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Health Canada’s annual reports show that Quebec has sometimes complied with its concerns. But in its 2003-2004 report, the agency observed that the Quebec government was “not at liberty to reveal the status of the province’s investigation” into user charges imposed by a private surgical clinic. A year earlier, Health Canada expressed concern “about private surgical clinics that allow individuals to privately pay for medically insured services and thus jump the queue. … Health Canada asked Quebec to confirm that the matter had been resolved.” A long-standing complaint of Quebec by Health Canada is that it allows patients to be charged for MRIs and CT scans if they are done in private clinics. In its 2004-2005 report, Health Canada held discussions with British Columbia, Alberta and Nova Scotia about charging for medical imaging in private clinics, but Quebec refused to participate. 

Health Canada officials did not respond to requests for an interview since last Thursday. Reacting to the Quebec lawsuit last week, federal Health Minister Jane Philpott said she’s a strong supporter of the CHA, and did not rule out reducing transfer payments to provinces that flout the law.

Ontario Health Minister Eric Hoskins predicted that the reduction in the annual "escalator" to three per cent would result in a "declining partnership." Yet considering Ottawa contributes only 23 per cent of the average provincial health budget, the three per cent difference in the annual "escalator" translates into a reduced rate of increase of only 0.69 per cent! Much of this is mere political bluster! Is it not finally time to revisit the Canada Health Act and fine-tune it?

As Konrad Yakabuski has stated (Globe and Mail, Oct. 19), "As long as the provinces remain bound by the Canada Health Act, which constrains their ability to dramatically alter the way health care is paid for and delivered, any new conditions on the use of federal transfers are only likely to further weigh down an already overly bureaucratic system."

When it was passed in 1984, it was understood that the federal government would pay half of health costs. Now it covers less than a quarter. Thanks to Ottawa's admission of refugees and migrants, overall growth of an aging, sicker population, new diseases, and new technologies, the provinces must shoulder an increasing burden.

Yet as Bacchus Barua (Ottawa Sun, Oct. 21) has stressed, more efficient health care systems in Europe allow a greater role for the private sector, use co-payments and user fees (with exemptions for the poor and elderly) and fund hospitals according to activity, not by global budgets, which have been frozen in many provinces.

MDs could be required to work - perhaps 25 to 30 hours per week - in the public system in order to receive government reimbursement for malpractice insurance. Most MDs would confine their practice to the public system. They deserve fair treatment. Thus Philpott should amend the CHA to mandate binding arbitration when provincial negotiations fail.

For those not a member of a "special group," the main option for timely care may be to go to the United States. This provides employment to American doctors and nurses and profits to U.S. hospitals. Would it not make more sense to allow all Canadians to spend their after-tax discretionary income on their own health in their own province?

Frozen hospital global budgets have caused excessive wait times for knee and hip replacements as operating rooms are often not functioning at full capacity. According to a 2013 survey, 15 per cent of Canadian surgeons considered themselves underemployed and 64 per cent cited poor access to ORs. Hence if orthopedic surgeons had access to additional "private" OR time, wait times could be shortened. If hospitals were permitted to operate electively on Americans and other foreign patients, this would bring in extra revenue for hospitals and relieve the strain on provincial health ministries.

Philpott has vowed to do more than just "open the federal wallet." She admits that "innovation" is required. Yet governments are being constrained by blindly adhering to certain parts of the CHA. Despite denials by politicians, a "two-tier" system has always existed. Federal prisoners, WSIB patients, members of the military and RCMP, politicians and professional athletes usually obtain more timely care - often at private facilities.

When the premiers meet with Prime Minister Justin Trudeau in December, besides discussing funding of the new Health Accord, they need to revisit the CHA and begin putting forth proposals as to how best to amend and modernize it. Where wait times are excessive, certain diagnostic services and surgical procedures should allow for private access for all Canadians - not just a select few.

This would utilize expensive equipment and provide new employment for nurses, technicians and surgeons. It would provide extra revenue - from both inside and outside the country - that would help to keep universal public health care sustainable and accessible for all Canadians. Ottawa should then enforce all sections of the CHA on all provinces and territories.

Ottawa physician Dr. Charles Shaver was born in Montreal. He graduated from Princeton University and Johns Hopkins School of Medicine. He is currently chair of the section on general internal medicine of the Ontario Medical Association.

hospital services be covered by the provincial and territorial health insurance plans, whether the services are provided in a hospital or in a facility providing hospital care. There are concerns about queue jumping and charges to insured persons at private surgical clinics in British Columbia, for services that are covered under its provincial health in

atient charges and queue jumping at private diagnostic clinics also remain issues in some provinces where private clinics are charging patients for medically

services and allowing them to jump the queue for insured health services.

