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The Canadian healthcare system: May 20, 2011


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This presentation was given on May 20, 2011, as an overview of healthcare in Canada to a group of American Congressional Fellows on Parliament Hill. The Fellows were in Canada on an official visit, sponsored by the Department of Foreign Affairs and International Trade Canada (DFAIT), as part of an exchange with the Parliamentary Internship Programme. The group included 20 mid- to senior career professionals from various departments in the American and some foreign Governments, professors from American universities and journalists. They also include a number of Robert Wood Johnson Foundation Fellows, who are all medical professionals.

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The Canadian healthcare system: May 20, 2011

  1. 1. Healthcare in Canada <ul><li>Stephen Samis, Vice-President, Policy </li></ul><ul><li>Jennifer Verma, Director, Policy </li></ul><ul><li>May 20, 2011 </li></ul>
  2. 2. Overview <ul><li>About CHSRF </li></ul><ul><li>How has Medicare evolved over time? </li></ul><ul><li>What are the key components of Canada’s healthcare “systems”? </li></ul><ul><li>What are the basic economics and some of the key quality and performance challenges? </li></ul><ul><li>Final thoughts – patient perspective </li></ul>
  3. 3. CHSRF profile <ul><li>publicly-funded organization </li></ul><ul><li>not-for-profit corporation, registered charity </li></ul><ul><li>$151.5 M endowment </li></ul><ul><li>$15-16 M annual operating budget </li></ul><ul><li>Approx. 50 staff – best place to work awards </li></ul>
  4. 4. CHSRF – Who we are <ul><li>Our work is directed at three levels: </li></ul><ul><ul><li>The policy level, to create policy environments that accelerate or enable transformation to occur </li></ul></ul><ul><ul><li>The health system or regional level, to support systems that show readiness to implement transformative initiatives and </li></ul></ul><ul><ul><li>The local or individual level, to help healthcare providers and citizens redefine their roles in the provision of person-centered care </li></ul></ul>
  5. 5. CHSRF – What we do <ul><li>In support of our mission, CHSRF offers customized: </li></ul><ul><ul><li>change management and implementation initiatives </li></ul></ul><ul><ul><li>research and policy analysis </li></ul></ul><ul><ul><li>consultation, workshops and dialogue events </li></ul></ul><ul><ul><li>education and training, assessment tools and decision support </li></ul></ul><ul><ul><li>outcomes evaluation </li></ul></ul>
  6. 6. Some Programs and Initiatives <ul><li>Healthcare FIT (Financial sustainability, Innovation and Transformation) </li></ul><ul><li>Better with Age: Health Systems Planning for the Aging Population </li></ul><ul><li>Mythbusters series </li></ul><ul><li>Leadership Survey </li></ul><ul><li>EXTRA (Executive Training for Research Application) </li></ul><ul><li>PEP (Patient Engagement Projects) </li></ul><ul><li>Harkness Fellowships </li></ul><ul><li>Excellence Through Evidence Award </li></ul><ul><li>Signature Events (CEO Forum, Picking up the Pace) </li></ul>
  7. 7. Lavis J. et al. 2009. SUPPORT Tools for evidence-informed health Policymaking (STP) . Health Research Policy & Systems 7(Suppl 1).
