Health Systems Around the World

October 30, 2015 10:20 am
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By Kathleen O’Grady

Comparing the performance of health systems around the world just got a little easier.

One morning, the media headline pronounces Canada’s health system should model that found in the Netherlands; the next week, we should follow Germany’s example, and yet another says Australia is leading the pack. Then there are the inevitable comparisons to the U.S. health system.

Think-tanks, politicos and pundits regularly weigh in with perennial favourites for how to improve Canadian healthcare. Such media coverage is often weighted with viewpoints steeped in ideological or economic vested interests. So, who can we believe?

Health systems are complicated. Journalists covering the issue often struggle – on short timelines – to gain enough knowledge of complex international health systems to ask the critical questions. But that’s about to change.

Now, health journalists from several countries are teaming together to create a free resource for journalists covering health systems and health policy issues from around the world. It’s journalists helping journalists, in other words.

The Panel of International Journalists was the brain child of U.S. health journalist, Trudy Lieberman. Liberman partnered with Dr. Noralou Roos, Professor of Health Policy at the University of Manitoba, and founder of EvidenceNetwork.ca, a non-partisan resource that creates original content for the mainstream media on health policy issues by bringing together health policy academics and journalists in partnership.

“Health reform is always a hot topic in Canada,” says Roos, “and often journalists are required to assess the quality of a source or a resource that compares our health system to those in other countries. It’s not an easy task, and certainly not on a deadline.”

Lieberman, who took part in a cross-Canada speaking tour at the invitation of EvidenceNetwork and as part of her Fulbright Fellowship in 2013, had a solution. Instead of just using the expertise of health policy experts, who aren’t always media savvy or available on media timelines, why not create a learning opportunity with seasoned health journalists working in the field around the world?

“The idea is for journalists covering healthcare to begin a dialogue with colleagues in other nations and learn from each other,” says Lieberman. “We also hope that this international exchange will foster the development of deeper and more informed health news stories.”

The Panel of International Journalists, with representation from Portugal, Italy, the United States, the United Kingdom, Australia, the Netherlands and Canada, have volunteered with EvidenceNetwork.ca to serve as resources for other journalists covering health systems they may not be familiar with. The individuals on the Panel are able to provide support and information on topics about patient safety; the rising cost of medical care; the marketing, pricing, and regulation of drugs and medical devices; and the workings of health insurance arrangements in their home countries.

The Panel is also available to health experts who are non-journalists, but who are searching for information about healthcare in other countries.

“It’s part of our on-going effort to raise the quality of health policy journalism,” says Roos, “by bringing academics and journalists together so they are on the same page, (they) understand each other’s needs and can inform each other’s work.”

Evidence Network has previously brought health policy experts and journalists together by creating original content for the mainstream media, including publishing hundreds of op-eds every year since their inception in 2011, in the largest media outlets in the country and internationally. They also have a regular podcast series on health policy issues and create media backgrounders on controversial health policy topics “so that journalists can quickly find the facts without the spin,” says Roos.

As with other EvidenceNetwork.ca projects, any material created from the International Panel is posted to their website with a Creative Commons license so that anyone can reprint the material with proper attribution.

“There is so much misconception about other nations’ health systems,” says Lieberman, “this Panel of International Journalists can be a resource for helping to set the record straight.

unnamedKathleen O’Grady is a Research Associate at the Simone de Beauvoir Institute, Concordia University and Managing Editor, EvidenceNetwork.ca. She lives in Ottawa, Canada. You can follow her on twitter at @kathleenogrady

 

The Digital Expert Will See You Now

September 9, 2015 11:01 am
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Why doctors and digital experts should work together to improve patient health 

As a family doctor, I have seen a dramatic shift in the range of people I work alongside every day – all for the better. When I was in training, most family doctors worked only with other family doctors and registered nurses. Today my health care team is rich with a variety of skilled people, including social workers, psychologists, chiropodists and dieticians. There are even examples of primary care teams engaging lawyers and accountants to help with health-related issues, such as housing and income.

But what’s missing – and should be an essential part of any healthcare team – is the digital expert. Here’s why.

Health care has been consistently changed by technology for decades. Historically, however, the change has been driven from within the healthcare system. PET scans, laparoscopic surgery, interventional radiology, digital imaging and electronic medical record systems are just a few examples of technological changes we now use routinely.These advances have been large scale, top down and expensive.

Now three relatively low cost, consumer owned, technological innovations are changing the game.

First, smartphones with a plethora of apps devoted to healthcare improvement, including those related to exercise, diet, chronic disease management and mental well-being, are ubiquitous among almost every demographic. Second, medical devices such as glucometers, scales and blood pressure cuffs are increasingly digitized and able to hold significant amounts of patient specific data. Finally, wearable technology, including watches, exercise bands, clothing and glasses, is exploding in popularity.

These technologies are even starting to merge as smartphones become medical devices capable of monitoring a person’s heart rate, heart rhythm, respiratory rate and oxygen saturation, among other critical health indicators.

Yet these important new technological innovations exist outside of my day to day family practice. The thousands of health related data points captured by these three types of personal technologies are not yet part of the health system. They should be.

Currently I rely on isolated data points and rough estimates. I take a blood pressure reading the day I see a patient, and I ask them how much alcohol they drank that week, what they tended to eat that month and push them to estimate how often they have exercised since our last visit. What I get are data points that reflect moments in time and the best efforts of an individual’s memory. Yet the information I need to help guide their care is often already nested in their smart phones, medical devices and wearable technologies.

But here’s the problem. Despite a steady growth in electronic medical records – and, simultaneously, patients investing in health-related personal technologies — the two worlds of technology can’t routinely talk to each other. Currently I may have a patient print out the results from their medical devices or apps and then scan the information into the medical chart as a static document.

Here’s what the future needs to look like: When patients come for their regular appointments, the first person they meet with should be a digital expert on the healthcare team. She has the ability to securely and quickly upload all the data from their various devices into the medical record in a manner that can be appropriately integrated, searched, displayed and programmed to show trends over time.

When the doctor – or any other member of the healthcare team – sees the patient a few minutes later, we now have days, weeks and months of helpful health information.

The digital expert on the team would offer far more than just synching devices at the appointment. They would be available to help link devices and apps remotely to a medical record without the patient even needing to come into the office. They could also act as a resource to help guide patients through the growing morass of choice in the wearable, digitized and app laden world of health care. They could also be key leaders in the research and evaluation of this emerging area.

Better data can improve healthcare decision-making and contribute to better quality care.

Patients already believe this, which is why they invest time and energy in collecting their health data. It’s time to take better advantage of their efforts – and a digital expert on the health team can help.

Tepper_Joshua_HIGH RESJoshua Tepper is a family physician at St. Michael’s Hospital and Associate Professor at the University of Toronto.

It Shouldn’t Matter Where You Go To School, But For Kids With Diabetes, It Does

August 11, 2015 12:00 pm
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Provinces, school districts need to adopt comprehensive diabetes policies now

Summer is a time to put thoughts of school aside, but some families are already worrying about September.  For parents of kids with diabetes, the beginning of each new school year brings not only the usual preparations, but also fears for their child’s health and safety.  This is especially true if their school or school district does not have a policy to ensure staff are knowledgeable about diabetes, know how to prevent emergencies, and are able to assist students with daily diabetes tasks, when needed.

Type 1 diabetes affects more than 34,000 Canadian children under the age of 19; another 1,800 have type 2 diabetes. Type 1 diabetes is when the body is unable to produce insulin, a hormone that controls blood sugar. It has no known cause or cure and usually begins in childhood.  Type 1 diabetes is the most common diabetes in children.

Type 2 diabetes is the most common among all people with the disease, where the body either cannot effectively use or produce enough insulin. Type 2 diabetes usually develops in adulthood, although more children and adolescents are being diagnosed.

Most students can manage their diabetes independently or with minimal support, and they can fully participate in school activities, including gym classes, field trips and celebrations. However, some, especially very young children with type 1 diabetes, may need trained personnel to help administer insulin, monitor blood sugar levels or supervise food intake and activity. Students with diabetes may also need flexibility in school rules to prevent low or high blood sugar, and may also need help with recognizing “lows” and “highs.”

A supportive school environment is critically important for keeping children with diabetes safe and healthy.

Proper diabetes management reduces the risk of life-threatening emergencies, prevents or reduces the risk of serious long-term complications such as heart disease, limb amputation, kidney failure and blindness. It also ensures that students with diabetes are able to learn and participate fully in all school activities. Yet only five provinces have guidelines for children with diabetes at school:  Newfoundland and Labrador, New Brunswick, Nova Scotia, Quebec and British Columbia.

Ontario recently formed a working group to address this issue and other jurisdictions have signaled their interest in forming such policies, but change has not been implemented as of yet. At the school-board level, some boards and even individual schools have developed policies, leading to a patchwork of different care standards among school districts, and even among schools in the same district.

