Healthcare in Canada

Stephen Samis, Vice-President, PolicyJennifer Verma, Director, Policy

May 20, 2011

Overview

• About CHSRF• How has Medicare evolved over time?• What are the key components of Canada’s

healthcare “systems”?• What are the basic economics and some of

the key quality and performance challenges?• Final thoughts – patient perspective

CHSRF profile• publicly-funded organization• not-for-profit corporation, registered charity• $151.5 M endowment• $15-16 M annual operating budget• Approx. 50 staff – best place to work awards

CHSRF – Who we are• Our work is directed at three levels:

– The policy level, to create policy environments that accelerate or enable transformation to occur

– The health system or regional level, to support systems that show readiness to implement transformative initiatives and

– The local or individual level, to help healthcare providers and citizens redefine their roles in the provision of person-centered care

CHSRF – What we do• In support of our mission, CHSRF offers

customized: – change management and implementation

initiatives – research and policy analysis – consultation, workshops and dialogue events – education and training, assessment tools and

decision support– outcomes evaluation

Some Programs and Initiatives• Healthcare FIT (Financial sustainability, Innovation and Transformation)

• Better with Age: Health Systems Planning for the Aging Population

• Mythbusters series • Leadership Survey• EXTRA (Executive Training for Research Application)• PEP (Patient Engagement Projects) • Harkness Fellowships • Excellence Through Evidence Award• Signature Events (CEO Forum, Picking up the Pace)

Lavis J. et al. 2009. SUPPORT Tools for evidence-informed health Policymaking (STP). Health Research Policy & Systems 7(Suppl 1).

http://www.health-policysystems.com/content/7/S1/I1

History & Roles

Healthcare in Canada

Constitutional responsibility for healthcare – Canada, 1867

• Power of (Federal) Parliament (section 91:11)– Quarantine and the Establishment and Maintenance of

Marine Hospitals.

• Exclusive powers of provincial legislatures (92:7)– The Establishment, Maintenance and Management of

Hospitals, Asylums, Charities, and Eleemosynary Institutions in and for the Province, other than Marine Hospitals.

Legacy of the Constitution

• 14 health systems – 1 for each province/territory + Health Canada

• In terms of spending, Health Canada is the 5th largest system– provider of supplementary health benefits to

750,000 First Nations and Inuit peoples– direct provider on reserves and isolated locations

Tax-Funded Systems (Beveridge)

Provision of healthcare for all people through central taxation and other compulsory financial contributions and a system of universal benefits.

Landmark Legislation

• Hospital Insurance and Diagnostic Services Act, 1957

• Medical Care Act, 1966• Established Programs Financing, 1977• Canada Health Act, 1984

Principles of Canadian Medicare• Public Administration – administered and operated

on a non-profit basis• Comprehensiveness – must insure all insured health

services• Universality – 100% of insured residents must be

entitled on uniform terms and conditions• Portability – coverage moves between provinces and

territories• Accessibility – no financial barriers (e.g., user fees)

Canada Health Act: Insured Services

“insured health services” means hospital services, physician services and surgical-dental services provided to insured persons, but does not include any health services that a person is entitled to and eligible for under any other Act of Parliament or under any Act of the legislature of a province that relates to workers’ or workmens’ compensation.

GovernanceFederal Government

– Canada Health Act– health protection– research (Canadian Institutes of Health Research)

Provincial/Territorial Governments– policy-setting (e.g., def. of insured services)– funding envelope– health professional regulation– regulation of hospitals

GovernanceRegional Health Authorities

– Funding allocation– Needs assessment

Hospitals and Agencies*– Program delivery– Quality assurance– Physician privileges

Professional Regulatory Bodies– Licensure– Discipline

*Note these would be subsumed under regional health authorities in most jurisdictions.

