HSCI 305
intergovernmental : canada health infoway
"Infoway helps to improve the health of Canadians by working with partners to accelerate the development, adoption and effective use of digital health solutions across Canada."
mandate of truth and reconcilliation commission TRC
"reveal to Canadians the complex truth about the history and the ongoing legacy of the church-run residential schools, in a manner that fully documents the individual and collective harms perpetrated against Aboriginal peoples, and honours the resilience and courage of former students, their families, and communities; and guide and inspire a process of truth and healing, leading toward reconciliation within Aboriginal families, and between Aboriginal peoples and non-Aboriginal communities, churches, governments, and Canadians generally. The process was to work to renew relationships on a basis of inclusion, mutual understanding, and respect."
events since the romanow report
2003: First Ministers' Accord on Health Care Renewal 2004: 10-Year Plan to Strengthen Health Care 2007: Patient Wait Times Guarantee (in priority areas) 2011: Harper conservative government continued to increase transfers at 6% per year past 2013/4, but enacted changes that would drop this annual increase to 3% per year starting in 2017 . . .
1977 federal-provincial fiscal arrangements and established programs financing act
50/50 cost sharing in place from 1957 up to this point, when cost sharing replaced by block fund, in this case a combination of: ◦ Cash payments - sum of money provided for a specific purpose ◦ Transfer of tax points - federal government reduces it tax rates while provincial and territorial governments simultaneously raise their rates a similar amount Increased flexibility for provinces to invest health care funding according to needs and priorities.
control knobs
A metaphor Includes changing the performance of some complex system to produce a specific result Imagine a pilot adjusting the controls of an airplane to maintain the desired altitude, flight path, and speed, or a factory adjusting the production of materials adjustments or changes in the control knob must be significant causal determinants of health system performance
Professional organizations : BC nurses union... what do they do?
BCNU represents most of BC's nurses Negotiates a province wide collective agreement with the Health Employers' Association of BC (HEABC) ◦ This includes terms and conditions of employment Represents nurses who have grievances around a wide range of issues as well
examples of industry associations
Canadian Generic Pharmaceuticals Association Canada's Research-Based Pharmaceutical Companies The Canadian Life and Health Insurance Association
executive summary
Canadians spent $34 billion on prescription medicines in 2018. Drugs are the second biggest expenditure in health care, after hospitals. We spend even more on drugs than on doctors. On a per capita basis, only the United States and Switzerland pay more for prescription drugs.
pharmaceutical industry in canada
Companies manufacturing brand-name drugs ◦ Innovative Medicines Canada founded in 1914 (as "Canadian Association of Manufacturers of Medicinal and Toilet Products") Generic companies (drugs that are ineligible for patents, drugs for which patents have expired and patented drugs for which they have obtained compulsory licenses) ◦ Canadian Generic Pharmaceutical Association (CGPA) Some Canadian-controlled in the mid 1970s and 1980s, now Now predominantly foreign owned mostly foreign owned Small biotechnology companies - generally early- stage research and development
monitoring drug safety
Companies required to notify Health Canada of any adverse reactions they become aware of MedEffect Canada ◦ Reports from health professionals and consumers ~5% of drugs approved eventually need to be taken
implementation
Creation of a Canadian drug agency and create a national formulary—the list of drugs to be covered by national pharmacare by January 2022, complete in January 2027 As with medicare, it will be up to individual provinces and territories to opt in to national pharmacare by agreeing to the national standards and funding parameters of pharmacare. Discussions should now take place between the federal government and First Nations, Inuit and Métis governments and representative organizations
cardiovascular and cancer mortality
Deaths from ischemic heart disease higher in men of South Asian or European origin Rates of death from cancer highest among women and men of European origin, moderate among those of Chinese origin, and lowest among those of South Asian origin
1984 canada health act
Despite Medical Care Act, user fees persisted ◦ Canada Health Act to correct this by withholding the value of all extra billing and user fees from the Established Programs Financing ◦ To enshrine the removal of user fees, federal government added "accessibility" to the other 4 tenets Accessibility not restricted to affordability Canada Health Act replaced previous hospital and medical acts
intergovernmental instruments
Direct and indirect instruments to coordinate policy programs between federal and provincial governments Direct instruments report to the Conference of F/P/T Deputy Ministers of Health
romanows messages to canadians
Equity, fairness, and solidarity at the heart of the system Medicare has served Canadians well System is as sustainable as we want it to be Canadians want and need a truly national health care system Canadians want and need a more comprehensive system Accountability must be improved
public insurance
Every provincial and territorial government has a prescription plan that covers outpatient prescription drugs for designated populations (e.g. seniors and social assistance recipients. Coverage under Non-Insured Health Benefits (NIHB) Program for First Nations and Inuit peoples
epidemiology of diabetes mellitus among first nations and non first nations adults
Examined rates among indigenous men and women in Saskatchewan from 1980-2005 Incidence and prevalence of type 2 diabetes was 4 times higher among indigenous women relative to non-indigenous women and 2.5 times higher among indigenous men relative to non-indigenous men Indicates an epidemic of type II diabetes is occurring, especially among women of reproductive age
insurance
Example given: an indemnity contract sold to individuals by commercial (private) insurance companies ◦ Security or protection against financial burden of health event ◦ Contract to assist paying some or all of medical/surgical bills incurred ◦ May include a "deductible" or "co-insurance" payment
ethnic and sex differences in the incidence of hospitalized acute myocardial infarction BC Canada 1995-2002
Explore hospitalizations for acute myocardial infarction among three main ethnic groups in BC, Canada: Whites, South Asians, and Chinese South Asians had the highest rates of hospitalizations, Chinese had the lowest Difference pronounced among younger men
federal government : statistics canada
Federal agency charged with producing statistics to understand Canada ◦ Produces stats for federal and provincial use
first nations health authority
First and only in Canada Since 2013, responsible for planning, management, service delivery and funding of health programs, previously provided by Health Canada's First Nations Inuit Health Branch.
Those supportive of expanded government involvement:
Fundamental difference in health care oriented to the prevention and treatment of illness vs. insurance for sick care All Canadians should have access to effective health care irrespective of ability to pay Coverage is currently too low to be promising, under voluntary programs The hospital insurance plan shows universal coverage feasible Taxation acceptable by most Canadians
primary care
GPs independent contractors paid for each Dentists, opticians and pharmacists also generally provided services as independent contractors Local Councils/Trusts administered contracts and payment, maintained lists of practitioners and patients.
those opposed to expanded government involvement
Government should be considered last resort to meet needs of those who can't otherwise pay or those who pay in part Financial burden on government (and by extension, taxation) should be minimized Compulsion should be avoided
ottawa charter for Health promotion
Held based on growing international focus on public health and public health interventions Developed the need for health promotion across countries and jurisdictions
why?
Highly decentralized, because of ◦ Provincial/territorial responsibility for funding and delivery ◦ Many organizations within provinces that operate at arm's length from provincial government Health Authorities, privately-administered hospitals, organizations to delivery home and community care, etc. ◦ Status of physicians as independent contractors
rationale behind regionalization ( in theory...)
Improve responsiveness to local population needs Increase public participation in decision making Move away from "silos" of individual organizations to integrated "systems" Political benefits as well. . .
history of pharmaceuticals
Latter half of the 19th century saw isolation of: ◦ Cocaine from coca leaves ◦ Salicylic acid from willow bark ◦ Quinine from cinchona bark ◦ Digitalis from foxglove ◦ Opiates from opiumpoppy Parallel developments in chemistry led to ability to synthesize drugs Emergence of germ theory followed by advances in antibiotics post-WWI to WWII
thalidomide and regulation
Licensed for prescription use by Health Canada in April 1961 ◦ Had been available in West Germany from 1957 Post-market studies in Europe revealed side effects Withdrawn from West Germany and in December 1961 Remained legally available in Canada until March 1962 Tragedy prompted strengthening of safety standards in 1963
plan for implementation
Low copayments that do not pose a barrier to access A strategy to improve access to expensive drugs for rare diseases A responsible implementation plan that requires federal leadership
1974 lalonde report
Mark Lalonde, Canadian Minister of Health summarized effects of social determinants on health: ◦ Income ◦ Biological endowment ◦ Age ◦ Gender ◦ Employment ◦ Personal behaviours Helped understand why even given universal insurance we still see variability in health outcomes
obesity, overweight and ethnicity
Obesity and being overweight (higher body mass index) is higher among indigenous women, relative to white women, with twice as great a risk of having a high BMI For some ethnic groups, time since immigration to Canada was related to BMI
current problems for canadians
One in five Canadians struggle to pay for their prescription medicines. Three million don't fill their prescriptions because they can't afford to. One million Canadians cut spending on food and heat to be able to afford their medicine. We are the only country in the world with universal health care that does not provide universal coverage for prescription drugs.
