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Slide 1 - SSCC - Home

  1. 1. The Canadian Health Care System<br />Ben Swanson, Eric Hoyt, Scott Thompson, and Nancy Thao<br />
  2. 2. Overview<br />Health Insurance Industry <br />Hospitals<br />Physicians<br />Nurses<br />Patients<br />
  3. 3. The Health Insurance Industry in Canada<br /><ul><li>Health insurance:</li></ul> -Public<br /> -Private<br /><ul><li>How Public Insurance Functions:</li></ul> -Finance<br /> -Hospitals<br /> -Employment of Providers<br /><ul><li>Effects of Public Insurance</li></li></ul><li>Public Health Insurance<br />Financed: 70 percent public health care<br />Covered: standard hospital and physician medical services<br />Not covered: elective surgery, prescription drugs, medical devices, dental care, eye care, homecare (Tuohy 2009)<br />Provinces: global budgets, fee-for-service schedules, capacity constraints (Phelps 2010)<br />Five conditions: public administration, comprehensiveness, universality, portability, and accessibility (Detsky 2003)<br />
  4. 4. Private Health Insurance<br />Prohibited: private insurance for public services<br />Covered: elective surgery, prescription drugs, medical devices, dental care, eye care, homecare (Flood and Archibald 2001)<br />2/3 of Canadians carry private health insurance<br />Financed through employers (Tuohy 2009)<br />Private insurance + out-of-pocket expenses = 27% health care expenditures (Marchildon, 2005) <br />Provision of healthcare is undertaken by the private sector<br />
  5. 5. Finance of Public Health Insurance<br />Financed: 70% public insurance, 12% private insurance, 15% out-of-pocket, 3% other (Tuohy 2009)<br />Financed: (in 2004) 64% provincial government, 6.2% federal government (Zhong 2009)<br />Federal funding capped at 25% of provincial health expenditure (Detsky 2003)<br />Tax Revenue: (in 1988) 37% personal income tax, 25% commodity tax, 14% payroll tax, 9% corporate income tax, 10% property tax, and 5% estate/other tax (Vermaeten et. al. 1995)<br />
  6. 6. Hospitals<br />Approx. 900 hospitals, mostly private non-profit organizations(Decter 1997)<br />Public funding accounts for 91% of hospital expenditure (Madore 2005)<br />Public global funding = guaranteed annual reserves regardless of patient volume (Botz 1993)<br />Global funding channeled to Regional Health Authorities (RHAs) (Brown et. al. 2006)<br />Provincial RHAs decide: capital expansion, bed allocations, introduction of technologies, hospital budgets, categories of staff to be hired (Madore 2005)<br />
  7. 7. Employment of Providers<br />80% physicians paid by fee for service scheme (Wranik 2009)<br />Provinces set physicians’ pay through fee schedules negotiated with medical associations (Brown et. al. 2006)<br /><ul><li>Faculty physicians, residents, nurse practitioners, nursing assistants are paid by salary (Spitzer et. al. 1976) </li></ul>62.9 % of nurses work in hospitals, 13.9% in community health, 10.6% in nursing homes, 12.5% in other places<br />
  8. 8. Effects of Public Insurance in Canada<br />2007: Total Health Care spending was $160 billion (10.6% of GDP)<br /> Health care expenditures increased from $600 per capita in 1960, nearly double the OECD median, to $2,250 per capita in 1998, about equal to OECD median (Iglehart 2000)<br />In 1961, public insurance  2% rise in employment<br />In 1961, public insurance  rise in wages of 3%-4% (Gruber and Hanratty 1995)<br />Eliminates adverse selection by community rating (Feldman et. al. 1998)<br />
  9. 9. Canadian Hospitals<br />Hospital Expenditures<br />Where the money goes<br />Acute-Care Hospitals<br />Current issues for Hospitals<br />Infectious Diseases<br />Adverse Drug Effects<br />
