Canadian Health Care “It Takes a System”

1. Canadian Health Care“It Takes a System” Lori Whittaker, MD, MPH Family Physician: Swedish Physicians Consultant: Puget Sound Health Alliance

3. Canadian Health Care- Evolved Over Time Saskatchewan established universal coverage for hospital care for its population. The federal government agreed to match provinces 50:50 for hospital care plans 1961 By 1961, all provinces and territories insured hospital care programs. 1962 Saskatchewan government began covering doctors’ services.

4. Brief History of Canadian Health Care 1966National Medicare program established, with federal government paying half the costs. 1972All provinces and territories participating in Medicare program. 1977 Federal 50:50 matching is replaced with block funding 1984CANADA HEALTH ACT

5. The Canada Health Act 1984 5 Principles: Public Administration Comprehensiveness Universality Portability Accessibility

6. The Commision for the Future of Healthcare in Canada 2003: The Romanow Report

7. Romanov Report- 2003 • “Canada’s healthcare system is adequate to meet our needs, but there is room for improvement” • Strong national consensus for a universal publicly funded health care system

8. Myths… • Canadians have substandard health care • Canadians die waiting for medical services • Thousands of Canadians come to the U.S. for care

9. …and Reality • Population health indicators, such as life expectancy and infant mortality, are better in Canada than the U.S. • Outcome studies have generally shown that Canada does as well or better than the U.S. for most medical services or conditions* • Fewer than 0.1% of Canadians receive care in U.S. (and roughly an equal number of Americans receive care in Canada) *see for example: 1. ICES 1999. Health Care Delivery in Canada and the United States: Are There Relevant Differences in Health Care Outcomes? 2. A systematic review of studies comparing health outcomes in Canada and the United States.Open Medicine 2007. http://www.openmedicine.ca/article/view/8/15

10. Further realities… • In 2006, Canada spent $3676 per capita on health care, or 55% of the $6714 per capita spent in the U.S. • Organization for Economic Cooperation and Development (OECD) 2007 (http://www.oecd.org/dataoecd/46/33/38979719.pdf) • <1% of Canadians lack health insurance compared to16% of Americans (47 million people) • KFF State Health Facts 2006 • Health care administrative costs in Canada were 16.7% in Canada in 1999 compared to 31% in the U.S. • Woolhandler et al., N Engl J Med 2003;349 (25):2461

11. What about those wait times? • The only way to have no waiting times for diagnostic or therapeutic procedures is to have greatly excess capacity • Excess capacity costs money to build and maintain, and encourages unnecessary use of services, as well as increased pricing to recoup capital investments • Canada has a priority system for procedures, and in general, waiting times are not associated with worse outcomes

12. What about those wait times? • “Bladder surgery wait time unsafe” • The Montreal Gazette, July 26, 2006 • McGill University study • Bladder cancer patients are dying unnecessarily because of delays in treatment • If patients waited 12 weeks or more for surgery, they had a higher chance of dying • This was the first study to show that a delay in treatment affected outcomes

13. What about those wait times? • Supreme Court of Canada Chaoulli Decision (2005) • Quebec patient George Zeliotis had to wait one year for a hip replacement. He and his physician, Dr Chaoulli, sued the Quebec government, saying it violated his constitutional rights to life, liberty and security of the person. • Decision: In favor of the plaintiffs. • “Access to waiting lists is not access to health care”

14. What about those wait times? • Results of Supreme Court Decision: • The Province of Quebec had to allow private insurance coverage for procedures for which wait times did not meet specific standards • Quebec passed legislation allowing private insurance coverage for hip replacements, cataract surgery and knee replacements. • So far, no insurers have offered such products in Quebec • In fear of legal action, all provinces have been working with the federal government to set wait time standards, and to develop mechanisms for meeting those standards

15. Wait Times Alliance • Made up of 6 national medical specialty groups and the Canadian Medical Association • To recommend medically acceptable wait times based on evidence for treatment in the areas of: • cardiac procedures • cancer treatment • diagnostic imaging • joint replacement (hip and knee) • sight restoration (cataract surgery)

16. Taming of the Queue • Taming of the Queue Conference IV (April 2007) • Canadian Primer Minister Harper announced agreement with provinces and territories to meet specific Patient Wait Time Guarantees by 2010, in return for federal funding

17. Taming of the Queue • Priority areas: • cancer care • hip and knee replacement • cardiac care • diagnostic imaging • cataract surgeries • primary care • Budget 2007: • $612 million for the Patient Wait Times Guarantee Trust • $30 million for wait times pilot projects • $400 million for Canada Health Infoway

18. Surgical Wait Times (Weeks)-British Columbiahttp://www.health.gov.bc.ca/cpa/mediasite/waitlist/median.html

19. The Healthcare Balance Cost Access Quality

20. Healthcare = Health • The healthcare system contributes only about 15% to a population’s health • Social determinants of health • Poverty, housing, education, literacy, environment, social disparities, discrimination, etc. • Healthcare systems tend to do better with disease care than with health care • In the US, there are perverse incentives to “do more” in terms of treatment, rather than invest in prevention or in improving the social determinants of health

21. Healthcare = Health • In Canada: • Same payer (the government/taxpayer) funds health care, public health, social services, public assistance programs, education, etc. • Incentive to coordinate activities • Failure in one area leads to higher costs in another • Social and public health services are integrated with health care services in Canada, coordinated through community health and social service centers.

22. Discussion Scenario • The CMA recommends that: • “When access to timely care cannot be provided in the publicly funded system, Canadians should be able to use private health insurance to reimburse the cost of care obtained in the private sector.” (CMA Policy Statement July 2007)

23. Discussion Scenario • Top doctor admits to queue-jump “No wait times should exist, CMA head argues” CanWest News Service (12/3/07) • The story: • Dr Brian Day’s (president of CMA) 5 year old daughter had sudden pain in her leg. She was taken to the ER by her mother, who was also a doctor. • An X-ray revealed a bone tumor (benign vs malignant?) • The hospital scheduled a CT scan for one week later • Dr Day felt this was an unacceptable time to wait to find out if his daughter had cancer, and used his clout to get a CT that day

24. Discussion Questions • How long is too long to wait for healthcare services? How do we decide? • Should people be able to pay more for better or quicker healthcare services in the private sector if they can afford it? What would that do to the public system? • Is access to health care a right or a privilege? If it is a right, then how do we define “health care”?

25. Summary It takes a system….

26. Further Reading • Newsweek January 19, 2009 • Obama’s Unhealthy Choices by Robert J. Samuelson • Harper’s February 2009 • Sick in the Head by Luke Mitchell