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The topsy-turvy world of hospital budgets; MUHC's plight shows activity-based... - 0 views

  • Montreal Gazette Tue Nov 1 2016
  • Imagine a business providing a service so popular that demand is 30 per cent higher than anticipated. That would be good news, right? Admittedly, there might be an adjustment period as more equipment is purchased and additional staffis hired. But still, you would expect more demand to be a positive thing. Now imagine this business complaining about having too many clients. And not just complaining, but reducing the use of new equipment and firing staff. Sounds crazy? Welcome to the topsy-turvy world of public health care in Canada, where patients are a source of additional expenses for a hospital instead of being a source of revenue.
  • The latest instance of this madness is the Quebec government telling the McGill University Health Centre (MUHC) that it is taking on too many cancer and emergency-room patients, according to a report in Monday's Gazette. In particular, ER admissions at the new superhospital that opened in April 2015 are 30 per cent higher than expected. The government is refusing to fund these "volume overruns," with the result being that the MUHC will have a $10-million shortfall for this fiscal year. The MUHC is apparently responding by mothballing some cutting-edge medical equipment, closing new operating rooms, postponing elective surgeries, and possibly cutting 750 full-time and part-time jobs.
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  • The main reason for these counter-intuitive reactions to increased demand is the way hospitals are funded. As in most of the rest of Canada, hospitals in Quebec currently receive their funding in the form of global budgets based essentially on the amounts they spent in the past. This kind of lump-sum funding leaves hospitals with a tough choice: Limit admissions or go over budget. There is no incentive for hospital administrators to innovate and become more efficient, since an innovation that reduced expenditures would lead to an equivalent decrease in the hospital's next budget. On the other hand, an innovation allowing wait times to be reduced and more patients to be treated entails increased pressure on the fixed budget.
  • Almost all other industrialized OECD countries fund their hospitals to a large extent based on services rendered. With such activitybased funding, hospitals receive a fixed payment for each medical procedure, adjusted to take into account a series of factors like geographic location and the severity of cases. The more patients a hospital treats, the more funding it receives. Generally speaking, in countries where activity-based funding is widely used, there is more competition between medical facilities and quicker access to care. Health Minister Gaétan Barrette has said that the Quebec government wants to adopt activity-based funding for medical facilities in the health network. This would make a lot more sense than demanding that MUHC doctors refer oncology and ER patients to other hospitals, as the Health Ministry is currently doing.
  • But getting rid of Quebec's anachronistic funding of its hospitals through global budgets, while a step in the right direction, should be accompanied by other, complementary measures such as mandatory quality reporting for hospitals. Giving patients and referring doctors access to the information they need in order to determine the best hospital for each case would allow for some healthy competition, leading to quality improvements throughout the system, as has happened in Germany in recent years.
  • If Brian Day's constitutional challenge now being considered by the British Columbia Supreme Court is successful, two other European measures could also come to Canada: allowing a market for private insurance to develop, and allowing doctors to practise both in the public sector and in the private sector.
  • International experience confirms that the presence of a mixed health care system is not incompatible with health care services that are accessible to all. Indeed, such measures could improve access to health care by encouraging entrepreneurship without undermining the principles of equality and universality that Canadians hold dear. Jasmin Guénette is vice-president of the Montreal Economic Institute.
Heather Farrow

Quebec to invest $22M in home health care, especially for seniors - Montreal | Globalne... - 0 views

  • August 24, 2016
  • By Raquel Fletcher
  • Trained home health care workers will be providing services to more Quebec seniors, including house-cleaning, cooking, laundry and running errands.The provincial government is investing over $8 million to help more people access home care.
Cheryl Stadnichuk

Pointe-St-Charles group seeks class action against "illegal" medical fees | Montreal Ga... - 0 views

