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    Add as FriendCanada’s Health Care System

    by: Rogers

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    1 : Canada’s Health Care System
    2 : Canada’s Health Care System: Fact and Fiction Ernie Lightman Professor of Social Policy University of Toronto Faculty of Social Work
    3 : Outline Two qualifications A brief history of medical care in Canada The details: How medicare works The principles What’s good? What’s bad? An assessment Future prognosis
    4 : Two caveats Limits to international comparisons Different cultures, value systems, priorities E.g. Role of government No model is perfect
    5 : Generic Social Policy Questions relevant to this presentation What is the role of the state and that of individual responsibility? Universality/selectivity Cash/In-kind Is health care different from other goods and services we buy in the marketplace? (posed by Richard Titmuss, 1954)
    6 : Some comparative data
    7 : Canada: Decentralized Federalism Due to court interpretations and the politics of Quebec Constitutional division of responsibilities Social Union Framework Agreement (SUFA), 1999
    8 : A Brief History of Health Insurance 1946: Hospital care in Saskatchewan 1957: Federal 50/50 cost-sharing 1961: All provinces participated in hospital care 1962: Saskatchewan doctors’ strike 1965: Federal 50/50 sharing for health/physician care Post-1965: All provinces participated
    9 : 5 Key Principles (1957) Introduced for hospital care; later formed the basis of health care coverage Public administration Comprehensive Universal Accessible Portable
    10 : Canada Health Act (1984) Reaffirmed the 5 principles of medicare; and also Explicitly prohibited user fees/co-payments Earlier legislation silent on the issue
    11 : How does it work? (Based on 5 Principles) Coverage All ‘insured persons’ Permanent residents with legal status No ‘pre-existing condition’ or other disqualification All ‘medically necessary’ services, in hospital or delivered by a physician (usually) Defined by provinces: can vary No user fees/co-payments
    12 : Providers Hospitals are almost all non-profit corporations, funded by provinces Block funding by the province Physicians usually private entrepreneurs, paid on a fee-for-service basis In or out: No mixed models as in Europe, etc No extra-billing Single payer means fast, guaranteed payments Few/no restrictions on professional autonomy
    13 : Role of the State Single payer Program is paid for through taxes (general revenues) plus in some provinces, premiums High degree of coverage (95% of pop) 70% of health costs covered by medicare Vs 45% in US Gaps are with drugs, dental, ambulance, long-term/community care
    14 : Private insurance No private insurance permitted for medicare-covered services (“medically necessary”) The “Buffalo” option exists Industry exists at the fringes, covering other services (drugs, semi-private coverage, etc)
    15 : Overall program Highly effective on coverage Highly effective on meeting certain needs Weak on others (which are not covered) Weak on cost control and cost minimization High power to medical profession Emphasizes traditional medical model at expense of other approaches
    16 : What’s good? What’s bad? A more detailed look at the program and its impact
    17 : Coverage: Good 95% of population required Pooling of risks Excluded 5% include new arrivals (90-day waiting period), illegals, street people who lose cards Formerly easy to get cards Sarah Palin travelled to Canada Now much harder to get coverage
    18 : Accessibility: Mostly Good No financial barriers to ‘insured services’ Often high barriers to uninsured services Has led to a very traditional, medical model People go to a psychiatrist (an MD) in preference to a psychologist or social worker (who cannot bill medicare) Homeopathy, naturopathy, physio, dietician, chiropractors, Chinese medicine all excluded (except when ‘controlled’ by a physician)
    19 : Accessibility (cont’d) Uninsured services can be costly One estimate 65% have private insurance for drug coverage Number seems high (to me) today ‘catastrophic’ coverage out of lottery funds (Ontario) May have to enter hospital to get coverage Inadequate LTC/Home care leads to premature institutionalization
    20 : Access to health insurance by income quintile
    21 : Accessibility (cont’d) Go on/stay on welfare to get eyeglasses, drugs, dental Changes in definitions of ‘insured’ services over time Cosmetic surgeries, sex changes, circumcision (‘bris’) Restrict coverage to save money
    22 : Accessibility (cont’d) Can be questions of timely access Somebody decides who gets served first Criteria can be financial or bureaucratic/need Triaging exists in every system For non-emergency services, we do wait longer than often in the US Emergencies/crises are handled well
    23 : Comprehensiveness What is ‘medically necessary’? All services are rationed in every system Sometimes by the market; sometimes by administrative procedures There are bureaucratic procedures and budget issues to approve new hardware and procedures in Canada There are no ‘death panels’
