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individualization of programs and services, the adoption of a life-course perspective, and the ongoing use of evidence-based information in designing and adapting policy.

Moreover, with citizens having direct access to the same information, they will be better equipped and able to make their own choices or decisions on courses of action.

A major restructuring of Canada’s income security system will likely be required in order to follow through on these principles. Here, Hicks recommends reconfiguring the system around three pillars: guaranteed annual income, social insurance and lifetime accounts.

The first pillar would ensure that every Canadian has access to a relatively modest minimum income so that no one falls through the cracks. As Hicks notes, governments are not far away from achieving this objective thanks to programs such as the National Child Benefit Supplement/Canada Child Tax Benefit, the Working Income Tax Benefit and the Guaranteed Income Supplement/Old Age Security.

reduce the disincentive to work in older age.

In recent years these two objectives have become intermingled as programs such as employment insurance (EI) have taken on new roles and responsibilities (parental, sickness and care leave, for example). This has created unintended disparities within the labour market between those who qualify for assistance and those who do not, making it difficult for many people to manage key transitions in life.

integrated lifetime accounts

These lifetime accounts would operate in a similar way to retirement and other tax-preferred savings accounts (RRSPs, TFSAs, RESPs), which allow accumulation of capital through direct contributions over time and follow individuals through life. The pillar would incorporate lifetime accounts that already exist (such as public pension and education saving programs), while extending the model to a number of other areas including the many special benefits programs currently administered within EI, as well as various tax credit and loan programs for individuals. There are a range of options for how such accounts could be used, financed and managed.

It would also require the Ministry of Health to publish a statement of the amount each physician receives through OHIP billings, explaining the figures do not represent a physician's net income. "Had the sunshine list been applied to ORNGE and had the ombudsman been allowed oversight, we would not have witnessed the tragedies that resulted from the destruction of our air ambulance services," said Gelinas. "The people of Ontario deserve assurances they can trust their health-care services whenever and wherever they need it."

"We are in frequent contact and continue to co-operate" with U.S. authorities, Valeant said in a written statement. "We do not comment on rumours about investigations, and cannot comment on or speculate about the possible course of any ongoing investigation. Valeant takes these matters seriously and intends to uphold the highest standards of ethical conduct." A Pearson lawyer, Bruce Yannett, declined to comment. Dan K. Webb, a lawyer for Schiller, didn't immediately comment. Spokespeople for the FBI and Preet Bharara, the U.S. attorney in Manhattan, declined to comment. Jonathan Rosen, a lawyer for Philidor, didn't respond to requests for comment.

Prosecutors are examining the actions of J. Michael Pearson, Valeant's former CEO, and Howard Schiller, the ex-CFO who became interim CEO during a medical leave by Pearson, according to the people, who discussed the confidential proceedings on the condition of anonymity. Prosecution of individual executives could go beyond just those two, one person said, adding that Philidor executives could also be charged.

While the precise contours of the government's case against Valeant aren't clear, allegations of questionable company practices have emerged in the past year as lawsuits and government investigations mounted. Pearson, the former CEO, was a key architect of Valeant's growth over the years. He stepped down from his role last spring and continues to work as a consultant to the company from a Valeant office near his home, according to the people familiar with the matter. Schiller was blamed by Valeant for "improper conduct" that led the company to restate its earnings for 2014 and 2015, an assertion disputed by Schiller. He stepped down as CFO in 2015 and left the company board this year.

U.S. prosecutors in Boston and Philadelphia are also said to be conducting separate inquiries of Valeant. Boston's investigation, according to a person familiar with the matter, focuses on Valeant's payments to charities that then helped patients make co-payments for the soaring cost of Valeant drugs, some of the most expensive on the market. The Philadelphia case is examining Valeant's billing of government health-care programs for the company's drugs, another person said. The U.S. Attorney's Office in Boston didn't respond to a request for comment. Michele Mucellin, a spokesperson for the U.S. attorney in Philadelphia, declined to comment. Valeant said in October 2015 that federal prosecutors in New York had issued subpoenas seeking information on the company's drug distribution and pricing decisions. It later disclosed an investigation by the SEC. Judy Burns, an SEC spokesperson, declined to comment. Short-sellers first raised questions about Valeant's accounting practices and relationship with Philidor a year ago. As it turned out, Valeant had offered Philidor executives tens of millions of dollars in incentives to sell its products at a time when the relationship between the companies was still secret, according to hundreds of pages of evidence released by U.S. Senate investigators this year. Though they were nominally separate companies, Valeant was Philidor's only client, a class-action lawsuit in New Jersey alleges. Valeant ultimately acknowledged its financial control of Philidor.