  • Adjust Comment Print A Pointe-St-Charles community health clinic is seeking court authorization to launch a class action against the Quebec government and private medical centres to put a stop to what it claims are “abusive and illegal” fees charged to patients under medicare — fees ranging from $50 to access one’s file to $10 to have one’s blood sample transported. If a Quebec Superior Court judge grants the authorization, the plaintiffs would then be able to pursue a class-action lawsuit seeking up to $150 million in medical fees billed to patients in the past three years. “We will be asking the court for patients to be repaid what they spent on these illegal fees,” said Cory Verbauwhede, one of the lawyers involved in the case.
  • “We’re opposed to all of these fees because they create a two-tier system,” Defoy said. “What these fees do is undermine our public health system.” In February 2015, the Pointe-St-Charles clinic launched a registry for patients to list questionable fees that they have had to pay doctors. To date, more than 700 patients in the low-income district have submitted data to the registry. In May, a coalition of patient-advocacy groups across Quebec filed a petition in federal court to compel Ottawa to enforce the Canada Health Act, which prohibits both user fees and extra billing.
Heather Farrow

Disabled man's plea reignites debate about nursing home hygiene | Montreal Gazette - 0 views

  • May 26, 2016 5
  • QUEBEC — “Hello. My name is François. I am 43 years old. I live in Quebec City and I am a prisoner of my body. Please help me escape.” That is how François Marcotte began his post on Go Fund Me, a personal fundraising website. Marcotte, who suffers from multiple sclerosis and is completely paralyzed, is trying to raise at least $25,000 to hire someone to give him three showers a week at the nursing home where he is now forced to live, and to pay for an adapted vehicle.
Heather Farrow

CUPE supports legal action to abolish extra billing for health services | Canadian Unio... - 0 views

  • May 3, 2016
  • Ottawa, Ontario – CUPE has given its support to a judicial remedy to eliminate extra patient fees in Quebec and to ensure the enforcement of the Canada Health Act. A suit to this effect was filed on May 2 by the Réseau FADOQ, the largest seniors’ association in Quebec and Canada, with 425,000 members.
  • “On behalf of more than 635,000 CUPE members across Canada and more than 110,000 CUPE members in Québec, I heartily congratulate the Réseau FADOQ on this initiative. Billing for medically required health care is a growing scandal. It is an attack on the dignity of the less fortunate and an attack on the very foundations of our public health care system. It is high time for the Couillard Government to be put in its place on this issue,” said Lucie Levasseur, President of CUPE-Quebec and General Vice-President of CUPE.
Heather Farrow

Private long-term care facility workers launch strike - Montreal - CBC News - 0 views

  • About 3,000 workers on strike in 42 different senior residences across Quebec
  • May 11, 2016
  • The largest strike to hit private long-term care homes across Quebec starts today. For the first time ever, more than 3,000 workers will hold rotating walkouts in favour of better working conditions. This will affect 42 private long-term care homes in the province.
Irene Jansen

Medical scan mistakes: what's behind the problems? - Health - CBC News - 1 views

  • A review by the B.C. Patient Safety and Quality Council eventually showed that these four radiologists were not qualified to read the scans they were interpreting.
  • A similar problem surfaced in Quebec just a couple of weeks ago, when a review of thousands of mammograms flagged for possible errors found 109 breast cancers that were missed. Newfoundland, Saskatchewan and Alberta have also faced problems with potential misinterpretations of medical scans.
  • medical imaging has always been an inexact science, but part of the problem stems from rapid advances in diagnostic imaging technology in the last decade.
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  • Not only is there more data, analyzing these scans is not as simple
  • another factor is the plethora of scans and images on record which make it easy to scrutinize the work of doctors after the fact.
  • But Jean-François Leroux, whose Montreal law firm represents nine women considering or already taking legal action against a Quebec radiologist who missed dozens of breast cancers, says these were not isolated incidents. "It was really the absence of any control of the quality of the procedures," he said.
  • The Quebec College of Physicians has recommended better oversight of radiologists, digitized mammograms to make them easier for others to consult and more uniform standards for private clinics.
Irene Jansen

Health transfer data shows Alberta wins at other provinces' expense - Winnipeg Free Press - 1 views

  • Ottawa is moving toward a pure per-capita system of calculating how much each province should receive in federal health-care funding, starting in 2014. The new system means the existing equalization component in health transfers — intended to even things out among have and have-not provinces — will disappear.
  • the change means Alberta will receive $1.1 billion extra each year, on average
  • Redford added that Alberta got the short end of the stick for years and this finally evens the playing field.
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  • 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.
  •  
    Quebec 2012 Budget http://www.budget.finances.gouv.qc.ca/Budget/2012-2013/en/documents/budgetplan.pdf Section E pp 273 - 98. See in particular: P 281 P 290 P 297
Irene Jansen

