The Canadian Healthcare System

1. The Canadian Healthcare System Lecture 4 Tracey Lynn Koehlmoos, PhD, MHA HSCI 609 Comparative International Health Systems

2. Where are we?

3. Canada: Updated info. • 2nd largest country in the world—10 provinces, 2 territories • Population: 31.5 million (2005) • Life Expectancy: 78 m/ 82 f (2005) • Population over 60: >17% • All cause mortality: #1 Cancer, #2 CHD • Healthcare 10.4% GDP (2005) • $142 billion (Canadian) (2005) • $2,931 (US) per capita health exp.

4. Health System Overview • Medicare (started in 1968) • Single-payer, universal coverage • 12 separate provincial programs • Funding: personal, sales, corporate taxes and federal transfer payments (<25%) • Federal gov’t: only provides to special populations (military, native Canadians, federal prisoners), <2% pop.

5. Birth of a system • 1966 National Medical Care Insurance Act • Medicare went into effect 1968 • Widely supported legislation • Eliminated financial barriers to care • Patient choice of physician • Physician choice of practice location/style • Health care is a right, not a privilege • Capitalism w/ social responsibility (collectivism)

6. Organization of Healthcare • Health Canada department: Federal responsibility for national health programs: • Occupational and Environmental Health • Health Promotion • Indian Health Services • Health Protection • Medicare: decentralized, provinces determine the management, delivery and financing of health services

7. Private Market • Private insurance exists to cover services NOT covered under Medicare (vision, dental, pharmaceuticals for non-elderly) • Private insurance is most often employment based 15% of total health expenditures

8. Economics--Revenue • Total: $142 Billion (Canadian) in 2005 • Public spending covers 69.9% • Private Insurance: 15% • Out of Pocket 15% • Funding: >25% federal transfer funds • Provinces raise money through taxes: corporations, personal income, fuel, lottery • Two provinces require a low, monthly flat-rate premium paid by employers

9. Economics--Expenditures Where does the money go? • $2,931 (US) per capita health exp. • 34% Hospital payments (global) • 14% Physician payments (FFS) • Salary Caps • Negotiated rates between province and providers • 14% Pharmaceuticals • 10% Other institutions (LTC, Mental)

10. Management • Provincial level planning • Prevents duplication of technology or services • National oversight of pharmaceuticals, emphasis on health protection & promotion, R&D • National and provincial controls on physician production and practice • Strong nation-wide reliance on health administrators: powerful, make policy, emphasis on leadership, cost efficiency, social responsibility

11. Health Services Workforce • ~54,000 physicians (1.8 per 1,000) • >50% generalists, FP’s • 99% reimbursed by provincial health plans • Most fee-for-service, some capitation, some salary (community health centers) • Out-migration of MD’s to USA (salary caps) • All Canadian medical schools are US accredited, easy transfer, much recruiting

12. More Health Services Workforce • Nurses: <300,000 • Low salaries, low job satisfaction • Little autonomy, little professional development (MD’s discourage use of mid-level practitioners) • Much out-migration to the USA

13. Hospitals • 95% not-for-profit (community boards) • Global Budget negotiated annually with province. • Capital expenditures are separate from Operating expenditures, gives province control of facilities and renovation. • Hospitals developed based on provincial planning

14. Hospitals • Advanced technology is hospital based • Waiting time for non-emergency procedures • Hospital beds declining due to shift to ambulatory setting for procedures.

15. Delivery of Services • Most patient care takes place in the office of the private physician. • Increased emphasis on prevention/promotion • Close monitoring to not duplicate secondary and tertiary services within a region • Rationing via review process and wait lists of expensive services (MRI, CTscan) • Cost containment shift from inpatient to ambulatory setting (like USA)

16. Long Term Care • Each province has a different program • 23% of hospital beds are used for LTC: low intensity, low service needs (cost efficient versus acute care services) • Hospital based LTC causes waiting lists • Especially for the elderly: no cost pharmaceuticals, special poverty preventing programs

17. Current Concerns • Inequity in care across provinces and territories (next slide) • Increasing number of elderly citizens • System-wide rising costs • Citizen dissatisfaction with long waits for some services and procedures • Cost-containment efforts and global budgeting will interfere with adoption of new technologies.

18. Illustration of Problems with Rurality Infant Mortality Rates by Province, 1995 Source: Statistics Canada, Births and Deaths, 1995.

19. Compared to US • Canada has similar health outcomes—OECD ranked 30th v. US at 37th. • Considerably lower portion of GDP spent on healthcare system • 300% per capita less in Canada on administrative fees • A true single payer system • All inclusive access • Waitlists are bad, but exclusion for 44 million Americans is bad, too.

20. Summary • Canadian Healthcare System: Medicare • Single-payer insurance based in each province • Physicians in private practice • Global Budgeting for hospitals • Healthcare is a right, not a privledge