In February, Valeant restated its results for 2014 and 2015, disclosing it recorded $58 million in revenue from Philidor earlier than it should have.

While the access agenda has been the central focal point of the 2004 health accord, it is time to have the 2014 health accord focus on quality, of which access is one important dimension, with the others being effectiveness, safety, efficiency, appropriateness, provider competence and acceptability.

we also propose three specific funds that are strategically focused in areas that can contribute to improved access and wait time

Can the 2014 health accord act as a catalyst to ensure appropriate post-hospital supportive and preventive care strategies, facilitate integration of primary health care with the rest of the health care system and enable innovative approaches to health care delivery? Is there an opportunity to move forward with new models of primary health care that focus on personal accountability for health, encouraging citizens to work in partnership with their primary care providers and thereby alleviating some of the stress on emergency departments?

one in five hospital beds are being occupied by those who do not require hospital care — these are known as alternative level of care patients, or ALC patients

the creation of an issue-specific strategically targeted fund designed to move beyond pilot projects and accelerate the creation of primary health care teams — for example, team-based primary health care funds could be established — and the creation of an infrastructure fund, which we call a community-based health infrastructure fund to assist in the development of post-hospital care capacity, coupled with tax policies designed to defray expenses associated with home care

consider establishing a national health innovation fund, of which one of its stated objectives would be to promote the sharing of applied health system innovations across the country with the goal of improving the delivery of quality health services. This concept would be closely aligned with the work of the Canadian Institutes of Health Research in developing a strategy on patient oriented research.

focus the discussion on what is needed to ensure that Canada is a high performing system with an unshakable focus on quality

of the Wait Time Alliance

Dr. Simpson

the commitment of governments to improve timely access to care is far from being fulfilled. Canadians are still waiting too long to access necessary medical care.

Table 1 of our 2011 report card shows how provinces have performed in addressing wait times in the 10-year plan's five priority areas. Of note is the fact that we found no overall change in letter grades this year over last.

The WTA has developed benchmarks and targets for an additional seven specialties and uses them to grade progress.

the lack of attention given to timely access to care beyond the initial five priority areas

all indications are that wait times for most specialty areas beyond the five priority areas are well beyond the WTA benchmarks

we are somewhat encouraged by the progress towards standardized measuring and public reporting on wait times

how the wait times agenda could be supported by a new health accord

governments must improve timely access to care beyond the initial five priority areas, as a start, by adopting benchmarks for all areas of specialty care

look at the total wait time experience

The measurements we use now do not include the time it takes to see a family physician

a patient charter with access commitments

Efficiency strategies, such as the use of referral guidelines and computerized clinical support systems, can contribute significantly to improving access

In Ontario, for example, ALC patients occupy one in six hospital beds

Our biggest fear is government complacency in the mistaken belief that wait times in Canada largely have been addressed. It is time for our country to catch up to the other OECD countries with universal, publicly funded health care systems that have much timelier access to medical care than we do.

The progress that has been made varies by province and by region within provinces.

Dr. Michael Schull, Senior Scientist, Institute for Clinical Evaluative Sciences

Many provinces in Canada, and Ontario in particular, have made progress since the 2004 health accord following large investments in health system performance that targeted the following: linking more people with family doctors; organizational changes in primary care, such as the creation of inter-professional teams and important changes to remuneration models for physicians, for example, having a roster of patients; access to select key procedures like total hip replacement and better access to diagnostic tests like computer tomography. As well, we have seen progress in reducing waiting times in emergency departments in some jurisdictions in Canada and improving access to community-based alternatives like home care for seniors in place of long-term care. These have been achieved through new investments such as pay for performance incentives and policy change. They have had some important successes, but the work is incomplete.

Examples of the ongoing challenges that we face include substantial proportions of the population who do not have easy access to a family doctor when needed, even if they have a family doctor; little progress on improving rates of eligible patients receiving important preventive care measures such as pap smears and mammograms; continued high utilization of emergency departments and walk-in clinics compared to other countries; long waits, which remain a problem for many types of care. For example, in emergency departments, long waits have been shown to result in poor patient experience and increased risk of adverse outcomes, including deaths.

Another example is unclear accountability and antiquated mechanisms to ensure smooth transitions in care between providers and provider organizations. An example of a care transition problem is the frequent lack of adequate follow-up with a family doctor or a specialist after an emergency department visit because of exacerbation of a chronic disease.

A similar problem exists following discharge from hospital.

