Group items tagged

In response to the view that interprovincial equity is more appropriately addressed through the Equalization program, in Budget 2007 the federal government committed to remove the equalizing component of the CHT by legislating that the cash transfer move to an equal-percapita allocation in 2014–2015

Concerns about the equalizing component of the cash transfer have been raised more recently due to economic shifts resulting from high natural resource prices, a stronger Canadian dollar, and a decline in manufacturing. For example, even though Ontario became a poorer province relative to provinces with abundant natural resources, its per capita CHT cash transfer continued to be lower than average due to its relatively strong tax point transfer.

In response to these recent economic shifts, Budget 2009 facilitated the move to an equal-per-capita cash transfer for Ontario by ensuring that the province immediately receive the same per capita CHT cash as other relatively poorer provinces

the 1990s saw a perception of widespread physician shortages though only a handful of provinces had declines in the per capita number of physicians (Ontario, BC, Alberta, PEI and Nova Scotia), and by 2010 these declines have turned into marked increases in most of these provinces

The recent increase in physician numbers more than makes up for the small decline of the 1990s

a positive correlation between physician numbers and health spending is not automatic. In other words, a high per capita number of physicians is not always associated with high per capita health spending. Quebec, for example spends the lowest amount per capita on public health care spending and yet has one of the highest number of physicians per capita. Manitoba, on the other hand has the second highest per capita public health spending in the country but is one of the lowest in terms of physicians per capita.

"The federal government's commitment to increase their transfer payment by 6 per cent this coming year has actually be been broken and rather than getting 6 per cent Ontario will be getting only 3.4 per cent," Matthews said, referring to the health increase.

As well, the 6-per-cent increase was a national average and not all provinces would receive the same rate.

According to Library of Parliament estimates from 2011-2012, Alberta is the only province to benefit from the change to equal-per-capita funding.

Sousa said Tuesday he was "infuriated" to learn from federal Finance Minister Jim Flaherty that Ottawa's funding to Ontario for 2014-15 would be $19.158 billion - down $641 million, or 3.24 per cent, from this year's $19.799-billion allotment

Has a doctor   85.1% Heavy drinkers          17.9% High blood pressure 17.7% Overweight or obese adults 54.0% Overweight or obese youth (12-17)          23.1% Physically active (leisure time)       53.7%

In 2014, roughly 3.4 million Canadians aged 12 and older (11.2 per cent) reported that they did not receive health care when they felt they needed it. Overall, females (12.4 per cent) were more likely than males (10 per cent) to have reported an unmet health-care need. Among age groups, unmet health-care needs were lowest for those aged 12 to 19 and those aged 65 or older, and were highest for those aged 20 to 54. Source: Health Canada

Top 10 Causes of Death in Canada (2012) Ischaemic heart disease       13.8% Alzheimer’s and other dementias   9.5% Trachea, bronchus, lung cancers     8.1% Stroke             5.4% Chronic obstructive pulmonary disease     4.5% Colon and rectum cancers   3.7% Diabetes mellitus      2.7% Lower respiratory infections           2.3%

Breast cancer             2.2% Falls    1.9% Source: World Health Organization International Comparison of Health Spending  Canada           OECD Average           Canada’s OECD Ranking Total Health expenditure as a percentage of GDP            10.2    8.9       10/34 Total Health expenditure per capita           $4,351            $3,453            10/34

Public expenditure on health per capita   $3,074            $2,535            13/34 Public share of total health expenditure   70.60%          72.70%          22/34 Hospital expenditure per capita     $1,338            $1,316            15/29 Physician expenditure per capita   $720   $421   27-Apr Drug Expenditure per capita          $761   $517   2/31 Source: OECD Health Statistics 2015           

Canadian medical schools have expanded their annual enrolment by 80% over the last 13 years

it is politically extremely difficult, almost impossible, to cut back on medical school places once they have been opened.2

In the last decade, medical expenditure per physician has also risen, by nearly 35% above general inflation.

Each of these waves of expansion responded to widespread perceptions of a looming "physician shortage." How accurate were those perceptions? In the case of the first wave, they rested on assumptions that were simply wrong, and by a wide margin. Medical schools were built to serve people who never arrived.

major increase in physician supply per capita, from 1970 to 1990, did not result in underemployed physicians. Utilization of physicians' services adapted to the increased supply. Whether the additional physicians were "needed," and what impact their activities might have had on the health of Canadians, are good and debatable questions

Does all this increased diagnostic activity among the very elderly actually generate health benefits?

As in the case of the previous major expansion, the impact on the total supply of physicians will unfold slowly, but relentlessly, over decades.

Table 1. Canadian health spending, percentage increase per capita, inflation-adjusted   1999–2004 2004–2009 1999–2009 Hospitals 19.1 11.7 33.0 Physicians 16.4 24.4 44.8 Rx drugs 46.1 19.0 73.7 Total health 22.2 16.5 42.3 Provincial governments 21.2 17.7 42.6  

Over the nine-year period, there were very large increases in the per capita volume of diagnostic services – imaging and laboratory tests. Adjusting for fee changes, per capita expenditures on these rose by 28.4% and 42.1%, respectively.

much greater among the older age groups – 59.4% and 64.4%, respectively, for those over 75

money has been poured into reimbursing diagnostic services for the elderly and very elderly, but access to primary care for the non-elderly appears to have been constrained

insofar as more recently trained physicians tend to be more reliant on the ever-expanding arsenal of diagnostic technology, overall expenditures per physician will continue to rise as their numbers grow

(Population has grown by about 14%.)

a lot of money is going out the door and no one has a clear picture of what it is buying

The question of Canadian physician supply is now moot. The new doctors are on their way, and whether or not we will need them all is no longer relevant. It may be that as cost containment efforts begin to bite we will again see renewed limits on the inflow of foreign-trained physicians, but we will not be able to turn down the domestic taps as supply increases.