  8. 8. History & Roles Healthcare in Canada
  9. 9. Constitutional responsibility for healthcare – Canada, 1867 <ul><li>Power of (Federal) Parliament (section 91:11) </li></ul><ul><ul><li>Quarantine and the Establishment and Maintenance of Marine Hospitals. </li></ul></ul><ul><li>Exclusive powers of provincial legislatures (92:7) </li></ul><ul><ul><li>The Establishment, Maintenance and Management of Hospitals, Asylums, Charities, and Eleemosynary Institutions in and for the Province, other than Marine Hospitals. </li></ul></ul>
  10. 10. Legacy of the Constitution <ul><li>14 health systems – 1 for each province/territory + Health Canada </li></ul><ul><li>In terms of spending, Health Canada is the 5 th largest system </li></ul><ul><ul><li>provider of supplementary health benefits to 750,000 First Nations and Inuit peoples </li></ul></ul><ul><ul><li>direct provider on reserves and isolated locations </li></ul></ul>
  11. 11. Tax-Funded Systems (Beveridge) <ul><li>Provision of healthcare for all people through central taxation and other compulsory financial contributions and a system of universal benefits. </li></ul>
  12. 12. Landmark Legislation <ul><li>Hospital Insurance and Diagnostic Services Act, 1957 </li></ul><ul><li>Medical Care Act, 1966 </li></ul><ul><li>Established Programs Financing, 1977 </li></ul><ul><li>Canada Health Act, 1984 </li></ul>
  13. 13. Principles of Canadian Medicare <ul><li>Public Administration – administered and operated on a non-profit basis </li></ul><ul><li>Comprehensiveness – must insure all insured health services </li></ul><ul><li>Universality – 100% of insured residents must be entitled on uniform terms and conditions </li></ul><ul><li>Portability – coverage moves between provinces and territories </li></ul><ul><li>Accessibility – no financial barriers (e.g., user fees) </li></ul>
  14. 14. Canada Health Act: Insured Services <ul><li>“ 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. </li></ul>
  15. 15. Governance <ul><li>Federal Government </li></ul><ul><ul><li>Canada Health Act </li></ul></ul><ul><ul><li>health protection </li></ul></ul><ul><ul><li>research (Canadian Institutes of Health Research) </li></ul></ul><ul><li>Provincial/Territorial Governments </li></ul><ul><ul><li>policy-setting (e.g., def. of insured services) </li></ul></ul><ul><ul><li>funding envelope </li></ul></ul><ul><ul><li>health professional regulation </li></ul></ul><ul><ul><li>regulation of hospitals </li></ul></ul>
  16. 16. Governance <ul><li>Regional Health Authorities </li></ul><ul><ul><li>Funding allocation </li></ul></ul><ul><ul><li>Needs assessment </li></ul></ul><ul><li>Hospitals and Agencies* </li></ul><ul><ul><li>Program delivery </li></ul></ul><ul><ul><li>Quality assurance </li></ul></ul><ul><ul><li>Physician privileges </li></ul></ul><ul><li>Professional Regulatory Bodies </li></ul><ul><ul><li>Licensure </li></ul></ul><ul><ul><li>Discipline </li></ul></ul><ul><li>* Note these would be subsumed under regional health authorities in most jurisdictions. </li></ul>
  17. 17. Health Canada – Core Roles <ul><li>Leader/Partner through the administration of the Canada Health Act </li></ul><ul><li>Funder through policy support for the federal government’s Canada Health and Social Transfer </li></ul><ul><li>Guardian/Regulator regulates and approves the use of thousands of products (e.g., medical devices, pharmaceuticals </li></ul><ul><li>Service Provider through the provision of supplementary health benefits to approximately 749,725 eligible First Nations and Inuit (e.g., pharmaceuticals, vision care, transportation) </li></ul><ul><li>Information Provider through performing high quality science and research </li></ul>Source: Health Canada.
  18. 18. Public Health Agency of Canada - Core Roles <ul><li>Promote health; </li></ul><ul><li>Prevent and control chronic diseases and injuries; </li></ul><ul><li>Prevent and control infectious diseases; </li></ul><ul><li>Prepare for and respond to public health emergencies, and </li></ul><ul><li>Strengthen public health capacity </li></ul>Source: Public Health Agency of Canada.
  19. 19. Selected National Organizations <ul><li>Accreditation Canada </li></ul><ul><li>Canadian Agency for Drugs and Technologies in Health </li></ul><ul><li>Canada Health Infoway </li></ul><ul><li>Canadian Institute for Health Information </li></ul><ul><li>Canadian Medical Association </li></ul><ul><li>Canadian Nurses Association </li></ul><ul><li>Canadian Patient Safety Institute </li></ul><ul><li>Health Council of Canada </li></ul>
  20. 20. Financing & Cost Drivers Healthcare in Canada
  21. 21. Total health expenditure per capita, US$ PPP Source: Public Accounts and 2000 budgets.