advisory council on the inplementation of national pharmacare
Part of federal budget in February 2018. Launched in June 2018. Travelled across Canada, elicited feedback in person at meetings and online, met with clinicians and stakeholders, met with Inuit, First Nations, and Metis people. Studied Canadian and international models of healthcare.
federal government : patented medicine prices review board
Patented Medicine Prices Review Board (PMPRB): arms- length quasi-judicial body Protects consumers by ensuring manufacturers' prices of patented medicines not "excessive"
traditional , complementary and alternative medicine
Payment mostly out-of-pocket, or very limited insurance coverage Natural Health Products regulated by Health Canada's Natural and Non-prescription Health Products Directorate (NNHPD) Some degree of professionalization including self-regulation (e.g. naturopathy, homeopathy, traditional Chinese medicine)
canada health act
Piece of legislation that specifies (really, re- specifies) criteria that provinces/territories must conform to in order to receive federal transfer payments Canada Health Act is mostly about health care financed
pharmaceutical care
Prescribed by physicians, nurse practitioners, midwives, dentists (limits on classes of drugs for non-physician prescribers) Inpatient (in hospital) drugs covered by public provincial insurance
health authorities commit to
Provide Ministry with details of their health services delivery plan, including regular updates of the plan Provide Ministry with estimates of its capital budget requirements Meet agreed budget targets (no deficits) Provide Ministry with other information relevant to assessing its health services Comply with provincial agreements with physicians, nurses etc.
provincial health services authority
Province-wide mandate for specialized health services Unique in Canada
federal government responsibilities
Public health Health research Health data collection Some responsibility for establishing standards of care across country ◦ Through the Canada Health Act and health transfers ◦ In more recent history, conditional transfers (funding packages) have been delivered to promote improvement in key areas of service delivery: e.g. wait times, e-health and infoway, telehealth
financing - public drug benefits programs
Relatively comprehensive public coverage for selected populations, such as senior citizens and social assistance recipients. Universal drug plans that provide all residents protection against "catastrophic" drug costs only, regardless of age. Majority still private insurance/out/of pocket.
professional organizations : doctors of BC .. what do they do
Represents all physicians within BC Acts like a trade union Negotiates with the province to determine a wide range of issues affecting physicians ◦ Most significant is the fee-for-service schedule Also decides who will represent physicians on a variety of joint committees with the Ministry of Health
how do income-based plans work?
Residents are eligible to participate without being charged premiums. Benefits and the deductibles are calculated based on the household income of beneficiaries
what do regulatory organizations do
Responsible for maintaining professional standards and disciplining their members when they fail to meet standards Develop practice guidelines for professionals They have disciplinary boards that hear complaints from the public and providers ◦ Boards have the right to adjudicate complaints and assign penalties
home and long term care
Serve older adults, as well as individuals of any age with physical or learning disabilities or chronic diseases, home supports available to people with short-term needs May be offered in a range of settings (home, assisted living, chronic care institutions) ◦ Mix of public, non-profit, and for-profit institutions Referrals can be made by doctors, hospitals, community agencies, families and patients themselves
prepayment
Service contracts (rather than per item) set up between medical profession and patient (client) ◦ Incentive is to keep patient base healthy - fewer services to be requested/provided ◦ In most cases no additional fees incurred by patient ◦ Idea is physician is paid per item delivered directly from prepayment plan
what the council learned
Significant gaps in coverage and access that are unfair and lead to poor outcomes. Spiraling drug costs that are unsustainable
regionalization : recent trends
Since 2001, move to centralized authorities Regional Health Authorities (RHAs) have contracted in numbers, geography has expanded Alberta, Saskatchewan, Nova Scotia have fully amalgamated health authorities Doug Ford may eliminate LHINs in Ontario
informal caregivers
Some financial support in the form of: ◦ Tax credits ◦ Compassionate Care Benefit (paid leave) Direct support for caregivers vary widely
insurance
Specific definition: guarantee of compensation for specified risk in exchange for payment of premium More generally, a mechanism for "risk pooling"
mental health care
Treatment now largely on an outpatient basis ◦ Episodictreatmentinthe psychiatric wings of hospitals ◦ Pharmaceutical therapies overseen by psychiatrists Family physicians provide majority of primary mental health care Services by non-physician providers (psychologists, counselors) largely private (health insurance or out-of- pocket) Mental health care part of new agreements between federal government and provinces
non-governmental : accreditation canada
Voluntary, non- governmental organization that accredits: hospitals, health facilities, and regional health authorities (1,100 clients, 6000 sites)
other sources of funding
Workers' Compensation Boards Automobile insurers (ICBC) Out-of-pocket payments Private insurance (funded via payment of premiums) Voluntary and charitable donations (hospital, disease-based foundations, volunteers)
pharmacare only covers drugs with
" a proven record of safety and effectiveness"
Big Data'
"A term that describes the large volumes of data - both structured and unstructured" (SAS, NC) "Big data is an all-encompassing term for any collection of data sets so large and complex that it becomes difficult to process using on-hand data management tools or traditional data processing applications" (ScienceDirect)
context for TRC calls to action and categories
"Calls to Action" to "redress the legacy of residential schools and advance the process of Canadian reconciliation categories : legacy and reconcilliation
policy
"a set of interrelated decisions taken by a political actor or group of actors concerning the selection of goals and the means of achieving them within a specified situation where these decisions should, in principle, be within the power of these actors to achieve.
administrative data
"data which are derived from the operation of administrative systems" (Connelly et al 2016) "Administrative records are data collected for the purpose of carrying out various non-statistical programs" (Statistics Canada)
unique features of canadian data
(1) Health insurance registries (2) Data on both inpatient and outpatient healthcare utilization (and pharmacy for some jurisdictions) (3) Ability to link various databases using personal identification numbers (e.g., PHNs in British Columbia)
3.3.3 Governments act promptly to:
(a) conclude agreements recognizing their respective jurisdictions in areas touching directly on Aboriginal health; (b) agree on appropriate arrangements for funding health services under Aboriginal jurisdiction; and (c) establish a framework, until institutions of Aboriginal self-government exist, whereby agencies mandated by Aboriginal governments or identified by Aboriginal organizations or communities can deliver health and social services operating under provincial or territorial jurisdiction.
3.3.5 Governments and organizations collaborate in carrying out a comprehensive action plan on Aboriginal health and social conditions, consisting of the following components:
(a) development of a system of Aboriginal healing centres and healing lodges under Aboriginal control as the prime units of holistic and culture-based health and wellness services; (b) development of Aboriginal human resources comp (c) full and active support of mainstream health and social service authorities and providers in meeting the health and healing goals of Aboriginal people; and (d) implementation of an Aboriginal community infrastructure development program to address the most immediate health threats in Aboriginal communities, including the provision of clean water, basic sanitation facilities, and safe housing."
pharmacist visits
- date of service -medication -dosage -duration
the clearest articulation of member states' consensus on health system priorities emphasizes on...
- overarching values of universality, - access to good quality care, equity, solidarity and operating principles of quality, safety, evidence, and ethics, patient involvement
Government role
- statutory health insurance system, with >3,400 non-competing public, quasi-public, and employer-based insurers. National government sets provider fees, subsidizes local governments, insurers, and providers and supervises insurers and providers
the ministry commits to
-Consult with Regional Authorities on all matters that directly impact their operations and finances Ensure that Regional Authorities are consulted in the drafting of the Ministry's Annual Service Plan for the province's health system Provide data and other information Regional Health Authorities require Provide details of funding for both operations and capital projects, including projections for future years to facilitate service planning by regional health authorities
indegnous services in canada consists of
-Public health and health promotion services on- reserve and in Inuit communities -Supplemental coverage for "non-insured health benefits -Primary care services on-reserve in remote and isolated areas, where there are no provincial services readily available
approval by health canada steps
1. Preclinical New Drug Submission with all known data on the substance Clinical research stage -Safety -Effectiveness 2. New Drug Submission with complete information on the new drug 3.Notice of Compliance allowing the drug to be sold Includes product monograph with all information about the drug
provincial health human resources organization professional organizations
1. Advocacy 2. Labour negotiations
key ideas from hall comission
1. Almost complete agreement that medical insurance should be available to all 2. Almost unanimous agreement that there should be some government action to bring this about
provincial health human resources organization regulatory organizations
1. Covered by provincial/federal legislation (Health Professions Act in BC) 2. Governed by professional corporation/authority
events since the Canada Health Act
1990s: Aggressive federal action to cut spending 1992: Royal Commission on Aboriginal Peoples (RCAP) 1995: Canada Health and Social Transfer 1997: Gathering Strength - Canada's Aboriginal Action Plan 2000: ◦ Medical Services Branch was renamed the First Nations and Inuit Health Branch ◦ Institute of Aboriginal Peoples' Health formed at CIHR 2002: Romanow and Kirby Reports 2007: Agreement that BC, Canada, and BC First Nations would develop a new First Nations Health governing body (now First Nations Health Authority) 2013: FNHA assumed the programs, services, and responsibilities formerly handled by Health Canada's First Nations Inuit Health Branch - Pacific Region 2015 - Truth and Reconciliation Commission Final Report, including Calls to Action 2017 -Indigenous Services Canada announced
aspects of RCAP
3.3.3 governments act prompty to... 3.3.5 governments and organization collaborate in carrying out a comprehensive action plan on aboriginal
recommendations for rural and remote health services
30-33
recommendations for international health
45-47
private insurnace role
67% of canadians buy complementary coverage for non - covered benefits benefits ( eg. private rooms in hospitals, drugs, dental care, optometry)
We have more doctors per capita in Canada than ever before. A. True B. False
A but its in the middle
system
A group of parts that work together as a whole
recommendation 8
A personal electronic health record for each Canadian that builds upon the work currently underway in provinces and territories.