Growth in diagnostic testing has to be brought under control, both in how ordering decisions are made and in how tests are paid for.

he Ontario government spent 1.6 per cent less of provincial Gross Domestic Product (GDP) compared to the other provinces in 2010-11. With sharp cutbacks in Ontario, that gap had increased to 2.1 per cent by 2014/15. On this basis, Ontario spent about $15-billion less on programs than the other provinces and territories. On a per capita basis, Ontario is the lowest spending (and lowest revenue) provincial government in Canada. Ontario spent $1,200 less per person in 2010/11 than the other provinces and territories and almost $2,000 less per person in 2014/15. Here the gap is even larger – Ontario spent about $27-billion less on a per capita basis than the other provinces and territories.

Over the last two years, Ontario has lost 19,000 public sector workers, with most of the loss occurring in the last year. The downward trend in Ontario contrasts with the upward trend across the rest of Canada.

On a per-capita basis, Ontario has fallen 60,825 public sector jobs further behind the rest of Canada in just two years. When you need a healthcare worker, this reality will come home to roost.

According to CIHI, Ontario government per capita funding for hospitals is $1,395.73. The rest of Canada, excluding Ontario, spends $1,749.69 per capita on hospitals. In other words, provincial and territorial governments outside of Ontario spend $353.96 more per person on hospitals than Ontario does, or roughly 25 per cent more. According to the findings, these numbers have increased steadily over the years and in 2005-2006 the gap between Canada and Ontario was at just 4.3 per cent.

"With working in the hospital you see reductions and they may seem small at first, but year-to-year you really see their growing impact," said Rodrigues. "Our front line workers hear the frustrations. They also hear about being sent home too early and see the readmissions." According to the report, Ontario has the fewest number of hospital beds in

any province and the length of hospital stays continue to be reduced for this reason. This decrease leads to an increase in readmissions. "We have a drop in admissions and an increase in readmissions," explained Hurley. "In terms of readmissions, Ontario is higher than the rest of Canada and Kingston is actually higher than the rest of Ontario. From our point of view, readmissions represent failures of the system to actually repair people properly."

The report also looked at funding for homecare and long-term care, an area the government has claimed they are expanding to meet growing needs. "We have been told that investments are being made in those areas," said Hurley. "But long-term care is 7.2 per cent behind the rest of the country and for homecare and community care we spend 14.3 per cent less. We have the fewest number of hospital beds, so you think we would have the most vibrant homecare system, but in fact we underspend."

Overall, Hurley emphasized that while hospitals require about a three per cent increase year to year to keep up with inflationary needs, hospitals in Ontario and in Kingston are only receiving about one per cent. "The increase should actually be around five per cent when you take into account additional pressures like population growth and aging and we are nowhere near that," he said. "Because of that we see nursing and staff cuts as a result and that is not acceptable." In terms of staffing, the reports conclude that in Kingston, across all hospitals, approximately 137 registered nurses and about 407 other staff would need to be added to equal comparable staffing in other provinces like Manitoba or New Brunswick.

That is a lot of people," said Hurley. "This lack of staffing means there is less care in the hospital for mothers who have just given birth, or people recovering from surgery and than again leads to readmissions and complications." So what can be done about these issues?

"People can talk to their Member of Provincial Parliament about these issues. That would be really appreciated," said Hurley. "We are doing these reports in every major community in the province and we are hoping to get some traction with the government to increase the funding." Illustration:

Mandy Marciniak / Michael Hurley, president of the OCHU (left) and Mike Rodrigues, president of CUPE 1974 (Kingston General Hospital).

Imagine if a Canadian diagnosed with cancer were told she could receive chemotherapy paid for by the health-care system, but would have to cough up the cash herself if she needed radiation. Or that she could have a few weeks of treatment, and then be sent home even if she needed more. That would never fly. If doctors, say, find a tumour in a patient's colon, the government kicks in and offers the mainstream treatment that is most effective. But for many Canadians diagnosed with a mental illness, the prescription is very different. The treatment they receive, and how much of it they get, will largely be decided not on evidence-based best practices but on their employment benefits and income level: Those who can afford it pay for it privately. Those who cannot are stuck on long wait lists, or have to fall back on prescription medications. Or get no help at all. But according to a large and growing body of research, psychotherapy is not simply a nice-to-have option; it should be a front-line treatment, particularly for the two most costly mental illnesses in Canada: anxiety and depression - which also constitute more than 80 per cent of all psychiatric diagnoses.

Why aren't we providing evidence-based care?" .. The case for psychotherapy Research has found that psychotherapy is as effective as medication - and in some cases works better. It also often does a better job of preventing or forestalling relapse, reducing doctor's appointments and emergency-room visits, and making it more cost-effective in the long run.

Therapy works, researchers say, because it engages the mind of the patient, requires active participation in treatment, and specifically targets the social and stress-related factors that contribute to poor mental health. There are a variety of therapies, but the evidence is strongest for cognitive behavioural therapy - an approach that focuses on changing negative thinking - in large part because CBT, which is timelimited and very structured, lends itself to clinical trials. (Similar support exists for interpersonal therapy, and it is emerging for mindfulness, with researchers trying to find out what works best for which disorders.) Research into the efficacy of therapy is increasing, but there is less of it overall than for drugs - as therapy doesn't have the advantage of well-heeled Big Pharma benefactors. In 2013, a team of European researchers collated the results of 67 studies comparing drugs to therapy; after adjusting for dropouts, there was no significant difference between the most often-used drugs - selective serotonin reuptake inhibitors (SSRIs) - and psychotherapy.

The issue is not one against the other," says Montreal psychiatrist Alain Lesage, director of research at the Douglas Mental Health University Institute. "I am a physician; whatever works, I am good. We know that when patients prefer one to another, they do better if they have choice." Several studies have backed up that notion. Many patients are reluctant to take medication for fear of side effects and the possibility of difficult withdrawal; research shows that more than half of patients receiving medication stop taking it after six months. A small collection of recent studies has found that therapy can cause changes in the brain similar to those brought about by medication. In people with depression, for instance, the amygdala (located deep within the brain, it processes basic memories and controls our instinctive fight-or-flight reaction) works in overdrive, while the prefrontal cortex (which regulates rational thought) is sluggish. Research shows that antidepressants calm the amygdala; therapy does the same, though to a lesser extent.

