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OECD country surveys are mainly put together by the OECD Economics Department with major input from the Canadian Department of Finance and the Bank of Canada. There is relatively little input from the social policy directorate at the OECD (DELSA) or social departments here

OECD messages tend to hue very closely to the neo liberal economic mainstream, and are tweaked by Finance to build support for desired policy shifts.

explicitly calls for cuts in health care (or at least very constrained growth of spending.)

The OECD report itself notes (p.137) that the Canadian system is the best in the OECD in terms of providing equitable access to physician and hospital services.

The report also notes (Fig. 3.6) that Medicare costs have not grown as a share of GDP since the early 1990s and are well in line with the costs of other national public health care systems.  It shows that it is in the private not the publicly insured part of our system that cost pressures have been greatest.

The OECD report similarly endorses more private delivery of hospital services

To its credit, the OECD report calls for the inclusion of pharmaceutical drugs and home care into the public part of the health care system

Between 1998 and 2011, the number of all types of hospital beds in Ontario remained “virtually constant at approximately 31,000” while the population increased by 16%, according to a 2011 Ontario Hospital Association document.

It may come as a surprise that despite these statistics, Ontario Hospital Association president Pat Campbell is not advocating for more hospital beds.

The United Kingdom and Australia consider an 85% acute care bed occupancy rate to be the safe upper limit, according to the OECD. But Campbell, who says the OECD’s figures on Canadian occupancy rates are probably accurate, is not interested in debating appropriate overall rates.

Rose says, for example, that occupancy rates in surgical critical care units, characterized by rapid turnover and short stays, should be about 75% to be efficient.

This kind of cooperation could also work when hospital crowding becomes excessive, for example when flu season hits, says Mike Tierney, vice-president for clinical programs at The Ottawa Hospital and one of the editors of Healthy Debate. What is needed is “an ability to look at hospital occupancy

and bed availability across a region in real time, rather than each hospital trying their best to manage on their own

Occupancy rates matter if you accept the premise that high rates lead to poor access for patients who need to be admitted from emergency departments, notes Michael Schull, an emergency room doctor at Sunnybrook who has published on wait times in emergency and overcrowding risks.

Still, Schull does not advocate for more hospital beds. “It would be a mistake to add beds to a dysfunctional system,” he says.

The sobering reality is that Ontario hospitals are tight for capacity largely because of the number of beds occupied by patients, most of them elderly, waiting for admission to another facility (such as rehabilitation or long-term care) or for support to return home.

Administrators at Health Sciences North in Ontario have discovered the benefit of very active cooperation between the 459 bed Ramsey Lake Health Centre (formerly the Sudbury Regional Hospital) and the local Community Care Access Centre (CCAC).

Working together, the result has been a reduction of ALC patients at the health centre from 133 to 78 in the period between September and December 2012, says David McNeil, vice president of clinical services and chief of nursing.

The challenge for the CCAC was to expand its capacity for community-based care, and some funding was received from the province for new programs including behavioural support and mobility programs. For its part, the hospital recruited a new geriatrician, gradually closed beds at the former Memorial Hospital site that had been used for ALC patients, and redirected money towards chronic disease management.

As well, community groups have been engaged “to help them understand that the hospital is no longer the centre of the universe,” McNeil says

Canadians appeared to experience higher rates of some hospital errors or adverse events, including trauma during delivery of babies

Canada has higher rates of foreign bodies being left in incisions after surgeries but that may be because Canada does a better job collecting adverse events data than some other countries

wait times to receive care were highest in Canada in an 11-country survey cited in the OECD report

While survival rates for breast cancer and colorectal cancer are among the highest in the OECD, the country has a relatively high rate of cancer compared to other countries, the CIHI report says.

As well, the country's self-reported obesity rate is the second-highest in the G7 countries.

lower smoking rates in Canada today may mean fewer lung cancer cases in the future — but some of this progress could be offset by higher obesity rates

The OECD report says Canada spent 11.4 per cent of its gross domestic product on health in 2009, more than the OECD average of 9.6 per cent. The United States spent the most, at 17.4 per cent of GDP, with the Netherlands, France and Germany spending slightly more than Canada.