recommendation 31
A portion of the Rural and Remote Access Fund should be used to support innovative ways of expanding rural experiences for physicians, nurses and other health care providers as part of their education and training.
public coverage of essential medicines
A public plan that covers a more limited formulary of medicines for all Canadians with little or no patient cost sharing.
comprehensive public coverage
A public plan that includes coverage for a broad formulary of medicines for all Canadians; the government would pay all drug costs or there would be a limited copayment where the patient would pay a certain percentage and then the government would pay the remainder
income based deductible public coverage
A public plan that includes coverage for a broad formulary, with the cost of drugs paid for by the patient or a private drug plan until a specific amount is reached. After this threshold is reached, the government pays all costs.
individual mandate
A requirement that all Canadians must be insured either privately or publicly. The details of each plan might vary by provider, but would generally be subject to a minimum formulary and cost-sharing provisions.
solidarity
A social relation in which a group, community, or nation stands together. It is often appealed to in discussions about justifications for the welfare state or shared risks through insurance pooling, and in thinking about how states might defend the interests of vulnerable groups within their populatio
romanow report
AKA Royal Commission on the Future of Health Care in Canada Recommended sweeping changes Background to 2004 round of federal-provincial/territorial bargaining with an additional $41 billion committed Set out 47 recommendations on topics including
aboriginal health policy
Aboriginal health policy in Canada is made up of a complicated "patchwork" of policies, legislation and agreements that delegate responsibility between federal, provincial, municipal and Aboriginal governments in different ways in different parts of the country
other frameworks
Advocacy Coalition Framework Institutional Analysis and Development Framework
PHAC
Agency of Government of Canada responsible for public health, emergency preparedness, and responses to infectious and chronic disease control/prevention ◦ Disease control and detection ◦ HealthSafety Travel Alerts National immunization and vaccination initiatives Emergency preparedness Health Promotion Injury Prevention ◦ Research and statistics
stages heristic
Agenda ->Policy formulation ->Policy adoption ->Policy implementation ->Policy assessment
jordan's principle
Aims to make sure that federal and/or provincial funding disputes do not interfere with First Nations children accessing government services that are available to other Canadian children. The government of first contact pays for the service and resolves jurisdictional/payment disputes later.
provincial efforts toward insurance
Alberta 1929: Legislative Commission on Medical and Hospital Services BC 1932: Royal Commission on State Health Insurance and Medical Benefits report Newfoundland 1934: Cottage Hospital System
universality
All insured persons must be covered for services provided by the plan on uniform terms and conditions ◦ Only applies to "insured persons" ◦ Only applies to "insured health services"
Health sector or healthcare system
All those who deliver health care, public or private, cultural, licensed or unlicensed Includes money flows that finance such care: official or unofficial Financial intermediaries, planners, and regulators that control, fund, and influence those who provide care Activities of organizations that deliver preventive services
2015 Angus Reid Poll- access barriers by household which province have the lowest and highest rate of prescription access barriers by region
BC- highest Quebec and SK - lowest
proprietary or patent medicine act
Beginning of efforts to protect the public against drugs administered without medical supervision
Canadian institutes of Health research embraces 4 pillars of research... what are they?
Biomedical Clinical Health Systems and Services Social, cultural and environmental factors
hall commission broad mandate
Broad mandate: "to recommend such measures, consistent with the constitutional division of legislative powers in Canada, as the Commissioners believe will ensure the best possible health care is available to all Canadians" Central to the development of our thinking about government role in health care
comprehensiveness
Broad range of services, referral to other services where needed
recommendations- CHA
CHA should be modernized and strengthened by : confirming the principle of public administration, universality, and accessibility and updating the principles of portability and comprehensiveness and establishing a new principle of accountability; Expanding insured health services beyond hospital and physician services to immediately include targeted home care services followed by prescription drugs in the longer term; Clarifying coverage in terms of diagnostic services; Including an effective dispute resolution process; and Establishing a dedicated health transfer directly connected to the principles and conditions of the Canada Health Act.
CADTH Common Drug Review can recommend
Can recommend: (1) Do not cover at all, (2) cover but only if the manufacturer lowers their price, (3) cover but only for certain patients or under certain conditions, and (4) cover as a regular benefit
recommendation 9
Canada Health Infoway should continue to take the lead on this initiative and be responsible for developing a pan-Canadian electronic health record framework built upon provincial systems, including ensuring the interoperability of current electronic health information systems and addressing issues such as security standards and harmonizing privacy policies.
1997: Gathering Strength -
Canada's Aboriginal Action Plan ◦ Some commitments around improving health and public safety ◦ Recognition of the need for community control of health resources
intergovernmental : CADTH
Canadian Agency for Drugs and Technologies in Health (CADTH)
federal government CIHR
Canadian Institutes of Health Research (CIHR)
non-governmental : CMA
Canadian Medical Association (CMA) is national umbrella organization of regional groups: physicians, consultants, specialists It is SEPARATE from the provincial colleges of physicians and surgeons and the Royal College of Physicians and Surgeons of Canada (RCPSC)
health disparities consists of
Certain identifiable groups (ethnicity, sex/gender, socioeconomic status) have higher rates of chronic diseases in both Canada and internationally
1961-4 ROYAL COMMISSION ON HEALTH SERVICES (RCHS)
Chaired by Justice Emmett Hall • Hall Report, 1964 • Recognized the need for national statistics and ability to draw comparisons across regions.
permanent residence
Citizenship, immigration
incremental cost effectiveness ratio ( ICER)
Cost and effect estimates of the interventions are combined into a single outcome measure *used to describe the improvement of an intervention compared to the status quo*
what are the two broad approaches to bridge jurisdictional gaps, enhance participation in identifying health priorities for Indigenous peoples, designing strategies, and coordinating approaches to improve health
Cross-jurisdictional coordinating mechanisms ◦ Intergovernmental health authorities
dental care coverafe
Delivered by independent practitioners operating their own practices ◦ Private health insurance (~54%) or out-of-pocket ◦ Coverage under Non- Insured Health Benefits (NIHB) Program for First Nations and Inuit ◦ Some coverage for people receiving social assistance Much lower public support than almost all wealthy countries Source: Chicago Tribune Wide socioeconomic inequities
1961-4 ROYAL COMMISSION ON HEALTH SERVICES (RCHS) + Hospital medical records institute
Developed to facilitate the administration of hospital insurance plans Standardization of coding for diseases and procedures • International Classification of Diseases (ICD) system
marketing
Direct-to-consumer advertising of prescription drugs is not legal ◦ But disease awareness ads are "ask your doctor about . . ." ◦ Over-the-counter drugs can be marketed Promotion directed at doctors is widespread ◦ Pharmaceutical reps and samples ◦ Continuing medical educations ◦ Journal articles and advertisement ◦ "Key Opinion Leaders"
pharmanet
Drug (DIN/PIN), dosage, days supply
who is the payer for the bismark model
Employer/employee earmarked payroll tax
equity
Equity focuses on equal outcomes and this may require an unequal distribution of some good to bring about the equal outcome. Health equity requires responding to "differences in health which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust"l
primary care payment
FFS
1966 medical care art
Federal cost sharing (50%) for medical services outside hospital Provinces must extend 4 conditions to private practices: pubic administration, portability, universality, comprehensiveness Cost sharing to commence in 1968 provided conditions met By 1972 all provinces/territories on board
Primary care physicians
Fee for service in most provinces, with some use of quality incentives. In Ontario, physicians are now primarily reimbursed through capitation payments adjusted for the age and sex of rostered patients
access
First-contact care for each health concern
coordination
Follow- up when services are needed elsewhere
federal department of health established in 1919
Food and Drugs Act introduced in 1920 Specific requirements for licensing drugs
long term care homes
Global budgets in most provinces; some per diem adjustment funding for case mix in Ontario and Alberta.
public subsidies - individuals or insurance funds
Government to subsidize families or individuals to meet premiums of insurance or prepayment plans (after premium set for everyone) based on ability to pay Government tax revenues subsidize insurance funds so that premiums removed, similar to current hospital operations
Health promotion
Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment.
medical services plan
ICD-9, service date, practitioner number
before health systems...