But psychotherapy also appears to tune up the prefrontal cortex more than does medication. This is why, researchers believe, therapy works especially well in preventing relapse - an important benefit, since extending the time between acute episodes of illnesses prevents them from becoming chronic and more debilitating. The theory, then, is that psychotherapy does a better job of helping patients consciously cope with their unconscious responses to stress.

According to treatment guidelines by leading international professional and scientific organizations - including Canada's own expert panel, the Canadian Network for Mood and Anxiety Treatments - psychotherapy should be considered as a first option in treatment, alone or in combination with medication. And it is "highly recommended" in maintaining recovery in the long term. Britain's independent, research-guided scientific body, the National Institute for Health and Care Excellence, has concluded that therapy should be tried before drugs in mild to moderate cases of depression and anxiety - a finding that led to the creation of a $760million public system, which now handles therapy referrals for nearly one million people a year.

In 2012, Canada's Mental Health Commission estimated that only about one in three adults and one in four children are receiving support and treatment when they need it. Ironically, anti-stigma campaigns designed to help people understand mental illness may only make those statistics worse. In Toronto, for instance, putting up posters in subway stations in 2010 had the unexpected effect of spiking the volume of walk-ins at nearby emergency rooms by as much as 45 per cent in 12 months. Dr. Kurdyak treated many of them at CAMH. The system, he says, "has been conveniently ignoring this unmet need. It functions as if two-thirds of the people suffering won't get help." What would happen if the healthcare system outright "ignored" two-third of tumour diagnoses?

Essentially, argues Dr. Lesage, adding therapy into the health-care system is like putting a new, highly effective drug on the table for doctors. "Think about it," he says. "We have a new antidepressant. It works as well as many others, and it may even have some advantages - it works better for remission - with fewer side effects. The patients may prefer it. And [in the long run] it doesn't cost more than what we have. How can it not be covered?" ..

A heavy price This isn't just a medical issue; it's an economic one. Mental illness accounts for roughly 50 per cent of family doctors' time, and more hospital-bed days than cancer. Nearly four million Canadians have a mood disorder: more than all cases of diabetes (2.2 million) and heart disease (1.4 million) combined.

Mental illness - and depression, in particular - is the leading cause of disability, accounting for 30 per cent of workplace-insurance claims, and 70 per cent of total compensation costs. In 2012, an Ontario study calculated that the burden of mental illness and addiction was 1.5 times that of all cancers, and more than seven times the cost of all infectious diseases. Mental illness is so debilitating because, unlike physical ailments, it often takes root in adolescence and peaks among Canadians in their 20s and 30s, just as they are heading into higher education, or building careers and families. Untreated, symptoms reverberate through all aspects of life, routinely trapping people in poverty and homelessness. More than one-third of Ontario residents receiving social assistance have a mental illness. The cost to society is clearly immense.

Yet, when family doctors were asked why they didn't refer more patients to therapy in a 2008 Canadian survey, the main reason they gave was cost. For many Canadians, private therapy is a luxury, especially if families are already wrestling with the economic fallout from mental illness. Costs vary across provinces, but psychologists in private practice may charge more than $200 an hour in major centres. And it's not just the uninsured who are affected.

Although about 60 per cent of Canadians have some form of private insurance, the amount available for therapy may cover only a handful of sessions. Those with the best benefits are more likely to be higherincome workers with stable employment. Federal public servants, notably, have one of the best plans in the country - their benefits were doubled in 2014 to $2,000 annually for psychotherapy. Many of those who can pay for therapy are doing so: A 2013 consultant's study commissioned by the Canadian Psychological Association found that $950-million is spent annually on private-practice psychologists by Canadians, insurance companies and workers compensation boards. The CPA estimates t

These are the patients that family doctors juggle, the ones who eat up appointment time, and never seem to get better, the ones caught on waiting lists. Sometimes, they have already been bounced in and out of the system, received little help, and have become wary of trying again. A 40-something mother recovering from breast cancer, suffering from chronic depression post-treatment, debilitated by fear her cancer will return. A university student, struggling with anxiety, who hasn't been to class for three weeks and may soon be kicked out of school. A teenager with bulimia removed from an eatingdisorder program because she couldn't follow the rules. They are the ones dangling on waiting lists in the public system for what often amounts to a handful of talk-therapy sessions, who don't have the money to pay for private therapy, or have too little coverage to get the full course of appointments they need.

Canada's investment does not match that burden. Only about 7 per cent of health-care spending goes to mental health. Even recent increases pale when compared to other countries: According to a study by the Canadian Mental Health Association, Canada increased per-capita funding by $5.22 in 2011. The British government, meanwhile, kicked in an extra 12 times that amount per citizen, and Australia added nearly 20 times as much as we did. Falling off a cliff, again and again

In Winnipeg, Dr. Stanley Szajkowski watched for months as his patient, a woman in her 80s, slowly declined. Her husband had died and she was spiralling into a severe depression. At every appointment, she looked thinner, more dishevelled. She wasn't sleeping, she admitted, often through tears. Sometimes she thought of suicide. She lived alone, with no family nearby, and no resources of her own to pay for therapy. "You do what you can," says Dr. Szajkowksi. "You provide some support and encouragement." He did his best, but he always had other patients waiting.

hat 30 per cent of private patients pay out-ofpocket themselves. When the afflicted don't seek help, the cost isn't restricted to their own pocketbook. People with mental-health problems are significantly more likely to abuse drugs and alcohol, and to become physically sick, further increasing health-care costs. A 2014 study by Oxford University researchers found that having a mental illness reduced life expectancy by 10 to 20 years, roughly the same as did smoking and obesity. A 2008 Statistics Canada study linked depression to new-onset heart disease in the general population. A 2014 U.S. study found that women under the age of 55 are twice as likely to suffer or die from a heart attack, or require heart surgery, if they have moderate to severe depression. The result: clogged-up doctors' offices, ERs, and operating rooms. And an inexorable burden for the patients' families forced to fill the gaps in caregiving - or carry on when they lose a loved one.