There is a need to identify financing options that do not impose burdens on government budgets.

The social insurance (SI) model, common in Europe and used in Canada to finance public pensions and employment insurance, has been suggested as a way to raise revenue to improve access to non-CHA services.

This paper examines the implications of using the SI model to expand coverage to services such as pharmaceuticals and long-term care.

thanks to predictable and escalating funding over the first seven years of the plan

however, there are, unfortunately, pockets of inattention and/or mediocrity as well

Six areas, in fact, were identified by CHA

funding matters; health human resources; pharmacare; wellness, identified as health promotion and illness and disease prevention; continuing care; and leadership at the political, governance and executive levels

The focus of this 10-year plan has been on access. CHA would posit that it is at this juncture, the focus must be on quality and accountability.

safety, effectiveness, efficiency, appropriateness

Canada does an excellent job in providing world-class acute care services, and we should; hospitals and physicians have been the core of our systems for decades. Now is the time to ensure sufficient resources are allocated to other elements of the continuum, including wellness and continuing care.

Home care is one readily available yet underused avenue for delivering health promotion and illness prevention initiatives and programs.

four critically important themes: dignity and respect, support for caregivers, funding and health human resources, and quality of care

Nadine Henningsen, Executive Director, Canadian Home Care Association

Today, an estimated 1.8 million Canadians receive publicly funded home care services annually, at an estimated cost of $5.8 billion. This actually only equates to about 4.3 per cent of our total public health care funding.

There are a number of initiatives within the home care sector that need to be addressed. Establishing a set of harmonized principles across Canada, accelerating the adoption of technology, optimizing health human resources, and integrated service delivery models all merit comment.

great good has come from the 10-year plan

Unfortunately, there were two unintended negative consequences

One was a reduction in chronic care services for the elderly and

a shift in the burden of costs for drugs and medical supplies to individual and families. This was due to early discharge and the fact that often a number of provinces do not cover the drugs and supplies under their publicly funded program.

Stakeholders across Canada generally agreed that the end-of-life expectations within the plan were largely met

How do we go from having a terrific acute care system to having maybe a slightly smaller acute care system but obviously look toward a chronic care system?

Across Canada, an estimated 30 to 50 per cent of ALC patients could and should benefit from home care services and be discharged from the hospital.

Second, adopt a Canadian caregiver strategy.

Third, support accountability and evidence-informed decision making.

The return on investment for every dollar for home care is exponentially enhanced by the in-kind contribution of family caregivers.

Sharon Baxter, Executive Director, Canadian Hospice Palliative Care Association

June 2004

a status report on hospice, palliative and end-of-life care in Canada

Dying for Care

inconsistent access to hospice palliative care services generally and also to respite care services; access to non-prescribed therapies, as well as prescription drug coverage

terminated by the federal government in March of 2008

the Canadian Strategy on Palliative and End-of-Life Care

Canadian Hospice Palliative Care Association and the Canadian Home Care Association embarked on what we called the Gold Standards Project

In 2008, the Quality End-of-Life Care Coalition released a progress report

progress was made in 2008, from the 2004 accord

palliative pharmaceutical plan

Canadians should have the right to choose the settings of their choice. We need to look for a more seamless transition between settings.

In 2010, the Quality End-of-Life Care Coalition of Canada released its 10-year plan.

Seventy per cent of Canadians at this point in time do not have access to hospice palliative care

For short-term, acute home care services, there was a marked increase in the volume of services and the individuals served. There was also another benefit, namely, improved integration between home care and the acute care sector.

last summer, The Economist released a document that looked at palliative services across 40 countries

The second area in the blueprint for action is the support for family caregivers.

The increasing need for home-based care requires us to step up and strive for a comprehensive, coordinated and integrated approach to hospice palliative care and health care.

Canadian Caregiver Coalition

in Manitoba they have made great strides

In New Brunswick they have done some great things in support of family caregivers. Ontario is looking at it now.

we keep on treating, keep on treating, and we need to balance our systems between a curative system and a system that will actually give comfort to someone moving toward the end of their life

Both the Canadian Institute for Health Information and the Canadian Health Services Research Foundation have produced reports this year saying it is chronic disease management that needs our attention

When we look at the renewal of health care, we have to accept that the days of institutional care being the focus of our health care system have passed, and that there is now a third leg of the stool. That is community and home care.