In 1884, almoners became the gatekeepers of what would in the future be the national health system in England They are referred to in the history of social workers in the UK Access to hospitals was means tested The rich paid for their care, and stayed at home
The Ottawa Charter for Health Promotion affirms social, economic and environmental aspects of 'health. In order to be healthy...
In order to be healthy: "an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment."
behaviour control knob
Includes efforts to influence how individuals act in relation to health and health care, including both patients and providers. Includes health education and social marketing campaigns to patients, and working with regulator bodies and training programs to influence providers' behaviour
health transfer policy
Increasing recognition that Indigenous communities are best positioned to identify priorities, manage and deliver health services ◦ Health Transfer Policy initiated in 1989 - varying levels of health care responsibility transferred from FNIHB to community/council level ◦ Modern treaties and self-government - control over issues beyond health care, flexibility to respond to community needs rather than Federal objectives
what did the indian act ( 1876) failed to do
Indian Act (1876) failed to provide clear legislative authority for Indian health to the federal government
recommendation 10
Individual Canadians should have ownership over their personal health information, ready access to their personal health records, clear protection of the privacy of their health records, and better access to comprehensive and credible information about health, health care and the health system.
block funding/global budgets
Institution paid certain amount per year to provide service. Generally calculated based on previous year's amount and types of services offered, adjusted for demographic change, health care costs, and inflation.
provinicial government also provide
Institutional and community care - palliative care post-operative care home oxygen long term care assessment home care rehabilitation ◦ Drug plans for those without access to Private Health Insurance
outcomes of hall commission
Interviewed hundreds of witnesses and found grave inequities in health system and lack of access to health care *Concluded that government action is imperative, should immediately mobilize resources to establish efficient, universal, comprehensive health services programmes* ◦ *Recommended more services than ultimately offered by Medicare: free dental care for schoolchildren and welfare recipients; free glasses and drugs for needy/elderly; free prosthetics; and free home care services* . Report finished after Diefenbaker replaced by Pearson and Liberals
challenges of regionalization
Lack of individual-level data to make informed service distribution decisions Economies of scale Regional health authorities lack authority to control major expenditures Not true integrated systems or "accountable care" organizations
Specialist physicians
Largely fee for service. Some use of alternative payment arrangements for academic hospitals and for certain specialties - e.g., emergency medicine. Often paid separately than the hospitals they work in.
hospitals
Largely historically based global budgets. Some provinces (notably Ontario) have adjusted a share of the global budget funding for case mix and have made limited use of activity-based funding models.
Ontario Workmen's Compensation Act (1914):
Legislation to provide benefits, medical care, rehabilitation to individuals injured at work/contract occupational diseases ◦ Took the onus off the employee to prove negligence of employer - at the same time employees were no longer allowed to sue
health services approach
Like hospitals, resources should be planned to organize/deliver care to ensure everyone has appropriate access ◦ Also called for more included in services besides primary physician care: prescription drugs, dental services, home care, and provision of consequences of illness/injury (recall employment insurance)
community services
Local authorities responsible for maternity and child welfare clinics, health visitors, midwives, health education, vaccination & immunization and ambulance services, environmental health services were the responsibility of local authorities. Continuation of the role local government had held under the Poor Law.
government role
Medicare: age 65+, some disabled; Medicaid: some low-income; for those without employer coverage, state-level insurance exchanges with income-based subsidies; insurance coverage mandated, with some exemptions (10.4% of adults uninsured)
medifund
Medifund (introduced in 1993): fund for patientswho face financial difficulties government endowment fund to subsidize health care for low-income and those with large bills. Government regulation of private insurance, central planning and financing of infrastructure and some direct provision through public hospitals and clinics.
Private insurance role - .
Medisave-approved integrated shield plans (private insurance plans) supplement Medishield coverage to provide catastrophic health coverage for additional ward classes. Other types of private insurance are also available, including private insurance provided by employers
home and community care
Mix of global budgets and a variety of other payment mechanisms.
perinatal registry
Mom (age, parity) & baby (weight, gestational age) data
TERTIARY care:
More specialized consultative care usually in-hospital (e.g cancer treatment, neurosurgery, cardiac surgery
hospital services
Mostly organized by regional health ◦ Some hospitals run by health authorities, some privately administered (not-for-profit) ◦ First-dollar coverage by provincial insurer for medically necessary services authorities
1991 national health information council
National meeting on health information • Create a national coordinating centre
what countries uses the out of pocket model
No country operates on a OOP model only. India and the US rely heavily on such models
who created the first welfare state in the modern world
Otto van Bismarck, Chancellor of United Germany
continuity
Patient- focused (rather than disease focused) care over time
incentive payments/pay for performance
Payment provided for reaching target outcome (e.g. number of cervical cancer screenings proportional to eligible patients)
activity -based funding
Payments are allocated funds based on the type and volume of services provided, and the complexity of the patient served.
prescription drugs
Prescription and dispensing fee - essentially fee-for- service
typical payment arrangements by sector
Primary care physicians Specialist physicians
recommendation 47
Provincial, territorial and federal governments and health organizations should reduce their reliance on recruiting health care professionals from developing countries.
outpatient rehabilitation
Public coverage varies by province and territory ◦ Also covered by: Workers compensation has a role Private health insurance Out-of-pocket payments
potential scope of government action
Public subsidies - individuals OR insurance funds? Voluntary insurance OR compulsory participation
optional public coverage
Publiclyfundedplanswithpremiumswouldbe available for all Canadians, should they wish to become insured.
regulation control knob
Refers to use of coercion by the estate to alter the behaviour of actors in the health system, including providers, insurance companies, and patients, and may or may not be enforced
who is the payer for the national health insurance model
Regionally administered universal public insurance program
health insurance is complusory
Salaried workers earning less than an income threshold (~50,000 euros) automatically enrolled into one of 130 public, non-profit "sickness funds" (Krankenkassen) Social welfare beneficiaries are also covered but the state covers their premiums Germans who make more than this can opt out and pay out of pocket for medical expenses, or pay into private insurance ◦ Provider payments negotiated in corporatist social bargaining with government and physician groups
provincial funding... where does the money go to
Service provision (physicians, hospitals, regional health authorities.)
secondary care
Services provided by medical specialists (e.g. cardiologists, urologists), and acute care for brief but serious conditions - injury, childbirth)
CADTH Common Drug Review
Should the drug be eligible for public reimbursement? Review of new drugs, or existing drugs approved for new indications Analyzes clinical effectiveness, safety and cost-effectiveness Compares drugs with current accepted therapy to determine therapeutic advantages and disadvantages, as well as cost- effectiveness
emergency department ( ED)
Staffed by specialist Royal College of Physicians and surgeons of Canada (RCPSC) fellows or specialist family physicians ◦ First-dollar coverage by provincial insurer also serves as primary care for many patients
The choices of indicators influences the results. Ideally we should be able to assess all relevant dimensions:
Sustainability, equity, efficiency
recommendation 30
The Rural and Remote Access Fund should be used to attract and retain health care providers.
recommendation 33
The Rural and Remote Access Fund should be used to support innovative ways of delivering health care services to smaller communities and to improve the health of people in those communities.
recommendation 32
The Rural and Remote Access Fund should be used to support the expansion of telehealth approaches.
case study
The case study of preventing vitamin D deficiency in England and Wales The United Kingdom's National Diet and Nutrition Survey reports intake of vitamin D below optimal and widespread vitamin D deficiency in the population
provincial government : regionalization
The creating of an intermediary administrative and governance structure (often referred to as a regional health authority or board) that assumes responsibility for organizing and delivering health care services to a defined population"
recommendation 45
The federal government should build alliances with other countries, especially with members of the World Trade Organization, to ensure that future international trade agreements, agreements on intellectual property, and labour standards make explicit allowance for both maintaining and expanding publicly insured, financed and delivered health care.
recommendation 46
The federal government should play a more active leadership role in international efforts to assist developing nations in strengthening their health care systems through foreign aid and development programs. Particular emphasis should be placed on training health care providers and on public health initiatives.
opportunity cost
The opportunity cost of a resource is the value of the benefits from the foregone alternative In healthcare: • The opportunity cost of a decision is the health benefits that could have been achieved had the money been spent on the best alternative intervention
path dependence
The range of options available is limited by choices made in the past, even when the circumstances giving rise to those circumstances are no longer relevant
Lord William Beveridge' report.