Patients refer to it as falling repeatedly off a cliff. And they can only manage the climb back up so many times. Family doctors interviewed for this story admitted that they are often "handholding" patients with nowhere else to go. "I am making them feel cared for, I am providing a supportive ear that they may not get anywhere else," says Dr. Batya Grundland, a physician who has been in family practice at Toronto's Women's College Hospital for almost a decade. "But do I think I am moving them forward with regard to their illness, and helping them cope better? I am going to say rarely." More senior doctors have told her that once in a while "a light bulb goes off" for the patients, but often only after many years. That's not an efficient use of health dollars, she points out - not when there are trained therapists who could do the job better. However, she says, "in some cases, I may be the only person they have."

Family doctors aren't the only ones struggling to find therapy for their patients. "I do a hundred consultations a year," says clinical psychiatrist Joel Paris, a professor at McGill University and research associate at the Montreal Jewish General, "and one of the most common situations is that the patient has tried a few anti-depressants, they have not responded very well, and from their story it is obvious they would benefit from psychotherapy. But where do they go? We have community clinics here in Montreal with six-to-12-month waiting lists even for brief therapy." A fractured, inefficient system

"You fall into the role that is handed to you," says Antoine Gagnon, a family doctor in Osgoode, on the outskirts of Ottawa. He tries to set aside 20-minute appointments before lunch or at the end of the day to provide "active listening" to his patients with anxiety and depression. Many of them are farmers or self-employed, without any private coverage for therapy. "Five of those minutes are spent talking about the weather," he says, "and then maybe you get into the meat of the problem, but the reality is we don't have the appropriate amount of time to give to therapy, even to listen, really." Often, he watches his patients' symptoms worsen over several months, until they meet the threshold of a clinical diagnosis. "The whole system could save on productivity and money if people were actually able to get the treatment they needed."

But these issues aren't insurmountable, as other countries have demonstrated. Britain, for instance, has trained thousands of university graduates to become therapists in its new public program, following research showing that, as long they have the proper skills, people don't need PhDs to be effective therapists. Australia, which has created a pay-for-service system, also makes wide use of online support to cost-effectively reach remote communities.

Except for a small fraction of GPs who specialize in psychotherapy, few family doctors have the training - or the time - to provide structured therapy. Saadia Hameed, a GP in a family-health team in London, Ont., has been researching access to psychotherapy for an advanced degree. Many of the doctors she has interviewed had trouble even producing a clear definition of therapy. One told her, "If a patient cries, than it's psychotherapy." Another described it as "listening to their woes." A 2007 survey of 163 family doctors in Ontario found that almost four out of five had not received training in cognitive behavioural therapy, and knew little about it. "Do family doctors really need to do that much psychotherapy," Dr. Hameed asks, "when there are other people trained - and better trained - to do it?"

What further frustrates treatment for physicians and patients is lack of access to specialists within the system. Across the country, family doctors describe the difficulty of reaching a psychiatrist to consult on a diagnosis or followup with their patients. In a telling 2011 study, published in the Canadian Journal of Psychiatry, researchers conducted a real-world experiment to see how easily a GP could locate a psychiatrist willing to see a patient with depression. Researchers called 297 psychiatrists in Vancouver, and reached 230. Of the 70 who said they would consider taking referrals, 64 required extensive written documentation, and could not give a wait-time estimate. Only six were willing to take the patient "immediately," but even then, their wait times ranged from four to 55 days. Psychiatrists are in increasingly short supply in Canada, and there's strong evidence that we're not making the best use of these highly trained specialists. They can - and often do - provide fee-for-service psychotherapy in a private setting, which limits their ability to meet the huge demand to consult with family doctors and treat the most severe cases.

A recent Ontario study by a team at CAMH found that while waiting lists exist in both urban and rural centres, the practices of psychiatrists in those locations tend to look very different. Among full-time psychiatrists in Toronto, 10 per cent saw fewer than 40 patients, and 40 per cent saw fewer than 100 - on average, their practices were half the size of psychiatrists in smaller centres. The patients for those urban psychiatrists with the smallest practices were also more likely to fall in the highest income bracket, and less likely to have been previously hospitalized for a mental illness than those in the smaller centres.

And those therapy sessions are being billed with no monitoring from a health-care system already scrimping on dollars, yet spending a lot on this care: On average, psychiatrists earn $216,000 a year. There is nothing to stop psychiatrists from seeing the same patients for years, and no system to ensure the patients with the greatest need get priority. In Australia, Britain and the United States, by contrast, billing for psychiatrists has been adjusted to encourage them to reduce psychotherapy sessions and serve more as consultants, particularly for the most severe cases, as other specialists do.

