federal government's performance in dealing with health care in Canada a very positive rating (i.e., an A); six times as many (30%) give the federal government’s performance in this area a failing grade. Similarly only 6% think the provincial government is doing a very good job in dealing with health care in their province (A rating), while fully 35% give their provincial government a failing grade.

60 Confidence in Various Players to Improve Health Care When asked how much confidence they have in each of a range of players to improve the health care system, health professionals such as doctors and nurses, and voluntary health organizations are given the highest confidence levels among the players tested. Two in three Canadians feel confident these groups can help to improve the health care system. Confidence levels drop sharply for both the federal and provincial governments. Only one in five Canadians express confidence in either federal or provincial government officials and politicians to help improve the health care system. Over twice as many express little confidence in the two senior levels of government to improve health care.

61 Canadians express mixed views regarding the health care system. The majority (61%) believe that many people misuse the health care system. Fifty-three per cent think the Health care system needs a complete overhaul (only 14% disagree with this idea). Moreover, only 17% believe there is nothing wrong with Canada’s health care system (three times as many disagree).

62 Despite these pessimistic views of health care, a majority of Canadians (58%) think Canada’s health care system is one of the best in the world (only 12% disagree with this notion), and a substantial minority (45%) think the current health system provides the best possible health care for them and their family.