Poorly integrated and coordinated care leads to readmission to hospital

This happens despite having tools to predict which patients are at higher risk and could benefit from more intensive follow-up.

Perverse incentives and disincentives exist, such as no adjustment in primary care remuneration to care for the sickest patients, thereby disincenting doctors to roster patients with chronic illnesses.

Critical reforms needed to achieve health system integration include governance, information enablers and incentives.

we need an engaged federal government investing in the development and implementation of a national health system integration agenda

complete absence of any mention of Canada as a place where innovative health system reform was happening

Dr. Brian Postl, Dean of Medicine, University of Manitoba, as an individual

the five key areas of interest were hips and knees, radiology, cancer care, cataracts and cardiac

no one is quite sure where those five areas came from

There was no scientific base or evidence to support any of the benchmarks that were put in place.

I think there is much less than meets the eye when we talk about what appropriate benchmarks are.

The one issue that was added was hip fractures in the process, not just hip and knee replacement.

in some areas, when wait-lists were centralized and grasped systematically, the list was reduced by 30 per cent by the act of going through it with any rigour

When we started, wait-lists were used by most physicians as evidence that they were best of breed

That continues, not in all areas, but in many areas, to be a key issue.

The capacity of physicians to give up waiting lists into more of a pool was difficult because they saw it very much, understandably, as their future income.

There were almost no efforts in the country at the time to use basic queuing theory

We made a series of recommendations, including much more work on the research about benchmarks. Can we actually define a legitimate benchmark where, if missed, the evidence would be that morbidity or mortality is increasing? There remains very little work done in that area, and that becomes a major problem in moving forward into other benchmarks.

the whole process needed to be much more multidisciplinary in its focus and nature, much more team-based

the issue of appropriateness

Some research suggests the number of cataracts being performed in some jurisdictions is way beyond what would be expected to be needed

the accord did a very good job with what we do, but a much poorer job around how we do it

the accord has bought a large amount of volume and a little bit of change. I think any future accords need to lever any purchase of volume or anything else with some capacity to purchase change.

We have seen volumes increase substantially across all provinces, without major detriment to other surgical or health care areas. I think it is a mediocre performance. Volume has increased, but we have not changed how we do business very much. I think that has to be the focus of any future change.

It is at these transition points, between the emergency room and being admitted to hospital or back to the family physician, where the efficiencies are lost and where the expectations are not met. That is where medical errors are generated. The target for improvement is at these transitions of care.

I am not saying to turn off the tap.

the government has announced, for example, a 6 per cent increase over the next two or three years. Is that a sufficient financial framework to deal with?

Canada currently spends about the same amount as OECD countries

Many of our physicians are saying these five are not the most important anymore.

they are not our top five priority areas anymore and frankly never were

this group of surgeons became wealthy in a short period of time because of the $5.5 billion being spent, and the envy that caused in every other surgical group escalated the costs of paying physicians because they all went back to the market saying, "You have left us out," and that became the focus of negotiation and the next fee settlements across the country. It was an unintended consequence but a very real one.

if the focus were to shift more towards system integration and accountability, I believe we are not going to lose the focus on wait times. We have seen in some jurisdictions, like Ontario, that the attention to wait times has gone beyond those top five.

people in hospital beds who do not need to be there, because a hospital bed is so expensive compared to the alternatives

There has been a huge infusion of funds and nursing home beds in Ontario, Nova Scotia and many places.

Ontario is leading the way here with their home first program

There is a need for some nursing home beds, but I think our attention needs to switch to the community resources

they wind up coming to the emergency room for lack of anywhere else to go. We then admit them to hospital to get the test faster. The weekend goes by, and they are in bed. No one is getting them up because the physiotherapists are not working on the weekend. Before you know it, this person who is just functioning on the edge is now institutionalized. We have done this to them. Then they get C. difficile and, before you know, it is a one-way trip and they become ALC.

I was on the Kirby committee when we studied the health care system, and Canadians were not nearly as open to changes at that time as I think they are in 2011.

One thing I heard on the Aging Committee was that we should really have in place something like the Veterans Independence Program

some people just need someone to make a meal or, as someone mentioned earlier, shovel the driveway or mow the lawn, housekeeping types of things

I think the risks of trying to tie every change into innovation, if we know the change needs to happen — and there is lots of evidence to support it — it stops being an innovation at that point and it really is a change. The more we pretend everything is an innovation, the more we start pilot projects we test in one or two places and they stay as pilot projects.

the PATH program. It is meant to be palliative and therapeutic harmonization

has been wildly successful and has cut down incredibly on lengths of stay and inappropriate care

Where you see patient safety issues come to bear is often in transition points

When you are not patient focused, you are moving patients as entities, not as patients, between units, between activities or between functions. If we focus on the patient in that movement, in that journey they have through the health system, patient safety starts improving very dramatically.