As the Canadian system exists now, says Benoit Mulsant, the physician-in-chief at CAMH and also a psychiatrist, the doctors in his specialty "can do whatever they please. If I wanted, I could have a roster of actor patients who tell me entertaining stories, and I would be paid the same as someone who is treating homeless people. ... By treating the rich and famous, there is zero risk of being punched in the face by a patient." Left out in all this, by and large, are other professionals who can provide therapy. It doesn't help that the rules are often murky around who can call themselves psychotherapists. While psychologists and social workers are licensed under their professional associations, in some provinces a person can call himself a marriage counsellor or music therapist with no one demanding they be certified. In 2007, Ontario passed a law to regulate psychotherapists, requiring them to register with a provincial college that would set standards and handle complaints. Currently, however, the law is in limbo, although the government has said it will finally bring it into force by December. The brain keeps many secrets

Science, however, has yet to find depression's equivalent of insulin. Despite being scanned, poked and stimulated over and over and over again, the brain keeps its secrets. The "chemical imbalance" theory is now viewed as simplistic at best. It may not do much for patients, either: A 2014 study published in the journal Behaviour Research and Therapy suggested that, rather than reassuring them, focusing on the biological explanation for depression actually made patients feel more pessimistic and lacking in control. SSRIs work by increasing the amount of serotonin, a chemical that helps deliver messages within the brain and is known to influence mood. But researchers aren't sure why the drugs help some patients and fail with others. "Basically, it's like we have a bucket of water and we pour it over the patient's head," says Dr. Georg Northoff, the University of Ottawa's Michael Smith chair of Neurosciences and Mental Health. "But you want a drug that injects the water in a very specific brain regions or brain system, which we don't have."

Critics of therapy have argued that it's basically "good listening" - comparable to having a sympathetic friend across the kitchen table - and that in the real world of mercurial patients and practitioners of varying abilities, a pill just works better. That's true in many cases, especially when the symptoms are severe and the patients is suicidal: a fast-acting medication is safer, and may even be necessary before starting talk therapy. The staunchest advocates of therapy do not suggest it should be the first course of treatment for psychosis, or debilitating chronic depression, or mania - although, in those cases, there is evidence that psychotherapy and medication work well in tandem. (A 2011 meta-analysis found that patients with severe depression who received a combination approach had higher recovery rates and were less likely to drop out of treatment.) But drugs also don't work as well as the manufacturers would like us to think. Roughly one-third of patients given a drug will see no benefit (although they often respond to a second or third medication). In randomly controlled trials, drugs often perform only marginally better than sugar pills.

Yet it's talk therapy that the public often views most skeptically. "Until you go to a therapist, or a member of your family has a serious psychological problem, people are unsympathetic [about therapy]," says Dr. Paris, the Montreal psychiatrist. "They are very skeptical, and they don't believe the research. It's amazing, because pharmaceutical trials will get approval for a drug on the basis of two clinical trials that they paid for. And we have 100 clinical trials and no one believes us."

Dr. Ajantha Jayabarathan, an assistant professor at Dalhousie University's medical school, spent her early years as a family doctor in Spryfield, N.S., trying to manage an overload of mental-health cases. Most of her patients had little insurance; there was one reduced-cost counselling service in town, but the waiting lists were long. In 2000, her group practice became a test site for a shared-care project, which gave the doctors access to a mental-health team, including weekly in-person consultations with a psychiatrist. "It was transformative," she says. "We looked after everything in-house.

Over time, Dr. Jayabarathan says, she learned how to properly assess mental illness in patients, and how to use medication more effectively. "I just made it my business to teach myself what to do." It's the kind of workaround GPs are increasingly experimenting with, waiting for the system to catch up. Who would pay - and how?

The case for expanding publicly funded access to therapy is gaining traction in Canada. In 2012, the health commissioner of Quebec recommended therapy be covered by the province; it is now being studied by Quebec's science-based health body (INESSS), which is expected to report back next year. A new Quebec-based organization of doctors, researchers and mental-health advocates called the Coalition for Access to Psychotherapy (CAP) is lobbying the government.

In Manitoba, the Liberal Party - albeit well behind in the polls - has made the public funding of psychologists one of its campaign platforms for the province's spring 2016 election. In Saskatchewan, the government commissioned, and has since endorsed, a mental-health action plan that includes providing online therapy - though politicians have given themselves 10 years to accomplish it. Michael Kirby, the former head of the Canadian Mental Health Commission, has been advocating for eight annual sessions of therapy to be covered for children and youth in need.

There are significant hurdles: Which practitioners would provide therapy, and how would they be paid? What therapies would be covered, and for how long? Complicating every aspect of major mentalhealth change in Canada is the question of who should shoulder the cost: the provinces or Ottawa. In a written statement in response to questions from The Globe and Mail, federal Health Minister Rona Ambrose lobbed the issue back at her provincial counterparts, pointing out that the Canada Health Act does not "preclude provinces and territories from extending public coverage to other services or providers such as psychologists."

One result can be overloaded family doctors minimizing mental-health problems. "If you have nothing to offer someone," asks Dr. Anderson, "how much are you going to dig around to find out what is going on?" Some doctors also admit that the lack of resources can lead to physicians cherry-picking patients who don't have mental illness. And yet family physicians alone bill about $361million a year for counselling or psychotherapy in Canada - 5.6 million visits of roughly 30 minutes each. This is a broad category, and not always specifically related to mental health (some of it includes drug counselling, and a certain amount of coaching is a necessary part of the patient-doctor relationship). When it is psychotherapy, however, doctors admit it's often more supportive listening than actual therapy.

So how would Canada pay for access to such therapy? It wouldn't be cheap, in the short term. The savings would come from what Canadians would not have to spend in the long term: in additional medical and drug costs, emergency-room visits and hospital stays, and in unnecessary disability payments, to say nothing of better long-term health outcomes for patients given good care earlier. Some of the figures being tossed around sound staggering. Rolling out a version of Britain's centre-based program across Canada would cost $950-million. Michael Kirby's plan would amount to $1,000 annually per patient. A 2013 report commissioned by the Canadian Psychological Association calculated that, based on predicted need, and assuming no coverage from private health-care plans, providing an average of six sessions of therapy a year would cost an estimated $2.8-billion annually.

But any of those figures would still be a fraction of the roughly $210-billion that Canada spends annually on health care. Figuring out how to make the system most costeffective is, according to sources, currently delaying the INESSS report to the Quebec government. "You need to facilitate the government," says Helen- Maria Vasiliadis, a professor of community health at the University of Sherbrooke. "You can't be going to policymakers and showing them billions and billions of dollars. People start having heart attacks. With evidence in hand, we have to present possible solutions."