    24 : Comprehensiveness (cont’d) Private insurance companies/for-profit hospitals/doctors use market criteria (profit) while bureaucracies use other, less clear criteria (intended to measure need) Time lags (and cost constraints) with new, ‘cutting-edge’ technologies in Canada These will be available at a private clinic in Houston before a public hospital in Toronto
    25 : One example Shona Holmes (2005), Ontario Went to Mayo Clinic for life-threatening brain cancer 2007, sued Ontario 2009, appeared in Republican Party ads Facts: Her illness was not cancer, but Rathke’s cleft cyst Not life-threatening; mortality rate is zero Issue: How would this have been handled in the US?
    26 : Shona Holmes and friends
    27 : Satisfaction: High 86.2% of Canadians surveyed supported or strongly supported "public solutions to make our public health care stronger.” (2009, Nanos Research) 82% of Canadians preferred their healthcare system to the one in the US (2009 Harris/Decima) 8% preferred a US-style system
    28 : Other polls show the same Gallup (2003) 25% of Americans either "very" or "somewhat" satisfied with "the availability of affordable healthcare in the nation," versus 50% of those in the UK and 57% of Canadians. Those "very dissatisfied" made up 44% of Americans, 25% of respondents of Britons, and 17% of Canadians
    29 : Less differences at the individual level Gallup (Sept 2009) "Overall, 80% (of Americans) are satisfied with the quality of medical care available to them, including 39% who are very satisfied. Sixty-one percent are satisfied with the cost of their medical care, including 20% who are very satisfied"
    30 : Effectiveness/Prevention Good within constraints of the traditional medical model Don’t need to wait until seriously ill to see a doctor But: may lead to unnecessary use/abuse?? Traditional medical model may limit use of other approaches, including prevention (diet, exercise, etc)
    31 : Efficiency Single payer is extremely important Rapid payment; no bad debts; no insurance companies Little bureaucracy Canada spends 10% of GDP on health care (public and private) versus 16% in US As noted, single payer does limit ‘freedom’
    32 : Equity: Good To the extent health outcomes depend on the delivery system, Canada has high equity But health, of course, depends on far more variables, such as income and economic class Social indicators Results of my recent research on health outcomes
    33 : Canadian Community Health Survey (2006 data)
    34 : Diabetes
    35 : Bronchitis
    36 :
    37 : Equity (cont’d) Do not/cannot (usually) pay extra for preferred access to insured services No ‘two-tiers’ of access Cannot privately insure for ‘medically necessary’ services Chaoulli case in Quebec Class matters Middle class are more articulate and demanding
    38 : Unnecessary services Fewer financial incentives to do unnecessary procedures The consequence of a more tightly rationed system Not getting access to necessary procedures is the greater concern Occasional problems of fraudulent billings by physicians
    39 : Two Tiers Doctors cannot work both in the public and the private system No way to bypass the public system by ‘going private’ as in Britain, other places Limits ‘freedom’, with the choice being to go abroad Cannot buy priority
    40 : Cost In general, Canada spends about the OECD average on health care, less than the US Rapid increase in health costs in recent years, but much of this in Drugs Less growth in spending on hospitals and doctors
    41 : Total health spending ($1997)
    42 : Major health costs Canada 1975 and 1997
    43 : Controlling Cost There are few effective controls on costs in either physician services or hospitals Governments are aware and are experimenting, with limited success Ont: Just announced hospitals will ‘compete’ as in the UK Didn’t work there as hospitals did more ‘high valued added’ procedures, neglecting others
    44 : Cost (cont’d) With doctors, fee-for-service is the problem Experiment with other models (salary, capitation, group practices, attempts to reduce ‘doctor shopping’, etc) Resistance from medical profession Seems to be lessening with generational change
    45 : Rationing, Wait times, Queues There is always rationing, triaging Based on market principles or ‘need’ We may wait for non-emergency services Long waits do happen In emergency cases, triaging works well In a market model, pay extra for excess capacity No waiting, but at high cost
    46 : Cutting Edge, innovation A free market system innovates quickly in search of profits Bureaucratic systems move more slowly A wealthy society will also innovate quickly Is speed of innovation determined by resources (wealth) or the delivery system??
    47 : Malpractice Less litigation in Canada But not necessarily less malpractice Does the direct link between payment and service encourage litigation, while the indirect link in Canada discourages it? Or are there national, cultural issues that make Americans litigious?
    48 : Future Concerns Loss of political commitment in Ottawa Culturally appropriate care in a multicultural milieu Excluded groups, esp First Nations, Innuit Controlling costs Public-private partnerships Other delivery models than fee-for-service Chaoulli case and other court action Aging of the population

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