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CDM Reports to the Senate Standing Committee on Social Affairs

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Canadian Doctors for Medicare was asked to provide a written submission to the Senate Committee on Social Affairs, Science and Technology as it examines the implementation of the 2004 10-Year Plan to Strengthen Health Care. As always, CDM provided an evidence-based assessment of the challenges in implementing the Plan, and moving forward on a renewed Health Accord in 2014. We recommended that:

 

1)       The federal government work with provincial and territorial agreements towards a 10-year Accord in 2014 that respects the principles of the Canada Health Act, sets a strong, accountable federal role in ensuring quality, accessibility and equity across the country.
 

2)       The federal government accept greater accountability to enforce the Canada Health Act with respect to extra billing and user fees, recognize the negative effects of for-profit, private delivery on our health care system, and apply thoughtful, consistent criteria to health care delivery models.
 

3)       The federal government take a greater leadership role in setting and implementing national standards for quality health care by:

·           Reforming primary and community health care

·           Implementing electronic health records

·           Widely implementing successful wait times initiatives

·           Moving toward a national pharmacare program

·           Placing greater emphasis on health promotion and prevention

·           Focusing on quality care based on sound evidence

·           Using health resources according to best practice 

·           Increasing access to affordable dental health care

·           Optimizing the use of health human resources 

·           Appreciating the role of relationships


 

 