An insurance-based plan is the proposal that has emerged from the Quebec-based CAP group, which sent its proposal to Quebec's health minister last month. In its design, the system would work much like Quebec's public drug plan - Quebeckers not covered through work plans would contribute to a provincial insurance program for therapy. That would be similar to the system that Germany has used for decades. One step forward, one step back

Last year, the Sherbrooke clinic where Marie Hayes works received provincial funding for a part-time psychologist and a full-time social worker. With a roster of 25,000 patients, the clinic team laid out clear guidelines for the psychologist, who would consult on cases and screen patients, and be limited to a mere four sessions of actual counselling with any one patient. "We wanted to be careful she didn't become a waiting list - like everything in the system," says Dr. Hayes. The social worker helps guide patients into services such as housing and addiction counselling. They have also offered group sessions for depression management at the clinic. As stretched as those new professionals are in such a large practice, Dr. Hayes says the addition of that mental-health team is improving the care she can provide patients. Recently, for instance, the 32- year-old mother with anxiety attended sessions with the psychologist. "She is making progress," says Dr. Hayes, "slowly."

At Women's College Hospital in Toronto, Dr. Grundland is not so lucky. Asked to describe a difficult case, the family-practice physician mentions a patient suffering from depression after a lifechanging accident. Every month, doctor and patient would repeat the same conversation they'd already had more than a dozen times - and make little real headway. Her patient, says Dr. Grundland, needs a trained therapist: someone she can see regularly, to help her move past her frustration, counsel her about addiction, and ease the burden on her family.

But there's no extra money in the patient's budget for a psychologist. "I do my best," Dr. Grundland says, "but it's not my area of expertise." Meanwhile, the patient isn't getting better, and in the time that it takes to make it through one appointment with her, Dr. Grundland could see three other people with problems she was actually trained to treat. "But," says Dr. Grundland, "she has nowhere else to go." Erin Anderssen is a feature writer at The Globe and Mail. OPEN MINDS How to build a better mental health care system

The Centre for Addiction and Mental Health has purchased advertisements to accompany this series. While CAMH professionals are quoted in this story, the organization had no involvement in the creation or production of this, or any other story in the series. $20.7-billion The cost, according to a 2012 Conference Board of Canada report, of lost productivity each year due to mental illness. What else does $20-billion represent?

$20B: Canadian spending on national defence, 2012-13 $20B: Market valuation of Airbnb, 2015 $21B: Kitchener-CambridgeWaterloo region's GDP, 2009 $21B: Amount food manufacturing contributed to the economy, 2012

In dollar terms, the size of all of that post-recession debt is staggering. Some fear that when interest rates return to normal, governments will face crippling debt-servicing costs. But the scope of the problem is a matter of significant debate in policy circles. Experts do agree that whether or not government debt is a serious problem depends on where you live. Government books in Western Canada are relatively healthy. East of Manitoba however, debt is already forcing hard choices. Political debate over government finances is typically focused on the annual bottom line, which shows whether there is a annual surplus or a deficit.

Economists say the often overlooked - but far more important figure - is the size of government debt in relation to the size of the economy. As a percentage of gross domestic product, the net debt of all provinces and territories has grown to 28.6 per cent in 201314 from 20.5 per cent in 2007-08. The federal debt grew to a peak of 33.3 per cent in 2012-13 from 29.2 per cent in 2007-08. That's nowhere near the 67.1 per cent debt levels reached by Ottawa in 1995-96, when The Wall Street Journal warned that Canada was at risk of hitting the "debt wall." The size of the federal debt has already started to decline, reaching 32.3 per cent in 2013-14. The 2015 budget forecast that the federal debt-to-GDP ratio will reach prerecession levels by 2017 and decline further to 25 per cent by 2021. The debt picture among the provinces varies dramatically.

Alberta and Saskatchewan are currently facing hard times owing to low oil prices, but they are the darlings of Confederation when it comes to low debt. Alberta had no debt at all as of last year. The real debt troubles can be found in Central and Atlantic Canada. Quebec's net debt is the largest, at 50 per cent of GDP, followed by Ontario, at 38.4 per cent, and Nova Scotia at 37.7 per cent, using figures for 201314. While Quebec announced a balanced budget this year, Ontario's deficit was up slightly to $10.9-billion last year. Ontario insists the deficit will be erased by 2017-18.

Provincial governments are responsible for programs such as education and health care that can affect people more directly than federal programs. Spending restraint is easier said than done. The 2015 budget season has coincided with student protests in Quebec, New Brunswick and Nova Scotia, while Ontario is dealing with labour unrest from teachers' unions. Many provinces have also been negatively affected by a recent change to the federal health-transfers formula. The move to per-capita funding won out over arguments that the average age of provincial populations should be factored into the equation. Some of the most indebted provinces also face the most challenging demographics, with a shrinking ratio of younger workers to cover the costs of growing numbers of older citizens. The Parliamentary Budget Officer has said that while federal finances are sustainable over the long term, the provinces are facing structural shortfalls that will demand spending cuts, higher taxes or both. University of New Brunswick economics professor David Murrell said the return to surpluses in Ottawa will likely rekindle pressure from the provinces for more generous transfers. Shrinking deficits, growing debt

Provincial finance ministers are quick to pat themselves on the back over shrinking deficits and balanced budgets, but economists urge Canadians to view these claims with a bit of skepticism. Accounting methods vary across the country, making comparisons difficult. Unlike the federal government, provinces generally present two sets of books: an operational budget and a capital budget. Boasts of balanced budgets are in reference to operational spending. A province's overall debt could still be rising on the capital side even though the government is in an operational surplus. Supporters of this accounting method - including Calgary Mayor Naheed Nenshi - argue that it separates good debt from bad debt: Using debt to build public assets such as roads and bridges is better than slipping into the red to pay for public service salaries and other operational costs.