  10. 10. Hospital Expenditures<br />Hospitals accounted for 28% of total Health Spending in 2005<br />Decrease from 45% in 1975<br />Hospital spending is continuously rising<br />Is becoming a smaller proportion of total health spending<br />(CIHI 2008)<br />
  11. 11. Where does the money go?<br />2006: Most of the money goes towards compensation for staff ($21 Million)<br />37% - Inpatient Nursing services<br />21% - Diagnostic & therapeutic Services<br />18% - Administrative & support services<br />13% - ER & Ambulatory Care<br />(CIHI 2008)<br />
  12. 12. Acute Care Hospitals<br />2004–2005<br />Acute Care accounted 47% of total hospital spending ($17 million)<br />Acute-care hospitals: those who have at least 200 beds or dedicate 50% of their total number of beds to acute care<br />Much of the literature correlates much of Health Care Spending to acute care<br />What is contributing to this cost?<br />(CIHI 2008)<br />
  13. 13. Acute-Care Hospitals: Most expensive to least expensive inpatient Care (2004 to 2005)<br /><ul><li>Circulatory diseases are the most expensive (heart attacks, strokes)</li></ul>19% of inpatient costs ($3 million)<br />High cost per stay (average of $11,260)<br />High volume of stays (292,562)<br /><ul><li>Injuries (falls, accidents, poisoning)</li></ul>10% of total inpatient costs ($2 million)<br />Average of $9,400 each stay<br />Diseases of the Respiratory System<br />9.5% of inpatient cost ($1.6 million)<br />Neoplasm (Cancers)<br />9.4% or $1.59 million<br />Important: Pregnancy & childbirth<br />accounted for the highest volume of stays (314,535)<br />only 5% of total inpatient costs<br />Low average cost per stay ($2,000 for vaginal delivery & $4,000 for caesarean)<br />(CIHI 2008)<br />
  14. 14. Current Issues for Hospitals<br />Infectious Diseases<br />Adverse Drug Effects<br />
  15. 15. Infectious Diseases<br />Every year, more than 250,000 Canadians are ill from preventable infections<br />Methicillin resistant Staph infection has increased 10-fold in less than a decade<br />Average about $14,000 (Canadian Dollars) per patient<br />$100 million (Canadian) for the whole country<br />Canadian hospitals have fewer regulations for controlling infectionsthan restaurants<br />Due to downsizing, they do nothave the required number of staff needed to combatinfections<br />(Spurgeon 2005) <br />
  16. 16. Adverse Drug Effects (ADE)<br />Patients being given the wrong drugs or the wrong dosage of drugs<br />Half of these cases are preventable<br />Increase use of Health Care technology<br />Bar-coding for drug dispensing & administration<br />Computerized Physician Order Entry System - Physicians type medication orders directly into a computer system<br />Clinical Decision Support System for Physicians - A rule-based, intelligent database that checks automatically and routinely for inappropriate drug orders<br />(M. Saginuret al. 2008)<br />
  17. 17. Physicians in Canada<br /><ul><li>Becoming a Doctor
  18. 18. Who are the Doctors?
  19. 19. Doctor Shortages</li></li></ul><li>Canadian Medical School<br />17 Medical Schools in Canada<br />132 in the United States<br />MCAT is required<br />Bachelor’s Degree is not<br />4-5 Year programs<br />Provincial residency has heavy impact on admissions<br />2006/2007 – 6093 female applicants, 4580 male applicants<br />Overall admissions rate = 25%<br />(AFMC 2010)<br />
  20. 20.
  21. 21. Who are Canada’s Physicians?<br />
  22. 22.
  23. 23. 38.7% of all physicians are located in urban areas<br />33.6% of Canada’s population lives there<br />Only 9.4% of physicians work in rural areas<br />21.1% of Canada’s population lives there<br />(CIHI 2005)<br />Where are they practicing?<br />
  24. 24.
  25. 25.