  22. 22. Source: OECD Health Data 2010. (latest data 2008) INDICATOR CANADA US OECD Average Total Health Expenditures as a % of GDP (32) 10.4 (6 th ) 16.0 (1 st ) 9.0 Total Health Expenditures Per Capita US $ (27) $4,079 (5 th ) $7,538 (1 st ) $3,060 Public % of Total Health Expenditures (31) 70.2 46.5 72.8
  23. 23. Canada: A Single-Payer System? <ul><li>Selected Category % Public Funding 2009 </li></ul><ul><li>Hospitals 90.8 </li></ul><ul><li>Other Institutions 71.5 </li></ul><ul><li>Physicians 98.9 </li></ul><ul><li>Other Professionals 7.0 </li></ul><ul><li>Prescription Drugs 45.0 </li></ul><ul><li>Capital 83.0 </li></ul><ul><li>Total Health Spending 70.2 </li></ul>Source: CIHI National Health Expenditure Trends 1975 to 2009
  24. 24. Health Expenditures by Selected Category Canada, 1984 and 2009 <ul><li>Selected Category 1984 2009 </li></ul><ul><li>% of total </li></ul><ul><li>Hospitals 41.8 27.8 </li></ul><ul><li>Other Institutions 10.7 10.0 </li></ul><ul><li>Physicians 15.0 14.0 </li></ul><ul><li>Other Professionals 10.0 10.9 </li></ul><ul><li>Prescription Drugs 6.1 13.9 </li></ul><ul><li>Capital 4.1 4.8 </li></ul><ul><li>Public Health 3.7 6.2 </li></ul><ul><li>Hospital/Physician Subtotal 56.8 41.8 </li></ul>Source: CIHI National Health Expenditure Trends 1975 to 2009
  25. 25. Federal Contribution to Health, Canada, 2009 <ul><li>$ Millions % of Total Public Expenditures </li></ul><ul><li>Canada Health Transfer 22,987 18.7 </li></ul><ul><li>Federal Direct Exp. 6,616 5.1 </li></ul><ul><li>Subtotal 30,603 23.8 </li></ul><ul><li>Total Public Exp. 128,597.3 100 </li></ul>Source: CIHI and Finance Canada
  26. 26. Consolidated Provincial and Territorial Government Revenue and Expenditures, Canada and Provinces 1999-2009 <ul><li>Average Annual % Increases </li></ul><ul><li>Total Health </li></ul><ul><li> Total Revenue Expenditures Expenditures </li></ul><ul><li>Canada* 5.6% 5.3% 6.9% </li></ul><ul><li>Newfoundland & Labrador 8.4% 6.3% 7.0% </li></ul><ul><li>Prince Edward Island 4.5% 5.4% 5.9% </li></ul><ul><li>Nova Scotia 5.0% 4.9% 5.6% </li></ul><ul><li>New Brunswick 4.0% 4.7% 8.2% </li></ul><ul><li>Quebec 5.0% 5.4% 6.4% </li></ul><ul><li>Ontario 5.3% 5.3% 7.5% </li></ul><ul><li>Manitoba 4.8% 5.0% 8.0% </li></ul><ul><li>Saskatchewan 7.7% 5.8% 7.9% </li></ul><ul><li>Alberta 9.4% 9.1% 9.7% </li></ul><ul><li>British Columbia 4.9% 2.7% 3.8% </li></ul><ul><li>*Territories are included in Canada total </li></ul>Source: Statistics Canada CANSIM Table 385-0001
  27. 27. Consolidated Provincial and Territorial Government Expenditures, Canada, 1999 and 2009 <ul><li>Category % of Total Expenditures* 1999 2009 </li></ul><ul><li>Health 32.3 35.4 </li></ul><ul><li>Social Services 19.4 18.9 </li></ul><ul><li>Education 27.6 25.1 </li></ul>* Less debt charges
  28. 28. Financial Sustainability <ul><li>Canada’s healthcare costs are increasing </li></ul><ul><li>Health has increased its share of GDP since 2000 </li></ul><ul><li>But recent increases in healthcare’s share of the GDP are almost totally due to the recession </li></ul><ul><li>Healthcare has slightly increased its share of provincial budgets due mainly to cuts in other areas rather than increases in health spending </li></ul><ul><li>Canada’s health costs are similar to other wealthy countries and substantially less than those in the US </li></ul>
  29. 29. What are the key cost drivers?