Many schools and districts have no diabetes policies in place at all.

It is important that all children with diabetes be afforded the same protections and given the same opportunities to succeed, no matter where they live or attend school.

It is a team effort to enhance the health, safety, emotional well-being and participation of each student with diabetes. Parents and guardians need to notify the school of the diagnosis and meet with the school to develop an Individual Care Plan (ICP). School personnel need to participate in annual diabetes education, training and resource review to learn how to manage diabetes, including emergency procedures. Healthcare providers act as resources to the schools and assist in creating the student’s ICP.

But perhaps, most importantly, our provincial governments need to make proper diabetes management at school a priority now.

Every province and territory should establish clear standards of care that school boards can follow to ensure the safety, health and optimal education for children with diabetes. In the interim, school boards can begin the process of creating pragmatic guidelines such as those outlined by the Canadian Diabetes Association so that diabetes care across regions is equitable, safe and organized. Clear and consistent policies are better for the schools, better for families and provide an open and transparent process for communities to work with.

Finally, everyone should work to prevent students with diabetes from experiencing stigma and discrimination by promoting a positive, caring and inclusive learning environment through communication, education and cooperation.

By Jan HuxJan Hux

Dr. Jan Hux is an expert advisor with EvidenceNetwork.ca and Chief Science Officer for the Canadian Diabetes Association.

 

 

 

Is Waiting Longer for New Prescription Drug Approvals Necessarily a Bad Thing?

July 30, 2015 3:00 pm
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Why Canada’s ‘slow and low’ approach to new pharmaceuticals may be the prudent approach.

The newest report from Canada’s brand name drug makers on access to new drugs has one key message: compared to other countries, Canada goes slow and low.  New drugs are slower to be covered by our provincial drug plans and the numbers of people who get access to new drugs are lower than in other countries.  The report is undeniably negative: Canadians are suffering because our governments don’t provide timely access to new medicines.

Produced by Rx&D (the association of Canada’s brand name drug manufacturers), the report ranks Canada 17th out of 18 industrialized nations in terms of new drug reimbursement—with only 23 percent of new medicines covered across the country (it is closer to 90 percent in the U.S.).  As far as the time it takes between when a drug gets approved by Health Canada and when the provinces start paying for it, Canada ranks 16th of 18 countries.

Canada’s drug makers believe that drug plans in Canada should be more generous and access should be simplified so when new and innovative medications come along—those to conquer cancer, heart disease or other life-threatening conditions—government health plans should quickly pay for them.  After all, if they extend the length and quality of our lives, we citizens deserve them, right?

But here’s the rub: what prescribers know about the potential benefits and harms of a new drug when they arrive on the market is often uncertain or problematic. Often new drugs are studied for a shorter period of time and with a very specific population, so end up with biases, there’s sometimes unpublished data and frequently we don’t have a full sense of the overall safety of the drug in the real population.

Canada is not wrong to be prudent in taking our time to decide how, or if, a new drug needs to be covered—a precautionary approach is just the smart way to go. Take for example the widely prescribed arthritis drug Vioxx, which caused as many as 60,000 excess heart attack deaths in North America according to some estimates.  Those Canadian provinces who were more restrictive in covering it (such as BC) likely had proportionally fewer deaths caused by the drug.

Lately we’ve heard a lot about cancer in Canada from a new report that says the number of new cases of cancer will rise dramatically over the next 15 years.  The rise in cancer rates will be due mostly to baby boomers acquiring more diseases of aging, says the report—and this will drive the demand for more and more effective cancer drugs.

But there is plenty to suggest caution in approaching this new reality.  A recent article in the British Medical Journal by two noteworthy pharmaceutical industry analysts, Donald Light and Joel Lexchin, made the case that cancer drugs are often rushed to market and have faster approvals even when they provide very little gain for patients.

Their study, “Why do cancer drugs get such an easy ride?” examined  nearly 9,000 oncology clinical trials conducted between 2007 and 2010 and compared those studies to drugs for other diseases. They found that cancer drugs were almost three times less likely to be evaluated in randomized studies or tested against comparator drugs, and were more likely to be ‘fast-tracked’ in approvals than other drugs, casting doubt on the long-term benefit and safety of the drugs.

Then there’s a little bit of sleight of hand around what’s being measured.  Does it matter if a clinical trial of a new cancer drug gets approved because it changes a surrogate outcome (that is, it shrinks a tumour) as opposed to doing something meaningful (such as making the patient live longer or healthier)?  The reality is that many cancer drugs can shrink tumours quite effectively (and expensively) but may not change the length of a person’s life, while possibly turning the last few months of a person’s life into medically-intensive misery.

There is some good news here because the age-standardized death rates from cancer have been falling quite rapidly in Canada. Compared to other industrialized countries, Canada has relatively good cancer care outcomes: above average survival and generally about average mortality compared with other OECD countries.

We all want access to newer and better drugs but could we better spend our cancer budgets towards an array of non-drug options that improve the lives of people with cancer?  Do we want to continue to allow expensive drug intensive therapy to eclipse all the other things we could do for cancer patients and their families?

Wildly expensive new cancer drugs are eating a growing share of our healthcare dollars and provinces are clearly voting with their budgets, going slow and low on approvals and coverage of new therapies.  Canada’s drug manufacturers are condemning us for this approach, but they’re wrong — regardless of how strenuously they try to paint Canadians as poor suffering underdogs with stingy and heartless healthcare systems.

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By Alan Cassels

Alan Cassels is a pharmaceutical policy researcher in Victoria and an expert advisor with EvidenceNetwork.ca.

Why We Should Think Twice Before We Institutionalize National Pharmacare

July 17, 2015 11:30 am
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Amalgamation always seems like a good idea.  Greater Victoria has 13 municipalities, 13 councils, oodles of separate fire and police departments and multiple separate teams of garbage-persons, road fixers, parks maintainers and others that you need to keep our cities humming.  Which makes everyone ask:  Wouldn’t it be easier (and cheaper) if we just had one of each?  That’s right, “Let’s amalgamate.”

I don’t know much about municipalities amalgamating, but joining forces, preventing duplication and saving money has been suggested with something I do know about — pharmacare programs. Canada has at least 16 separate drug public plans – each of the provinces, plus ones for the RCMP, veterans, aboriginals and others, as well as hundreds of private drug plans.

Wouldn’t it also be easier – and cheaper — if we just had one national drug plan?

Earlier this summer, at least eight provinces got together to discuss a national drug plan. Cost-efficiencies, a better ability to negotiate drug prices and other economies of scale make it a compelling idea.  I agree.  Yet, I also agree that if done poorly, a national drug plan could be an utter disaster, characterized by waste, political coverage decisions and even more irrational and unsafe pharmaceutical use than we’ve got now.

Bigger does not always equal better; sometimes bigger means dumber.

Let’s take a major new drug to see how we might fare with a national drug plan. The diabetes drug Januvia (generic name: sitagliptin) globally earns about $6 billion per year for its manufacturer, Merck.  It costs about $3.50 per pill in BC and lowers blood sugar on par with older, cheaper diabetes drugs.

Proponents of a national drug plan would assert that with the buying power of one big agency, we’d negotiate much better prices for Januvia. Instead of paying $3.50 per pill maybe we could get it for $2 a pill which is about what Australia pays, seeing as they have national buying power.  Sound good?

It would be good only if Januvia had advantages over older, cheaper diabetes drugs.  Sadly, independent experts say that drugs like Januvia are less effective than older diabetes medications.  So are they more dangerous?  A trial published in early June tested the drug in 14,000 people over three years and found it wasn’t any more harmful than “usual care” plus placebo.  This “non-inferiority” trial suggested that over three years Januvia won’t increase your risk of heart failure, heart attacks, death or cancer compared to placebo.  Hmm. Hardly a slam dunk.

Taxpayers in Ontario and in Quebec pay tens of millions a year for this drug.  And Canada’s private plans?  It’s a good chance if you get drug benefits through your employment, then you’re paying for Januvia as well.

For my tastes, the first priority of a national drug plan wouldn’t be price, but evidence.

If the best available evidence suggests that a new, more expensive drug like Januvia is in the “not better or worse than comparator drugs” category, you’d have strict rules to make sure the drug was only covered for the subset of people who can’t tolerate other diabetes drugs.  You’d use the money you saved to expand coverage for drugs that are cost-effective so that more Canadians can be covered for high drug costs.  These are the types of hard decisions you have to make when you’re facing the political power of one of the world’s biggest drug companies.

The BC government, just recently, made a hard decision when it decided BC Pharmacare won’t pay for Januvia.  Why?  Maybe given little evidence the drug could extend the quality or the length of a diabetic’s life and the fact that Merck refused to lower the price to bring it on par with the other DPP-4 inhibitors, the government made the decision not to kowtow to the lobbying pressure.