Patient advocates help bridge the gap - 0 views

  • Patient advocacy has always existed, but experts say that the phenomenon has become more pronounced than ever
  • the issue has caught the attention of the Canadian Medical Association Journal. In a two-part series published last week, the CMAJ concluded that "patient navigators (are) becoming the norm in Canada."
  • Historically, hospital social workers have fulfilled the role. But friends and relatives of patients have often stepped in to help. During the 2004 C. difficile hospital epidemic in Montreal, some family members whose loved ones fell ill from the diarrhea-causing bacterium told The Gazette that they hired private cleaners to scrub patient rooms.
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  • Today, patient advocacy has even evolved into a commercial industry of its own, with the so-called professional patient navigator - at least in the United States. But there are also signs of it emerging in Canada, too.
  • The U.S. advocates will accompany patients to their medical appointments with a prepared list of questions for the doctor. Afterward, they will follow up with the patients to make sure they're taking their prescriptions. They educate patients about treatment options that they might not have been aware of, especially after a cancer diagnosis. They also co-ordinate care among the various specialists a patient might see. Fees range from $75 to $400 an hour.
  • There are about 2,000 patient advocates in the U.S. - a tiny percentage of the population, but the number is climbing every year.
  • Llewellyn said her company is interested in expanding into the Canadian market.
  • In Montreal, a couple of private companies that specialize in services to the elderly - like finding placement in a seniors' residence - are also beginning to advertise limited patient advocacy.
  • Some observers argue that the need for patient advocacy is even stronger in Quebec because two-tier medicine is more entrenched here than elsewhere in the country.
  • Quebec has responded to what many have called the cancer crisis by creating the new position of the infirmiere pivot - a nurse who acts as a navigator for cancer patients. There are about 270 infirmieres pivot in Quebec, and other provinces have set up similar positions.In addition to the infirmiere pivot, CLSC clinics assign social workers and nurse liaisons to advocate on behalf of patients. Then there are hospital social workers like Johanna Salvanos, who assists the elderly in the geriatrics department at the Jewish General.
Irene Jansen

Walkom: Canada's never-ending medicare fight - thestar.com - 0 views

  • The most depressing element of Canada’s on-again, off-again medicare debate is its repetitiveness. The country is forced to fight the same battle again and again. It’s as if our political elites learn nothing. I was reminded of that this weekend when Reform Party founder Preston Manning showed up on CTV’s Question Period to — again — make his pitch for two-tier health care.
  • Manning has been pushing two-tier medicine since 2005. That’s when he and former Ontario premier Mike Harris wrote that Canada’s medicare system should be replaced by a narrowly defined scheme focused on catastrophic illness and financed, in part, by user fees. All other health care would be paid for privately.
  • Any number of studies have demonstrated that so-called single payer public insurance systems like Canadian medicare are more efficient than two-tier schemes
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  • And user fees? Even a Senate committee that had been warm to the idea of charging patients each time they saw a doctor changed its mind when faced with the evidence.
  • But the real problem with two-tier medicine, as former Saskatchewan premier Roy Romanow noted on the same CTV show, is that it simply shifts costs.
  • Manning made much of the fact that Quebec’s government devotes proportionally less of it provincial budget to health —30 per cent of program spending as opposed to about 40 per cent in Ontario. He appeared to attribute this to the fact that Quebec, unlike Ontario, allows physicians to opt out of medicare and bill patients privately. But the real reason why the Quebec government spends less in proportional terms on health care is that it spends more in absolute terms on everything else. Provincial government program spending per capita in Quebec is $11,457. In Ontario, the figure is $9,223.
  • total health spending in Ontario represents 11.9 per cent of the province’s gross domestic product. In Quebec, the comparable figure is 12.4 per cent
  • The Germans, Dutch and French, all of whom are praised by two-tier fans, spend more of their gross domestic product on health care than we do.
  • Surely it’s more productive to build on what we have — a successful, publicly funded, universal health insurance system that covers doctors and hospitals. It could be improved or even expanded. But it works. That’s why Canadians keep fighting for it. Over and over and over again.
Govind Rao

