SYSC4202A / BIOM5406 Clinical Engineering, T.Zakutney & S.Liddle Winter 2022 Health Services Organization and Policy History and overview of the system, funding, delivery, legislation. SYSC4202A / BIOM5406 Clinical Engineering, T.Zakutney & S.Liddle SYSC4202A / BIOM5406 Clinical Engineering, T.Zakutney & S.Liddle Winter 2022 Winter 2022 What is included in health? • Hospitals • Family doctors • Unemployment • Commodity prices • Financial markets • All of the above • 1, 2, and 3 SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 What is Health? • World Health Organization • “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Health Canada • The mission and vision of Health Canada is to: • “… be responsible for helping the people of Canada maintain and improve their health.” • “… is committed to improving the lives of all of Canada 's people and to making Canadians among the healthiest in the world as measured by longevity, lifestyle and effective use of the public health care system.” SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Five dimensions to explore • • • • • Defining the Canadian Health Care System(s). Origins: Constitution, History, Legislation Financing, Delivery, and Allocation of Resources. Health care spending and outcomes. Issues. SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Defining the health care system(s) • In reality, there are 13 systems, with common and differing features • 10 provinces and 3 territories • The federal government has basic national standards/rules and contributes financial support • The provinces oversee, plan, manage, and pay the lion’s share. • Financial amount varies for each province SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 The System: • What Canadians used to call “Medicare”: • 2 old historical agreements between the federal and provincial governments to cover all hospitals costs and doctors’ visits – and nothing else. • Several “health” factors are not included including • Prescription Drugs • Homecare (In-Home Care) • Long Term Care • Eye care • Dental care. SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 National Stakeholders • In addition to the governments, there are many other stakeholders in the system including: • Professional Associations • Industries: • Pharmaceutical • Medical Devices • Service Agencies • Canadians SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 International Stakeholders • World Health Organization (WHO) (Geneva). The Director General is Dr Tedros Adhanom Ghebreyesus • WHO African Region - 1st • Representative of the Director-General for Pandemic Influenza • Ethiopia Minister of Foreign Affairs (2012 - 2016) • Ethiopia Minister of Health (2005 - 2012) • Regional components of WHO: • Pan American Health Organization (PAHO) for the Americas (Washington) SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Additional Stakeholders • Organization for Economic Cooperation and Development (OECD) • Based in Paris, and also also studies health systems • World Bank (WB) • Washington, Paris, Tokyo • International Monetary Fund (IMF) • Washington • International Labour Office (ILO) • United Nations, Geneva SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 WHO indicates that health systems matter: • “ Health systems consist of all the people and actions whose primary purpose is to improve health. They may be integrated and centrally directed, but often they are not. After centuries as small-scale, largely private or charitable, mostly ineffectual entities, they have grown explosively in this century as knowledge has been gained and applied. • “They have contributed enormously to better health, but their contribution could be greater still, especially for the poor. Failure to achieve that potential is due more to systemic failings than to technical limitations. It is therefore urgent to assess current performance and to judge how health systems can reach their potential.” Source: The World Health Report 2000, WHO, Geneva, 2000, p.1 SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 The “system” is the sum total of… • … the interactions between all the players in Canada, three in particular: Health Canada and the Federal Government; the Provincial Ministries of Health and their respective governments; and organized medicine. No one really is “in charge” of the system, which rests on the constantly renegotiated equilibrium of these key players. SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 System Health Canada / Federal Government Health System Delivery Organizations SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Provincial Governments System Health Canada / Federal Government Delivery Organizations Health System Patients / Public SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Provincial Governments Health is “big business” • Mid 1970’s $17 billion was spent on universal health ($2B in 2012, Federal Budget) • 75% on institutional and physician services • 2021: $308 billion, or $8,019 per Canadian, 12.7% of GDP • Growth in health spending averaged 4% per year. • Hospitals (25%) • Drugs (14%) • Physicians (13%) are expected to continue to account for the largest shares of health dollars (more than 50% of total health spending) in 2021. • COVID-19 Response Funding — makes up 7% of total health spending, which includes federal direct and provincial/territorial government–sector spending. • 60% more than a decade ago, over half due to: • • • • 14% population growth 11% aging 27% inflation Pharmaceuticals increased 136% over 10 years SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Human Resources • Salaries constitute > 60% of costs • 30+ regulated professional groups • 426,000 Regulated Nurses (2017) • 89,911 Practicing Physicians (2018) • 1 in 10 employed Canadians work in health services SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Origins: Constitution, History, Legislation. • Constitution of 1867 • Health becomes a Provincial responsibility. This remained intact with the 1982 patriation of the Constitution. • History and “the spending powers” (given by constitution to the federal government) involved the federal government. • Direct responsibility • Veterans • Aboriginal health SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Responsibility… • Health care is of provincial jurisdiction. • However, the Constitution (1982), under its equalization provisions, requires the provinces to provide “reasonably comparable levels of public service for reasonably comparable levels of taxation”. • Through federal taxes, the richer provinces help the poorer ones, for a level playing field. SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Who was CBC’s Greatest Canadian? • Sir Frederick Banting • Terry Fox • Tommy Douglas • David Suzuki • Pierre Trudeau • Lester B Pearson SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Where does Medicare come from? • Beginning of the 20th century: our immigrants from countries of Europe (Germany: 1 million) bring with them a political culture and a union movement experience with a sense of the common good. (Bismarck 1815-1898, Germany: first health care system) • 1919: first proposal of universal health insurance after the 1st World War, on the platform of the Liberal Party of Canada. SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 …the 2nd World War, and after: • 1945: The Reconstruction Conference • The Minister of Health of Canada, Brooke Claxton, proposes the National Health Grants Program. Opposed by Ontario (George Drew) and Quebec (Maurice Duplessis). • 1948: Re-submitted by the new Minister of Health of Canada, Paul Martin, Sr. • The provinces approve! (Seed money towards a comprehensive health insurance program.) SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Saskatchewan’s CCF government • 1947: Premier T.C. (Tommy) Douglas decides to go it alone • Passes The Saskatchewan Hospital Services Plan. • 1957-58: The federal Liberal government. (Paul Martin, Sr.) follow • 50-50 offer, and it’s accepted by Provinces. Hospital Insurance and Diagnostic Services Acts (HIDS). All provinces are to adopt the program by 1961 SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 ... and then following: • 1962: Saskatchewan again, despite a dramatic doctors’ strike: The Saskatchewan Medical Care Insurance Plan. • 1964: Mr. Justice Emmett Hall’s Commission, set up by Diefenbaker, reports to the Pearson government: recommends a national Medicare program. • 1966: Federal Government creates The Health Resource Fund to help build hospitals and purchase equipment. • 1968: Federal Minister of Health, Allan McEachen (Liberal), succeeds with The Medical Care Act. • By January 1971, all provinces have “Medicare” SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 The Start of the Challenge • Between 1961 and 1971, the number of hospital beds increased by 33% where the population increase was 18% • Bed occupancy 80% • No mandate for organizational efficiency or prevention of service duplication • 50¢ dollars for hospitals, 0$ for non-hospital services • Provinces became hospital-intensive SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 The last 30 years are about: • Changing the funding mechanisms, from cost-sharing (50-50) to block funding. • 3-year moving average of the Gross National Product and per capita cash payment. • Re-enforcing the 5 old conditions by the Canada Health Act (1984) • Modifying the transfer of funds • The Canada Health and Social Transfer (1996) replaced the above. • What is missing from “Universal Health Care” SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Health Canada • The mission and vision of Health Canada is to: • “… be responsible for helping the people of Canada maintain and improve their health.” • “… is committed to improving the lives of all of Canada 's people and to making Canadians among the healthiest in the world as measured by longevity, lifestyle and effective use of the public health care system.” How realistically does the Federal Government support health of Canadians? SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 How many pillars are there in the Canada Health Act? SYSC4202A / BIOM5406 Clinical Engineering, T.Zakutney & S.Liddle Winter 2022 The Five Pillars • The five principles of the Canada Health Act are the cornerstone of the Canadian health care system, and have iconic status for Canadians. This legislation, passed unanimously by Parliament in 1984, affirms the federal government's commitment to a: • Universal • Accessible • Comprehensive • Portable • Publicly administered health insurance system SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Public Administration • The administration of the health care insurance plan of a province or territory must be carried out on a non-profit basis by a public authority. SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Comprehensiveness • All medically necessary services provided by hospitals and doctors must be insured. SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Universality • All insured persons in the province or territory must be entitled to public health insurance coverage on uniform terms and conditions. SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Portability • Coverage for insured services must be maintained when an insured person moves or travels within Canada or travels outside the country. • Maintain Canadian citizenship • Charter of Rights • “Snowbirds” • Subject to residency limitations and rules SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Accessibility • Reasonable access by insured persons to medically necessary hospital and physician services must be unimpeded by financial or other barriers. “that does not impede, or preclude, either directly or indirectly, whether by charges made to insured persons or otherwise, reasonable access to insured services by insured persons” SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 In addition • The Canada Health Act also contains provisions that ban extra-billing and user charges: • no extra-billing by medical practitioners or dentists for insured health services under the terms of the health care insurance plan of the province or territory; • no user charges for insured health services by hospitals or other providers under the terms of the health care insurance plan of the province or territory. • Experience in Ontario in 1980s SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Financing, delivery, allocation