Ensuring a More Equitable Healthcare System Canadian Doctors for Medicare Submission to the House of Commons Standing Committee on Finance February 16, 2016
Introduction Canadian Doctors for Medicare (CDM) was created in in 2006 in response to events in the medical profession and public policy that threatened to undermine Canada s national commitment to equitable health care access. As medical professionals, we are firmly committed to evidence-based health care policy reform. We advocate for innovations in treatment and prevention services to improve the quality, sustainability, and equity of our healthcare system. An example of our work is our Health Care Delivery Assessment Tool (HDAT), a series of checklists that help policy makers and health care personnel assess the potential benefits and consequences associated with new care delivery models. In 2014, the Canadian Medical Association voted unanimously to adopt the HDAT model as a means for safeguarding a sustainable and equitable future for our health care system. Our organization has an abiding interest in the evolution of the federal role in health care. We believe that our health care system can and should be improved. The evidence is clear that reform works best if it takes place within the public system so that it benefits all of our patients, not just those who can afford to pay for their care. As practicing physicians, CDM supporters see first-hand the disparity in care experienced by Canada's marginalized residents and those facing multiple barriers. CDM believes that improving the care experience of our most vulnerable communities is both necessary and achievable. Our recent advocacy for action has focused on three specific areas: Upholding the Canada Health Act Developing and implementing a new Canada Health Accord Improving access to prescription drugs through a national pharmacare program. Each of these reforms begins with strong, accountable federal leadership to enforce standards across the country and improve equity of care for our most vulnerable populations. There is much that can be done, by both political leaders and health professionals, to work towards a better public health care system for all Canadians. February 16, 2016 Page 2
1. Upholding the Canada Health Act Enforcing the Canada Health Act and ensuring that alternative delivery models uphold equity As part of its commitment to the Canada Health Act (CHA), the federal government must recognize new forms of privatization (e.g. user fees and extra billing) have emerged since the CHA was passed in 1984. Some of these take advantage of legislative loopholes while clearly violating the spirit of the CHA. All governments should work together to agree that such offenses will not be tolerated and commit to putting a stop to barriers to access to publiclyfunded services. Canada needs strong leadership on health care at the federal level to stop the provinces from violating the CHA. CDM recommends instituting an accountability framework that requires provinces to proactively regulate or investigate clinics for compliance. Furthermore, we propose stricter monitoring of the provinces and that violations of the CHA are tied to funding including penalties (i.e. reduced federal funding). Clear examples of CHA violations exist across the country. These include but are not limited to: Extra-billing by linking insured services to uninsured services Exorbitant block fees in primary care Using third party billing to sidestep prohibitions on payment for insured services. For instance, on November 10, 2015, Quebecois lawmakers approved Bill 20. This new health care legislation that allows physicians to charge patients who seek services already insured under public Medicare, with no clearly established limits. Extra-billing strains our existing system. We have seen the evidence in British Columbia. The BC government's 2012 audit of the Cambie Surgery Corporation reveals the cost of these violations to individual patients and provincial health care budgets. In roughly a thirty-day period, the audit found that the CSC has over-billed patients a total of $491,654 and submitted $66,734 in overlapping bills (where both the province and the patient paid for the same treatment). 1 This is a pertinent example of how for-profit delivery threatens the sustainability of the health care system while taking advantage of individual patients. 1 http://www.health.gov.bc.ca/msp/legislation/pdf/srccsc-audit-report-2012.pdf February 16, 2016 Page 3