Foreign cash for Quebec care - jumping the line or crossing it? | Montreal Gazette - 0 views

  • June 10, 2014
  • Quebec’s Ombudsman concluded this week that a cardiac patient from Kuwait who underwent surgery at the Royal Victoria Hospital in 2011 was able to jump the queue over Quebec patients in exchange for her government paying for her medical services. But despite the fact that Kuwait paid the McGill University Health Centre more than $196,000 for the woman’s surgery and stay in the intensive care unit, the MUHC still did not charge for her private room in the ICU, for lab tests, X-rays, emergency expenses and the salaries of the 17 medical residents who examined her. Furthermore, the woman’s surgery was performed in the context of a five-year, $86-million agreement that the MUHC, McGill University and a private Montreal
Govind Rao

More doctors leave public system in Quebec; Five-fold increase; Numbers are small, but ... - 0 views

  • Montreal Gazette Mon Jun 9 2014
  • The accumulated number of doctors who have gone private in Quebec - opting out of medicare and billing patients directly for medically necessary services - has increased more than five times since 2000, newly compiled government figures show.
  • Although the "opt-outs" represent a fraction of the total number of physicians practising under medicare in Quebec, supporters of public health care say it's a worrisome trend. Ontario, by comparison, does not let its doctors opt out of medicare, while other provinces have imposed restrictions. In 2000, 51 doctors withdrew permanently from the medicare plan administered by the Régie de l'assurancemaladie du Québec. As of April 17, the latest date for which statistics are available, the cumulative total reached 278.
Govind Rao

Governments across the country brace for looming crunch, political dilemmas - Infomart - 0 views

  • he Globe and Mail Wed May 13 2015
  • Canadian governments are bracing for rising debtservicing costs, attempting to lock in low interest rates before the inevitable rise forces unpopular decisions on spending and taxes. After years of deficit spending, Ottawa and some provinces are just starting to climb back into annual surpluses. Now, the country must grapple with hundreds of billions in accumulated government debt. This year's budget season revealed governments are taking steps to lock in current low interest rates. The question is whether they are doing enough.
  • Since the recession hit in 2008, Ottawa has added more than $150-billion to the national debt. Provinces piled on a further $217-billion. The federal government is currently weighing whether to issue another round of 50-year bonds. It started that practice last year, raising $3.5-billion with yields below 3 per cent. Meanwhile Canada's two most indebted provinces - Quebec and Ontario - are stretching out the average length of maturity of their debt. The average maturity of Ontario's debt is now 14 years, up from eight years prior to the recession. Nova Scotia now has more than half of its debt maturing in 15 years or more.
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  • 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
Govind Rao

Harper ignores Quebec's call for health care payments, finance minister says - Montreal... - 0 views

  • Finance Minister Carlos Leitao says the federal budget tabled Tuesday is “disappointing”
  • Apr 21, 2015
  • Quebec Finance Minister Carlos Leitao is not completely satisfied with the federal budget tabled Tuesday by the Harper government. Leitao told reporters in Quebec City that Quebec's requests for transfers in health care payments were not heard.
Govind Rao

'We have the evidence ... Why aren't we providing evidence-based care?'; Mental illness... - 0 views