That’s the kind of spine that would be essential in a national drug plan.

Yet if you look at other federal health-related organizations (Health Canada, CIHR and CADTH) you find very poor models of national spine.  We have a watchdog that doesn’t bite, a national health research funder that encourages Canadian researchers to “partner” with drug companies and a technology evaluator that takes money from drug companies  in the form of ‘fees,’ thus making them beholden to the very industry they are supposed to assess.

Any national pharmacare program would need an absolute firewall to protect it from the inevitable politics of drug coverage, otherwise you’d be left with even more irrational and expensive drug coverage decisions.

Amalgamation in Victoria and a national pharmacare program both sound great in theory. But in practice?  Hmm, I am usually optimistic about doing things collaboratively and working for efficiencies but I’d hate to see Victoria lose its character or Canada to accidently create a national form of institutionalized drug coverage that can’t make hard, politics-free and evidence-based decisions.

Cassells_Alan_new_high_res-apr2012_5x7[1]Alan Cassels is a pharmaceutical policy researcher, author and expert advisor with EvidenceNetwork.ca.  He lives in Victoria, BC.

Provincial Health Ministers Right to Push for National Pharmacare Program–But What Kind?

July 14, 2015 10:12 am
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Quebec’s outdated drug coverage policies should not be model for rest of Canada

In spite of very high expenditures for drug coverage, one in 10 Canadians cannot afford to fill their prescriptions. The current patchwork of public and private plans across the country means that Canadians are covered for their prescription drugs based on where they live or work, rather than on their medical needs.

Eight provincial health ministers organized a roundtable with healthcare professionals and academic experts on June 8 to discuss how we should transform drug coverage in Canada and several are now calling for a national pharmacare program. The question now is, what kind?

The suggested reforms discussed were based on international best practices, which overwhelmingly emphasize a single payer universal public drug coverage system equipped with the institutional capacity to ensure value for money. The evidence consistently shows that such a system would provide better access while substantially reducing costs.

Nevertheless, private insurers, the drug industry and some think tanks are advocating for the implementation of Quebec-style hybrid private-public drug coverage for the rest of Canada. Here’s why this won’t work for Canada–because it no longer works for Quebec.

In 1997, Quebec created a drug coverage system where it is mandatory for workers to enroll in private plans when they are available. Those for whom no private plan is available end up on the mandatory public plan. Thus, all Quebecers are covered by some form of drug insurance. Premiums can be very expensive, and patients still have to pay out-of-pocket a maximum copayment of 32.5 per cent when purchasing prescriptions, which can add up to more than $1,000/year.

What has been the result of Quebec’s hybrid model? Access to medications improved when the plan was implemented, but by keeping a fragmented system based on multiple public and private plans, Quebec has not developed the needed institutional capacity to contain costs. Canada has the world’s second-highest per capita costs for prescription drugs (only after the United States), and Quebec has the highest costs per capita among all provinces.

Twenty years ago, Quebec’s system was a great step forward, but it is certainly not a model for the 21st Century. While it did provide better access to prescription drugs, the system remains inequitable, inefficient and unsustainable, according to a recent official report by Commissaire à la santé et au bien-être.

Inequity persists in the Quebec system because the prices of drugs vary between the public and private plans. The public plan tends to balance its budget by shifting costs onto the shoulders of private plans rather than containing its costs. Since insurance companies are paid as a proportion of spending, they rarely complain.

So who pays? Employers and employees end up paying steep premiums. This increases labour costs and reduces the competitiveness of Quebec’s businesses.

Mandatory private coverage is also not related to income, so the costs can be substantial for some — especially the working poor. I was shocked when a student working part time told me that she had to pay $190 of her $514 net monthly income on drug premiums.

There’s also the systemic issue of institutional ‘skimming’ between “good” and “bad” risks. Seniors, people on social assistance, or unemployed end up on the public plan while those with a “good job” (the wealthier and healthier population) enrol in private plans.

Then there’s the inefficiency. For decades, private plans remained fixed on the idea that a “good drug plan” covered all new drugs at any cost, even when a lower cost alternative was available. Considering that the majority of new drugs do not provide therapeutic benefits over existing therapies, drug plans without the capacity to evaluate cost-effectiveness become a major source of waste. A good drug plan also requires the capacity to negotiate with drug companies to obtain better prices. Can you really negotiate prices if from the start your position is to pay for any product whatever the price?

When you look at the numbers, it really is surprising that all public employees in Quebec are required to enrol in costly private coverage given that administration costs account for 1.7 per cent for Quebec’s public plan, yet 18 percent for private insurers. In fact, more than 30 per cent of all people enrolled on private plans are public employees. This is a massive indirect subsidy to insurance companies, in addition to tax subsidies offered by the Federal Government, which represent 13 per cent of expenditures by private drug plans.

In a presentation last November, former health minister Jean Rochon, who implemented Quebec’s drug regime 20 years ago, said that, at the time, such a hybrid model was the right thing to do, but added that the system is now outdated and we needed to move on to tackle the new challenges relating to drug coverage.

The question, he said, is not “if,” but “how” we should implement universal public drug coverage for everyone.

Corporate lobbies and doubt manufacturers are working very hard, however, to tout Quebec as a model for the rest of Canada – against the best evidence.

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Marc-André Gagnon is an expert advisor with EvidenceNetwork.ca and assistant professor with the school of public policy and administration, Carleton University. Follow him on twitter at @MAG_Rx.

 

 

 

What Do Canadians Need from Pension Reform?

10:09 am
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A gentle policy nudge to enhance coverage and pension contributions—here’s how.

 Pension reform continues to hold interest across the country, especially given the willingness of the federal Conservatives to at least talk about expanding the Canada Pension Plan (CPP). Pundits and politicos are weighing in now with blunt talk of ‘voluntary’ or ‘mandatory’ enhancements to CPP. Neither may be exactly what Canadians want. Here’s why.

What do Canadians want out of a national pension system?old-people-616718_1280

I think it’s safe to guess they want at least the following: a system that
can be trusted, the lowest cost possible, high rates of return on investments, but within a range of prudent safety, transparency and a governing process that puts the interests of the plan participant (and not agents) first and foremost.

More importantly, perhaps, they want a system that will stay with them even if they change jobs and employers — turning savings into monthly cheques in retirement, until death.

So who is at retirement income financial risk today? A large number of workers.

We know only 32 per cent of workers have workplace pensions of any type. In the private sector, only 24 per cent of workers have anything. Further, the superior Defined Benefit Plan coverage is down everywhere.

We also know that very poor workers should not be forced into a mandatory system. Why? Because, after paying their mandatory contributions, they will receive very little to no extra benefits because of the claw back provisions in our Guaranteed Income Supplement (GIS) (usually alongside provincial supplements). In fact, the working poor can easily lose a full dollar for every new dollar of monthly income they produce on their own. Not to mention that the Old Age Supplement (OAS) and GIS benefits, now payable at age 65, will not be paid until age 67 starting in 2029.

Can we provide Canadians with a better system? The answer is a hearty, YES, although it will take some will on the part of legislators, both federal and provincial, since Pension Benefits Acts and the Income Tax Act will have to be amended.

Here is how it would work. The government makes it possible for institutions and agencies to create large pooled Retirement Income Funds to which any worker can contribute (within some tax limits). After a very short establishment period, these funds must achieve a minimum size (at least $10B in short order but even larger later). The funds must have a Board of Directors of experts who will guarantee good governance and guarantee that the plan participants’ needs are paramount and more important than any agent within the system. Expense ratios will be capped (and policed). 40 basis points (0.40%) seems appropriate since many larger pension plans today operate with expense ratios below 25 basis points.

You would be automatically enrolled, with an automatic payroll deduction if you are not in a Registered Pension Plan — but you can take action to opt out. This ‘nudge’ (according to the evidence) should result in ultimate participation rates in the 80 to 90 percent range. But, it will also allow poorer workers to opt out, as they should.

You and the fund will decide on your retirement income goal stated as a Defined Benefit. From this goal, one would subtract the benefits anticipated from OAS and CPP. The balance is what the fund is meant to provide.

Using slightly conservative actuarial assumptions as to rates of return and life expectancy, the fund will decide what contributions are necessary to attain your goal. Every year you will get a statement showing the record of the fund over the past year and whether you are ahead or behind the projected values necessary to reach your goal.

At retirement, you will continue in the fund and it will pay your monthly benefit cheques. Behind the scenes, the fund can carry the longevity risk of the group (not very volatile given the size requirements of the fund) or they can buy annuities (on a group basis — more competitive than for individual annuities).

Your benefits will be highly probable as to their attainment, but they will not be fully guaranteed. If we have another 2008 financial meltdown, you may face a short- term decrease in benefits. Note that what you get is a monthly benefit for life, not a lump sum at retirement.