The report provided a summary of principles necessary to banish poverty and 'want' from Britain - Beveridge's mantra throughout the report was 'Abolition of want'.
philosophical arguments with respect to government
Those opposed to expanded government involvement: Those supportive of expanded government involvement:
prepayment two types of people in population
Those who can pay premiums on own Those who will need government subsidy
three approaches considered from hall commission
Three approaches considered: a) Insurance, b) prepayment, c) health services approach.
what countries uses the beveridge model
UK, norway, NZ, italy
Voluntary insurance OR compulsory participation
Will voluntary insurance provide universal comprehensive coverage? Concerns about compulsion
multiple streams framework
Windows of opportunity when recognition of a problem, an acceptable solution, and politics align)
royal commission on aboriginal peoples
a Canadian government comission investigating the tension between Canada's First Nations and the government in the 1990s that concluded Aboriginals needed to be granted more self-determination and control over their lands.
eligible persons of NIHB
a First Nations person who is registered under the Indian Act (commonly referred to as a status Indian) ◦ an Inuk recognized by an Inuit land claim organization ◦ a child less than 18 months old whose parent is a registered First Nations person or a recognized Inuk
premium
a fixed amount ,not related to the number of prescriptions, that a beneficiary must pay to be eligible for prescription drug insurance.
deductible
a limit up to which a patient pays the full cost of the drug. After the deductible is reached, the patient either does not pay or has reduced payments for prescriptions.
formulary
a list of medicines that are included within the insurance plan.
what the council recommends
a national pharmacare plan that follows the principles of the canada health act
in the context of pharmacare public administration
a national pharmacare system should be both publicly funded and administered.
WHO definition of health
a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity
fixed copayment
a system where a patient pays a fixed, or set, amount per drug or per prescription.
co-insurance
a system where a patient pays a set percentage of the amount per drug or per prescription.
primary care components
access continuity coordination comprehensivess
in the context of pharmacare accessibility
access to prescription drugs should be based on medical need, not ability to pay;
cultural awareness
acknowledgement of difference
each province/territory is responsible for the ______ , ______, ______ of health care services
administration, organization, and delivery
discharge abstract database
admission & discharge date, ICD-9/10, procedure
2015 Angus reid poll which age group and income group has the highest and lowest rate of prescription access barriers
age : 18-36 - highest 55+ - lowest income <50k - highest 100k+ - lowest
federal government : health canada is comprised of
agencies and branches
interests
agendas of societal groups, elected officials, civil servants, researchers, and policy entrepreneurs" (Pomey et al., 2010, p709) Who wins and who loses? By how much do they win or lose? Have groups mobilized around specific interests?
financing control knobs
all mechanisms for raising money that pays for activities in the health sector, including taxes, insurance premiums, and direct payment by patients, and design of institutions that collect the money
in the context of pharmacare , universality
all residents of Canada should have equal access to a national pharmacare system;
primary care
almost all private, with some larger public clinics for lower-income population
copayment
an amount per drug or per prescription that a patient pays. In some jurisdictions, the dispensing fee charged by the pharmacist is charged to the patient.
Public Administration
applies to health care insurance plan, not service delivery *health care insurance plan must be administered and operated on a non-profit basis* publicly accountable for the funds-Provincial governments determine the extent and amount of coverage of insured services-management of provincial health insurance plans must be carried out by a not-for-profit authority, which can be part of government or an arm's-length agency
interprofessional team models
are teams with different healthcare disciplines working together towards common goals to meet the needs of a patient population. Team members divide the work based on their scope of practice; they share information to support one another's work and coordinate processes and interventions to provide a number of services and programs.
stage 1 - Health Canada Notice of Compliance based on
based on ◦ Safety ◦ Effectiveness (usually compared to placebo) ◦ Quality of manufacturing
the basic four health systems model
bismark model beveridge model national health insurance model out of pocket model
payment methods for institutions ( hospitals, long term care )
block funding/ global budgets activity based funding
Reconciliation
bring the federal and provincial governments and Indigenous nations of Canada into a reconciled state for the future Education for reconciliation, Commemoration, Newcomers to Canada
to take action on health
build healthy public policy create supportive environments strengthen community actions develop personal skills reorient health services
mechanisms to bridge payment
bundled payments population based integrated payment models
inusrable
can pay premium can't pay premiums and must be subsidized by government
what countries uses the national health insurance model
canada , taiwan, korea
benefit desgin
caps on cost sharing exemptions and low income protection
Hospital payment -
case-based per diem payments + FFS or FFS only (includes physician costs)
medishield
catastrophic health insurance;
non-insurable
chronically ill, aged, or handicapped, who represents abnormal risk
Cross-jurisdictional coordinating mechanisms:
committee based, bringing together multiple stakeholders E.g. Ontario's Aboriginal Health and Wellness Strategy
types of universal public coverage
comprehensive public coverage public coverage of essential medicines income based deductible public coverage
types of full economic evaluation
cost benefit analysis cost consequence analysis cost minimization analysis cost effective analysis cost utility analysis cost effective and utility are the most commonly used
practical considerations involves
cost of options issue of compulsion
universal coverage
coverage for prescription drugs that is available to all Canadians and enables them to access necessary medicines.
pan canadian research aim
create a platform to access various data sources across canada and to share analytic tools
administrative health data
data are routinely generated during the administration of the health care system, and include records from physician services, inpatient and emergency department care, long-term care, prescription medications, and health insurance registries
viral staistics - deaths
date of death, cause
Some First Nations/Inuit Organizations assumed responsibility for the
delivery of pharmacy, medical supplies and equipment, and dental benefits.
consolidation file
demographics and geographic data
physician visits
doctors log the data in a system that records date of service, diagnostic codes, and procedure codes
exemptions and low income protection
drug cost-sharing exemption for low income, older people, children, pregnant women and new mothers, and some disabled / chronically ill; financial assistance with transport costs available to people with low income; vision tests free for young people, older people and low income people
prescription drugs
drugs that are prescribed by a health care professional (e.g., a doctor, nurse practitioner, dentist, or, in some provinces, a pharmacist). Drugs that can be purchased over the counter without a prescription are excluded.
mortality rate for men and women and geographic distribution
european and other men and women have higher cases of death from cancer for men ,cases of deaths from IHD were from people from europ, south asia, and other
what factors are no considered as part of control knobs
factors in health system perform that cannot be changed as part of health reform are not part of the control knob
Health care is fundamental to Canada. Canada's publicly-funded health care system dates back to confederation in 1867. A. True B. False
false
In order to receive national accreditation, all medical and nursing schools must provide training in conflict resolution, human rights, responding to racism, and working effectively across cultures. A. True B. False
false
The Canadian health care system is centrally planned and funded, so that all Canadians receive the same services, no matter where they live. A. True B. False
false
->primary care
family doctor type services delivered to individuals - first contact access -long term continuity -coordination -comprehensiveness
payment methods to providers
fee for service salary capitation incentive payments mixed payment is also possible
Canadian Agency for Drugs and Technologies in Health (CADTH)
first established as Canadian Coordinating Office for Health Technology Assessment ◦ To encourage appropriate use of health technology through the use of HTA for decision makers ◦ There are provincial teams that do HTAs so CADTH coordinates some of that for knowledge dissemination Funded by Health Canada and provinces by proportion of population, except Quebec
primary care
first point of consultation, often with a general practitioner or family physician. This could also include walk-in clinics and some services in emergency departments
reorient health services
focus on preventive health
cultural competence
focuses on the skills, knowledge, and attitudes of practitioners
hospital payment
for public hospitals, combination of global budgets + case - based payments
Intergovernmental health authorities
formal organizations created through partnerships or self-government agreements E.g. Athabasca Health Authority
what are we spending money on
funds for services
Public system financing -
general tax revenue
who is the payer for the beveridge model
general tax revenue
public system financing
general tax revenue (includes employment-related insurance contributions)
Public system financing -
general tax revenue; insurance contributions
federal where does money come from
general taxation ( personal, and corporate income tax, gst)
provincial funding... where does the money come from
general taxation (income taxes, consumption taxes, corporate taxes, in some cases resource royalties)
what countries uses the bismark model
germany, france, belgium, japan
solidarity
government is responsible for ensuring access for those who need it
health system and public/private insurance role
government role public system financing private insurance role
Government role -
government subsidies at public health care institutions and some providers; Medisave: ; Medishield: Medifund:
health spending
has been increasing
germany
has the oldest national social health insurance system
if the ICER >10
have to ask how much are we willing to pay to avoid one DVT?
