Evolution of Medicare. 28/Nov/12. Canadian Health Care System 101. Outline. How has Medicare evolved over time?

Transcription

1 Canadian Health Care System International Medical Graduate Information Symposium October 23, 2012 Owen Adams Vice-President, Policy & Research Canadian Medical Association IMG Healthcare 101.ppt Outline How has Medicare evolved over time? What are the key components of the health care system What are the basic economics and some of the key challenges? Who are the key stakeholders and how do they influence health policy? Evolution of Medicare 1

2 Constitutional Responsibility for Health: Canada, 1867 POWERS OF (FEDERAL) PARLIAMENT Quarantine, Marine Hospitals POWERS OF PROVINCIAL LEGISLATURES All hospitals other than Marine Education Legacy of the Constitution 14 health systems 1 for each province/territory + Health Canada Health Canada is the 5 th largest spender Direct provider on reserves and isolated locations Provider of supplementary health benefits to 750,000 First Nations and Inuit peoples Tax-Funded Systems (Beveridge) Provision of health care for all people through central taxation and other compulsory financial contributions and a system of universal benefits. 2

3 Canada s Health Care System: It Wasn t Built Overnight! Hospital Insurance and Diagnostic Services Act, 1957 Medical Care Act, 1966 Established Programs Financing, 1977 Canada Health Act, 1984 Principles of Canadian Medicare Public Administration Comprehensiveness Universality Portability Accessibility Canada Health Act: Insured Services insured health services means hospital services, physician services and surgical-dental services provided to insured persons does not include any health services that a person is entitled to that relates to workers or workmens compensation. 3

4 Beyond the Boundaries of Medicare: Prescription Drugs by Source of Payment, Canada, 2011 Source of Payment $ (million) % Public 12, Private Insurance 10, Out-of-Pocket 4, Total 27, Source: Canadian Institute for Health Information Drug Expenditure in Canada, 1985 to 2011 Beyond the Boundaries of Medicare: Prescription Drugs by Source of Payment, Canada, 2011 Source of $ Millions % Payment Public 12,063 44% Private insurance 10,245 38% Out-of-pocket 4,874 18% Total 27, % Source: Canadian Institute for Health Information Drug Expenditure in Canada, 1985 to 2011 Governance in the Canadian Health Care System Federal Government - Canada Health Act - health protection - research and information (CIHR, CIHI) Provincial/Territorial Government - policy-setting (e.g., def. of insured services) - funding envelope - health professional regulation - regulation of hospitals 4

5 Governance in the Canadian Health Care System (Cont d.) Regional Health Authorities - funding allocation - needs assessment Hospitals and Agencies* - program delivery - quality assurance - physician privileges Professional Regulatory Bodies - licensure - discipline *Note these would be subsumed under regional health authorities in most jurisdictions. Elements of the Health Care System Health System A formal structure for a defined population, whose finance, management, scope and content is defined by law and regulations. It provides for services to be delivered to people to contribute to their health delivered in defined settings such as homes, educational institutions, workplaces, public places, communities, hospitals and clinics. Source: European Observatory on Health Care Systems 5

6 The Health Industry in Canada, 2006 Sector # of Workers Pharmaceutical manufacturing 29,715 Medical equipment and supplies manufacturing 20,515 Pharmaceuticals, toiletries, cosmetics wholesalers 37,005 Health and personal care stores 157,485 Ambulatory health care services 480,440 Hospitals 563,665 Nursing and residential care facilities 314,910 Total 1,603,735 % of total labour force 9.4% Source: Statistics Canada, 2006 Census Selected Health Professions, Canada 2010 Registered Nurses 268,512 Licensed Practical Nurses 81,224 Physicians 69,699 Pharmacists 31,389 Social Workers 36,312 Total 24 Professions 672,900 Source: CIHI Canada s Health Care Providers 2010 Provincial Profiles Accessing the Canadian Health Care System Family physician point of first contact telephone, walk-in, emergency dept. Family physician referral to diagnostic testing or a specialist Specialist consultation - treatment or further referral Patient choice of physician and second opinion No point of service charges for insured services 6

7 Practising Physicians (including residents) per 1000 pop, 2010 Canada ranks 26 out of 34 Canada and France include those in admin and research Source: OECD Health Data, 2012 Physicians per 100,000 population Canada, 1982 to 2010 Physicians per 100,000 popn Source: Supply, Distribution and Migration of Canadian Physicians, CIHI IMGs as a percentage of all physicians Overall: 24% 34% 13% 18% 28% 29% 54% 30% 26% 10% 41% 21% 26% 29% Source: 2012 CMA Masterfile 7