  • The Globe and Mail Sat May 23 2015
  • It's 4:30 on a Friday afternoon at her Sherbrooke, Que., clinic and Marie Hayes takes a deep breath before opening the door to her final patient of the day, who has arrived without an appointment. The 32-year-old mother immediately lists her complaints: She feels dizzy. She has abdominal pain. "It is always physical and always catastrophic," Dr. Hayes will later tell me. In the exam room, she runs through the standard checkup, pressing on the patient's abdomen, recording her symptoms, just as she has done almost every week for months. "There's something wrong with me," the patient says, with a look of panic. Dr. Hayes tries to reassure her, to no avail. In any case, the doctor has already reached her diagnosis: severe anxiety. Dr. Hayes prescribed medication during a previous visit, but the woman stopped taking it after two days because it made her nauseated and dizzy. She needs structured psychotherapy - a licensed therapist trained to bring her anxiety under control. But the wait list for public care is about a year, says Dr. Hayes, and the patient can't afford the cost of private sessions.
  • Meanwhile, the woman is paying a steep personal price: At home, she says, she spends most days in bed. She is managing to care for her two young children - for now - but her husband also suffers from anxiety, and the situation is far from ideal. Dr. Hayes does her best, spending a full hour trying to calm her down, and the woman is less agitated when she leaves. But the doctor knows she will be back next week. And that their meeting will go much the same as it did today. In its broad strokes, this is a scene that repeats itself in thousands of doctors' offices every day, right across the country. It is part and parcel of a system that denies patients the best scientific-based care, and comes with a massive price tag, to the economy, families and the health care system. Canadian physicians bill provincial governments $1-billion a year for "counselling and psychotherapy" - one third of which goes to family doctors - a service many of them acknowledge they are not best suited to provide, and that doesn't come close to covering patient need. Meanwhile, psychologists and social workers are largely left out of the publicly funded health-care system, their expertise available only to Canadians with the resources to pay for them.
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  • 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
Govind Rao

Aging population requires new health funding formula, Quebec Premier says - The Globe a... - 0 views

  • Quebec Premier Philippe Couillard is pushing his fellow premiers to adopt a new funding formula for health care transfer payments that would take into account a province’s aging population.The rookie federalist Premier is making his case behind closed doors at the Council of the Federation meeting in Charlottetown Thursday. He is hoping that his colleagues will accept his proposal and then lobby the federal government to change its formula, which many provinces argue punishes them for having an older population.
Govind Rao

Quebec nurses' union launches hotline for complaints about health care system - Montrea... - 0 views

  • Health care workers will collect complaints from the public
  • Aug 24, 2015
  • A new hotline that allows Quebecers to complain anonymously about issues in the health care system was launched today by the union representing heath care workers. 
Govind Rao

Healthier spending - Infomart - 0 views

  • The Globe and Mail Mon Aug 31 2015
  • Re More Cash Is Not The Solution, Aug. 27: Although Ottawa "only asks ... that provinces conform ... to the Canada Health Act," Quebec refuses to pay outof-province doctors at "host province" rates, and few doctors will accept a Quebec medicare card.
  • This affects Quebeckers who fall ill while on business or vacation outside their province, and those who move to another province and, for the first three months, are covered by a card few doctors honour. Would the Liberal and NDP leaders, both from Quebec, have the backbone to demand that Quebec obey federal law?
  • ...2 more annotations...
  • The federal government should do more than simply transfer money to the provinces; it should take an active role in co-ordinating health care for an aging population in which the prevalence of chronic diseases is expected to increase. Were it to help develop a national pharmacare program, for example provincial health ministries might enjoy major cost savings.
  • Charles S. Shaver, chair of Ontario Medical Association section on general internal medicine, Ottawa
Govind Rao

Dr. Ryan Meili on the dangers of the proposed Bill 20 amendment in Quebec | CDM in the ... - 0 views

  • September 15, 2015
  • Written by Mark Cardwell for Canadian Healthcare Network on September 15, 2015:
  • A coalition of Canadian groups dedicated to defending Canada’s publicly-funded health care system is sounding the alarm over a proposed amendment in Quebec that would give private medical clinics the right to bill patients fees that are now illegal.
  • ...1 more annotation...
  • “(It) will create a two-tier health-care system that limits care for people who can’t afford extra fees,” Dr. Ryan Meili, acting Chair of Canadian Doctors for Medicare, said about the proposed amendment to Quebec’s Bill 20, a highly controversial act that ironically aims to promote access to family medicine and specialized medical services.
Govind Rao

Quebec's Budget: Setting the Table for Either a Combative Government in the Face of a C... - 0 views

  • May 13th, 2014
  • The day following his election as Premier of Quebec, Philippe Couillard ordered a report on the state of the province’s public finances from Luc Godbout and Claude Montmarquette, two economists who have advocated for tax cuts and fee hikes in recent years. This unusual procedure led to the usual conclusion, which has recurred every time power has changed hands over the last 15 years: there is a gaping hole in public finances left by the previous administration. This entire masquerade is obviously put on to prepare Quebecers for the budget that the government will table in June. Let’s see how a Finance Minister creates the political space needed to act however he pleases.
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