If you require a lot of home care that is where the gap is

in terms of emergency room wait times, Quebec is certainly among the worst

Ontario has been quite successful over the past few years in terms of emergency wait times. Ontario’s target is that, on average, 90 per cent of patients with serious problems spend a maximum of eight hours in the emergency room.

One of the real opportunities, building up to the accord, are for governments to define the six or ten or twelve questions they want answered, and then ensure that research is done so that when we head into an accord, there is evidence to support potential change, that we actually have some ideas of what will work in moving forward future changes.

We are all trained in silos and then expected to work together after we are done training. We are now starting to train them together too.

The physician does not work for you. The physician does not work for the health system. The physician is a private practitioner who bills directly to the health care system. He does not work for the CEO of the hospital or for the local health region. Therefore, your control and the levers you have with that individual are limited.

the customer is always right, the person who is getting the health care

It is refreshing to hear something other than the usual "we need more money, we absolutely need more money for that". Without denying the fact that, since the population and the demographics are going to require it, we have to continue making significant investments in health, I think we have to be realistic and come up with new ways of doing things.

How do you help patients navigate a system that is so complex? How do you coordinate appointments, ensure the appointments are necessary and make sure that the consultants are communicating with each other so one is not taking care of the renal problem and the other the cardiac problem, but they are not communicating about the patient? That is frankly a frequent issue in the health system.

There may be a patient who requires Test Y, X, and Z, and most patients require that package. It is possible to create a one-stop shop kind of model for patient convenience and to shorten overall wait times for a lot of patients that we do not see. There are some who are very complicated and who have to be navigated through the system. This is where patient navigators can perhaps assist.

There have been some good studies that have looked at CT and MRI utilization in Ontario and have found there are substantial portions where at least the decision to initiate the test was questionable, if not inappropriate, by virtue of the fact that the results are normal, it was a repeat of prior tests that have already been done or the clinical indication was not there.

Designing a system to implement gates, so to speak, so that you only perform tests when appropriate, is a challenge. We know that in some instances those sorts of systems, where you are dealing with limited access to, say, CT, and so someone has to review the requisition and decide on its appropriateness, actually acts as a further obstacle and can delay what are important tests.

In 2007-2008, 5% of hospitalizations (N = 74,504) and 14% of hospital days (N = 1.7 million) involved ALC patients. The provincial range for ALC hospitalizations was 2-7% of all hospitalizations (Figure 1).

LC patients were also more than twice as likely to have a comorbid condition as measured by the Charlson Comorbidity Index (Sundararajan et al. 2004). Dementia, as a main or comorbid diagnosis, accounted for almost one quarter of ALC hospitalizations and more than one third of ALC days.

Patients with dementia as a main diagnosis had a median ALC length of stay of 23 days compared with 10 days for ALC patients overall.

Total 26 4

Overall, the predominant discharge destination (43%) was to a long-term care facility (Figure 3).

ALC portion 10 -

Acute portion 11 4

More than one quarter of ALC patients were discharged home. Seventeen (17%) percent of these patients were readmitted to hospital within 30 days.

This compares to 12% for non-ALC patients discharged home.

Of the 12% who died during their ALC hospitalization, 42% were receiving palliative care and 45% were awaiting admission to another facility.

This issue of ALC is a sizeable challenge for hospitals and health system managers in Canada, with over 1.7 million hospital days used for ALC outside of Manitoba and Quebec in 2007-2008.

ALC patients were older and had diagnostic, comorbidity and length-of-stay profiles that indicate complex follow-up care requirements.

The reasons for provincial and facility variations in the number of ALC patients and days are not well understood.

However, ALC variation may also arise from differences in documentation and data collection.

Patient Pathway: Transfers from Continuing Care to Acute Care. found that new long-term care admissions accounted for most of the ALC waits for long-term care beds

Still, the aging of Canada’s population has a surprisingly modest overall impact on health care budgets, contributing a mere 0.9% to total spending growth.

Overall, Canada spends $5948 annually on health care for each citizen, up 2.2% from 2011.

In terms of the split between health care paid for through taxes, or directly out of consumer pockets, public funds account for about 70% of the money spent on health care in Canada. In turn, hospitals and physician payments account for most of that money. Payments for drugs and nonphysician services account for the bulk of direct consumer spending.