Proponents of for-profit health care suggest that a parallel private stream can take pressure off the public system. It is important that the federal government recognizes the strong evidence, which demonstrates that more private care does not increase efficiency or access, and in many cases, it puts up barriers to both. 2 Private, for-profit medical clinics drain the limited supply of doctors and other health professionals from the rest of the health care system, lengthening waiting lists and reducing access. 3 Some service providers offer faster access to insured service at their clinics, but require patients to pay a membership fee or other payments in order to have access to that service. People who have not paid the fees cannot gain access. This may shorten waits for some patients who pay, but it ties up resources for the rest of the system, lengthening wait times overall. This drain has had the greatest impact on vulnerable Canadians who cannot afford to pay for priority treatment. Evidence shows that private, for-profit health care worsens patient outcomes at higher costs than public non-profit care, and its providers order more unnecessary tests and procedures. 456 Furthermore, for-profit clinics tend not to serve unprofitable markets like remote and rural communities, Aboriginal communities, marginalized urban populations, and those needing complex chronic care and emergency care. They focus on affluent populations in urban centres, who face the lowest barriers to care. 7 Private, for-profit clinics contribute least where the need is greatest and exacerbate inequity in our health care system. 2. A Strong Federal Health Accord in 2016 Canada needs federal leadership in health care and CDM is are pleased to see talks resume between the provincial, territorial and federal governments. The new health accord would have goals and criteria developed in partnership with the provinces and federal governments. Without national leadership, the quality and levels of service will vary widely, depending on who is in charge of your province, potentially violating the Canada Health Act. The 2003/2004 Accords were landmark developments in Canada, but in the decade that followed, they demonstrated mixed progress. For example, there were some successes in reducing wait times for certain procedures, but not uniformly across the country. There was 2 N Ivers, M Schwandt, S Hum, D Martin, J Tinmouth, N Pimlott. A comparison of hospital and nonhospital colonoscopy: Wait times, fees and guideline adherence to follow-up interval. Can J Gastroenterol 2011;25(2):78-82. 3 Duckett, S. J. Private care and public waiting. Australian Health Review; 29(1): 87-93. 2005. 4 Journal of the American Medical Association, 2002; 288:2449. 5 N Ivers, M Schwandt, S Hum, D Martin, J Tinmouth, N Pimlott. A comparison of hospital and nonhospital colonoscopy: Wait times, fees and guideline adherence to follow-up interval. Can J Gastroenterol 2011;25(2):78-82. 6 New England Journal of Medicine, 1997, 337:169. 7 Vaithianathan R. 2004. A critique of the private health insurance regulations. Australian Economic Review;37(3): 257-70. February 16, 2016 Page 4
virtually no progress on a national pharmaceutical strategy to reduce costs and increase access to prescribed medications. In addition, there was weak accountability for results the Accords provided for large transfers of money to provinces without enforceable conditions for delivery of outcomes. Overall, the achievements of the 2003/2004 Accords were mixed, and a renewed focus on achieving their unmet objectives, building on their successes, and rising to new challenges is needed. Specifically, CDM would like the federal government to: Initiate the timely development of a new health accord, negotiated jointly to ensure it reflects the needs of all regions and also reflects the priorities we share as Canadians Adjust the accord to include considerations for age, geographic distribution of population and economic disparity. The previous federal government revised the Canada Health Transfer payments to include an equal per capita cash allocation this privileges some provinces over others Negotiate an accord that commits to the use of evidence in achieving health policy objectives Reflect Canada s commitment to equitable access to medically necessary health care by honoring the principles of the Canada Health Act Negotiate an accord that ensures fair and equitable access to health care by explicitly committing to reforms that strengthen the principle of access to care based on need, rather than ability to pay. These principles will assist in crafting an accord that can overcome some of the weaknesses of the 2003/2004 Accords and lead more consistently to the objectives set out by participating governments and the Canadian people. 3. National Pharmacare Strategy Canadian Doctors for Medicare (CDM) strongly recommends that the government implement a national pharmacare strategy -- an unfulfilled commitment of the 2004 Canada Health Accord. Canada pays more for prescription drugs than any country within the Organization for Economic Cooperation and Development (OECD) except the United States, and 30% more than the OECD average. These costs result in 1 in 5 Canadian families not being able to afford their prescription drugs. February 16, 2016 Page 5