Background: Canadian Doctors for Medicare
Canadian Doctors for Medicare has an abiding interest in the evolution of the
federal role in health care. Canadian Doctors for Medicare was launched in 2006
by physicians in response to events in the medical profession and the world of
public policy that threatened to undermine our national commitment to equitable
access to health care. As medical professionals we are firmly committed to
health care policy based on good evidence and effective practice. We believe
that our health care system can and should be improved. The evidence is clear
that reform will work best if it takes place within the public system so that it
benefits all our patients, not just those who can afford to pay for their care.
Our vision is of a high-quality, equitable, sustainable health system built on the
best available evidence. We provide a voice for Canadian doctors who want to
strengthen and improve Canada's universal publicly-funded health care system.
We advocate for innovations in treatment and prevention services that are
evidence-based and improve access, quality, equity and sustainability.
Introduction
Canadian Doctors for Medicare has the unique perspective of health
professionals who have direct experience with the implementation of the 2003-
2004 Health Accords. Although some progress has been made, we need to
ensure that we continue progress through a new Accord in 2014. The 2014
Accord must advance an agenda of continued improvement while adhering to
the principles of the Canada Health Act, working to ensure that any reforms
support a universal public Medicare system.
An important part of reform begins with strong, accountable federal leadership to
enforce standards across the country. This requires enforcement of the Canada
Health Act, which has been sorely lacking in recent years.
Systematic improvements and innovation will be key to improving our health care
system. It’s also time to take a hard look at what isn’t working. This will require a
joint jurisdictional commitment to positive reform. There are many examples of
excellent innovations here in Canada, within our current health care system. If
these innovations are shared, scaled up and replicated, they can offer significant
potential improvements.
Similarly, there are many examples of initiatives that have been shown not to
work, and to undermine the very objectives that they purport to serve. A
commitment to reform should include a commitment to abandon failed strategies
and focus on those with real promise.
There is much that can be done, both by our political leaders, and our health
professionals, to work towards a better public health care system for all
Canadians.
A Strong Federal Health Accord in 2014
The 2003/2004 Health Accords were landmark developments in Canada, but
over the past 10 years, there has been mixed progress. For example, there have
been some successes in reducing wait times for certain procedures, but not
uniformly across the country. There has been virtually no progress on a national
pharmaceutical strategy to reduce costs and increase access to drugs. In
addition, there was weak accountability for results – the Accord provided for large
transfers of money to provinces without enforceable conditions for delivery of
outcomes. Overall, the achievements of the 2003/2004 Accords have been
mixed, and a renewed focus on achieving their unmet objectives, building on
their successes, and rising to new challenges is needed.
As 2014 approaches, governments have committed to renewed agreements to
ensure the stability and quality of Canada’s health care. To ensure a 2014 Health
Accord that serves Canadians well, Canadian Doctors for Medicare recommends
that federal, provincial and territorial governments:
1) Initiate the timely development of a new Health Accord, negotiated jointly
to ensure it reflects the needs of all regions and also reflects the priorities
we share as Canadians. Individual agreements between jurisdictions
damage portability and consistency of care, things that citizens
understandably expect.
2) Negotiate a long-term agreement. A 10-year Accord allows provinces and
territories to plan and implement effectively. Short-term contingent deals
do not.
3) Negotiate an Accord that reflects Canada’s commitment to equitable
access to medically necessary health care by honoring the principles of
the Canada Health Act .
4) Negotiate an Accord that ensures that the federal government has a
strong role in ensuring quality, accessibility and equity, and has the tools
to enforce the Canada Health Act, and support standards from coast to
coast.
5) Negotiate an Accord that ensures fair and equitable access to health care
by explicitly committing to reforms that strengthen the principle of access
to care based on need, rather than ability to pay
6) Negotiate an Accord that commits to the use of evidence in achieving
health policy objectives, such that best practices are put to use in support
of equity, access, quality and cost containment.
These principles will assist in crafting an Accord that can overcome some of the
weaknesses of the 2003/2004 Accords and lead more consistently to the
objectives set out by participating governments and the Canadian people.
Enforcing the Canada Health Act and ensuring that “alternative delivery
models” uphold equity
Enforce the CHA: Stop extra-billing and user fees