Critics such as tax-policy expert Jack Mintz have warned this approach allows provinces to play "hide the deficit." Charles Lammam, director of fiscal studies with the Fraser Institute, a conservative think tank that regularly warns about the dangers of mounting government debt, agrees that claims of improving budget balances can be misleading. "This is a real problem in places like British Columbia and Ontario," he said. "It doesn't seem like the growth in government debt will let up." Mr. Lammam's research found that Canadian governments - including municipalities - spend more than $60-billion a year servicing debt, which is about the same as the entire cost of providing primary and secondary education across the country. Ontario's recent budget said a one-point increase in interest rates would cost the government $400-million. "There's a real risk that provinces like Ontario, provinces like Quebec, can be subject to this very negative situation where they're paying even more to service their outstanding debt," he said. The new debt debate

The CHT associated equalization payment is expected to be $1.05 billion in 2008–2009.

Figure 1 – Total Canada Health Transfer Entitlement, 2004–2005 to 2008–2009

The federal government’s formula for calculating the value of the cash transfer, the tax point transfer and the associated equalization payment under the CHT ensures that the total entitlement provides an equal per capita amount across all provinces. Figure 2 presents the total CHT entitlement amount per capita and per province for 2008–2009. As can be seen, the total CHT entitlement per capita amounted to $1,100 for all provinces.

Hurley is travelling throughout the province, to explain how over the last decade Ontario's acute hospital funding has been on the slide compared to other provinces. In 2005-06, Ontario was "in the ballpark," with per capita funding of $1,112 compared to $1,159 for the rest of Canada, Hurley said, citing figures from the Canadian Institute for Health Information. Ten years later, Ontario's funding was $1,396 compared to $1,750 for the rest of Canada. He said the numbers extrapolated for Windsor are conservative, taking into account only the City of Windsor's 211,000 population, even though Windsor Regional's patients come from all over the Windsor-Essex region (population 389,000) and beyond.

Hurley said while Ontario did increase its funding for hospitals during the last decade, it did not come close to accounting for inflation, population growth and the aging population. This year, hospitals received a one per cent increase, but their actual costs rose 4.5 per cent, he said. "So their budgets have been cut again." Windsor Regional declined to comment on Hurley's assertions. In a statement, Health Minister Eric Hoskins said his government is doing what citizens want - continuing to invest in a health-care system that "puts patients first," asserting that 94 per cent of Ontarians now have a family doctor, and that wait times for some procedures are among the shortest in the country.

This year, it's increasing health funding by $1 billion, a 2.1 per cent increase, and it's increasing funding to hospitals by $345 million this year. "In Windsor, (since 2003) we've increased funding for local hospitals by more than $126 million - an increase of almost 50 per cent," said Hoskins. He also said Ontario is investing additional millions into home care, community health centres and home-based hospice and palliative care, because people prefer to receive their health care at home instead of a hospital. Hurley said the province argues that while it has been actively downsizing the acute care system, at the same time it's increasing investments in home care and longterm care, to "pick up the slack." But he said Ontario is actually spending less on long-term care and home care than the rest of the provinces. He said Ontario's high readmission rates are a sign the system is suffering. "So we have fewer beds, there's tremendous pressure to get people out of those beds and send them home, and often when they're sent home they haven't been made well actually and they return to hospital for a more lengthy and expensive readmission." Hurley said his council is calling on the government to fund hospitals "at least" at a level that reflects their rising costs, to stop reducing the number of beds and staffing, and to increase access to the people who need it.

The people being hardest hit by this are elderly, he said, who often have lived a long time without serious health problems, until they're hit with a health crisis that lands them at a hospital doorstep. "First they queue up in an ER for hours, and if they're going to be admitted it's likely a stretcher in a hallway," he said. And once admitted, there's likely pressure to get them discharged before they're fully well, he added. "For the elderly in particular they feel the brunt because there's rationing going on, the beds are so scarce." bcross@postmedia.com

Michael Hurley, president of the Ontario Council of Hospital Unions, discussed health-care funding in the province Thursday during a news conference at the Royal Canadian Legion Branch 255.

both the old and new formulas can be considered unfair in that they ignore that some provincial differences in health spending are rooted in population health differences.

The first component should be an equal per capita cash payment recognizing the fixed costs of operating a health system

The second component needs to base the payment on a formula that takes into account population growth, differences in the aged proportion of population, and perhaps even differences in the incidence of illnesses.

As a of the change, the other provinces — especially Ontario, British Columbia and Quebec — will all receive less than they otherwise would have. Ontario will be losing out on $382 million annually, British Columbia will be down $351 million and Quebec will see $210 million less each year.

A separate calculation by researchers at the Library of Parliament shows that on a per capita basis, the change in health funding penalizes Newfoundland and Labrador the most.

Government per-capita expenditures in Alberta were almost double those in Texas - Alberta spent $8,607 on average during the 2001-to-2013 period, while Texas spent $4,952. Mr. Prentice acknowledged that Alberta's spending is also out of line relative to other Canadian provinces. Compared to the Canadian average, Alberta spends about $1,300 more per capita on programs and services, and more than half of these costs are from salaries alone, he said. The School of Public Policy at the U of C argues the province could improve the way it forecasts oil revenue. According to author Sarah Dobson, there are "serious problems" with Alberta's forecasts. "In a province so dependent on resource royalties for its revenues, adding the unpredictability of unreliable forecasting methods can only put its fiscal planning at that much greater risk of instability," she writes. Unlike other critics, who in the past worried the province's forecasts were too rosy, Ms. Dobson argues Mr. Prentice might be inflating the government's expected shortfall this time around.