Though the growth of private sector outlays (4.6%) in 2012 is expected to outpace that of the public sector (2.9%), the public–private ratio has been stable for some time.

Canada's median age is now about 40, and heading upward. It was 26 in 1971. The median age could be worse; it's 46 in Germany and higher still in Japan. The total fertility rate (TFR) is about 1.6 children per woman. Population replacement rate is two per woman. As a result, and even after accounting for immigration, the annual population growth rate for the next half-century will be the lowest in Canadian history. More seniors means fewer people in the labour force, even if a few seniors keep working into their late 60s. The ratio therefore between those in the work force and those outside of it will change dramatically over time. What used to be a 5-to-1 ratio will slip to something like 2.5 to 1.

Both the federal Department of Finance and the Parliamentary Budget Office have alerted us to what lies ahead: Economic growth will be slower, the burden of expenditures on government for seniors programs will increase and government revenues will be stretched. It's arithmetic, not politics. The arithmetic of aging is politically uncomfortable. It's especially uncomfortable for provinces, the level of government that delivers labour-intensive services such as health, education, policing and welfare. The provinces' burden will also rise because, unless a new federal government changes the decision, Ottawa's yearly transfers to provinces for health care will increase less rapidly past 2017. The result will be a hole of some billions of dollars. Aging with its higher costs and lower growth is the context by which the electoral promises of every party might usefully be judged. They are all catering to today's middle class, fighting over which cares the most about their "anxieties." And they are fixated on seniors, too, since seniors vote.

You could say that the NDP daycare promise is future-oriented, in that if fully implemented it would encourage more women to work, which in turn would ease the ratio of those adults working to those who are not. It might up the fertility rate, which would help, as it has in Quebec. You could say that the Conservatives' decision to raise the age level for receipt of the Old Age Supplement to 67 from 65 recognizes that people are living much longer than when the OAS was implemented. (Women in the next decade are expected to have a life expectancy of 87.) All parties pledge to stoke up the engines of economic growth: in the NDP's case by lowering the small-business tax rate by two points. Except the party then proposes to raise the tax for large companies by two points, an impediment to creating more large companies of the kind Canada needs in a global economy.

Pledges to increase manufacturing are not worth much, since manufacturing has been more or less in decline in North America and Europe (except Germany) for a long time, for reasons rather outside the capacity of governments to influence, except by subsidies and other forms of direct or indirect help. Promises predictably have been pouring forth from every party, without any of them yet providing some sort of overall accounting for how they will be financed. Even when (if?) this accounting is provided, the chances are excellent it will be based on falsely optimistic assumptions about economic growth and the revenues it will provide. The demographic shift now beginning will likely mock those assumptions.

Perhaps the Central East Local Health Integration Network should also be questioned, Brady said. "That's their job. To make sure money is being spent properly." Part of the Canadian Health Coalition, the local health coalition aims to preserve Canada's medicare system and promote universal public health care.

Agriculture, Food and Rural Affairs Minister and Peterborough MPP Jeff Leal had just returned to the city late Wednesday afternoon when he learned of the news from the hospital. "It is a re-calibration of their financial statements involving a significant amount of money and the process will be ongoing," Leal said.

Figures compiled in CIHI’s database over 40 years show the share spent on physicians hit an all-time high in 1988, then slowly declined until 2007, when it turned around, growing at about 2.2% annually. It now accounts for 15.5%, comparable to levels seen in the late 1980s. Hospital spending has decreased from 45% of total health spending in the mid-1970s to just under 30% today, whereas drug spending has been increasing since the mid-1980s to account for just under 16% of spending.

“The guild has done a great job of protecting our income,” Dr. David Naylor said, referring to medical associations’ success in negotiations with governments. “But wouldn’t you expect [the share of spending on physicians] to drop a little?” Naylor, past president of the University of Toronto and chair of the Advisory Panel on Healthcare Innovation, spoke at a panel discussion on the CIHI findings, held Oct. 29 in Ottawa.

He said the “constancy of focus on doctors, drugs and hospitals … speaks to the stasis in the system. If anything, it’s in a state of arrested development.” While overall health spending has gone up in dollar terms, amounting to $6105 per capita in 2015, it has declined as a proportion of gross domestic product (GDP). After the 2008–2009 recession, health spending fell from 11.6% of to an estimated 10.9% of GDP today. When inflation and population growth are taken into account, health spending also shows a decline.

The first half of this movie seems similar to what happened in the 1990s,” said Don Drummond, an economist at Queen’s University. He said that in the 1990s, government austerity led to a decline in health spending, but a return to a good economy resulted in health spending growing “much faster than economic growth.”