Amongst Canadians without supplementary health insurance, this number increases to 1 in 4. 8 Inability to access medically necessary prescriptions results in decreased quality of life for patients while increasing demand on hospital resources as untreated conditions lead to hospitalizations. 9 There are a number of ways to start down this road. For example, a single national formulary of essential drugs based on independent, evidence-based drug evaluation could reduce costs by 8%. Additional savings from competitive bulk purchasing could also reduce expenditures substantially. One study estimated that a combination of strategies could reduce our prescription drug costs by as much as $10.7 billion per year, or an estimated 43% of Canada s $25.1 billion drug bill. 10 The 2004 Accord had the stated objective of establishing and implementing a national pharmaceutical strategy. It s time to recommit to this goal, and to the principle that affordable access to drugs is fundamental to equitable health outcomes in Canada. At the federal provincial health minister summit in January 2015, the federal government agreed to join the Pan-Canadian Pharmaceutical Alliance (PCPA) and join with these jurisdictions are to reduce the cost of some prescription medicines. This work results in over $260 million in combined savings annually. Yet this amount pales in comparison to the $5 billion dollars per year a comprehensive universal drug coverage program could save the healthcare system. 11 Economist and pharmaceutical policy expert Steve Morgan cautions that any attempts to institute a national pharmacare strategy requires active leadership from the federal government. 12 Policy analyst Marc-André Gagnon s research on pharmacare concluded that by offering first-dollar coverage, a universal pharmacare program would generate savings of 8 http://www.cmaj.ca/site/misc/pr/16jan12_pr.xhtml 9 Morgan, S.G., D. Martin, MA Gagnon, B Mintzes, J.R. Daw,and J. Lexchin. (2015) Pharmacare 2020: The future of drug coverage in Canada. Vancouver, Pharmaceutical Policy Research Collaboration, University of British Columbia. 10 Gagnon, M-A. The Economic Case for Universal Pharmacare: Costs and Benefits of Publicly Funded Drug Coverage for All Canadians. Presentation to the Canadian Association of Business Economics, Industry Canada, Toronto, November 30, 2010 11 Morgan, S.G., D. Martin, MA Gagnon, B Mintzes, J.R. Daw,and J. Lexchin. (2015) Pharmacare 2020: The future of drug coverage in Canada. Vancouver, Pharmaceutical Policy Research Collaboration, University of British Columbia. 12 Morgan, S.G., J.R. Daw and M.R. Law, Rethinking Pharmacare in Canada. C.D. Howe Institute: 2013. http://www.cdhowe.org/pdf/commentary_384.pdf February 16, 2016 Page 6
10% to 41% on prescription drugs, representing savings of up to $11.4 billion per year for Canada, when both public and public and private sectors are combined. 13 According to a July 2015 poll conducted by the Angus Reid Institute, 91% of Canadians want a national pharmacare program. 14 This leadership would result in a savings for health care systems across Canada as the cost of drugs decreases and hospitalizations due to medical nonadherence are eliminated. Of course, in addition to savings, it would help to improve health outcomes for Canadians on an equitable and sustainable basis. Conclusion The federal budget is a reflection of our government s values and priorities. As policy expert Matthew Mendelsohn wrote, Canadians are very attached and proud of their health care system they are very supportive of the principles of the Canada Health Act and what they understand to be the core elements of medicare, namely that the system is national and publicly-funded, and that it provides to Canadians universal coverage and medical care on the basis of need. 15 We recommend that the federal government: Enforce the Canada Health Act and close any loopholes that may allow for-profit clinics to violate its intent; Demonstrate leadership and vision by reopening health accord negotiations with provinces and territories; and Support the provincial and territorial health ministers initiative to develop and implement a national pharmacare strategy. Canadian Doctors for Medicare is grateful for this opportunity to present to the House of Commons standing Committee on Finance. 13 Gagnon, M.A. A Roadmap to a Rational Pharmacare Policy in Canada. The Canadian Federation of Nurses: 2014. https://nursesunions.ca/sites/default/files/pharmacare_report_0.pdf 14 http://angusreid.org/prescription-drugs-canada/ 15 Mendelsohn, M. Canadians Thoughts on Their Health Care System: Preserving the Canadian Model through Innovation. Queen s University: 2002. http://www.queensu.ca/cora/_files/mendelsohnenglish.pdf February 16, 2016 Page 7