Over 70 per cent of caregivers in Canada are women. They willingly take on this burden because they are good people; it is what they want to do. The patient wants to be in that setting, and it is better for them.

The Romanow report in 2002 suggested that $89.3 million be committed annually to palliative home care.

that never happened

What happened was a federal strategy on palliative and end-of-life care was announced in 2004, ran for five years and was terminated. At best it was never funded for more than $1.7 million.

Because our publicly funded focus has been on hospitals and one provider — physicians, for the most part — we have not considered how to bring the other pieces into the equation.

Just as one example, in the recent recession where there was special infrastructure funding available to stimulate the economy, the health system was not allowed to avail itself of that.

As part of the 10-year plan, first ministers agreed to provide first dollar coverage for certain home-care services, based on assessed need, by 2006. The specific services included short-term acute home care, short-term community mental health care and end-of-life care. It appears that health ministers were to report to first ministers on the implementation of that by 2006, but they never did.

One of the challenges we find with the integration of mental health services is

A lot of eligibility rules are built on physical assessment.

Very often a mental health diagnosis is overlooked, or when it is identified the home care providers do not have the skills and expertise to be able to manage it, hence it moves then over to the community mental health program.

in Saskatchewan it is a little more integrated

Senator Martin

I think ideally we would love to have the national strategies and programs, but just like with anything in Canada we are limited by the sheer geography, the rural-urban vast differences in need, and the specialized areas which have, in and of themselves, such intricate systems as well. The national picture is the ideal vision, but not always the most practical.

In the last federal budget we got a small amount of money that we have not started working with yet, it is just going to Treasury Board, it is $3 million. It is to actually look at how we integrate hospice palliative care into the health care system across all these domains.

The next 10-year plan is about integration, integration, integration.

the Canadian Patient Safety Institute, the Health Council of Canada, the Canadian Health Leadership Network, the health sciences centres, the Association of Canadian Academic Healthcare Organizations, the Canadian College of Health Leaders, the Canadian Medical Association, the Canadian Nurses Association, the Canadian Public Health Association, the Canadian Agency for Drugs and Technologies in Health and Accreditation Canada

We are all meeting on a regular basis to try to come up with our take on what the system needs to do next.

most people want to be cared for at home

Family Caregiver Tax Credit

compassionate care benefit that goes with Employment Insurance

Have you done any costing or savings? Obviously, more home care means more savings to the system. Have you done anything on that?

In the last federal election, every political party had something for caregivers.

tax credits

the people we are talking about do not have the ability to take advantage of tax credits

We have a pan-Canadian health/human resource strategy in this country, and there is a federal-provincial-territorial committee that oversees this. However, it is insufficient

Until we can better collaborate on a pan-Canadian level on our human resources to efficiently look at the right mix and scope and make sure that we contain costs plus give the best possible provider services and health outcomes right across the country, we will have problems.

We have not as a country invested in hospital infrastructure, since we are talking about acute care settings, since the late 1960s. Admittedly, we are moving away from acute care centres into community and home care, but we still need our hospitals.

One of the challenges is with the early discharge of patients from the hospital. They are more complex. The care is more complex. We need to train our home support workers and our nurses to a higher level. There are many initiatives happening now to try to get some national training standards, particularly in the area of home support workers.

We have one hospital association left in this country in Ontario, OHA. Their CEO will constantly talk about how the best thing hospitals can do for themselves is keep people out of hospitals through prevention promotion or getting them appropriately to the next place they should be. Jack Kitts, who runs the Ottawa Hospital, and any of the CEOs who run hospitals understand one hundred per cent that the best thing they can do for Canadians and for their institutions is keep people out of them. That is a lot of the language.

We have an in-depth brief that details a lot of what is happening in Australia

I would suggest that it is a potentially slippery slope to compare to international models, because often the context is very different.

Quebec has many private clinics. One performs 200 joint replacements per year; some 30 per cent of patients come from other provinces. When Philpott threatened to penalize Quebec for extra billing by MDs, its health minister, Dr. Gaétan Barrette, retorted that Quebec was not subject to the Canada Health Act. He is wrong. The CHA was passed unanimously in 1984, thus every Quebec MP voted for it. The solution is not to break the law, but to amend it.