In regard to the similar spending decline after 2011, Drummond asked “did we create efficiencies or just cut off the money and create pressure?” Drummond and Naylor clearly think that efficiencies are lacking. The solution, said Naylor, is integrating services, including home care and virtual care. “There’s not a single province that has taken steps in that direction.”

CMA President Cindy Forbes agreed. “We need integrated, appropriate and high-quality care.” She gave the example of a patient in an acute care hospital discharged to community care and later moving to palliative care. “The patient goes through three different systems. They all have their own budgets and caregivers. These silos have to be broken down so it’s one system.”

She stressed the need for a national seniors’ strategy to address a population that is aging and living longer, often with complex, multiple diseases. Integrated services could address the patients needing an alternative level of care who currently occupy 20% of beds in acute care hospitals, she said. “They are not ‘bed blockers,’” she said. “They are waiting for long-term or home care.”

Naylor also thinks changing the way physicians are paid is part of the solution. “The fee schedule is full of perverse incentives. It doesn’t create ‘integrative quarterbacks.’ There should be rewards for good prescribing and shorter hospital stays.”

Wide variations in the price tag for health care among provinces and territories also stood out in the data. Costs in Canada’s provinces range from $5665 per person per year in Quebec to $7036 in Newfoundland and Labrador. (In the territories, costs are much higher.) Seven provinces devote more than 40% of their budget to health, of which two devote more than 45%.

Demographics and geography account for some of the variation, according to Brent Diverty, CIHI’s vice-president of programs, especially costs to transport critical cases from remote areas. However, panellists expressed concern about inequalities in quality of care and access.

“People who are covered for a drug in one province are not covered in another,” pointed out Forbes. “Especially cancer drugs, which are expensive.”

Naylor added, “There’s a huge challenge for the [federal/provincial/territorial ministers] to understand this variation. We need to unbundle why these disparities occur. How do we get to a common higher ground as Canadians?”

Just now in Ontario this arrangement would appear to have hit a wall. Having negotiated a four-year deal offering average annual fee increases of 2.5 per cent, the Ontario Medical Association executive was dismayed to find it rejected by nearly two-thirds of its members, who complain it does not make up for cuts in fees imposed last year. How things should have broken down to this extent need not detain us here. But it does perhaps point to the need to find another way.

Because doctors' fees, as such, are not the issue. To be sure, they are part of the puzzle: at $11.5 billion annually, they are roughly one-fifth of Ontario's health-care budget. But all the hard bargaining in the world isn't going to rescue Canada's health-care system from the fiscal cliff to which it is headed. Much more important than doctors' fees are doctors' decisions, as the gatekeepers dictating how resources are allocated within the system: how many tests are ordered, what procedures are done, and so on.

The problem is that decisions about treatment are too often divorced from decisions about budgets. Governments set a budget constraint at the macro level, which filters down through the various regional health authorities and local health networks the provinces have seen fit to establish. But doctors typically do not: they make whatever they can bill. And the incentives of feefor-service are to perform as many surgeries and other treatments as they can. Absent changes in those incentives, simply capping fees isn't going to change much.

You can see why doctors felt the need to organize. Governments had set themselves up as sole purchasers of medical services. The idea was supposed to be that they could exploit that monopoly power to drive down costs. But it didn't quite work out that way: politicians in need of re-election, it seems, do not make terribly tough negotiators (who knew?). It was always easier to pass the problem on to the next government, or the next generation - or, as federal governments got in on the act, Ottawa. In consequence, health-care spending skyrocketed through much of the 1970s and 1980s.

Traditionally, doctors have been paid per service, while hospitals have been funded on a block grant basis. The key to reform is to turn this around: giving groups of doctors a fixed amount per patient, with which to purchase services from hospitals, clinics and other providers, that is on a per-treatment basis. Paying doctors a lump sum localizes the budget constraint, forcing doctors to take account of costs in decisions on treatment; paying hospitals per service makes it possible for lower-cost competitors to undercut them.

Even in the more recent wave of cuts following the last recession, these have been largely untouched. As documented in a new study by the C. D. Howe Institute

("Hold the Applause: Why Provincial Restraint on Healthcare Spending Might Not Last"), governments have largely resorted to the familiar public-sector strategy of starving the capital account to feed the operating account: while capital spending has been sharply curtailed, physicians' fees have not.

This is not sustainable in the long run - as new doctors enter the profession, and most of all, as the population ages. As it is, provinces are now spending more than 40 per cent of their budgets on health care; by 2030, a recent Fraser Institute paper projects the number will have risen to nearly 50 per cent. Yet wait times continue to mount: at more than 18 weeks, on average, from GP referral to treatment, they are nearly twice what they were 20 years ago.