Health spending per person in Canada was also higher than the OECD average. Canada spent $4,363 (U.S.) per person on health care in 2009; the OECD average was $3,233 (U.S.).

Canada is in or close to the top 25% of OECD countries on many measures of quality of care.

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

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

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

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

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

Sarah Gregory is a researcher in health policy at The King’s Fund.

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.

"Could be that it's complicated for low-income Canadians to take time off work or to find child care to see a physician?"

If nothing is done to transform the health care system, with the aging of the population this proportion will rise to 3.2 per cent by the year 2050.

This growth could be significantly reduced to 2.3 per cent if a sizable investment (e.g. 0.4 per cent of GDP or $5 billion) is made in home care now.

In the short term, a substantial return on investment (ROI) would be generated by keeping women in the work force and creating home care jobs in the public, private and social economy sectors. In the medium term, a further ROI would likely result from decreasing the use of hospital beds by patients waiting for nursing home beds and reducing the need for nursing homes.

home care should become a right and not a privilege as it is now

To achieve this, a public long-term care insurance plan should be created

to cover the necessary services from public (“in kind”), private, social economy or voluntary organizations

We should not opt for “cash-for-care” allowances as in some European countries since this type of benefit has undesirable effects: the creation of a “gray market” with untrained and underpaid workers, risk of financial abuse, poor quality services, and keeping women in traditional roles.

To finance this universal publicly funded insurance plan, a specific fund should be created to which the current budget for long-term care would be transferred to ensure a clear separation of this budget from the rest of the health care budget.

The fastest growing aspect of private health care insurance is for drugs, with premium inflation set at 12.1% this year.   That is down from 14% last year due reportedly to the implementation of government led generic drug pricing reform and the expiry of  patents for several major drugs.  Apparently, however, this will be offset in the future by the rise in expensive 'biologic' and specialty drugs.

One year after Dr. Parks’s letter was leaked, the government claims the ER wait times issue is under control.

Should we believe the hype?

In October 2010, local media published a leaked letter from the province’s chief emergency room doctor to Health & Wellness Minister Gene Zwozdesky and other government officials warning of “catastrophic collapse” if immediate action wasn’t taken. The letter was written by Dr. Paul Parks, president of the Alberta Medical Association Section of Emergency Medicine

Dr. Parks started to collect examples of substandard care and “adverse events” caused by overcrowding in the ER

When the letters and reports were eventually leaked to the media in 2010, they launched a firestorm.

It’s common to have five-plus EMS units and their medics tied up for hours while they wait for an ER stretcher to be freed up so that they can download their patient and get back on the streets

The situation has gotten so out of hand that we now have patients calling 9-1-1 from the ER

ER was overcrowded because hospitals were overcrowded

A study in the British Medical Journal found that patients whose ER wait times were six hours or longer were more likely to suffer an “adverse event,” such as the need for hospital admission, or even death.

Dr. Parks estimates that Alberta’s large-volume hospitals are still hovering at around 30 per cent of beds occupied by patients waiting to be admitted—meaning that those hospitals are still operating at well over capacity.

Dr. Parks, ER doctors were clear from the beginning of this crisis that the issue of overcrowding in emergency was due to downstream capacity problems, mostly a lack of long-term-care beds in nursing homes.

despite our vast wealth, Alberta has fewer hospital beds than the Canadian average.