Health Canada – Core Roles• Leader/Partner through the administration of the Canada

Health Act• Funder through policy support for the federal government’s

Canada Health and Social Transfer• Guardian/Regulator regulates and approves the use of

thousands of products (e.g., medical devices, pharmaceuticals• Service Provider through the provision of supplementary

health benefits to approximately 749,725 eligible First Nations and Inuit (e.g., pharmaceuticals, vision care, transportation)

• Information Provider through performing high quality science and research

Source: Health Canada. www.hc-sc.gc.ca

Public Health Agency of Canada - Core Roles

• Promote health;• Prevent and control chronic diseases and

injuries;• Prevent and control infectious diseases;• Prepare for and respond to public health

emergencies, and• Strengthen public health capacity

Source: Public Health Agency of Canada. www.phac-aspc.gc.ca

Selected National OrganizationsAccreditation CanadaCanadian Agency for Drugs and Technologies in HealthCanada Health InfowayCanadian Institute for Health InformationCanadian Medical AssociationCanadian Nurses AssociationCanadian Patient Safety Institute Health Council of Canada

Financing & Cost Drivers

Healthcare in Canada

Source: Public Accounts and 2000 budgets.

Total health expenditure per capita, US$ PPP

21

INDICATOR CANADA US OECD Average

Total Health Expenditures as a % of GDP (32)

10.4 (6th) 16.0 (1st) 9.0

Total Health Expenditures

Per Capita US $ (27)$4,079 (5th) $7,538 (1st) $3,060

Public % of Total HealthExpenditures (31)

70.2 46.5 72.8

Source: OECD Health Data 2010. (latest data 2008)

Canada: A Single-Payer System?Selected Category % Public Funding 2009

Hospitals 90.8

Other Institutions 71.5

Physicians 98.9

Other Professionals 7.0

Prescription Drugs 45.0

Capital 83.0

Total Health Spending 70.2

Source: CIHI National Health Expenditure Trends 1975 to 2009

Health Expenditures by Selected Category Canada, 1984 and 2009

Selected Category 1984 2009% of total

Hospitals 41.8 27.8

Other Institutions 10.7 10.0

Physicians 15.0 14.0

Other Professionals 10.0 10.9

Prescription Drugs 6.1 13.9

Capital 4.1 4.8

Public Health 3.7 6.2

Hospital/Physician Subtotal 56.8 41.8

Source: CIHI National Health Expenditure Trends 1975 to 2009

Federal Contribution to Health, Canada, 2009

$ Millions % of Total Public Expenditures

Canada Health Transfer 22,987 18.7

Federal Direct Exp. 6,616 5.1

Subtotal 30,603 23.8

Total Public Exp. 128,597.3 100

Source: CIHI and Finance Canada

Consolidated Provincial and Territorial Government Revenue and Expenditures, Canada and Provinces 1999-2009

Average Annual % Increases

Total Health Total Revenue Expenditures Expenditures

Canada* 5.6% 5.3% 6.9%Newfoundland & Labrador 8.4% 6.3% 7.0%Prince Edward Island 4.5% 5.4% 5.9%Nova Scotia 5.0% 4.9% 5.6%New Brunswick 4.0% 4.7% 8.2%Quebec 5.0% 5.4% 6.4%Ontario 5.3% 5.3% 7.5%Manitoba 4.8% 5.0% 8.0%Saskatchewan 7.7% 5.8% 7.9%Alberta 9.4% 9.1% 9.7%British Columbia 4.9% 2.7% 3.8%

*Territories are included in Canada totalSource: Statistics Canada CANSIM Table 385-0001

Consolidated Provincial and Territorial Government Expenditures, Canada, 1999 and 2009

Category % of Total Expenditures* 1999 2009

Health 32.3 35.4Social Services 19.4 18.9Education 27.6 25.1

* Less debt charges

Financial Sustainability• Canada’s healthcare costs are increasing• Health has increased its share of GDP since 2000• But recent increases in healthcare’s share of the GDP

are almost totally due to the recession• Healthcare has slightly increased its share of

provincial budgets due mainly to cuts in other areas rather than increases in health spending

• Canada’s health costs are similar to other wealthy countries and substantially less than those in the US

0

2

4

6

8

10

12

14Public sector

Private sector

Total

Canadian Health Care Costs as % of GDP

Data from: http://secure.cihi.ca/cihiweb/products/National_health_expenditure_trends_1975_to_2009_en.pdf

*

*

*

* The dashed lines indicate the results if the economy had grown in 2009 at the same rate as in 2008

What are the key cost drivers?