Clearly the answer does not lie in more money, least of all more federal money: for every additional dollar in federal transfers the Howe study's authors find that provincial health spending increases by 36 cents. But neither is the answer ever stricter doses of austerity - any more than one would improve a car's mileage by putting less gas in the tank. Rather, what's needed is systemic reform, altering the way that public funds flow through the system, and how the different players within it are remunerated.

Only with the onset of the early 1990s recession, and particularly the sharp cut in federal transfers as Ottawa tried to stabilize its finances, was there the first serious effort at retrenchment. But as the fiscal crisis eased, and particularly after the 2004 health-care accord, with its massive 10-year increase in federal transfers, whatever impetus for reform there might have been dissipated. Rather than "buying change," most of the new money went to increases in provider compensation.

In sum, rather than doctors and governments negotiating with each other at one gigantic bargaining table, what we need are lots of little bargaining tables, at which providers can haggle with each other.

? full privatization: where a government enterprise is sold in full to private investors. ? publicly funded with services and management delivered privately, sometimes unknown to the consumer. ? public funding of private services: government provides vouchers to consumers for the purchase of goods and services from private providers.

? public/private partnerships (P3s): full outside contracting, management and service delivery of traditionally delivered public services such as hospitals, roads, schools and prisons. This can include private finance, design, building, operation and possibly temporary ownership of an asset. Can privatization deliver? After decades of experimentation with privatization in different forms across Canada, the data is clear on the failure to deliver on its promises and the high cost society pays - multiple costs, not only in economic terms but also quality and access to services, quality and quantity of jobs, as well as transparency and accountability.

Public/private partnerships (P3s) are the fastest-growing model of privatization in Canada. The P3 models vary but all include the reliance on private sector borrowing to finance the development of public infrastructure projects in a long-term lease arrangement; it is effectively leasing rather than owning and sometimes that lease includes maintenance as well. P3s cost more. Governments have always been able to borrow money more cheaply than private corporations. According to a University of Toronto study of 28 P3 projects in Ontario, P3s cost, on average, 16 per cent more than a traditional public contract. A recent auditor general of Ontario report found that P3 projects cost the province $8 billion more than if they were done under the traditional model.

If they cost more, why do politicians promote them? Political expediency - in P3 lease agreements the debt stays off the books or is postponed for decades. P3s hide debt - which is a dream for politicians looking for easy wins in hard economic times. It is also ideological and it is about private sector lobbying and influence. Public services are a boon to private sector deliverers with guaranteed public payments and profit margins over the long term. Supporters of privatization claim that it leads to better pricing for the public as consumers. A comparison of privately owned Manitoba Telecom Services, privatized in 1997, to SaskTel, Saskatchewan's publicly owned telecommunications crown corporation shows this to not be true. Twenty years after privatization of MTS, the cost of a basic phone with SaskTel is $8 less per month than from MTS.

Private corporations demand a shroud of confidentiality in order to protect their competitive position. This means that privatization reduces both transparency and accountability. An example of this is the Ontario privatization of municipal water testing which has been linked to the May 2000 bacterial contamination of municipal water in Walkerton, Ont., led to the deaths of at least seven people and the serious illness of 2,300 more from water contaminated with E. coli. The absence of criteria governing quality of testing, and the lack of provisions made for notification of results to authorities contributed to the worst public health disaster involving municipal water in Canadian history.

Health care is a sector where there is huge pressure on government to control cost, particularly in Newfoundland and Labrador with the aging demographic. Private interests see great profit opportunities. But in health care, for-profit does not deliver. In Manitoba, living in a for-profit long-term care facility increased the odds of dying in hospital or being hospitalized.

In a metadata analysis of hospitals in the U.S., Dr. Philip Devereaux, a cardiologist at McMaster University, concluded that the death rate in for-profit hospitals was two per cent higher than in not-for-profit facilities. In Alberta, the Health Quality Council of Alberta's Long Term Care Family Experience Survey in 2012 found that, on average, private and volunteer operated facilities offered poorer quality in terms of staffing levels, care of residents' belongings, and assistance with daily living activities such as toileting, drinking and eating, than publicly operated ones.

The scathing Ontario auditor general report indicates that there needs to be extensive and comprehensive reviews of provincial privatization projects. Until proper cost-benefit analyses and public reviews and reform of private funding and procurement models occur, governments and public bodies should place moratoria on further public-private infrastructure contracts. The citizens pay either way, but they pay more in a privatized model - either as tax payers or out of pocket.