corporatism
health care professionals set out procedures
types of research using administrative health data
health policy health services health outcomes population health
salary
health professional is employee of organization and responsible for services as outlined in employment contract
fee for service
health professional paid set amount for each service provided
health services in canada are
highly decentralized..
provincial government work within parameters of canada health act to provide on
hospital care physician care
tripartite system
hospital services primary care community services
create supportive environments
i.e. having a workplace that supports health
strengthen community actions
i.e. having an active community centre
build healthy public policy
i.e. taxing unhealthy food
develop personal skilss
i.e. teaching people self-efficiacy to make healthy choices
fairness
impartial and just treatment
gatekeeping
in some insurance programs
what is an indicator of relative deprivation has been viewed as a potential determinant of individual health
income inequality high income have higher self perceived health as either excellent or very good
income band
income percentile
agencies
independent, accountable to Parliament through the Minister of Health
whos the payer for out of pocket model
individual
targeted public coverages
individual mandate optional public coverage
special features about health care and health insurance
information asymmetry lack of competition
Insurance two main groups of people in population
insurable non insurable
3-is framework
interest ideas institution
secondary prevention
intervention after a disease process has begun but before it is symptomatic
primary prevention
intervention before there is evidence of disease or injury
tertiary prevention
interventions after disease or injury occurs
health -sector reform
involves a significant purposeful effort to improve the performance of the healthcare system
it focus almost exclusively on treatment by physicians or hospitals to the exclusion of other health services
it does not address how health services outside medicare are to be provided leaving major gaps it does not deal with private insurance coverage outside medicare for drugs, dental services etc
other issues connected to the canada health act
it focuses almost exclusively on treatment by physicians or hospitals to the exclusion of other health services does not encourage interdisciplinary approaches to providing health services it does not deal with ownership of health facilities
if the ICER is negative...
it is either dominated or dominant
ideas
knowledge or beliefs abut what is..., views about what ought to be..., or combinations of the two" (Pomey et al., 2010, p709) What sources of evidence might be used? By whom? ◦ How would you describe this evidence (strong, weak, complex, consensual, uncertain, controversial)? What values and ideologies may come into play? ◦ Societal values ◦ Ideology of the government ◦ Values or ideology of professional groups
lack of competition
limited number of providers (or insurers) in most places, limited ability to shop around
Punctuated Equilibrium Framework (PEF):
long periods of small, incremental changes punctuated by brief bursts of major policy shifts
strengths of administrative health databases
longitudinal population level data study rare outcomes and adverse effects multiple linkable databases readily available ( ... kind of )
prevalence of heart disease or other chronic diseases are found commonly among ____ income groups in BC
low
prevalence of smoking is highest in which income group
low and attributed to over 5000 deaths each year
exemption of low income protection
low income: Medicaid; older people and some disabled: Medicare; premium subsidies and lower cost sharing for low and middle-income families on the exchanges; some affordability exemptions from insurance mandat
Exemptions & low income protection -
low-income monthly oop ceiling; reduced cost-sharing for young children, older people, those with chronic conditions, mental illness and disabilities. Tax-funded health services for those on social assistance.
hospital payment
mainly case- based payments plus budgets for mental health, education, and research and training. all include physician
Hospital -
mainly private non-profit (~80% of beds), some public (~20%)
primary care
mainly private, limited number of NHS owned practices with salaried physicians
hospital
mainly public , 20-30% private based on activity
Canadian Institutes of Health Research (CIHR)
major federal agency responsible for funding health research in Canada
United states health care system
majority of health care facilities private sector - 58% of hospitals non profit, 21% gov owned, 21% for profit emergency medical treatment and active labor act ( 1986) about 65% of public health care provision goes to medicare, medicaid, children's health insurance program and veterans health administration ◦ Restgoestofacilities ◦ Anyone not covered by above mentioned public schemes covered by personal or family member's employer OR buy insurance on their own ◦ Despite coverage, many patients pay copayments for services
Private insurance role -
majority of population have coverage for cash benefits in case of sickness, usually together with life insurance. Limited role of complementary and supplementary insurance offered separately from life insurance..
health insurance bill of 1883
mandatory health insurance first for low income workers, then expanded to the majority of the population
subsidarity
matters ought to be handled by the smallest, lowest, or least centralized competent authority
portability
means that Canadians are covered by a provincial insurance plan during short absences from that province.
accessibility
means that Canadians must have reasonable access to insured services without charge or paying user fees
public system financing
medicare ; payroll tax, premiums, federal tax revenue; Medicaid: federal, state tax revenue
payment control knobs
methods for transferring money to healthcare providers (doctors, hospitals, public health workers) and includes fees, capitation, and budgets, and may in turn create incentives which influences how providers behave
primary care payment
mix capitation/ffs/pfp
hospital
mix of non profit ( ~70% beds ), public ( ~15%) and for profit (~15)
public and private spending in canada
more spending on public than private
primary care payment
most FFS, some capitation with private plans; some incentive payments
Primary care payment -
most FFS, some per-case daily or monthly payments
primary care payment
mostly FFS(~45-85% depending on province), but some alternatives (e.g. capitation) for group practices
hospital payment
mostly global budgets, case-based payment in some provinces (does not include physician costs)
hospital payment
mostly per-diem and case-based payments (usually does not include physician costs)
Primary care -
mostly private
hospital
mostly public, some private
what's the coverage for out of pocket model
n/a
government role
national health service ( NHS)
health care system of england
national health service act 1946 uses the tripartite system
Registration with GP required -
no
caps on cost sharing
no
gatekeeping
no
registration with GP reqiored
no
registration with GP required?
no
caps on cost sharing
no general cap, but OOP payments almost exclusively apply to prescription drugs and medical appliances only. Per year ceiling for those needing a large number of prescription drugs.
Gatekeeping -
no, but some large hospitals and academic centres charge extra fees to patients not referred
federal program
non -insured health benefits program ( NIHB)
registration with GP required
not generally, but yes for some capitation models
health-sector reform 2 dimensions
number of aspects of healthcare system that were changed and how radically the changes depart from past practice
division of federal responsibilities under the british north american act
o Federal government responsible for : public health, health research, and health data collections o They finance and deliver services for : eligible first nation people, veterans and armed forces, inmates in federal pens., and refugees.