  26. 26. Doctor Shortages<br />OECD Numbers<br />OECD mean = 3.1 doctors per 1000 pop.<br />Canada = 2.2 per 1000 pop.<br />Rural areas can be much worse <br />Issue boils down to two major problems<br />Recruitment <br />Finding doctors to work in rural areas<br />Retention<br />Keeping doctors in rural areas<br />
  27. 27. This wasn’t always the case<br />Recent literature focused on surplus<br />“This point cannot be stressed too hard: there are too many doctors.”<br />(Roos 1976)<br />Barer-Stoddart Report 1991<br />Called for reductions in Med School admissions<br />Policies were implemented<br />Physicians per 1000 pop was essentially capped<br />(Esmail)<br />
  28. 28. The picture today<br />Health Outcome<br />Higher doctor to population ratios show decreased mortality rates<br />(Or, 2001)<br />Strains rural doctors<br />Curran 2004<br />Threats to Access<br />Weak MIZs average 10.4 km to a physician<br />No MIZs average 33.5 km to a physician<br />Canadian Average = 3.4 km to a physician<br />Large Urban centers = .9 km to a physician<br />CIHI 2005<br />
  29. 29. Recruitment <br />Difficult to find doctors to work in rural areas<br />Solutions?<br />Recruitment of foreign Doctors<br />Around 20% are already foreign <br />(CIH)<br />Can get complicated…<br />Fee system changes<br />Curran<br />Risks to hospitals and treatment centers<br />Amount of care provided, and even the existence of facilities is threatened<br />(Curran)<br />
  30. 30. Retention<br />Doctors leave the provinces they are trained in<br />For highly populous areas, or the US<br />(Rytek)<br />“The situation has never been as dire.”<br />(Shuchman)<br />
  31. 31. The Nurse Industry<br /><ul><li> The different types (RN, LPN, RPN)
  32. 32. Educational Requirements
  33. 33. Who are they? (Gender)
  34. 34. Employment Areas
  35. 35. Current Work Climate
  36. 36. Nurse Migration
  37. 37. Aging of the Nurse Population
  38. 38. Internationally Educated Nurse</li></li></ul><li>The Different Types<br /><ul><li>76.7% - Registered Nurses (RNs)
  39. 39. 21.8% - Licensed Practical Nurses (LPNs)</li></ul>1.5% - Registered Psychiatric Nurses (RPNs)<br />Nurse Distribution by Province/Territory<br />
  40. 40. Educational Requirements<br />Registered Nurses (RNs)<br />1960s and1970s: diploma in nursing from a 2 or 3 year hospital-based program<br />1990s: <br />3 year diploma from a community college<br />4 year University degree (some require & others in progress)<br />Passing the national Canadian Registered Nurses Examination (CRNE)<br />Licensed Practical Nurses (LPNs)<br />1 or 2 year diploma from a community college<br />Passing the national Canadian Practical Nurses Registration Examination (CPNRE)<br />(CIHI 2008)<br />
  41. 41. Who are they?<br />The Nurse Population is predominantly female<br />RNs -94% female<br />LPNs - 92.8% female<br />
  42. 42. Employment – RNs vs LPNs<br /><ul><li> Provinces of Canada in 2007
  43. 43. Majority works in Hospitals
  44. 44. Consistent over last 5 years</li></ul>Registered Nurses<br />Licensed Practical Nurses<br />Canada Institute for Health Information<br />
  45. 45. Current Work Climate<br />1990s – recent restructuring, <br />increase in dissatisfaction in work environments<br />Unlike the popular stereotype<br />80.1% - Good Nurse-Physician Relationship <br />78.2% - physicians provided high-quality care to patients<br />Dissatisfaction:<br />Hospital Management<br />Only 34.9% - listens & responds to concerns<br />Only 39.7% - gives them opportunity to participate in policy decisions<br />Only 37.0% - the contributions they make to patient care are acknowledged<br />Overload & Burnout<br />39.9% decrease in the number of nurse managers<br />25% decrease chief nursing officers<br />63.6% - experienced an increase in the number of patients assigned to them<br />Overall, 36% of nurses felt overworked<br />(Aiken 2001)<br />
  46. 46. Nurse Migration<br />1990 – 2000:<br />81,044 graduates from Canadian nursing schools <br />only 64,394 (79%) registered in 2001 as working in Canada<br />To the United States<br />1993-1994: <br />40% of Canadian registered nurses left to U.S.<br /> Canada projects a RN shortage of 100,000 by 2016<br />(Bundred 2000)<br />
