Summary and Wrapup: Facts, Issues and Future

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Summary and Wrap-upFacts, Issues and Future

• Raisa Deber, PhD
• University of Toronto
• November 21, 2005

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What we heard

We need evidence!
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Policy dilemmas

• Conference clarified that there is still much we
  need to know
• Many issues up for debate

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Need to separate facts fromvalues

• What is Marys health status? Fact
• What services will help Mary remain in the
  community? Fact (once we get the data!)
• What are the implications of various ways of
  organizing and delivering those services? Fact
  (once we get the data!)
• How much would those services cost? Fact (but
  varies with how they are organized)

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Need to separate facts fromvalues

• Who should pay for those services? Value
• How much should the people who provide the
  services be paid? Value (with labour economics
  fact constraints)

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Is health insurance immoral?

• It can also be stated that the systems
  underlying egalitarianism is immoral in that it
  rewards that segment of the population that shows
  no concern for the medically deleterious
  consequences of its lifestyle.
• Source  Jean-Luc Migué, The Fraser Institute
  (Funding and Production of Health Services
  Outlook and Potential Solutions.  Discussion
  Paper No. 10, Commission on the Future of Health
  Care in Canada, 2002)

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Is profit immoral?

• ..making profits off the suffering of others is
  deplorable.
• It is is ethically and morally wrong to allow
  wealthy people to buy their way to the front of
  the line. Putting profits ahead of patients is
  wrong.
• Source Canada Health Coalition, For-Profit
  MRI/CT Clinics Reality Check. Downloaded Aug 28,
  2002 from http//www.healthcoalition.ca/realityche
  ck4.htm

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One clue we are talking about ideas

• Can these statements be proven to be true or
  false?
• What evidence (if any) might cause the
  individuals making them to change their minds?

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Ideas are not right or wrong

• You may agree or disagree with them
• They are an integral part of policy making
• But they should not be confused with facts

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Some issues are contentious

• No agreement about what we want to do
• If policy is about who gets what, then it may
  involve redistribution of resources
• It will be about winners and losers
• E.g., competition vs. cooperation

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Many policies have implications for women

• As recipients of care
• As providers of care
• Health professionals (e.g., nursing)
• Health workers (e.g., PSWs)
• Volunteers
• Family care givers
• Various policies will have different winners and
  losers

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Slide for Bea Levis (and my 85-year old
mother-in-law)
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But some issues are not contentious at all

• Research may be needed about how toaccomplish
  particular goals
• But little disagreement about the goals
• I.e., Elinor Caplans point about BETTER care for
  more people, rather than just more care

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Example, falls

• General consensus that falls are not a goodthing
• For individuals
• Or for the health care systemEvidence about how
  best to prevent them is thus
• Valuable
• Not particularly controversial (unless you market
  throw rugs)

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Policy issue institutional constraints

• Canada Health Act requires coverage based on
• Where care delivered (in hospital)
• Or by whom (physicians)
• Governments can insure beyond thisBut they are
  not required to
• Community support services do not fall under CHA
• Should this be changed?

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For Camille
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The issue of effectiveness

• Are various services/interventions
• effective?
• cost-effective?
• Which services?  For whom?Can we target groups
  most likely to be helped?

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Evidence

• We need the evidence!
• This should not be that contentious
• Although, as Pat Armstrong noted, what counts as
  evidence may well be!

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But not always clear cut

• Sliding scale of ability to benefit implies
  boundary issues
• Services may be cost-effective if they replace
  more expensive services
• But also add ons (even if often useful ones) if
  they are used by people who would otherwise not
  have been served
• How do we tell the difference?

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Who should pay for what?

• What is the responsibility of society?
• What is the responsibility of voluntary
  organizations (including faith-based groups)?
• What is the responsibility of individuals
  andtheir families?
• How should workers be treated (and how much
  should they be paid)?
• Not a question of evidence, but of values

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Whats in, Whats out Stakeholders views
about the boundaries of Medicare

• Research team
• Raisa Deber
• Earl Berger
• A. Paul Williams
• Brenda Gamble
• Acknowledgments M-THAC for funding
• Ann Pendleton for survey mailing and data entry
• Cathy Bezic for coordination and survey mailing

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With the assistance of the following research
partners

• Physicians Canadian Medical Association and
  provincial medical associations from
  Newfoundland and Labrador, PEI, Québec,
  Saskatchewan, Alberta, B.C. and Yukon
• Medical Reform Group
• Nurses Canadian Nurses Association and
  provincial nursing associations from BC,
  Alberta, Ontario, Québec, N.B., PEI, and Yukon
• Hospitals Canadian Healthcare Association, and
  Ontario Hospital Association
• Canadian Home Care Association
• Pharmacists Canadian Pharmacists Association
• BusinessConference Board of Canada, the Ontario
  Chambers of Commerce, and the Canadian Federation
  of Independent Business

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For full results of Boundaries of Medicare Project

• Results posted at
• From Medicare To Home And Community (M-THAC)
  Research Unit
• www.m-thac.org

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For 48 specific items, we asked What should
coverage be?

• Universal?
• Full coverage, no co-pays
• Subsidized?
• Payment split between government and individuals
  (co-pays allowed)
• Means tested?
• Government payment only for the poor
• Not?
• No government payment

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Responses given by group

• Doctors (CMA)
• Medical Reform group
• Nurses 3 bars
• CNA, RNAO Board, RNAO members
• Hospitals 3 bars
• CHA, OHA Chairs, OHA CEOs
• Can. Home Care Assoc.
• Pharmacists (Can. Pharm. Assoc.)
• Business 3 bars
• Ont Chamber of Commerce, Small business (Can.
  Fed. Independent Bus.), Big Business (Conference
  Board)

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Acute hospital care (in- patient)
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Long Term Care Facilities
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Nursing at Home
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Medical Supplies/Equipment at Home
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Personal Support at Home
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Community Support
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Homemaking
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Respite Support for Family Caregiver
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Stipend for Family Caregiver
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Bottom line?

• Consensus that hospital-based services should
  continue to be fully insured
• Consensus that long-term care in institutions
  should involve user fees
• Hypothesis Tendency to see home care as more
  similar to LTC facilities than to hospitals

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Result?

• Little support for full universal coverage for
  home-based professional care
• Even less support for full universal coverage for
  community support services
• Almost no support for paying for womens work

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But

• Nucleus of support for believingthat they can be
  part of the system,with costs subsidized
• Evidence thus likely to be veryimportant in
  clarifying which servicesare valuable, and for
  whom

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Policy analysis or policy advocacy

• Policy analysis
• balanced, objective analysis
• assesses multiple positions and interests
• may recommend a policy option
• nPolicy advocacy
• starts from a particular position
• may use tools of policy analysis to justify

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Role of CRNCC?

• Go beyond yea \ boo
• Try to
• Analyze what the issues are
• Distinguish between facts and values
• Clarify implications of ideas, institutions, and
  interests
• Recognizing that the data can be used for more
  effective advocacy should you wish to do so