When the 2004 Accord was struck, the impact of creeping violations of the
Canada Health Act were modest and the evidence was less striking. Today,the
impact is substantial, the infractions are widespread and the evidence is
compelling.
As we look towards the re-negotiation of the Health Accord in 2014, we see a
clear need for the federal government to commit to a stronger role in
accountability to stop the negative effects of private, for-profit health care
delivery. That accountability should start with enforcing the Canada Health Act, to
ensure equitable, accessible and quality health care for all Canadians.
Clear examples exist across the country of CHA violations. These include but are
not limited to:
• Extra-billing by linking insured services to uninsured services
A recent study in the Canadian Journal of Gastroenterology found that
31.7% of patients in private clinics were being charged for access to
colonoscopy services.i
• Exorbitant block fees in primary care
Complaints of block fees for primary care have been increasing, with
disciplinary action being taken against one Ontario doctor who charged a
$1,500 annual fee to access her breastfeeding clinic. ii
• Using third party billing to sidestep prohibitions on payment for insured
services
Injured Ottawa area workers are being sent by the WSIB to Quebec to
receive MRIs at private clinics, bypassing waiting queues by paying private
clinics directly for medically-insured services.iii
These examples do not represent solely a violation of federal law. They also
represent an increasing pressure on the part of a small but well-funded lobby to
be able to charge patients for access to medically necessary care and undermine
the principle of access based on need, rather than ability to pay. Advocates of
this approach would prefer either explicit or tacit non-enforcement of the CHA.
They suggest that a parallel private care stream can take pressure of the public
system. It is important that the federal government recognize that there is strong
evidence which shows that more private care does not increase efficiency or
access, and in many cases, it puts up barriers to both.iv Furthermore, such an
approach contradicts the express wishes of Canadians, who time and again say
both in polls and at the ballot box that they want single-tier health care.
As part of its commitment to the CHA, the federal government must recognize
that “new” forms of privatization, user fees and extra billing have emerged since
the Act was passed in 1984. Some of these take advantage of legislative
loopholes while clearly violating the spirit of the Act. All governments should
come together to agree that such violations will not be tolerated and commit to
putting a stop to barriers to access to publicly funded services.
An accountability framework that requires provinces to proactively regulate or
investigate clinics for compliance with these laws is clearly needed to ensure the
CHA is upheld.
Canadian Doctors for Medicare also calls on the federal government to ensure
that a new Accord will make new monies conditional on adherence to the
Canada Health Act, and to take a proactive stance in enforcing the prohibitions
on extra billing and user fees.
Awareness of effects of for-profit delivery on publicly funded services
The commitment to equity is even more vital in the context of this federal
government’s expressed interest in “alternative models of delivery.”v Private forprofit
firms have a clear interest in finding ways to maximize their profit. In the
context of health care, this interest can conflict directly with patients’ needs to
access services free at the point of care. Before governments consider exploring
greater involvement of the for-profit sector in the delivery of publicly funded
services, a commitment in principle, and then regulation in practice, must be
firmly in place to protect patients.
a) Effect on Access and Wait Times
Private for-profit clinics drain the limited supply of doctors and other health
professionals from the rest of the health care system, lengthening waiting lists
and reducing access.vi Some service providers offer faster access to insured
service at their clinics, but require patients to pay a membership fee or other
payments in order to have access to that service. People who have not paid
the fees cannot gain access. This may shorten waits for some patients who
pay, but it ties up resources for the rest of the system, lengthening wait times
overall.
Not only do they reduce access in general, for-profit clinics tend not to serve
unprofitable markets like remote and rural communities, Aboriginal
communities, marginalized urban populations, and those needing complex
chronic care and emergency care. They focus on affluent populations in
urban centres, who face the lowest barriers to care. vii Private, for-profit clinics
contribute least where the need is greatest, and exacerbate inequity in our
health care system.
b) Effect on Patient Mix in Public Hospitals
Private, for-profit clinics also reduce access to those who are sickest, often
“cherry-picking” the healthiest patients, who are easiest, and cheapest, to
treat.viii Patients who are very sick, and no longer profitable to treat, are often
referred back into the public system, putting added stress on public
resources.ix
c) Effect on Health Care Costs
Contrary to the belief that extra private capacity in our health care system will