japan health care system
origins with employee health insurance plans multiple employee health insurance Citizens over 40 must also pay into separate insurance scheme for long term care (about 2% of income) ◦ Managed by municipal governments Costs within the system are tightly regulated and fees for every service are set every 2 years at the national level ◦ If physicians try to over prescribe a particular procedure, that procedures fees can be lowered by the government the following cycle
capitation
payment according to number of patients. Fee structure can include premium for complex cases and may be adjusted for sociodemographic differences. Pays practice whether consult occurs or not. Practice team may include number of disciplines
necessities for health
peace shelter education food income a stable eco-system sustainable resources social justice and equity
justice
people getting what they deserve
in the context of pharmacare portability
pharmacare benefits should be portable across provinces and territories when people travel or move; and
in the context of pharmacare comprehensiveness
pharmacare should provide a broad range of safe, effective, evidence-based treatments;
how is this data being captured
physician visits pharmacist visits
what are included in databases
prescriptions physciain visits ( inpatients and outpatient ) emergency department visits demographics and vital statistics ++ more ( childhood, perinatal, occupational, etc )
provider ownership
primary care hospital
Primary Care vs Primary Health Care
primary care -
provider payment
primary care payment hospital payment
primary health care
primary health care - Approach to health policy and service provision that includes population-level public health functions as well as individual patient care May also include additional principles articulated by the WHO ◦ Universal access ◦ Commitment to health equity ◦ Community participation (WHO 1978)
private insurance role
primary private voluntary insurance covers ~66% of population (employer-based and individual); supplementary for Medicare
primary care
private
who's the provider for out of pocket model
private
who is the provider for the national health insurance model
private for the majority
outpatient prescription drugs covered by some combination of
private insurance public insurance out of pocket
health insurance refers to
programs that pool resources to provide protection against the cost of medical services ◦ This includes both contributory insurance and health care provided through general taxation ("public" health insurance)
early regulation of medicines in canada
proprietary or patent medicine act ( 1909) Federal Department of Health established in 1919 In 1951 it became mandatory to submit safety data to then Health and Welfare Canada (now Health Canada) prior to bringing drug to marke
information asymmetry
providers know more about how health services will affect patients than patients do
canadian institute for health information
provinces and territories submit health data to CIHI data includes • Hospital care • Community care • Specialized care • Patient safety • Health workforce • Spending • Access and wait times
comprehensiveness
provincial health insurance programs must include all medically necessary services Provinces allowed but not required to insure additional services Provinces decide beyond physicians what "other health care practitioners" qualify for payment under the Act E.g. midwives, nurse practitioners
public system financing
provincial/federal general tax revenue
who is the provider for the bismark model
public
who is the provider for the beveridge model
public ( majority)
federal government PHAC
public health agency of canada
hospital
public/private mix ( proportions vary by region ) , mostly not for profit
recommendations for electric health records
recommendation 8 , 9, 10
legacy
redressing the harms resulting from the Indian residential schools Child welfare, education, language and culture, health, justice
organization control knobs
refers to mechanisms reformers use to affect the mix of providers in healthcare markets, their roles na functions, and how the providers operate internally, includes competition, decentralization, and direct control of providers making up government service delivery. Also includes who does what and who competes with whom, and managerial aspects of how the providers work
hospital services
regional hospital boards administer majority of hospital services individual hospitals nested within them under hospital management committees
government role
regionally - administered universal public insurance program that plans and funs ( mainly private ) provision
cultural sensitivity
respecting difference
issues in workforce planning - involvement of other professionals to their full capacity
scope of practice interprofessional team models
specialist physician ambulatory services is an example of
secondary care
1946 national health service act
services were provided free at the point of use services were financed from central taxation everyone was eligible for care
caps on cost
sharing - no
1995: Canada Health and Social Transfer
single block funding mechanism through consolidation of federal cash and tax transfers in support of: ◦ Health care ◦ Post-secondary education ◦ Socials services ◦ Social assistance
bundled payments
single payments that are disbursed to groups of provider entities involved in delivering a defined "episode" of care for a particular health condition or procedure
population-based integrated payment models
single, time- defined payments to groups of providers for a population of enrolled patients or residents of a particular geographic area, regardless of whether they use health services or not
principles of health insurance bill of 1883
solidarity subsidiarity corporatism
according to roberts et al a control knob is
something that can be adjusted by government action
the drug review process for pharmacare in BC
stage 1 - Health Canada Notice of Compliance based on stage 2 Common Drug Review (CDR) through the Canadian Agency for Drugs and Technologies in Health (CADTH) stage 3 BC Ministry of Health PharmaCare Drug Review
exemptions and low income protection
subsidized care for low-income population, with income- and asset- based means-test to target subsidies. Medifund as safety net to pay for low-income and people with no means to pay for their health care bills.
what is cost effective public health strategy to prevent vitamin D deficiency in england and wales
supplementing populations at risk fortifying foods
fortifying foods consists of
target population dietary profiles candidate foods costs
2003: First Ministers' Accord on Health Care Renewal -
targeted reforms including primary care reform, catastrophic drug coverage, and support for health information technology (e.g. electronic health records, telehealth)
where does the money come from ? where does it go?
tax payers and then its split to private insurers, federal gov, provincial , municipal, etc
hospital services is an example of
tertiary care
health legislation
the body of rules that regulates the promotion and protection of health, health services, the equitable distribution of available resources and the legal position of all parties concerned, such as patients, health care providers, health care institutions and financing and monitoring bodies
institutions
the formal and informal rules, norms, precedents, and organizational factors that structure political behaviour" (Pomey et al., 2010, p709) How might the following shape, reinforce, or constrain policy developments and choices: ◦ Government structures (political arrangement and accountability structures)? ◦ Policy networks (relationships between government and outside actors)? ◦ Policy legacies (past policies and 'path dependence')?
personally mediated racism
the prejudice and discrimination that can manifest itself as a lack of respect, suspicion, devaluation, scapegoating, and de-humanization
scope of practice
the procedures, actions, and processes that a healthcare practitioner is permitted to undertake in keeping with the terms of their professional license. ◦ Not all professionals are working to their full scope of practice.
health disparities are due to
the social determinants of health (characteristics related to individuals or groups that have been shown to be related to health and health status)
institutionalized racism
the structure of society and the codified institutions of practice, law, and governmental inaction in the face of need
exemptions and low income protection
there is no cost-sharing for publicly covered services; protection for low income people from cost of prescription drugs varies by region
Canada has among the highest out-of-pocket costs for health care among high-income countries A. True B. False
true
branches
under the leadership of the Assistant Deputy Ministe
singapore
unique system of complusory savings for medical expenses , subsidies, and price controls - series of mandatory savings accounts ( ordinary : school/home, special account : old age/ retirement -mediasave was introduced - medifund was introduced
what was the coverage for the bismark model
universal
what's the coverage for the beveridge model
universal
whats the coverage for the national health insurance model
universal
supplementing populations at risk consists of
utake target populations costs
TRC calls to action - health ( legacy)
vFor example: "18. We call upon the federal, provincial, territorial, and Aboriginal governments to acknowledge that the current state of Aboriginal health in Canada is a direct result of previous Canadian government policies, including residential schools, and to recognize and implement the health-care rights of Aboriginal people as identified in international law, constitutional law, and under the Treaties."
what challenges the system
vitamin D deficiency
internalized racism
when those who are stigmatized believe it. This leads to resignation, helplessness, and lack of hope
stage 2 Common Drug Review (CDR) through the Canadian Agency for Drugs and Technologies in Health (CADTH) which looks at
which looks at: ◦ Performance of drug compared to similar drugs used for the same condition ◦ Value for Money
gatekeeping?
yes
registration with GP required?
yes
caps on cost sharing
yes for most private insurance plans: $6,600 yearly limit for individuals; $13,200 for families as of 2015
gatekeeping
yes, mainly through financial incentives varying across provinces: e.g., In most provinces, specialists receive lower fees for patients not referred
Caps on cost-sharing -
yes. Coinsurance reduced to 1% after monthly cap, depending on enrollee age and income. Annual cap of total OOP payments depending on income and ages of household members.
private insurance role
~11% buy supplementary coverage for more rapid and convenient access (including to elective treatment in private hospitals)
what is economic evaluation in healthcare?
• *Comparative analysis of alternative decisions in terms of both costs (resource use) and health consequences (outcomes, effects)* • To determine the decision that provides the best value for money (minimizing opportunity cost)
mccormick et 2019 study
• 151 individuals completed the online survey • 77% female • 56% from BC, 25% ON, 8% QC, 1-5% AB, NB, NS, PEI • 58% were university graduates • 67% had a chronic disease
Development of Population Data BC:
• 1988: BC Linked Health Data Project (BCLHD) • 1990: UBC Centre for Health Services and Policy Research (CHSPR) • CHSPR partnered with UBC to create PopData BC
mccormick et al for data access controls, top rated measures in place were
• Applications to access data (62%) • Need for approval from institutional research ethics board (59%) • Required approval from data stewards (e.g., Ministry of Health) (51%) à 67% of participants wanted to learn more about this particular process
an incremental approach
• Broadly, economic evaluation attempts to answer the following question: 'What is the difference in costs and the difference in effects of option A compared to option B?'
1847 census and statistics act
• Collection of vital statistics (e.g., births, deaths) as well as property ownership, demographics • Census was a provincial responsibility until 1867
QALYs (quality-adjusted life years)
• Combines life years and quality-of-life • Often explicitly required by decision makers
How is the data accessed?
• Data Access Request (DAR) • Remote access using PopData's Secure Research Environment (SRE)
limitations of administrative health databases
• Data is collected for billing purposes, not research • Not all variables needed for research are captured (e.g. disease activity) • Extensive experience and training necessary to analyze these huge databases
challenges of pan-canadian research
• Different data access request procedures and timelines • Differences in the content and storage of data • Legislation governing patient's privacy and confidentiality
Federal government is responsible for the delivery of healthcare services to select groups of people:
• First Nations and Inuit • Members of the Canadian Armed Forces • Veterans • Incarcerated individuals • Refugees
1948 statistics act amendment
• Gave the federal government authority to collect hospital data • 1949: national system for vital statistics
what kind of questions was the survey based on
• Initial knowledge and perceptions • Perceived uses and benefits • Access and privacy
Bismarck inspired by worker grievances: such as ...