  30. 30. The effect of key cost drivers on health spending growth: - Synthesis of Canadian studies
  31. 31. Quality & Performance Healthcare in Canada
  32. 32. 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. Health Quality Council of Alberta. (2009). Alberta Quality Matrix for Health. Saskatchewan Health Quality Council. (2009). Quality Insight—Dimensions of Quality. Ontario Health Quality Council. (2009). 2009 Report on Ontario’s Health System. LSSS, L.R.Q., chapitre S‐4.2 Loi sur les services de santé et les services sociaux. New Brunswick Health Council (2009). Quality Dimensions. Most frequently used dimensions internationally¹ Quality dimension Accreditation Canada B.C. PSQC² HQCA³ SHQC⁴ OHQC⁵ Province of Quebec 6 NBHC 7 Acceptable ■ ■ ■ X Accessible/ Timely ■ ■ ■ ■ ■ ■ ■ X Appropriate ■ ■ ■ ■ Appropriately resourced ■ Competence ■ Continuity ■ ■ ■ X Effective ■ ■ ■ ■ ■ ■ ■ X Efficient ■ ■ ■ ■ ■ ■ ■ X Equitable ■ ■ ■ ■ Integrated ■ Patient/Client centred ■ ■ ■ ■ ■ Population Health ■ ■ ■ ■ X Safe ■ ■ ■ ■ ■ ■ ■ Work life ■ ■
  33. 33. Comparative performance <ul><li>Access </li></ul><ul><li>Capacity </li></ul><ul><li>Effectiveness </li></ul><ul><li>Equity </li></ul><ul><li>Patient-centredness </li></ul><ul><li>Safety </li></ul>
  34. 34. QUALITY DOMAIN CANADA US Access <ul><li>87% (public) report access to a regular doctor </li></ul><ul><li>28% (sicker adults) waited > 1 week for primary care </li></ul><ul><li>29% (public) waited in the ED > 4hrs </li></ul><ul><li>57% (sicker adults) waited to see a specialist > 4 wks </li></ul><ul><li>74% </li></ul><ul><li>20% </li></ul><ul><li>12% </li></ul><ul><li>23% </li></ul>Capacity <ul><li>2.1 practicing physicians per 1,000 population </li></ul><ul><li>8.8 practising nurses per 1,000 population </li></ul><ul><li>23% primary care physicians’ use of electronic patient medical records </li></ul><ul><li>2.4 </li></ul><ul><li>10.5 </li></ul><ul><li>28% </li></ul>Effectiveness <ul><li>adherence to recommended care processes - 53% foot care; 69% eye care </li></ul><ul><li>78.6% childhood immunization coverage for diphtheria, tetanus and pertussis </li></ul><ul><li>61%; 68% </li></ul><ul><li>85.2% </li></ul>
  35. 35. QUALITY DOMAIN CANADA US Equity (cost concerns as a barrier care) <ul><li>9% had a specific medical problem but did not visit doctor </li></ul><ul><li>10% skipped or did not get a recommended medical test, treatment or follow up </li></ul><ul><li>16% did not fill a prescription for medicine or missed doses </li></ul><ul><li>29% needed dental care but did not see the dentist </li></ul><ul><li>34% </li></ul><ul><li>36% </li></ul><ul><li>39% </li></ul><ul><li>47% </li></ul>Patient Centredness <ul><li>patient rating of overall quality in the preceding 12 months (29% excellent, 32% good, 23% very good, 10% fair, 4% poor) </li></ul><ul><li>clinician-patient engagement (for patients with chronic conditions) – 47% given written plan to manage own care; 65% discussed main goals or priorities for care </li></ul><ul><li>23% excellent, 32% good, 25% very good, 16% fair, 4% poor </li></ul><ul><li>66%; 74% </li></ul>Safety <ul><li>80% patients having received clear instructions on discharge from hospital </li></ul><ul><li>doctors routinely receiving alerts about potential problems with drug doses or interactions – 10% computerized system; 31% manually </li></ul><ul><li>87% </li></ul><ul><li>23% computerized; 28% manually </li></ul>
  36. 37. Final points Healthcare in Canada
  37. 38. Key System Issues <ul><li>Citizen engagement </li></ul><ul><li>Financial sustainability </li></ul><ul><li>Health Human Resources </li></ul><ul><li>Marginalized Populations (Aboriginal Populations) </li></ul><ul><li>Pharmaceutical Policy </li></ul><ul><li>Primary Healthcare Reform </li></ul><ul><li>Private Sector Care </li></ul><ul><li>Quality Improvement and Patient Safety </li></ul><ul><li>Regionalization and Integration </li></ul><ul><li>Wait Times </li></ul>
  38. 39. +/- 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 <ul><li>Medicare coverage is narrow and deep; therefore not offering a broad spectrum of insured services, e.g., </li></ul><ul><li>dental and vision </li></ul><ul><li>3.5 million Cdns without/inadequate coverage for catastrophic costs for drugs </li></ul><ul><li>Acute-care focus criticized as not meeting chronic care management needs and full patient continuum of care (home care, long -term care) </li></ul>Portability – coverage within and across provinces Universality – all Canadians have coverage
  39. 40. Visit us at w or email [email_address] [email_address] Thank You