Who can offer such a fund? Anyone who can meet the capital requirements – likely any banks, insurance companies that exist today could expand into this activity. But, also, large pension funds would be invited to offer this product.

It can be done. It just requires some imagination and a few (but important) tweaks to existing pension and income tax laws. Canadians want this. They deserve no less.

Brown_Rob.High resBy Robert L. Brown

Robert Brown is an expert advisor with EvidenceNetwork.ca, a Retired Professor of Actuarial Science, University of Waterloo and Immediate Past President of the International Actuarial Association.

 

Canadians Care About Healthcare—So Why Don’t We See More Health Policy Coverage in the News?

July 8, 2015 10:03 am
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For the last 30 years or so, Canadians have repeatedly flagged healthcare as the most important national concern and the issue they want their political leaders to prioritize. Surveys and studies and polls and panels—there have been plenty—all come up with the same finding: Canadians care about healthcare.

That doesn’t mean we are satisfied with the healthcare system we have. These same data sources show that Canadians often have concerns over health care quality, timeliness and availability, and we frequently believe we are not getting the best healthcare bang for the buck. But one thing holds fast: Canadians want their health system to remain universal, publicly financed and based on need, not income.

How healthcare is delivered in this country, to whom, where, and even how health providers are paid for health services is often the subject of vigorous debate. Whether it be public delivery, private, for-profit delivery or variations on private-public-partnerships—this is the stuff of heated polemic. This debate can be partisan with preferences frequently drawn down party lines and with differing perspectives across regions. But polls show that the vast majority of Canadians—across the political spectrum—continue to value our single-payer system (medicare) to cover the costs for essential health services for all Canadians. Many pundits have pointed out that this viewpoint is so pervasive and long-standing that it is no longer just a Canadian preference, it has become a Canadian value.

Nevertheless, we’ve had some significant changes to our health system in recent years. These include court challenges on how medicare operates, substantial alterations in federal government funding formulas used to determine critical healthcare dollars and a variety of changes in what is classified as an “essential health service” from provincial and territorial governments. There have also been systemic reforms in hospital funding in many regions—not to mention shifts in health human resource availability and changes in technology (screening and pharmaceutical) that disrupt the traditional healthcare landscape. Then there’s the perpetually evolving social and economic terrain that indirectly affects both our public policies and our health status, such as our aging population, growing economic inequities, challenges for affordable housing and childcare, among others.

All of this should be big news, right? Not so fast. It is terrifically strange to see health policy issues so important to Canadians frequently absent in media coverage. So where’s the news?

Changing media landscape

The media landscape has changed dramatically over the last several years with legacy media outlets being elbowed from the front of the pack by new online media sources with agile operations (unhampered by the restrictions and costs of a print medium) and nimble economic restraints (frequently engaging non-unionized, young recruits). At the same time, Canadian patterns for media consumption are changing in a now predictable fashion: the dwindling of print broadsheets and magazines, particularly in the youngest demographics, and a steady upswing in the use of tablet and mobile devices to access both traditional and new media stories.

But there are some constants. Turns out, Canadians continue to be immersed in media stories about sports, the economy and the weather, in that order. How much might surprise many.

According to 2014 metrics, there were 10.9 million news items last year in Canadian media outlets (across mediums), and a whopping 37 per cent of those stories were sports-related. (Perhaps less surprising is that coverage of the NHL constituted 44 per cent of all Canadian sports news). Measured another way, of the top 50 news stories of 2014, 21 were related to sporting events.

Canada also has the dubious honour of covering weather in the news 229 per cent more frequently than other countries. Let’s not forget the economy and mostly national and regional (not international) politics. Nearly half of all of our media stories last year were about sports, politics and the economy. You throw weather in there, and there’s not room for much else.

Why does this matter? It’s when you get to the bottom layer of data–the scrapings on the floor–that you find that the least covered news stories in Canada might be the most important. Turns out, we spend the least amount of media time on stories that address poverty, the elderly, education, childcare and aboriginal issues. These five issues amount to less than one tenth of the space devoted in the Canadian media to cooking, says one recent report.

Health content does slightly better, but constitutes a minor blip of just over two per cent of all media stories.

In other words, we are all too frequently entertained—and not educated—by our media outlets. The stories that help us understand what influences public policy and the factors that determine our health status—the so-called social determinants of health—are left largely untold. ‘Health policy’ writ large may be a topic of interest to Canadians, but it is not an easy sell for the media.

On the whole, it seems health policy issues are absent or thinly covered by the bulk of media outlets (television, radio, print and online) now available to the public. This is not the fault of journalists; Canada has some exceptionally talented public health reporters, including the Globe and Mail’s André Picard, Vox’s Julia Belluz, the National Post’s Tom Blackwell, Hamilton Spectator’s Steve Buist, Winnipeg Free Press’ Mary Agnes Welch and freelancer Ann Silversides, to name just a few.

But since media outlets are struggling for survival, competing for precious ad dollars and strapped to meet the changing demands of a highly techno-savvy audience, policy rich stories are often left by the wayside. It is a constant struggle for health policy stories to compete for space in the media with sports, celebrity, economics and the weather — and ‘clickbait’ stories with snappy headlines and ever shorter, punchy narratives too often take over.

EvidenceNetwork.ca has tried to mitigate this reality and inject more health policy content into the news. How?

Partnership between journalists and health policy academics

Since 2011, we’ve worked to create a dialogue between Canada’s journalists and academic health policy experts to enrich the quality and quantity of health policy stories in the Canadian media. We work with a Media Advisory Board made up of journalists and professors of journalism from across the country who let us know what their needs, constraints and objectives are from a journalistic perspective. We also have a network of more than 80 health policy academics who are ready and available to be interviewed by the media and provide a non-partisan, evidence-based perspective from their areas of expertise.

Working together, we have created a number of tools for enabling media coverage of health policy issues in Canada, including the preparation of media backgrounders, infographics, posters, podcasts and videos that highlight the evidence, and we conduct webinars, seminars and conferences by and for both journalists and academics alike.

But our most successful initiative thus far has been having our academic experts author Op-Ed articles on health policy issues—highlighting the evidence; they work with a professional editor to follow specific media guidelines, and then we publish the commentaries in the biggest media outlets across the country. The table below illustrates how successful this strategy has been and how receptive media outlets have been to these stories—increasingly so.

OpEds by Media Category HUFF POST CATEGORY B_APRIL 2015 2011 - 2012 OpEds by Media Category_Apr 13 2015-jpeg2013 - 2014 OpEds by Media Category_Apr 13 2015-jpeg

Do op-eds make a difference? Well, we are trying to track key outcomes. But we can say already that as a result of the publication of the op-eds, some of our academic experts have been invited to give testimony at court hearings, provide evidence at government proceedings, give presentations to royal commissions, invited to international conferences—real world consequences, in other words (and there are more). We’ve also seen published op-eds in one paper instigate stories in other media outlets, creating a kind of domino effect, and thus expanding the coverage of the topic further. We’ve also had several major broadsheets endorse a position in their editorial pages that was originally outlined in one of our op-eds. Social media sharing for many of our top stories has been in the thousands, ensuring an audience reach of several million for a single story. This hasn’t happened once or twice, but multiple times, indicating that there’s an appetite in our country for rigorous, meaty policy content on health policy issues.

With our project, we hope to engage and enrich the dialogue and debate on a healthcare system that’s so important to Canadians. As we head into a federal election year in 2015, it seems certain that many of these issues will come to the fore, and it serves our democratic system that they be aired and discussed with evidence as the foundation. With journalists and academics in partnership to communicate health policy in the news, we can help navigate the evidence together.

A version of this essay appears in the new free ebook: Navigating the Evidence: Communicating Canadian Health Policy in the Media edited by Noralou Roos, Kathleen O’Grady, Shannon Turczak, Camilla Tapp and Lindsay Jolivet. Available in Kindle, Apple, Google and PDF formats:

1276991_588866957837667_1084464500_o KathRoos_Noralou_2007leen O’Grady is the Managing Editor of EvidenceNetwork.ca and a Research Associate at the Simone de Beauvoir Institute, Concordia  University, Montréal, Québec.

Noralou Roos is a Professor in the Department of Community Health Sciences, Faculty of Medicine, University of Manitoba and Director of EvidenceNetwork.ca.

Aging In The Right Place Is What Many Canadian Seniors Want And Need

June 29, 2015 10:08 am
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Here’s how to make it happen

A shift in thinking on seniors’ care issues is taking place across the country, and it’s making our government leaders sit up and take notice.

The opportunity to provide cutting edge seniors’ care has never been more within reach. Worldwide, there is a movement to take better care of aging adults and this is reflected in exciting technology, design and conceptual communities—which completely flip the notion of what it is to age on its head.