• Insecurity of existence • Link between illness and poverty • Societal obligation to workers/poor
The top rated benefits of using administrative data were:
• Long-term effects and rare events (76%) • Large sample sizes (73%) • Studying adverse effects (50%)
some of the challenges faced
• No data for non-white British populations • Lack of 'belief' that vitamin D deficiency was a serious problem • Resistance from policy makers to implement population wide interventions
Who can access this data?
• Researchers working in Canadian institutions
cost utility analysis
• Similar to CEA but outcomes measured as utilities • Utility refers to the preference that individuals or society has for a particular health state • In practice: generic measure of HRQoL • The quality-adjusted life year (QALY)
what does CADTH do?
• The Health Technology Assessment (HTA) program conducts impartial, rigorous, evidence-based reviews of the clinical effectiveness, cost effectiveness and broader impact of drugs, health technologies and health systems. • The Common Drug Review (CDR) conducts objective, rigorous reviews of the clinical and cost effectiveness of new drugs and provides formulary listing recommendations to the publicly funded drug plans in Canada (except Quebec) • Produces reference guidelines for standardizing the economic evaluation of health technologies in Canada
pressures to the health system
• Underlying population's poor health • Vitamin D deficiency impacts health, quality of life, productivity and wellbeing • Resources spent on: testing for vitamin D, GP appointments, hospital admissions
2002: Romanow and Kirby Reports
◦ Agree that Canada best served by a universal publicly funded health care system ◦ Urge federal government to take a bigger share of the cost in order to promote change
cultural safety
◦ Analyzes power imbalances, institutional discrimination, colonization and colonial relationships as they apply to health care ◦ Requires self-reflection and analysis of power differentials-we are all bearers of culture and our own culture impacts our behaviour
Benefits and the deductibles are calculated based on the household income of beneficiaries
◦ Below the deductibles, patients are required to cover 100 percent of the costs of their prescriptions - either out-of-pocket or through voluntary private insurance, if it is available to them. ◦ Once their deductible is reached, patients may still be required to cover a proportion of drug costs by way of coinsurance, which can also depend on their household income. ◦ The total prescription drug costs borne by patients may be limited to a percentage of household income.
economies of scale
◦ Canadian provinces already relatively small, as health systems go
stage 3 BC Ministry of Health PharmaCare Drug Review
◦ Drug Benefit Council (DBC) reviews above information, as well as impact on PharmaCare budget and coverage, input from BC residents and clinicians ◦ Final decision based on federal, national, and DBC reviews
federal government : patented medicine prices review board what does it establish
◦ Establishes maximum price that drugs can be sold at: Only for patented drugs Generic drugs at provincial discretion No jurisdiction over prices charged by wholesalers or pharmacies, or fees charged by pharmacists
2004: 10-Year Plan to Strengthen Health Care
◦ Federal government committed to annual increases in the Canada Health Transfer from 2006/7 to 2013/14
what does the Canadian institute for Health information do and what are they
◦ Gathers and analyzes financial and administrative data for provinces, federal government Identifies/defines national health indicators and frameworks Develops/maintains pan-Canadian data standards Develops/manages of health databases/registries Disseminates health data through reports
specialist physician ambulatory services
◦ Generally provided in outpatient departments of hospitals, some provided in private doctors offices ◦ Most specialists paid fee-for-service, though some paid salaries or under other arrangements ◦ Some specialist and diagnostic services may be provided in for-profit clinics ◦ First-dollar coverage by provincial insurer for medically necessary services
When assessing the outcomes of control knob actions, you need to consider:
◦ How improant are different kinds of disability and disease? ◦ What is the relative value of years of life lost at different ages? ◦ Do economically productive persons matter more than the unemployed or retired? ◦ What impact does a person's non-health status have of the value of their life Should public attitudes toward different diseases or causes of death matter? For example, public perception is to reduce cancer deaths. How does one combine death and disability? Are future gains to be discounted? How is uncertainty addressed? Do you estimate average effects, and ignore differences, or be less chance-neutral?
Lack of individual-level data to make informed service distribution decisions
◦ How much potential is there really to optimize care based on regional needs?
what does CMA do?
◦ Lobbies for groups' interests ◦ Conducts active policy research ◦ Canadian Medical Association Journal (CMAJ)
Canadian Partnership Against Cancer explored three factors related to disparities in cancer care access:
◦ Low neighbourhood income level ◦ Residential rurality and remoteness ◦ Individual immigrant status and neighbourhood immigrant density
TRC calls to action - education for reconiliation For example: "62. We call upon the federal, provincial, and territorial governments, in consultation and collaboration with Survivors, Aboriginal peoples, and educators, to:
◦ Make age-appropriate curriculum on residential schools, Treaties, and Aboriginal peoples' historical and contemporary contributions to Canada a mandatory education requirement for Kindergarten to Grade Twelve students. ◦ Provide the necessary funding to post-secondary institutions to educate teachers on how to integrate Indigenous knowledge and teaching methods into classrooms."
mediasave
◦ Medisave (introduced in 1984): mandatory savings for health care expenses and buying approved medical insurance Workers up to 50 years of age must set aside 20% of wage in health savings accounts, with 16% match by employers Contribution to Medisave is 7.5-9% of wage (depending on age) up to $43,500 after which you no longer have to put money in it and can divert savings into either of other two accounts ◦ Medishield ($33/year to $69/years depending on age) for catastrophic costs such as dialysis and cancer treatment (90% of Singaporeans pay into it) mandatory medical savings program for routine expenses
inpatient rehabilitation
◦ Orthopedics - e.g. joint replacement surgery, amputations ◦ Stroke, brain dysfunction, spinal cord injury ◦ First-dollar coverage by provincial insurer
Regional health authorities lack authority to control major expenditures
◦ Physician services Especially primary care!!! ◦ Drug costs
Public health programs and policies generally target populations rather than individuals ... why?
◦ Population health assessment ◦ Health promotion ◦ Disease and injury control and prevention ◦ Surveillance ◦ Emergency preparedness ◦ Epidemic response
federal government jurisdiction
◦ Prescription drug regulation and safety (but NOT purchasing) ◦ Financing and service delivery for Eligible First Nations people and Inuit Armed forces and veterans Inmates in federal penitentiaries Refugees and refugee claimants
first nations health authority services
◦ Primary Health Care ◦ Children, Youth and Maternal Health ◦Mental Health and Wellness ◦ Communicable Disease Control ◦ Environmental Health and Research ◦ First Nations Health Benefits ◦ eHealth and Telehealth ◦ Health and Wellness Planning ◦ Health Infrastructure and Human Resources
division of provincial responsibilities under the british north american act
◦ Provinces responsible for establishing, maintaining and managing: Hospitals, asylums, charities and charitable institutions ◦
Spiraling drug costs that are unsustainable
◦ Research by drug companies is resulting in extraordinary treatments—from biologics, made from living cells or organisms, to gene-based therapy. ◦ Challenging to develop and often expensive to administer, they can carry staggering price tags. ◦ Today's top selling brand name drugs often cost thousands or even tens of thousands of dollars per year. ◦ Drugs for rare diseases are even more expensive
medically necessary
◦ The CHA does not define "medically necessary" ◦ The CHA sets terms and provinces must meet these minimums to receive funding for hospital and doctor's services ◦ Paying costs of hospital stays and doctor visits is the easiest to meet This doesn't mean provinces can't cover other services ◦ Does mean that services outside core CHA are inconsistent across jurisdictions
Cost of options
◦ The number of people that would need some level of subsidy from the government was so large that means testing would be costly and impractical ◦ Private insurance costly due to administration and profit Found with insurance Canadians paying 30-40% above the cost of services received
1990s: Aggressive federal action to cut spending
◦ This period is the source of many misconceptions that persist through to today
federal money goes to
◦ Transfers to provinces ◦ Direct payment for Armed forces Residents of federal correctional facilities Some services for First Nations and Inuit
Emergency medical services (EMS)
◦ Transportation (road or air ambulance) ◦ Pre-hospital or inter-hospital patient care ◦ Some out-of-pocket payment
issue of compulsion
◦ Voluntary insurance would be slow and incomplete ◦ As long as decided by democratic intuitions, patients can choose physicians and additional (uninsured) services, and democratic ideals will be protected (or more fully realized) ◦ Compulsion has been applied to acquisition of other services such as education, payment of taxes, licensing physicians, regulating companies etc. to ensure social good Made comparison with education: With education you have to pay taxes for school but you also have to attend With health, you would have to pay into the system but no one can force you to GET care