  47. 47. Aging of the Nurse Population<br />Many of the nurses are old and retiring<br />2008:<br />58.3% of the RN were between 40 to 60 yrs old<br />55.2% of the LPN were between 40 to 60 yrs old<br />16.6% - planning to leave present job in the next year<br />Only10.3% consisting of those who are under 30 yrs old<br />29.4% - planning to leave present job in the next year<br />Canada Institute for Health Information<br />
  48. 48. Internationally Educated Nurses<br />Number of IEN increasing<br />2008: <br />Total Nurse force: 7.2%<br />RNs: 8.2%<br />LPNs: 2.0%<br />Most are from Philippines & UK<br />Greatest continuing increase from India<br />(Little 2007)<br />
  49. 49. Patients in the Canadian Health Care System<br /><ul><li> Incomplete Access
  50. 50. Inefficiently Long Wait Times
  51. 51. The Costs Due to Incomplete Access
  52. 52. Addressing Problems With Access
  53. 53. Quality of Care Received
  54. 54. Satisfaction of Care Provided </li></li></ul><li>Issues With Access<br />Who is covered?<br />Government provided health care.<br />70% of total health care costs.<br />Large provincial variation in coverage. (Marchildon, 2005)<br />Medically necessary coverage.<br />Elective surgery.<br />Medical devices.<br />Optical and Dental coverage.<br />Prescription drugs. (Demers et al, 2008)<br />Access to providers<br />Primary care, 1-2 days.<br />Specialized care, 2 months – Over 1 year. (Howard et al, 2009)<br /> Rationing through waiting lists. <br />
  55. 55. Wait Times by Statistics<br />Canada’s wait times exceed established benchmarks in every category. (Christou et al, 2010)<br />Cardiac surgery <br />3.5 months (Legare et al, 2010)<br />Colorectal cancer. <br />2 months (Singh et al, 2010)<br />Bariatric surgery.<br />5 years. (Christou et al, 2010)<br />Digestive disorders<br />47.6% of patients waited over a month for treatment of, <br />23% waited over three months <br />12.5% waited over six months <br />3.5% waited over a year. (Paterson et al, 2010)<br />
  56. 56. Wait Times Continued<br />Bladder Cancer (Cystectomy)<br />50 days (Kulkarni, 09) <br />MRI’s<br />16% of centers meet benchmark times (Emery, 09)<br />Depression and Anxiety<br />Significant deterioration (Janzen, 08) <br />Corneal Transplant<br />30 weeks (Rasoli et al, 09)<br />
  57. 57. Costs Due to Incomplete Access<br />Private insurance is available.<br />The offering of, or purchasing of, private insurance for a health care service provided by the government plan however is illegal.<br />Private insurance and out of pocket expenditures are minimal in this system, making up 12% and 15% of total health care expenditures respectively.<br />Adverse effects of wait times.<br />
  58. 58. Addressing Access Problems<br />Efforts to Improve the situation.<br />Elimination of waste and inefficiencies.<br />Prioritizing wait lines. (Wijeysundera et al, 2010) <br />British Columbia Cancer Agency<br />Plan reduces wait times by 70% (Santibanez, 09)<br />Emergency Departments.<br />Reduced wait times from 3.6 hours in 2004, <br /> to 2.8 hours in 2006. (Ng, et al 2010)<br />Emergency Departments’ effect on wait times,<br /> 73 days on average as compared to 105 days. (Legare et al, 2010)<br />
  59. 59. Quality of Care Received<br />Above OECD average<br />Life expectancy<br />Life expectancy at age 60<br />Infant Mortality <br />Below OECD average<br />Obesity levels<br />Coronary bypass procedures<br />Patients undergoing dialysis (Anderson et al, 2001)<br />
  60. 60. Satisfaction With Care Provided<br />A survey of 770 patients in Ontario in 2005 yielded, on average, high levels of satisfaction with primary care physicians. (Howard et al, 2009)<br />Conversely, patients surveyed about quality of care received in hospitals yielded primarily unsatisfactory results. <br />(Patterson et al, 2010)<br />Wait times rated lowest. (Richard, 2010)<br />Canadians enjoy the benefit of having most of their health care costs covered by government funds, but also struggle with the realities of an imperfect system.<br />
  61. 61. Summary<br />Health Insurance<br />Hospitals<br />Physicians<br />Nurses<br />Patients<br />