We know now seniors’ issues include more than just better health-care coverage. It’s about more than just beds for long-term care, more money for care-providers and the obvious need for updating older seniors’ facilities with sprinklers and other mobility-related accommodations so people who don’t move as easily as they once did, can get around and out as needed.

But it’s also about more than providing in-home supports and retrofits to allow seniors to, so called, “age-in-place.”

Those of us in the industry who are committed to providing quality seniors’ housing and care—many of whom also deal with the reality of aging parents—believe there is a long overdue conversation Canadians should be having with their families. It’s also a conversation our governments should be having with every single one of us, as most of us will live longer than generations past, but will need greater supports.

These discussions should be based on having all of the options and information available for our aging seniors—which should include the more appropriate goal of “aging in the right place.”

When most people think of seniors’ care, they skip a step or maybe two. They might think resentfully of the hospital bed being taken up by a senior who is waiting for appropriate supports to be able to go home or to some draconian long-term care institution we imagine with horror.

Thinking about end-of-life quickly moves us to think of something else, and so we cling to the notion of staying in the family home as the best place to be. This may not be true for all.

Unfortunately, statistics and surveys describe a sometimes different reality, where seniors living alone wait for the kids to call, become isolated, depressed and under-nourished. For many elderly, living the dream of aging-in-place can instead mean their world becomes a seniors’ Bermuda triangle: moving alone between the bedroom, the fridge, the TV and back.

The home that once worked for the family, may not exactly be fulfilling or suitable as we age.

It turns out most people’s notions of seniors’ care facilities are outdated. These outdated notions may also not reflect the value of the supports that are available in congregate living.

Seniors’ housing options are no longer just one-stop-fits-all. The move to ‘supportive living,’ for example, can offer greater safety, more balanced meals, increased access to home care, with the added value of engagement with a vital social community.

Eventually when the time is right and when it’s needed, there is also ‘full support’ available in the senior housing sector. All of these may be more finely tuned, responsive, efficient, cost effective, and most importantly, appropriate housing options for seniors than staying in the family home.

There is an industry of professionals who are organized, armed with research, prepared and excited to assist with respect to providing better housing and care for aging Canadians. Seniors’ issues may not be the ‘squeaky wheel’ that drives the revenue of our economy; however, if not supported, it will drive costs.

For the growing number of seniors and for those with an aging family member, we need to keep the foot on the pedal.

Arlene AdamsonArlene Adamson is CEO of Silvera for Seniors, a charitable non-profit organization which provides homes to over 1,500 lower-income seniors. She is also co-chair of the Seniors and Special Populations Sector Housing Committee and is on the Board of the Alberta Seniors Communities and Housing Association.

Four Things you Should Know About the Pending Charter Challenge Against Medicare

June 25, 2015 10:00 am
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A long-running dispute between Dr. Brian Day, the co-owner of Cambie Surgeries Corporation and the British Columbia government may finally be resolved in the BC Supreme Court this year – and the ruling could transform the Canadian health system from coast to coast.

The case emerged in response to an audit of Cambie Surgeries, a private for-profit corporation by the B.C. Medical Services Commission. The audit found from a sample of Cambie’s billing that it (and another private clinic) had charged patients hundreds of thousands of dollars more for health services covered by medicare than is permitted by law. Dr. Day and Cambie Surgeries claim that the law preventing a doctor charging patients more is unconstitutional.

Dr. Day’s challenge builds on the legacy of a 2005 decision by the Supreme Court of Canada overturning a Quebec ban on private health insurance for medically necessary care. But this case goes much further, not only challenging the ban on private health insurance to cover medically necessary care, but also the limits on extra-billing and the prohibition against doctors working for both the public and private health systems at the same time.

A trial date was set to begin in 2012, but was adjourned until March 2015 so that the parties could resolve their dispute out of court and reach a settlement. It now appears such a resolution has not been reached and the court proceedings may resume in November.

Here’s why this case matters.

1. Legal precedent: Whatever way the case is decided at trial, it is likely to be appealed and eventually reviewed by the Supreme Court. A decision from this level will mean all provincial and territorial governments will have to revisit equivalent laws. The foundational pillars of Canadian medicare–equitable access and preventing two-tier care — could well be vanquished in the process.

2. Wait times: Day will likely argue that Canada performs poorly on wait times compared to other countries, and that other countries allow two-tier care; thus, if Canada is allowed two-tier care, our wait times would improve. But this approach is too simplistic.

Common comparisons to the English health system, for example, fail to recall that despite having two-tiers, they have in the past suffered horrendously long-wait times. Recent efforts to tackle wait times have come from within the public system, with initiatives like wait time guarantees and tying payment for public officials to wait times targets.

By looking to England we are not measuring like to like but apples to oranges. English doctors are generally full-time salaried employees while most Canadian physicians bill medicare on a fee-for-service basis. Consequently, the repercussions for permitting extra billing in Canada could eviscerate our publicly funded system, whereas this is not the case in England. Imagine if most doctors in Canada could bill, as those at the Cambie clinic have done, whatever they want in addition to what they are paid by governments?

3. Conflict-of-interest incentives: Evidence suggests there is a danger in providing a perverse incentive for physicians who are permitted to work in both public and private health systems at the same time. Wait times may grow for patients left in the public system as specialists drive traffic to their more lucrative private practice.

Sound improbable? Academic studies have noted this trend in specific clinics that permit simultaneous private-public practice. And recent UK news reports have profiled a case where a surgeon bumped a public patient in need of a transplant for his private-pay patient.

4. Competition: Proponents of privatized health services often claim that it would add a healthy dose of competition, jolting the “monopoly” of public healthcare from its apathy. But free markets don’t work well in healthcare. Why? Because public providers and private providers won’t truly compete if the laws Dr. Day challenges are struck down. Instead, those with means and/or private insurance will buy their way to the front of queues. Public coverage for the poor will likely suffer, as is clearly evident in the U.S., with many doctors refusing to provide care to medicaid (low-income) patients in preference for those covered by higher-paying private insurance.

Of course, this is all based on an outcome that is not yet known. It may be that the Charter challenge in B.C. is unsuccessful but clearly the stakes for ordinary Canadians are very high. Sadly Dr. Day is not bringing a challenge for all Canadians. Isn’t it long past time our governments and our doctors work to ensure all Canadians – and not just those who can afford to pay – receive timely care?

Flood_ColleenO'Grady_KathleenColleen M. Flood is Professor and University Research Chair in Health Law & Policy at the University of Ottawa and an expert advisor with EvidenceNetwork.ca

Kathleen O’Grady is a Research Associate at the Simone de Beauvoir Institute, Concordia University and Managing Editor of EvidenceNetwork.ca.

We Have Built a Sickness Care System Rather Than A Health System

June 24, 2015 11:58 am
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We have designed that system for the convenience of practitioners, not patients: Convocation speech delivered to graduating MDs at the University of Manitoba on the receipt of an honorary doctorate.

Mr. Chancellor, Mr. President, distinguished guests, soon-to-be MDs and their deeply indebted family members. I’m touched and humbled to receive an honorary degree from the University of Manitoba. Thank you for letting me share this special moment with you.

I’m not a doctor. I never will be. I’m a lowly journalist. I tell stories.

For almost 30 years I’ve tried to help Canadians understand their health system and their medical care.

In that time, I’ve seen tremendous advances in medicine and I’ve met, quite literally, thousands of health professionals, from students to Nobel Prize winners — and patients, from those with rare genetic mutations to those with everyday ailments, from those cured miraculously to those who died needlessly.

Today, I’d like to take few minutes to share some of what I’ve learned from telling their stories.

One of the greatest privileges in our society is to have the letters M.D. after your name. Those two letters confer great power. And with that power comes great responsibility, to quote Voltaire — or Spiderman, depending on your literary predilections.

Shortly, you will be taking the Hippocratic oath. You’ve probably all heard that it says: “First do no harm.” It doesn’t actually – that’s just bad media reporting.

But it does say a lot of important things. I think the line that matters most in the oath is this:

“Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient.”

Sadly, too many physicians fail to honor that part of the pledge.

We have built a sickness care system rather than a health system. We have designed that system for the convenience of practitioners, not patients.

Modern medicine has become so specialized that many physicians treat specific syndromes and body parts, and the patient herself gets lost in the process. We have filled our temples of medicine with such bedazzling hi-tech tools that we’ve forgotten that we should treat people where they live.

In our desire to cure, we over-treat.

We fail too often to say the three most important words in medicine: “I don’t know.” We see death as a failure, instead of aspiring to make patients’ comfortable and at peace at end-of-life.

In our unrelenting quest for efficiency and measurement, we too often lose sight of what really matters. The patient.

What does your patient want? What are his or her goals? Those are the questions that must guide your practice.

