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