Philpott admits "innovation" is required. Yet governments are constrained by blindly adhering to certain parts of the CHA, while ignoring others. As Ben Eisen of the Fraser Institute has emphasized, provinces have been forbidden to experiment with user-fees, copayments, etc. that would encourage individuals to use health services more responsibly. A "two-tier" system has always existed. Federal prisoners, Workplace Safety and Insurance Board patients, members of the military and RCMP, politicians and professional athletes usually obtain more timely care - often at private facilities. For those not near an inter-provincial border and not a member of a "special group," the main option for timely care may be to go to the United States. This provides employment to American doctors and nurses and profits to U.S. hospitals. Wouldn't it make more sense to allow all Canadians to spend their after-tax discretionary income on health in their own province? Frozen hospital budgets have caused excessive wait times for knee and hip replacements as operating rooms often don't function at full capacity. According to a 2013 survey, 15 per cent of Canadian surgeons considered themselves underemployed and 64 per cent cited poor access to ORs. About 25 per cent of nurses in Newfoundland and Labrador work only part of the year.

If orthopedic surgeons had access to additional "private" OR time, wait times could be shortened for all Canadians and new employment would be created for health-care professionals. If hospitals were permitted to operate electively on Americans and other foreign patients, this would bring in extra revenue and relieve the strain on provincial health ministries. So that MDs did not abandon the public system, they could be required to work 25 to 30 hours per week in the public system in order to receive government reimbursement for malpractice insurance. Most MDs would confine their practice to the public system. They deserve fair treatment. Philpott should amend the Canada Health Act to mandate binding arbitration when provincial negotiations fail, as they have in Ontario. Since 1984, the population has grown and aged, new diseases have been recognized, and new drugs and technologies have developed. Some 32 years ago, it was understood that Ottawa would pay half of health costs. Now it covers less than a quarter. We need to amend and modernize the Canada Health Act. Where wait times are excessive, certain diagnostic services and surgical procedures should allow for private access for all Canadians - not just a select few. This would maximally utilize expensive equipment and provide new employment for nurses, technicians and surgeons. It would provide extra revenue that would help to keep universal public health care sustainable and accessible for all Canadians. Ottawa should then enforce all sections of the Canada Health Act on all provinces and territories. Dr. Charles Shaver Ottawa

Louie has said their self-government agreement says the band does not need approval from the province to build and run the hospital. But Christie says the agreement doesn't deal with issues like a First Nation operating a hospital for profit.

"This proposed health facility would raise Canada Health Act concerns if insured persons are charged for insured health services provided there."

Westbank First Nations

"We've had discussions with Johns Hopkins but nothing is concluded yet.

"Patients could drink a nice bottle of wine the night before [their surgery] and there will be chefs preparing food," said Louie, adding the facility would not provide emergency, maternity or psychiatric care .

"The way legislation is written, you can't call it a hospital but that's what it will be, although it will also be a holistic medical wellness centre

A Health Canada spokesman said the federal government would be concerned if Canadian patients were charged for insured health services.

intention to serve inter-national clientele while improving health care access for WFN members.

The clinic would also benefit Canadians on waiting lists who might otherwise seek care outside the country, Louie added.

meetings about the medical facility have included Dr. Lyle Oberg, a former Alberta Conservative cabinet minister who is now an adviser to that province's Wildrose Alliance Party.

Oberg, who retired from political office nearly five years ago, was a founder of an Edmonton-based company called the Canadian Centre for DNA Diagnostics (C2DNA) which was touted as the first private DNA sequencing lab in Canada.

Mark McLoughlin is a partner

"We're not looking at any money from the government or any other agency.

Christou said he asked some patients to pay his surgical fees at the Royal Victoria once he had opted out of medicare.

He said he has had enough of working in the public system, which is poorly funded, and would rather devote himself to a few patients in private practice.

"We realized that maybe it's not appropriate for a doctor who has opted out of RAMQ to continue to be part of the MUHC,"

"I am perfectly within my legal rights as a non-participating physician to charge my surgical fees even if I do my surgery within a public institution

And charge whatever surgical fees within the code of deontology (of the physician's board) - you can't ask for a million dollars - but you can ask for whatever the market will bear as long as you are completely non-participating physician," Christou said.

RAMQ, the Quebec health insurance board disagrees. It says patients can't be charged for medically necessary treatments, which are covered by medicare, whether these are performed in public or private institutions.

The insurance board recently reimbursed eight patients $73,000 for improper user fees charged at a private clinic, Rockland MD surgical centre, and has investigations pending at several other private clinics.

CUPE submission on NS health care legislation