For some of your patients, the goal is to repair their acute woes, to help them live long. But most of your patients will be older, and have a number of chronic conditions and be nearing the end-of-life. Their goals are different.

They’re not going to be cured. You have to focus on their quality of life.

They want to be at home. They don’t want to fall. They don’t want to be in pain. They don’t want to be a burden. They don’t want to be alone. They don’t expect miracles – but they would like respect.

They don’t fear dying. They fear losing their autonomy and their dignity. They don’t care about your metrics, or your age-adjusted mortality rates, or your fancy new genomic test. They want to be listened to, and heard.

We hear a lot these days about personalized medicine, about drugs and treatments that can be tailored to specific genomic and epigenetic markers. But you know what people really long for: personal medicine, not personalized medicine.

They crave a human connection. Not just care, but caring.

The very best medicine you can offer your patients is a listening ear. The very best treatment you can offer them is a compassionate heart.

Now you may be sitting there thinking, this is all feel-good nonsense. It’s not. The more sophisticated and complex medicine becomes, the more the basics matter.

What did you learn in medical school? Anatomy, biochemistry, genomics, countless mnemonics to help you remember bits of knowledge; you know how to deliver babies and treat cancer and diabetes and depression and asthma, take out people’s appendix and do MRIs and PCIs, and countless other things.

What you’re going to learn now, in the real world, is that physical woes are the least of patients’ worries. Their health problems aren’t strictly caused by mutating cells, opportunistic pathogens and poor genes, but by poverty, lack of education, poor housing, stress and social isolation.

You’re going to, sooner or later, learn humility. And, the earlier you do, the better the doctor you’re going to be.

In this, the Internet age, we are drowning in information, but starving for wisdom. I urge you, as you forge long, successful and prosperous careers, to not just be smart, but be wise.

In every interaction you have, embrace the ancient wisdom of Hippocrates: “Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient.”

A version of this speech was delivered May 14, 2015 to the graduating class at the University of Manitoba.

Globe and Mail business journalist Andre Picard poses in the Montreal offices on September 6, 2012. For Promotions (Christinne Muschi for The Globe and Mail)

André Picard is a health reporter and columnist at The Globe and Mail, where he has been a staff writer since 1987. He is also the author of three bestselling books.

Pros and Cons of an Expanded Canada Pension Plan

June 23, 2015 10:00 am
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A new report came out this week that reiterates what we’ve heard from other sources a few times now: Canadians aren’t saving nearly enough for retirement. The Deputy Chief Economist of the CIBC warns that without pension reform now, younger workers today will see a steep decline in living standards as they retire.

The Conservative government has recently announced it would like to have a dialogue with Canadians about a potential expansion of the Canada Pension Plan (CPP). While this, in itself, is a purely political action–since it commits the government to nothing–it is worth looking at what the possible outcomes might be.

We know 76 per cent of workers in the private sector have no pension plan at all. They are left totally to their own initiative. They are not trained in this “retirement-income-security” science. They can get retirement savings products but have to pay extremely high fees (e.g., 250 to 300 basis points or a full 2.5 to 3 per cent of their cash flow) for this expert management. And sometimes, their agent does not even work on their behalf, but rather acts to maximize the income of the agent.

Might it thus be wise to finally consider an expansion of the CPP at a time when both the CPP and its investment arm (the Canada Pension Plan Investment Board—CPPIB) are riding high in the polls?

The answer is not obvious. Far from it.

Amendments made to the CPP in 1996 state that any new benefits must be fully-funded. That means you only get back what you have paid for in full. Under current rules, it takes 39 years at a minimum to earn a full benefit. So if you make a contribution today (2015) you would only have earned 1/39 of a full benefit. Full benefits would not be available until 2054.

So if we think we have a problem in terms of people who plan to retire in 2054 not saving enough today, then we must amend the CPP now.

The CPP is currently organized and administered like a Defined Benefit plan. Moving to Voluntary Contributions, as the Conservatives wish, would force it to be administered much more like a Defined Contribution plan.

Why does this matter?

If workers can move their money in and out of the CPP fund freely, this will create the potential for anti-selection on the part of the participants (move in when the times are good and out when bad), resulting in the need for the CPPIB to move toward much more liquid shorter-term assets with lower rates of return. It would also mean much higher administrative costs for the CPP (especially the investment arm, the CPPIB, as they would have to track the cash flows of individual accounts).

This would be on top of the high expense ratio for the CPPIB–estimated in the range of 90 to 100 basis points (i.e., 0.90 to 1.00 per cent) which is multiples of what other very large plans cost (e.g., HOOPPs, BC Public Service and even some private sector plans like Bombardier) which run with expense ratios closer to 25 basis points.

It would also make all Canadian workers much more dependent on the investment capabilities of the CPPIB and the decisions they make versus the myriad of private managers now being used. So, the word “voluntary” cannot be taken lightly.

Further, the CPPIB is having problems keeping all of its $265 billion invested in safe, but high yield investments today. What will it do with another tier of contributions?

Finally, one can certainly expect a vehement push-back from the private sector that caters to retirement savings today at a nice profit margin.

So, what if the contributions are mandatory? That will result in serious problems for very poor workers (and their employers).

Consider forcing low-income workers (and their employers) to contribute to a new tier of the CPP. Not only do they not receive full benefits for another 39 years, but when they do get their extra CPP benefits, they will lose the impact of these extra payments as they see their Old Age Security (OAS) Guaranteed Income Supplement (GIS) benefits clawed back.

Since GIS payments are often matched by provincial schemes (e.g., GAINS in Ontario), many poor workers will lose $1 of OAS/GIS and provincial supplements for every new dollar of CPP benefits. So, they, and their employers, contribute out of money they need for higher order needs now (like food and rent) and they get no new net benefits at all. That is regressive. And we know that employers, such as those represented by the Canadian Federation of Independent Business (CFIB) will aggressively oppose any such mandatory imposition.

In summary, we are faced with a myriad of questions and not only do we not have any good answers, we have no answers at all. It’s time our governments started looking at the complexity of the issue with some serious attention.

Brown_Rob.High res (1)Robert Brown is an expert advisor with EvidenceNetwork.ca, a Retired Professor of Actuarial Science, University of Waterloo and Immediate Past President of the International Actuarial Association.

The Real Costs of Informal Caregiving in Canada

June 15, 2015 11:13 am
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National strategy needed for unpaid caregivers in the workplace

The phenomenon is not exactly marginal: according to a recently released government report, one in every three workers in Canada is assisting a chronically disabled person–many of them seniors–with transportation, household maintenance or day-to-day tasks. The 6.1 million employed workers who are providing such care, free of charge, to a family member or friend are more likely to experience interruptions at work and to arrive late or even be absent from work. Many are less available than they would otherwise be to work overtime, travel for work or advance their careers.

Without a doubt, the impacts of informal caregiving commitments do not remain confined to the home: they are felt in the Canadian workplace and reduce productivity. They translate into 2.2 million hours of reduced effort in the workplace every week and cause an estimated $1.3 billion productivity loss annually, says the report.

With the anticipated growing numbers of seniors requiring care, the costs of unpaid caregiving and reduced productivity will likely expand over the next two decades. What should we do about them?

As Canadian employers are increasingly confronted with the reality the work of informal caregiving has on their employees, it only makes sense that they should be the first to recognize and support informal caregiving. Some of them already offer flexible arrangements (e.g., compressed work weeks, work from home, unpaid and even paid leaves) to employees with caregiving commitments. This said, not all employers are equally supportive, if at all, and many Canadian workers with caregiving responsibilities are paying the price: reduced income, career limitations and exit from the labour force.

A year ago, the federal government established the Employer Panel for Caregivers which consulted with employers to help them find ways to better support their employee caregivers. The consultation was premised on the (realistic) assumption that unpaid care will remain the main source of long-term care in this country.

The most significant insight it gained is this: while employer support to employee caregivers may foster engagement and greater retention in the workplace, there might not be a business case for many employers to voluntary engage in this. Put another way, moral appeal and compassion for employee caregivers will not translate into a massive, spontaneous movement in the Canadian workplace to address the issue any time soon.

What else is needed? Should the costs of caregiving and reduced productivity belong uniquely to caregivers and their employers?

It is becoming increasingly difficult for Canadian policymakers to ignore their own essential role–beyond that of offering limited and sporadic supports–to address the issue.

Confronted with a similar situation, the United Kingdom, Australia and New Zealand have, in recent years, adopted national caregiver strategies. At home, Manitoba and Nova Scotia are leading in many ways, but efforts across the country remain fragmented and inconsistent.

Canada can do better.