The same situation exists for long-term care, where Alberta’s number of beds per capita falls below the national average. But don’t think the province makes up for this by supporting those folks in their homes. Alberta also sits close to the bottom of provinces for home-care spending.

the government opened 360 new hospital beds in Edmonton and Calgary in 2011. It announced plans to open 5,300 new long-term care beds by 2015 (1,174 of them were ready by April 2011), to make additional investments in home care (800 new clients in Edmonton and Calgary) and to improve patient discharge planning. It also announced a five-year plan that includes a primary-care focus

But there’s no plan to increase full long-term care, nursing homes and auxiliary hospitals. This is the category of care that is most needed to take pressure off our hospitals

He also says that even if beds are created, they may not match the needs of hospitalized patients, because of the lower levels of nursing support and the high personal cost for the patient and his family. “Indications are that the private, for-profit care model may actually create barriers to moving patients out of hospital beds,” he says.

preferred provider networks, mandatory generic substitution, agreements between pharmacies and insurers (which stipulate that a pharmacy will lower its costs for the clients of a certain insurer if that insurer directs its clients to the pharmacy in question), and step therapy (which requires plan members to try certain drugs first before switching to more costly medications). Add to that the new high-cost drug pooling agreement for fully insured plans—which shelters firms from the full expense of any high-cost and recurring drug claims—and it’s clear that the pace of change in the insurance market has been unprecedented.

The overall mission of the PMPRB needs to change so that it strives for the lowest possible prescription drug prices for all Canadians.

one that recognizes and rewards truly breakthrough drugs

Stephen Frank is vice-president, policy development and health, with the Canadian Life and Health Insurance Association. sfrank@clhia.ca

Insurance companies would like us to believe private health care is preferable. They would like a bigger chunk of the action à la Obamacare in the U.S., where tax dollars flow to health-insurance companies. Private health companies would like us to believe profit pays. And, of course, some wealthy individuals would like to buy their way into first-class care without the annoying wait times and the indignity of being treated like everyone else. The woman with a coffee jones and high anxiety over her husband's stay in post-op was mollified quickly enough. They found him a bed at the Civic campus in a few hours.

Had she been in the U.S. her husband's surgeries could have cost her as much as $500,000 - brain surgery runs anywhere from $75,000 to $125,000 not counting the extras like doctors' fees and hospital stays and convalescence. If she had insurance, there's a good chance a U.S. health-insurance provider would have dropped her long ago. Most of us have had friends or family that have been through the heart bypass or hip-replacement mill. They have survived. They have better lives. They waited, sometimes painfully long, but came out the other end without declaring bankruptcy or selling their homes.

Polls show Prime Minister Stephen Harper's popularity circling the drain as he talks about pipelines and the economy and getting tough on crime. Voters are thinking the crime is his lack of interest in their health and well-being. No, our system is not perfect. Wait times can be long if you're not knocking on heaven's door. The Fraser Institute wants us to know we pay too much - according to their figures a family of four earning about $110,000 pays about $11,000 of their taxes toward health care. If there's an underlying problem, it's our taking this massive system for granted and seeing only the faults. Canada's health care saves and improves lives without the attendant anxiety of how we will afford it. Yes, it can be better. It can use more money. It can be more efficient. But ask the people who have survived a crisis and were treated with dignity regardless of their bank balance, and they'll undoubtedly tell you it works pretty damned well. David Sherman is a Montreal writer and musician.

Although many Canadians complain about the cost of health care, it works much better than they think it does.

That means more than just finding new places for seniors to live: ¦¦ In Calgary, the tight job market driven by the oil boom has pushed the city to look for ways to keep more seniors employed, by retaining retired workers on short-term projects. And the share of those 65 and over is projected to double by 2042, so the city is also trying to rein in sprawl and increase the availability of transit, with an eye to making it easier for the elderly to reach social services. Cologne, Germany, started a program that lets students move in with seniors for free, in return for acting as caregivers. In Helsinki, an emphasis on keeping people in their homes for as long as possible, combined with an expected shortage of trained home-care staff, led to the development of floor-sensor systems that let nurses monitor seniors remotely. The OECD report shows that most developed cities face a variation of the same basic challenges: increasing the supply of affordable and accessible housing, making it easier for the elderly to get around safely and stay active, and finding ways to provide social services and other care for less money.