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 world10 provinces, 2
  territories
• Population 31.5 million (2005)
• Life Expectancy 78 m/ 82 f (2005)
• Population over 60 gt17
• 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 (lt25)
• Federal govt only provides to special
  populations (military, native Canadians, federal
  prisoners), lt2 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 gt25 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, RD
• 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)
• gt50 generalists, FPs
• 99 reimbursed by provincial health plans
• Most fee-for-service, some capitation, some
  salary (community health centers)
• Out-migration of MDs to USA (salary caps)
• All Canadian medical schools are US accredited,
  easy transfer, much recruiting

12
More Health Services Workforce

• Nurses lt300,000
• Low salaries, low job satisfaction
• Little autonomy, little professional development
  (MDs 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 outcomesOECD 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