The government has alternatives. The Newfoundland and Labrador Federation of Labour has published a number of reports and fact sheets on the progressive revenue options open to the provincial government. There are a variety of progressive revenue options open to municipalities as well. There are no silver bullets. It is time to stop stigmatizing government and public services and recognize them for what they are: the way we pool our resources to buy services cheaper, control costs, and maintain accountability for quality.

his should be a debate based on evidence, not ideology. Mary Shortall, president, Unifor Local 597

£7 an hour, receives an extra £1 an hour for a night shift and £2 an hour for weekends.

"The NHS encourages you to have these NVQs, all this training, improve your knowledge, and then they [private care companies] come along and it all comes to nothing.

Care UK expects to make a profit "of under 6%" by the end of the three-year contract

£700,000 operating profit in the six months between September last year and March this year,

In 1993 the private sector provided 5% of the state-funded services given to people in their homes, known as domiciliary care. By 2012 this had risen to 89% – largely driven by the local authorities' need for cheaper ways to deliver services and the private sector's assurance that they could provide the answer. More than £2.7bn is spent by the state on this type of care every year. Private providers have targeted wages as a way to slice out profits, de-skilling the sector in the process.

1.4 million care workers in England are unregulated by any professional body and less than 50% have completed a basic NVQ2 level qualification, with 30% apparently not even completing basic induction trainin

Today 8% of care homes are supplied by private equity-owned firms – and the number is growing. The same is true of 10% of services run for those with learning disabilities

William Laing

report on private equity in July 2012

"It makes pots of money.

Those profits – which are made before debt payments and overheads – don't appear on the bottom line of the health firms' company accounts, and because of that corporation tax isn't paid on them.

Some of that was in payments on loans issued in Guernsey, meaning tax could not be charged. Its sister company, Silver Sea, responsible for funding the construction of Care UK care homes, is domiciled in the tax haven of Luxembourg

Bridgepoint

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Underlying both reforms is a quiet resignation to the idea that two-tiered health care is inevitable. This sense of resignation is understandable, coming as it does on the heels of a decade-long void in federal leadership on health care. Throughout the Harper government's time in office, the Canada Health Act went substantially unenforced as private clinics popped up across the country. Even in its reduced role as a cheque-writer, the federal government took steps that undermined national unity on health care, switching the Canada Health Transfer to a strict per capita formula, which takes no account of a province's income level or health-care needs. If Canadians hope to reverse this trend, we cannot simply wage a rearguard battle for the enforcement of the Canada Health Act as it was enacted in 1984. Even if properly enforced, the act protects universal access only for medically necessary hospital and physician services. This is not the blueprint of a 21st-century public health-care system.

We desperately need universal coverage for a full array of health-care goods and services -- pharmaceuticals, mental-health services, home care and out-of-hospital diagnostics. Canada is unique among Organization for Economic Co-operation and Development countries in the paucity of what it covers on a universal basis despite falling in the top quartile of countries in levels of per capita health spending. Far from being our saviour, the Canada Health Act in its current incarnation is partly to blame -- not because of its restrictions on queue-jumping and private payment, but because it doesn't protect important modern needs, such as access to prescription drugs.

There are limits on what a public health system can provide, of course -- particularly as many provinces now spend nearly half of their budgets on health care. But fairness requires these limits be drawn on a reasoned basis, targeting public coverage at the most effective treatments. Under the current system, surgical removal of a bunion falls under universal coverage, while self-administered but life-saving insulin shots for diabetics do not. A modernized Canada Health Act would hold the provinces accountable for reasonable rationing decisions across the full spectrum of medically necessary care.

Instead of modernizing medicare, Saskatchewan and Quebec are looking to further privatize it. Experience to date suggests allowing two-tiered care will not alleviate wait times in the public system. Alberta has reversed course on its experiment with private-pay MRIs after the province's wait times surged to some of the longest in the country.

The current wisdom is long wait times are better addressed by reducing unnecessary tests. A 2013 study of two hospitals (one in Alberta, one in Ontario) found more than half of lower-back MRIs ordered were unnecessary. Skirmishes over privatization have to be fought, but they should not distract us from the bigger challenge of creating a modern and publicly accountable health system -- one that provides people the care they need, while avoiding unnecessary care.

Achieving that will make National Medicare Week a true cause for celebration. Bryan Thomas is a research associate and Colleen M. Flood is a professor at the University of Ottawa's Centre for Health Law, Policy and Ethics. Flood is also an adviser with EvidenceNetwork.ca.