The premier has warned that if West Texas Intermediate crude averages US$65 a barrel this fiscal year, provincial revenue would drop by $6 billion to $7 billion, while a WTI price below US$50 could mean a shortfall of up to $10 billion. That's a big bite out of a $45-billion budget. Ms. Dobson said Alberta is assuming a Canadian dollar exchange rate of 88¢ to the U.S. dollar, which is high compared to most forecasters, who see the Canadian dollar falling further to potentially US75¢ by the end of the year. She estimates the government's high exchange rate view is increasing the shortfall by $2 billion. The exchange rate has a big impact on Alberta revenue because oil is sold in U.S. dollars. The revenue picture could be clearer if the province was more transparent about its royalties revenue, she said. The province doesn't provide key information such as how much production has reached "payout" and is subject to higher royalties, how much bitumen has been upgraded, how much bitumen qualifies for a royalty discount, or information on the productivity of crude oil wells, Ms. Dobson said. Rather than being protective of the ways of the past, Mr. Prentice is leading the shakeup and asking Albertans to do their part. The question is whether the resolve sticks when the oil-price roller-coaster turns in Alberta's favour, and the unbridled optimism that comes with oil booms temps politicians to reopen the taps.

briefing notes prepared for Intergovernmental Affairs Minister Peter Penashue shortly after the May 2 election

calls by think-tanks and groups such as the Canadian Medical Association to "begin a national dialogue on the future sustainability of the health-care system."

The C.D. Howe Institute report, co-authored by former Bank of Canada governor David Dodge, predicted that health-care spending as a share of GDP will increase to 18.7 per cent in 2031 from 12 per cent in 2009."Traditional cost drivers related to salary costs and technology costs, as well as significant pressures from increased demands due to demographic pressures raise questions about the sustainability of the system," Penashue is advised.

The agreement, which was agreed to by the former Klein government, pays Alberta approximately $558 per capita (nearly $2 billion in total) compared to a minimum $805 per person for every other province — costing the province around $930 million annually.

Alberta has been calling for equal treatment with the other provinces, and it appears that message has been received in Ottawa.

"The government of Canada is committed to moving to an equal per capital allocation of the CHT as of 2014-15," say the internal documents

The premiers say they need to know soon, for planning purposes, how much money they can count on in the long term. They would like a first ministers conference with Harper, but unlike previous prime ministers, that is not his style.Since coming to office in 2006, he has gathered the premiers only three times for a meeting — twice, in person, to discuss the economic recession, and once, in a conference call, to discuss the economy and the H1N1 epidemic.

"While the federal government makes an important contribution to fund health care, the P/Ts carry the majority of the costs and control decisions with respect to delivery."

Ontario has the fewest hospital beds per capita of any jurisdiction almost in the world

According to the Organization for Economic Development and Co-operation, Ontario has two hospital beds for every 1,000 residents. Only Mexico has fewer. Canada-wide, there are three hospital beds per 1,000 residents, an amount also considered relatively low.

The current model for paying physicians is “expensive, outdated and doesn’t support the efforts of doctors to provide the best care possible,” said Health Minister Sarah Hoffman at a Feb. 8 policy forum in Edmonton on the health system’s fiscal sustainability.

In 2014, Alberta spent $1060 per capita on physician services — the third highest in the country. More than 80% of payments are through fee-for-service, where doctors bill the government for each medical service provided. Proponents of fee-for-service say it gives doctors the incentive to see as many patients and provide as many services as possible. Hoffman wants some of the doctors on fee-for-service to adopt Alternative Relationship Plans (ARP), which she said are not only less expensive, but also reward doctors for the quality of care they provide.

Under clinical ARPs, doctors are paid for providing a set of services at a facility to a target population. There are several types. The annualized ARP, the most common in Alberta, provides compensation based on a formula that determines the number of full-time equivalents (hours per year or days per year) required to deliver services.

In Ontario, the most common ARP is the capitation model, under which physicians are paid a fixed fee per month for each patient registered with their practices, regardless of services received.

The Alberta Medical Association (AMA), which represents the province’s 8921 licensed physicians, supports the change. President Dr. Carl Nohr told CMAJ that ARPs are part of the move toward modernizing the health care system, which now deals with more chronic illness. They give doctors more flexibility, he said.

“They’ll be able to vary the amount of time they spend with individual patients, define how frequently they see patients — all in the context of what’s good for the patients and not necessarily from the business perspective.”

Neither the AMA nor Hoffman could specify the number of doctors they want to adopt this model. Nohr said compensation under an ARP will remain optional, but “our goal is to make it as attractive as possible and make changes to the model as we go, and hopefully over time see a substantial uptake.”

Alberta’s total health budget is $19.7 billion for 2015–16 — the second highest per capita ($4800) among the provinces. But, Hoffman said, “Given how much money is spent on health care in Alberta, the health outcomes in our province can and should be better.”

Hoffman said health care accounts for 45% of the government’s overall budget, and continues to grow faster than both inflation and the population, which grew 2.17% in 2015. If health care spending continues to rise by an average of 6% annually, it will account for 60% of the province’s budget in 20 years. Hoffman wants to decrease growth in health care spending to 2% annually in the next few years, but stressed this does not mean cutting funding; it means curbing spending growth.

Hoffman doesn’t know how much will be saved by changing the physician compensation system, but said “changing the way we pay doctors will have a ripple effect on the entire health system.”

The government’s contract with t

e AMA expires in 2018, and both parties are discussing redirecting funds and developing alternative compensation models. Nohr said they’re looking into a blend of ARP and fee-for-service among primary-care physicians.

One of the very good things that gives me hope for the future is that the profession and the government have a very good relationship,” Nohr said. “So there’s a collaborative, positive relationship between the Alberta Medical Association and the Ministry of Health and that creates the possibility for productive, useful change.”

In fact, only Americans, at $1,147 per capita, spend more on drugs than Canadians, at $890.

unlike citizens of most other developed countries, Canadians pay for the majority of their prescription drugs with private insurance or out-of-pocket.

About 39 per cent of prescription drug costs are financed by the public sector in Canada, compared to 85 per cent in Britain.

Public spending on prescription drugs was $12.1-billion last year, up just 2.2 per cent; private spending was $15.1-billion, up 6.8 per cent.