Needed as part of a national strategy are integrated policy instruments to support caregivers and their employers. First, Canada’s workplace legislation, which is primarily a provincial jurisdiction, needs to ensure minimum standards to protect workers with caregiving commitments. Second, we also need a comprehensive set of financial instruments–possibly a combination of private or public programs–to better protect the workers’ incomes and their employers’ productivity losses. Third, more substantial coverage of homecare, nursing care and supportive services (e.g., adapted transportation or supervised day centers) for the disabled is an essential component that would benefit everyone.

Is this financially realistic? Policymakers still need to recognize the undeniable costs of unpaid caregiving. So the real question should be instead: How should these costs be shared?

Caregivers are already contributing a lot: A study estimated that if governments had to pay for caregiving provided free of charge by people 45 and over in this country, it would have cost about $25 billion in 2009.

Some argue that governments should compensate caregivers. I don’t think they should. But governments do need to ensure that while providing unpaid caregiving, workers never incur catastrophic income losses or lose their jobs as a result.

Financial and in-kind supports are critical especially when caregiving commitments extend to several hours a week over a long period of time. This should be covered by public programs.

Instead of having a situation where we have some employers who provide workers with coverage and some not, only a coherent national strategy will allow Canadian workers looking after a spouse or relative to better focus on their work, their employers to better focus on their mission and disabled persons to get the care they need.

Bernier_NicoleNicole F. Bernier is an expert advisor with EvidenceNetwork.ca and research director of the Faces of Aging program at the Institute for Research on Public Policy.

The Other Drug Problem in Canada’s Cities

June 11, 2015 12:05 pm
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How Canada’s piecemeal pharmaceutical drug insurance coverage costs Canadian cities—and taxpayers—plenty

Canada’s cities face a number of problems: traffic, housing, crime, infrastructure—the list goes on. Prescription drugs are one of these problems—one that is costing local governments as much as $500 million every year.

How so? Municipalities, like most employers, realize the value of a healthy workforce. Recognizing that access to necessary medicines is critical for health and wellbeing, many cities offer their employees private insurance coverage for prescription drug costs. For example, the cities of Toronto and Calgary spend approximately $43 million and $20 million, respectively, on private drug insurance plans for their employees. The coverage they offer is relatively comprehensive, resulting in costs per employee that are equal to private sector averages. Vancouver and Halifax offer less comprehensive drug coverage for their employees but still at considerable cost: about $3 million each.

The numbers add up. According to Statistics Canada, there are over 600,000 local government employees across the country, about two-thirds of whom receive private health insurance from the cities, towns and districts they work for. Based on the cost of such coverage for the four cities above, these local governments are spending about $500 million a year on private drug insurance for their employees.

Cities have to spend this money taken from local taxpayers because Canada’s medicare system is the only universal, public health care system among developed countries that does not include universal coverage of prescription drugs.

It is not wrong for cities to care for their employees. But leaving these costs to the cities makes about as much sense as requiring every homeowner to maintain the roads and infrastructure surrounding their property. Here’s why.

Just as would happen if infrastructure was left to individual homeowners, the system that leaves drug coverage to individual patients and employers, including cities, creates an uncoordinated patchwork. Most cities provide coverage, but some can’t afford to. Some workers qualify for coverage, but some don’t.

The same pattern plays out in cities, hospitals, schools and businesses across the country. As a result, millions of Canadians are without drug coverage and one in 10 Canadians cannot afford to fill their prescriptions.

This patchwork is not just inequitable, it is profoundly inefficient because it fails to place responsibility for drug coverage and costs with the right level of government.

Provinces and the federal government are responsible for Canada’s health care system. They are best suited to manage access to medicines as an integral part of health care for all Canadians. They are also best positioned to reduce waste and overspending on pharmaceuticals.

Having multiple drug plans operating in every province, including multiple private plans for public sector employees, needlessly duplicates administrative costs. Worse yet, this fragmentation diminishes Canadians’ purchasing power on the global market for pharmaceuticals.

Provincial governments wield about $10 billion in purchasing power when negotiating rebates for prescription drugs. This reduces public drug plan costs by millions of dollars. But it does not lower costs for cities and other organizations who insure their workers through the private drug plans that are miniscule in comparison.

No matter how hard they try, cities would have about as much chance of negotiating competitive drug prices as homeowners would have of securing the best prices for infrastructure planning, engineering and construction. Some things are best done through well-planned, population-level procurement processes.

A recent study in the Canadian Medical Association Journal shows how a universal public drug plan run by provinces could provide all Canadians coverage for prescription drugs while saving taxpayers $7 billion per year. Such a program would end the downloading of $500 million worth of prescription drug costs to local governments and thereby allow cities to better address problems like traffic, housing, crime, etc.

For these reasons, the federal and provincial governments should take responsibility for our prescription drug problem by implementing universal pharmacare for all Canadians. Doing so would support the health and wellbeing of public and private sector workers alike at far lower cost than Canadians are paying for our disorganized, patchwork system today.

For more information, watch this and this.

By Steve MorganMorgan_2012

Steve Morgan is an expert advisor with EvidenceNetwork.ca and professor and Professor of Health Policy at the University of British Columbia School of Population and Public Health.

 

 

Why this U.S. Doctor is Moving to Canada

June 3, 2015 12:08 pm
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I’m a U.S. family physician who has decided to relocate to Canada. The hassles of working in the dysfunctional health care “system” in the U.S. have simply become too intense.

I’m not alone. According to a physician recruiter in Windsor, Ont., over the past decade more than 100 U.S. doctors have relocated to her city alone. More generally, the Canadian Institute for Health Information reports that Canada has been gaining more physicians from international migration than it’s been losing.

Like many of my U.S. counterparts, I’m moving to Canada because I’m tired of doing daily battle with the same adversary that my patients face – the private health insurance industry, with its frequent errors in processing claims (the American Medical Association reports that one of every 14 claims submitted to commercial insurers are paid incorrectly); outright denials of payment (about one to five per cent); and costly paperwork that consumes about 16 per cent of physicians’ working time, according to a recent journal study.

I’ve also witnessed the painful and continual shifting of medical costs onto my patients’ shoulders through rising co-payments, deductibles and other out-of-pocket expenses. According to a survey conducted by the Commonwealth Fund, 66 million – 36 per cent of Americans — reported delaying or forgoing needed medical care in 2014 due to cost.

My story is relatively brief. Six years ago, shortly after completing my residency in Rochester, New York, I opened a solo family medicine practice in what had become my adopted hometown.

I had a vision of cultivating a practice where patients felt heard and cared for, and where I could provide full-spectrum family medicine care, including obstetrical care. My practice embraced the principles of patient-centered collaborative care. It employed the latest in 21st-century technology.

I loved my work and my patients. But after five years of constant fighting with multiple private insurance companies in order to get paid, I ultimately made the heart-wrenching decision to close my practice down. The emotional stress was too great.

My spirit was being crushed. It broke my heart to have to pressure my patients to pay the bills their insurance companies said they owed. Private insurance never covers the whole bill and doesn’t kick in until patients have first paid down the deductible. For some this means paying thousands of dollars out-of-pocket before insurance ever pays a penny. But because I had my own business to keep solvent, I was forced to pursue the balance owed.

Doctors deal with this conundrum in different ways. A recent New York Times article described how an increasing number of physicians are turning away from independent practice to join large employer groups (often owned by hospital systems) in order to be shielded from this side of our system. About 60 per cent of family physicians are now salaried employees rather than independent practitioners.

That was a temptation for me, too. But too often I’ve seen in these large, corporate physician practices that the personal relationship between doctor and patient gets lost. Both are reduced to mere cogs in the machine of what the late Dr. Arnold Relman, former editor of The New England Journal of Medicine, called the medical-industrial complex in the U.S.

So I looked for alternatives. I spoke with other physicians, both inside and outside my specialty. We invariably ended up talking about the tumultuous time that the U.S. health care system is in – and the challenges physicians face in trying to achieve the twin goals of improved medical outcomes and reduced cost.

The rub, of course, is that we’re working in a fragmented, broken system where powerful, moneyed corporate interests thrive on this fragmentation, finding it easy to drive up costs and outmaneuver patients and doctors alike. And having multiple payers, each with their own rules, also drives up unnecessary administrative costs – about $375 billion in waste annually, according to another recent journal study.

I knew that Canada had largely resolved the problem of delivering affordable, universal care by establishing a publicly financed single-payer system. I also knew that Canada’s system operates much more efficiently than the U.S. system, as outlined in a landmark paper in The New England Journal of Medicine. So I decided to look at Canadian health care more closely.

I liked what I saw. I realized that I did not have to sacrifice my family medicine career because of the dysfunctional system on our side of the border.

In conversations with my husband, we decided we’d be willing to relocate our family so I could pursue the career in medicine that I love. I’ll be starting and growing my own practice in Penetanguishene on the tip of Georgian Bay this autumn.