of resources • The beginning of equalization, and lack of financial control. • 1977: Bill C-37, Federal-Provincial Fiscal Arrangements and Established Programs Financing Act (EPF) • Replaced cost sharing with mix of block funding / tax points • Provinces now have: • Greater Flexibility • Fewer reporting responsibilities • But greater fiscal responsibility • Financing: • Who pays for what services? • Delivery: • Who delivers what services? • Allocation: • How are resources allocated to those delivering services? SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Health Care System (3 models): • National Health Service (Beveridge model): • Universal coverage for residents, financed by general taxation, with national ownership/control of factors of production. • Social Insurance (Bismarck model): • Universal coverage within social security, financed by employer/employee, with a combination of public/private ownership. • Private Insurance (Consumer Sovereignty model): • Individual or employer-based purchase of private health insurance coverage, financed via individual and/or employer contributions, with private ownership of factors of production. SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 What system does Canada use? • National Health Service • Social Insurance • Private Insurance • All of the Above • None of the Above SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Health Care is a Business … • In Canada we speak of “private” delivery of services in Canada • Physicians are “individual entrepreneurs” • Allied health, nurses are hospital employees, which are corporate entities • Public funds pay for delivery even if private sector provides specific services • Nutrition • Health Care Linen • Laboratory Medicine • Specialized services such as Imaging, Dialysis SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Physician Payment Models • Fee-for Service • Pay based on service • Capitation • Based on patient list • “money follows the patient” • Salary • Funder controls primary care directly SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Financing of Health Care in Canada • General taxation • personal income, corporation, sales • Specific taxes • payroll taxes, excise taxes on specific goods • Premiums • User charges • co-payments, deductibles • Charitable contributions • Research & Development SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Funding / Reimbursement in Canada • Base budget for In-Patient procedures: • The base budget, provided annually covers all inpatient care, diagnosis, and procedures performed and overhead costs of operating the organization. • Organizations are responsible for providing identified services under their base budget including salaries, infrastructure, and technology. SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Funding / Reimbursement in Canada • Additional funding for Out-Patient Procedures: • The Province will reimburse a predetermined professional fee directed toward the physician performing the procedure and also a technical fee directed toward the organization to cover operating costs, overhead, staffing, and ancillary costs associated with the procedure. SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Funding / Reimbursement in Canada • Priority programming for specialized care (ex. Cardiac procedures): • For specialized and targeted procedures that are of interest to the Provincial government, special funding is provided the hospital to perform a number of predetermined procedures (ex. Stents, transplants, ICD implants) SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Funding of Medical Devices • Provincial Government Funding: • Ministry of Health and Long-Term Care (MOHLTC): • Base budget allocation and depreciation costs for equipment replacement • Special infrastructure or priority program expansion (ex. cardiac services) • Research Funding Programs • Other External Funding Sources: • Federal Funding Programs (ex. CIHR, CFI, etc.) • Philanthropy & Fundraising (ex. Telethons) • Foundations (ex. Heart and Stroke Foundation) SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 and allocation of resources… • The provincial government allocates • The budgets for hospitals • … for continuing care • … for public health • … for mental health, rehab services • …the global budget for physicians’ fees (each provincial medical association allocates it in turn by specialty, etc.) SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 How is Canadian Health Care Funded? SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 OECD Countries Health Care Spending: • Organization for Economic Co-operation and Development (OECD) • 30 Countries • Production of comparable statistics in the economic, health, and socials fields. SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 OECD Total Health Expenditure SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 How do we place amongst the OECD? • Canada has a narrower universal coverage base than OECD countries • Is one of the biggest spenders on health care (OECD) • Very good on life expectancy (WHO) • Very poor on efficiency: we ranked overall 30th in 2000 (WHO) • https://www.cihi.ca/en/oecd-interactive-tool-international-comparisons SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Is there a role for Private HC? • Yes • No SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 What is not being respected? Your experiences… • Universal • Accessible • Comprehensive • Portable • Publicly Administered Health Insurance System SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Building on Values: The Future of Health Care in Canada • The Romanow Commission on the Future of Health Care in Canada was created to: • review Canada's health care system • engage Canadians in a national dialogue on its future and • Make recommendations to enhance system quality and sustainability • November 2002 • 47 recommendations SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022 Next Lecture: • Introduction to Medical Devices and Technology • Quiz #2 Next Week • Questions? SYSC4202A SYSC4202A // BIOM5406 BIOM5406 Clinical ClinicalEngineering, Engineering,T.Zakutney T.Zakutney&&S.Liddle S.LiddleWinter Winter2022 2022