The effect of key cost drivers on health spending growth: - Synthesis of Canadian studies

Quality & Performance

Healthcare in Canada

Most frequently used dimensions internationally¹

Quality dimension

Accreditation Canada

B.C. PSQC²

HQCA³ SHQC⁴ OHQC⁵ Province of Quebec6

NBHC7

Acceptable ■ ■ ■

XAccessible/Timely ■ ■ ■ ■ ■ ■ ■

X Appropriate ■ ■ ■ ■Appropriatelyresourced ■

Competence ■

Continuity ■ ■ ■

X Effective ■ ■ ■ ■ ■ ■ ■X Efficient ■ ■ ■ ■ ■ ■ ■X Equitable ■ ■ ■ ■

Integrated ■

Patient/Clientcentred ■ ■ ■ ■ ■

Population Health ■ ■ ■ ■

X Safe ■ ■ ■ ■ ■ ■ ■Work life ■ ■

Source: Adapted with permission from Accreditation Canada (2007). “Quality Frameworks: National and International Overview, Common/Unique Dimensions & Key Messages” Note: Shaded rows indicate common dimensions across all organizations.Kelley, E. and Hurst, J. (2006). Health Care Quality Indicators Project: Conceptual Framework Paper. OECD Health Working Papers.BC Patient Safety and Quality Council. (2009). BC Health Quality Matrix. www.bcpsqc.caHealth Quality Council of Alberta. (2009). Alberta Quality Matrix for Health. www.hqca.caSaskatchewan Health Quality Council. (2009). Quality Insight—Dimensions of Quality. www.hqc.sk.caOntario Health Quality Council. (2009). 2009 Report on Ontario’s Health System. www.ohqc.caLSSS, L.R.Q., chapitre S 4.2 Loi sur les services de santé et les services sociaux. www.publicationsduquebec.gouv.qc.ca‐New Brunswick Health Council (2009). Quality Dimensions. www.nbhc.ca

Comparative performance

• Access• Capacity• Effectiveness• Equity• Patient-centredness• Safety

QUALITY DOMAIN

CANADA US

Access •87% (public) report access to a regular doctor•28% (sicker adults) waited > 1 week for primary care•29% (public) waited in the ED > 4hrs• 57% (sicker adults) waited to see a specialist > 4 wks

•74%•20%•12%•23%

Capacity •2.1 practicing physicians per 1,000 population•8.8 practising nurses per 1,000 population•23% primary care physicians’ use of electronic patient medical records

•2.4•10.5•28%

Effectiveness •adherence to recommended care processes - 53% foot care; 69% eye care•78.6% childhood immunization coverage for diphtheria, tetanus and pertussis

•61%; 68%•85.2%

QUALITY DOMAIN

CANADA US

Equity (cost concerns as a barrier care)

•9% had a specific medical problem but did not visit doctor•10% skipped or did not get a recommended medical test, treatment or follow up•16% did not fill a prescription for medicine or missed doses•29% needed dental care but did not see the dentist

•34%•36%•39%•47%

Patient Centredness

•patient rating of overall quality in the preceding 12 months (29% excellent, 32% good, 23% very good, 10% fair, 4% poor)•clinician-patient engagement (for patients with chronic conditions) – 47% given written plan to manage own care; 65% discussed main goals or priorities for care

•23% excellent, 32% good, 25% very good, 16% fair, 4% poor•66%; 74%

Safety •80% patients having received clear instructions on discharge from hospital•doctors routinely receiving alerts about potential problems with drug doses or interactions – 10% computerized system; 31% manually

•87% •23% computerized; 28% manually

Final points

Healthcare in Canada

Key System Issues• Citizen engagement• Financial sustainability• Health Human Resources• Marginalized Populations (Aboriginal Populations)• Pharmaceutical Policy• Primary Healthcare Reform• Private Sector Care• Quality Improvement and Patient Safety• Regionalization and Integration• Wait Times

+/- for Patients+ -

Choice of primary care provider and specialist (where possible)

Canadians can face long waits for non-urgent care

No point of service charges for insured (mostly hospital and physician) services

Medicare coverage is narrow and deep; therefore not offering a broad spectrum of insured services, e.g., -dental and vision-3.5 million Cdns without/inadequate coverage for catastrophic costs for drugs -Acute-care focus criticized as not meeting chronic care management needs and full patient continuum of care (home care, long -term care)

Portability – coverage within and across provinces

Universality – all Canadians have coverage

Visit us at www.chsrf.ca or email stephen.samis@chsrf.ca jennifer.verma@chsrf.ca

Thank You