I’m excited about resuming my practice, this time in a context that is not subject to the vagaries of backroom deals between moneyed, vested interests. I’m looking forward to being part of a larger system that values caring for the health of individuals, families and communities as a common good – where health care is valued as a human right.

I hope the U.S. will get there some day. I believe it will. Perhaps our neighbor to the north will help us find our way.

By Emily S. Queenan

Emily QueenanEmily S. Queenan, M.D., currently resides in Rochester,  New York, where she had, for five years, a solo full-spectrum family medicine practice Queenan Family Medicine and Maternity Care. She is an advisor with EvidenceNetwork.ca, a graduate of the University of Pennsylvania School of Medicine, and completed her family medicine residency at the University of Rochester/Highland Hospital in Rochester, N.Y., where she also served as chief resident.

The Fletcher Effect

June 2, 2015 12:10 pm
health

I like Stephen Fletcher. Our brief encounters, typically in airports or the occasional public event, are always friendly and cordial. It is hard not to admire him. Despite quadriplegia, he has found the strength and determination to serve his country as a Member of Parliament, at various times holding appointments as Minister of State (Democratic Reform), Minister of State (Transport); and currently, as a member of the Treasury Board Cabinet Committee. As of late, Mr. Fletcher has been focusing his formidable energy on promoting physician-hastened death. It appears many share his perspective, with public opinion and legislative reform starting to turn his way. Just last month, the Supreme Court of Canada overturned the prohibition against assisted suicide.

According to a recent IPSOS Reid poll, nearly 70 per cent of Canadians support the availability of death hastening alternatives for people living with significant disabilities that might impair their quality of life. In other words, Canadians find it inconceivable to imagine themselves confined to a body that even remotely approximates the one Mr. Fletcher now permanently resides in. While the majority of Canadians admire him, at some level I suspect they are afraid of the abject vulnerably his life proves is possible within the repertoire of human experience. This fear is so deeply seated that they imagine themselves preferring death. For anyone wondering why physician-hastened death makes disabled people feel vulnerable, wonder no more.

Human beings are not good at predicting how they will react in circumstances that have yet to unfold. While Mr. Fletcher argues that death should sometimes trump disability, studies of people who become disabled due to spinal injuries, head trauma or strokes, offer a strikingly different perspective. Just under 10 per cent of these patients become suicidal and the majority relinquish their wish to die within a year or two. In his biography, What Do You Do If You Don’t Die?, Mr. Fletcher recounts suicidal thoughts that lingered long after his catastrophic accident. He says that had doctor-assisted suicide been an option after his 1996 car accident, he would have considered signing up and checking out. Thankfully, it was not. His recovery took determination and strength, but such is the stuff that Stephen Fletcher is made of. It also took the support of family and friends, the unwavering commitment of medical professionals and it took time.

Those of us working in health care understand that life-altering illness, trauma or anticipation of death can sometimes sap will to live. In those instances, health care providers are called upon to commit time; time to manage distress, provide unwavering support and to assuage fear that patients might be abandoned to their hopelessness and despair. That is the essence of how medicine has traditionally responded to suffering. Stopping time by way of arranging the patient’s death has never been part of that response. In light of the decision by the Supreme Court, we must now contemplate Canada’s future euthanologists. What professional designation will they require? What disciplines will they be drawn from? What training will they receive? What ethical and practice guidelines will they abide by? And what judicial oversight will they submit to?

Mr. Fletcher and I, along with Professor Margaret Somerville, spoke at a recent forum on euthanasia and assisted suicide. Mr. Fletcher said he did not want to die drowning in his phlegm and in pain. I assured him, on behalf of Canada’s palliative care community that we would not let that happen. He said that he did not want to be reliant on machines to keep him alive. I told him that competent Canadians, under our current laws, are entitled to refuse or discontinue treatment, including life-sustaining measures. He described autonomy as a core Canadian value. I reminded him that autonomy has its limits, particularly when it causes others to feel more vulnerable and implicates the physician’s role in response to suffering.

Mr. Fletcher says he has received supportive letters from across the country from people who fear what dying will look like. With too few Canadians having access to palliative care, there is little wonder that people are afraid. Offering the option to have their physician end their lives feels akin to confronting homelessness by eliminating guardrails from bridges. Nonetheless Mr. Fletcher feels that safeguards, such as a ‘cooling off’ period to establish that a request to die is sincere, not coerced and sustained are possible. If so many in your circumstance change their mind, I asked him, do we now require a two-year waiting period? His response was, “maybe.”

To be fair, perhaps Mr. Fletcher has not contemplated these particular complexities. He may not have considered how asking physicians to stop time could undermine their most powerful response to suffering. His voice has become an important one in how we conceive of disability, death and dying and no doubt is one that all Canadians anxiously await to hear.

(Mr. Fletcher was provided the opportunity to respond to this editorial; he declined to do so).

By Dr. Harvey Max ChochinovChochinov_Harvey_high res NEW

Dr. Harvey Max Chochinov holds the only Canada Research Chair in Palliative Care. He is the Director of the Manitoba Palliative Care Unit, CancerCare Manitoba, and Distinguished Professor, University of Manitoba.

Canada has Mixed Wait Time Results in Health Care

May 27, 2015 12:35 pm
Side view closeup portrait sad stressed female doctor

We need governments to promote best practices across the country and improve patient outcomes

Wait times have long been a source of concern for Canadians, and in some jurisdictions, remain a significant problem. Recently the Canadian Institutes of Health Information (CIHI) released its report for 2015. There is both encouraging news and areas in need of attention.

CIHI follows the wait times for five interventions across all jurisdictions in Canada, including cancer care (radiation), cataract removal, surgery for hip fractures and total joint replacements of the hip and knee. In each instance, the question posed by CIHI is: “What percentage of people receive treatment in a timely fashion?”

Establishing what constitutes “timely treatment” can be contentious, but in 2004, the provinces and territories agreed to standards for wait time maximums based on the best available evidence. CIHI continues to deploy these benchmarks to the present day.

The positive news is that wait times have remained stable over time in spite of increased demand. For example, the numbers of patients receiving radiation therapy has grown by 34 per cent since 2010, yet 98 per cent of patients are treated within the benchmark. Surgery for hip fractures has shown an improvement of six per cent to 84 per cent for timeliness. Eighty-three percent of hip replacements were performed within benchmark while 79 per cent of knee replacements made the mark. For cataract surgery, the number within benchmark was 80 per cent.

Unfortunately, CIHI is not able to address the question of appropriateness of treatment. The critical question: “Does this patient really need this surgery, now?” remains unanswered.

Other studies show Canadian wait times in a mixed light. In an OECD study, Canada fares well in terms of timeliness of access compared to six OECD peer countries (United Kingdom, Australia, New Zealand, Finland, Estonia and Portugal), ranking first in cataract surgery and second in knee and hip replacements. (The other two interventions are not tracked in the other nations.)

But a third study by the Commonwealth Foundation found that Canada does not fare well compared to peer nations with universal health care when accessing appointments for primary care and consultations for specialty care. Since accessibility is one of the five core principles of the Canada Health Act, it is a substantial issue that needs urgent attention. Furthermore, delays experienced in accessing these services would add to the total wait times for health care interventions.

In other words, there’s much room for improvement in the Canadian health system.

Fortunately there are means at hand to address the problems of wait times and appropriateness of care, means that are already being deployed successfully in Canada, such as the work of the Cardiac Care Network in Ontario or the Alberta Bone and Joint Institute—or the Choosing Wisely Canada initiative of the Canadian Medical Association. But we need a broader uptake of such best practices across the country.

Best practices not only enhance health care efficiency, they result in substantial economic savings too—a minimum of 15 per cent according to most analyses. So how do we get there?

Effective wait time management requires support from government leaders as well as cooperative administrative and clinical leadership. IS/IT infrastructure support to manage centralized wait lists is fundamental, as is a committed full-time staff monitoring wait times performance in jurisdictions, measuring performance against benchmarks and identifying “outliers” or patients who are experiencing untoward delays.

With these elements in place, a system can be created that includes the ability to track the key information of broad trends, as well as the means to identify individual problems.

In addition to timely care, we must also establish a clear rationale for treatment in the first place: Is this knee replacement really necessary now or should the patient lose weight or possibly have non-surgical management? When, why and how interventions need to be undertaken should be re-examined across the country.

Building on the successes of best practices already established in some regions of Canada should set the agenda for the future—to enhance efficiency and quality of care at lower costs. Acting now will only strengthen Canada’s most coveted social program.

McMurtry_RobertBy Robert McMurtry

Robert Y. McMurtry is an expert advisor with EvidenceNetwork.ca, an active orthopedist and formerly Dean of Medicine at Western University and Assistant Deputy Minister of Health Canada. He was a special medical advisor to the Royal Commission of the Future of Health Care in Canada (Romanow Commission).

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