make wiser use of our dollars, we know that Canadians are not getting good
value for money with private, for-profit delivery. Private for-profit clinics use up
needed resources scheduling unnecessary procedures, reducing the services
available to other patients requiring medically necessary procedures.x The
evidence shows that private, for-profit health care produces worse patient
outcomes at higher costs than non-profit care, and order more unnecessary
tests and procedures. xi,xii,xiii
Thoughtful and consistent criteria for appropriate delivery models
In making reforms to our health care system, and working towards fulfilling the
goals of the 2003/2004 and future Accords, the federal government should
recognize that effective health care delivery is needed.
Canadian Doctors for Medicare has four important criteria in assessing a
potential health care delivery model:
1. Equitable access to medically necessary physician and hospital
services: The need to turn a profit means that accessibility can suffer, as
private clinics exclude very sick patients or patients who need complex
care and are too expensive to treat.
2. High quality care: Making a profit can compromise quality – it means that
all of a clinic’s resources aren’t being put into optimal care for patients.
3. Delivery of effective, clinically indicated services: The need to make a
profit can push private clinics to order tests and procedures that aren’t
medically necessary.
4. Effective planning and integration of health care: Increased competition
between private and public delivery is inefficient – it’s harder to
coordinate, it’s less accountable, and it’s less effective at delivering an
integrated continuum of care.
System Improvement and Innovation
Progress on the implementation of the 2004 Accord has been well-documented
by organizations such as the Health Council of Canada and the Canadian
Institute for Health Information. While there has been progress on some aspects
of the 2004 Accord, there is evidence to show that we can be doing more to
improve and innovate in our health care system. As physicians, we know that
national leadership can contribute to progress on the ground level towards the
goals of the 2004 Accord.
We should be shifting from hospitals to less expensive community care in many
cases. In the context of an aging population, it is clear that this is the right thing
to do: Canadians want to stay at home as they age, and it also contains cost.
Too many people are in expensive hospital beds when they should be in a longterm
care home, or in community-based rehabilitation, or at home, receiving
support. We can better manage chronic diseases in community settings instead
of in the emergency room. Expanding access to these kinds of community-based
health care take the pressure off of overcrowded hospitals, and it’s much more
cost-effective.
We also need to start taking steps towards a national pharmacare program - an
unfulfilled commitment of the 2004 Accord. Canada pays more for prescription
drugs than any country within the Organization for Economic Cooperation and
Development (OECD) except the United States, and we pay 30% more than the
OECD average. There are a number of ways to start down this road. For
example, a single national formulary of essential drugs based on independent,
evidence-based drug evaluation could reduce costs by 8%. Additional savings
from competitive bulk purchasing could also reduce expenditures substantially.
One study estimated that a combination of strategies could reduce our
prescription drug costs by as much as $10.7 billion per year, or an estimated
43% of Canada’s $25.1 billion drug bill.xiv
The 2004 Accord had the stated objective of establishing and implementing a
National Pharmaceutical Strategy. It’s time to recommit to this goal, and to the
principle that affordable access to drugs is fundamental to equitable health
outcomes in Canada.
There are a number of successful innovative programs in Canada that reduce
wait lists for surgical procedures, but we haven’t been identifying and scaling up
these successes. It is time to move beyond individual priority areas, as was the
strategy in 2004, and instead develop an overall approach to wait time
management in the system. Dr. Brian Postl’s work for the federal government
identifies key approaches that can be applied across the system.
We also see room for national leadership in evidence and translation to provide
the highest quality care possible. Quality care based on sound evidence requires
a coherent strategy to translate research into action. For example, according to
the Canadian Association of Radiologists, as many as 30% of CT scans and
other imaging procedures are inappropriate or contribute no useful information.xv
A national body tasked with continuously reviewing the evidence and issuing
guidance to health care providers, similar to the National Institute for Health and
Clinical Excellence in the United Kingdom, would likely improve the quality of
Canadian health care and save money. Translating clinical guidelines for health
professionals could determine when expensive diagnostic tests, such as MRIs
and CT scans, are truly needed
This kind of evidence gathering can help to make the best use of our health
resources. In a 2010 report, the Health Council of Canada cautioned Canadians
that the inappropriate prescribing of drugs and over-use of diagnostic imaging