8 First Year Enrolment in Medical Schools (including Visa students) MD graduation peaks at % enrolment cut CMF recommends 2000 by 2000 CMA recommends 2500 by 2007 Source: Medical Education Statistics, AFMC Opportunities for Medical Students Country 1 st year enrolment Population Ratio UK 8, million 1:7,177 Australia 3, million 1:6,364 USA* 21, million 1:13,950 Canada 2, million 1:12,400 Sources: 2008 and 2009 admission/acceptance statistics for first year enrolment for UK, Can, Australia & USA * Includes estimate for osteopathic medicine MD Graduates and PGY-1 Trainees: Canada and the U.S., 2010 MD Grads PGY-1 Trainees* Canada 2,448 2,951 1:2.1 U.S ,478 25,292 1:4.1 Ratio PGY- 1 to Grads *Refers to program year 1 Sources: 1 Association of Faculties of Medicine of Canada. Canadian Medical Education. Statistics, 2010 and CAPER Census of Post MD Trainees 2 Barzansky B, Etzel S. JAMA Sept. 7, 2011 Vol 306 #9, Brotherton S, Etzel S. JAMA Sept. 7, 2011 Vol 306 #9,

9 IMGs in Ministry funded positions across all rank levels (excludes visa trainees) Source: Canadian Post-MD Education Registry Projected Physician Supply Status quo from 1999 and Phys per 1000 popn status quo 1999 status quo Source: 1999 and 2012 CMA Physician Resource Evaluation Template Women in Medicine Females as % of first year enrolment Females as % of all physicians 46% 57%* 17% 36%** *2011 ** 2011 and in 2012 Sources: Canadian Medical Association, Association of Faculties of Medicine of Canada 9

10 Hours worked per week (excl on call) by age and gender, < Males Females Source: 2010 National Physician Survey (CFPC, CMA, Royal College) Percentage reporting 90%+ fee-forservice remuneration 80% 70% 60% 50% 40% 30% 20% 10% 0% 68% 66% 64% 62% 58% 51% 48% 42% Source: 1990 to 2002 CMA Physician Resource Questionnaire; 2004, 2007 & 2010 National Physician Survey (CFPC, CMA, Royal College) Remuneration Modes Actual Mode 2010 Preferred Mode % 32% 42% 51% 90%+ f-f-s 90%+ salary 90%+ capitation 90%+ sessional 90%+other blended not stated f-f-s salary capitation sessional service contract blended not stated n= n= 7,347 Source: Actual: 2010 National Physician Survey (CFPC, CMA, Royal College) Preferred: 2007 National Physician Survey (CFPC, CMA, Royal College) 10

11 Economics Health Expenditures: Canada and the OECD 2009 Indicator Canada Ranking OECD Average Health expenditures as % of GDP Public health exp. per capita US$ $3,081 8 $2,310 Public % of total health exp Source: OECD Health Data 2011 Canada: A Single Payer System? Source: CIHI National Health Expenditure Trends 1975 to

12 Health Expenditures by Selected Category Canada, 1984 and 2010 Prescription Drugs Physicians Prescription Drugs Physicians Hospitals Hospitals Source: CIHI National Health Expenditure Trends 1975 to 2010 Federal Contribution to Health, Canada, 2010 $ Millions % of Total Public Expenditure Canada Health Transfer 25,426 19% Federal Direct Exp. 6,6523 5% Federal Total 32,079 24% Other Public 102,990 76% Total Public Expenditure 135, % Source: CIHI and Finance Canada The Stakeholders 12

13 Health Policy A formal statement of procedure within institutions (notably government) which defines priorities and the parameters for action in response to health needs, available resources and other political pressures. Source: European Observatory on Health Care Systems Policy Goals of Public Health Care Systems sufficient resources to deliver services improve efficiency manage demand reduce inequality within and between generations promote cost-effectiveness improve quality meet the needs of the population Policy Levers Type of Policy Lever Method Taxation - General tax revenues - Limited use of premiums Spending - Transfers - Funding envelopes - Reimbursement mechanisms Regulation - Insured services - Health professions Information - Health services research - Administrative data - Population surveys 13

14 Stakeholders in the Determination of HHR Policy Governments - health - education Health Sciences/Faculties of Medicine Certifying Bodies Regulators Professional Associations Unions Health Care Institutions Patients/Public/Communities (e.g., recruitment) Axes of HHR Policy Development in Canada Along the east-west north array of provinces and territories; Health versus education ministries? Between the fed/prov/terr and regional authority/municipal levels of govt/administration; Among a range of stakeholders: governments, professions, non-governmental associations (NGOs) and citizens International linkages (Commonwealth, World Health Organization) Health Canada Core Roles Leader/Partner: via Canada Health Act Funder: via Canada Health and Social Transfer Guardian/Regulator: regulates and approves medical devices and pharmaceuticals Service Provider: supplementary health benefits to approximately First Nations and Inuit Information Provider: high quality science and research 14

15 Public Health Agency of Canada - Core Roles Promote health Prevent and control chronic diseases and injuries Prevent and control infectious diseases Prepare for and respond to public health emergencies Strengthen public health capacity Selected National Health and Medical Organizations Accreditation Canada Association of Canadian Academic Health Organizations Association of Faculties of Medicine of Canada College of Family Physicians of Canada Canada Health Services Research Foundation Canadian Healthcare Association Canadian Institute for Health Information Canadian Institutes of Health Research Canadian Medical Protective Association Canadian Nurses Association Royal College of Physicians and Surgeons of Canada rcpsc.medical.org Thank You! CMA Canadian Collaborative Centre for Physician Resources - National Physician Survey (CFPC, CMA, RCPSC) owen.adams@cma.ca 15