can not only can harm patients, but also add unnecessary costs to the health
care system.xvi We need to have a set of best practices that tell our health
professionals when more tests and more drugs are not helping, and in fact, may
be harmful.
Canadian Doctors for Medicare has developed a Top 10 list of ways to transform
Canadian health care (some of which were discussed above). It includes:
• Primary and community health care reform
• Implement electronic health records
• Widely implement successful wait times initiatives
• Move toward a national pharmacare program
• Place greater emphasis on health promotion and prevention
• Focus on quality care based on sound evidence
• Use health resources according to best practice
• Increase access to affordable dental health care
• Optimal use of health human resources
• Appreciating the role of relationships
Our Bottom 10 outlines the practices we know aren’t helping our health care
system:
• User fees
• Using risk selection to pick patients
• Bringing more private money into the system
• Private care as a “safety valve” for a strained public system
• For-profit corporate health care within medicare
• Bypassing the public queue
• Adhering to “more health care is better”
• Mandatory extras that are not publicly covered
• Overlooking relationships
• Sacrificing collaboration for competition
Full discussions of our Top and Bottom 10 can be found at
www.canadiandoctorsformedicare.ca.
Conclusion
Canadian Doctors for Medicare is pleased to have the opportunity to contribute to
the Senate Committee’s examination of progress on the 2004 Accord. As
physicians, we see a larger role for federal leadership to improve progress at the
level of delivery. In conclusion, we recommend that:
1) The federal government work with provincial and territorial agreements
towards a 10-year Accord in 2014 that respects the principles of the
Canada Health Act, sets a strong, accountable federal role in ensuring
quality, accessibility and equity across the country.
2) The federal government accept greater accountability to enforce the
Canada Health Act with respect to extra billing and user fees, recognize
the negative effects of for-profit, private delivery on our health care
system, and apply thoughtful, consistent criteria to health care delivery
models.
3) The federal government take a greater leadership role in setting and
implementing national standards for quality health care by:
• Reforming primary and community health care
• Implementing electronic health records
• Widely implementing successful wait times initiatives
• Moving toward a national pharmacare program
• Placing greater emphasis on health promotion and prevention
• Focusing on quality care based on sound evidence
• Using health resources according to best practice
• Increasing access to affordable dental health care
• Optimizing the use of health human resources
• Appreciating the role of relationships
i N Ivers, M Schwandt, S Hum, D Martin, J Tinmouth, N Pimlott. A comparison of hospital and
nonhospital colonoscopy: Wait times, fees and guideline adherence to follow-up interval. Can J
Gastroenterol 2011;25(2):78-82.
ii Li, Anita. “Coalition calls for ban on doctors’ flat fees.” The Toronto Star, September 25, 2011.
iii Greenberg, Lee. “Injured workers seek care in Quebec: WSIB sending three out of four to
Gatineau to bypass MRI delays.” The Ottawa Citizen, September 6, 2011.
iv N Ivers, M Schwandt, S Hum, D Martin, J Tinmouth, N Pimlott. A comparison of hospital and
nonhospital colonoscopy: Wait times, fees and guideline adherence to follow-up interval. Can J
Gastroenterol 2011;25(2):78-82.
v Wherry, Aaron. “Stephen Harper and the Canada Health Act.” Maclean’s, April 18, 2011.
vi Duckett, S. J. “Private care and public waiting.” Australian Health Review; 29(1): 87-93. 2005.
vii Vaithianathan R. 2004. “A critique of the private health insurance regulations.” Australian
Economic Review;37(3): 257-70.
viii Perry, Joshua E., A Mortal Wound for Physician-Owned Specialty Hospitals? The Legal and
Ethical Prognosis for Market-Driven, Entrepreneurial Medicine in the Wake of 2010 Health Care
Insurance Reforms (May 13, 2010).
ix Perry, Joshua E., A Mortal Wound for Physician-Owned Specialty Hospitals? The Legal and
Ethical Prognosis for Market-Driven, Entrepreneurial Medicine in the Wake of 2010 Health Care
Insurance Reforms (May 13, 2010).
x N Ivers, M Schwandt, S Hum, D Martin, J Tinmouth, N Pimlott. A comparison of hospital and
nonhospital colonoscopy: Wait times, fees and guideline adherence to follow-up interval. Can J
Gastroenterol 2011;25(2):78-82.
xi Journal of the American Medical Association, 2002; 288:2449.
xii N Ivers, M Schwandt, S Hum, D Martin, J Tinmouth, N Pimlott. A comparison of hospital and
nonhospital colonoscopy: Wait times, fees and guideline adherence to follow-up interval. Can J
Gastroenterol 2011;25(2):78-82.
xiii New England Journal of Medicine, 1997, 337:169.
xiv Gagnon, M-A. The Economic Case for Universal Pharmacare: Costs and Benefits of Publicly
Funded Drug Coverage for All Canadians. Presentation to the Canadian Association of Business
Economics, Industry Canada, Toronto, November 30, 2010.
xv Canadian Association of Radiologists. (2009). Do you need that scan? Ottawa: CAR.
xvi Health Council of Canada. Decisions, decisions. Family doctors as gatekeepers to prescription
drugs and diagnostic imaging in Canada. Toronto, ON: Health Council of Canada; 2010.