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The Alliance, a coalition of medical specialists, is calling on provincial and federal leaders to help fashion a "new national vision for health care," one that sets national benchmarks that go beyond the 2004 initiative that targeted five procedures: hip and knee replacements, cataract surgery, heart operations, diagnostic imaging and cancer radiotherapy.

We still don't measure nearly enough," said Dr. Chris Simpson, chair of the alliance and a former president of the Canadian Medical Association. "You can't fix what you can't measure."

At a time when more care is moving out of the hospital, Dr. Simpson said wait times for home care and long-term care beds should be monitored by all provinces, as should the number of patients in hospital because they cannot access these services.

When health ministers meet in January in Vancouver, Dr. Simpson said he hopes a partnership to establish such standards will be part of the discussion, rather than just the level of federal funding. "If we have made a collective mistake in the past, it is to say to the federal government, 'It's all up to you,' " he said.

The annual report card provides a snapshot of wait times across a range of measures gathered from provincially available information this summer. In doing so, it highlights the variation in the information available among provinces, and this year also notes that the federal government - responsible for delivering health care to First Nations, refugees, veterans, Canadian Forces and inmates in federal prisons - provides only limited data on its own performance.

The study, which gives a grade to provinces across a range of procedures, finds those provinces that got high marks last year - Saskatchewan, Ontario and Newfoundland and Labrador - continue to do well.

Both studies point to the success of Saskatchewan in cutting wait times as evidence of what can be done with a focused effort and both note that the improvement came from more than increased funding.

In five years, the number of patients in Saskatchewan waiting more than six months for surgery dropped by 96 per cent, the Alliance report card finds, thanks to a $176-million investment over four years and also because of innovative practices. Bacchus Barua, a senior economist at the Fraser Institute and author of its wait-time study, said measures such as a pooled referral system helped give Saskatchewan the shortest wait times in the survey.

The report from the Fraser Institute is based on a survey of specialists and tracks the time between the initial referral and the appointment with a specialist as well as the time between seeing a specialist and treatment. At the national level, it found the median wait time from referral to treatment was 18.3 weeks, almost the same as the 18.2 weeks recorded in 2014, but almost double the 9.3 weeks recorded in 1993 when the survey began.

Across Canada, wait times have stabilized, but they have stabilized at a very high level," Mr. Barua said

Saskatchewan had the shortest total wait at 13.6 weeks and Prince Edward Island had the longest at 43.1 weeks, although the small sample size in PEI makes that result less reliable. Among specialties, the longest waits were for orthopedic surgery at 35.7 weeks and the shortest were for patients in line for radiation oncology at 4.1 weeks, the study said.

On Tuesday he said whether Switzer collects the entire amount is unknown at this point, because the LHIN recently learned that Switzer was hired at the Alzheimer Society but hasn't learned how much he'll be paid. According to Switzer's contract, if he lands a job during the 23 months that pays at least 75 per cent of his former pay, the LHIN will pay out 50 per cent of the balance owed. If he makes less than 75 per cent, the LHIN owes him a lump sum equivalent to the balance owed, less statutory deductions. "So the amount he's going to get in terms of severance isn't determined yet," said Girash, who described the 22-month provision as "generous." But he explained it was part of Switzer's original contract from 10 years ago. Last year, when the LHIN board was negotiating a new contract for Switzer, members really wanted to get rid of some costly provisions, particularly a 14 per cent performance bonus. "We wanted to eliminate that, which we were successful in doing," said Girash.

He said to get that bonus provision eliminated, the board felt it had to agree to continue with the 22-month severance clause. "It looks big but it was, I think, a good stewardship of what we were dealing with from 10 years ago and moving to make it better," said Girash. "The 22 months is really almost a safety net if the individual can't get anything else, but obviously he has." The board agreed to the one-time $16,150 payment in 2015 during negotiations in order to eliminate the 14 per cent bonus clause, he said. Switzer started working at the Alzheimer Society on Aug. 15. Attempts to reach him Tuesday - to ask what he makes - were not successful. He was replaced at the LHIN on an interim basis by the second in command, Ralph Ganter, who remains the acting CEO. The LHIN is a planning agency that co-ordinates health care in the Windsor/Essex, Chatham-Kent and Sarnia-Lambton region. It's responsible for almost 100 different agencies - including hospitals - doling out more than $1 billion annually in Ministry of Health funding. Girash wouldn't say what Ganter makes but indicated it's less than what Switzer made, and because Ganter's old job hasn't been filled, the actual cost of Switzer's termination amounts to the topup Ganter receives. Ganter made $201,920.69 in 2015 when he was senior director at the LHIN. Girash said the board isn't going to decide on a permanent CEO at this time because the LHIN is in the midst of planning for big changes expected when the Ontario government passes its Patients First legislation. Patients First would see LHINs take on big new roles, including co-ordinating primary care (family doctors) and home care.

It's very, very demanding and takes a lot of stafftime, a lot of board time," said Girash. "So it wouldn't be fair to lay on top of everyone a recruiting process." bcross@postmedia.com twitter.com/winstarcross © 2016 Postmedia Network Inc. All rights reserved. Illustration: • Nick Brancaccio, Files / Former LHIN CEO Gary Switzer, right, sits on a panel with David Musyj, Dave Cooke and Janice Kaffer at a hospital town hall meeting in November 2015. Switzer was terminated in May. His severance of more than $500,000 is being described as "one hell of a golden parachute."

Either British Columbians are rapidly becoming much sicker, or this increase in prevalence is a reflection of what Welch and colleagues describe as “looking harder” and “changing the rules.”

about one-third of the increasing cost of testing is related to physician adherence to guidelines

patients now often request particular tests

Earlier diagnoses and more aggressive treatments appeal to our self-definition as fighters of illness—and we all shudder at the successful lawsuit against the physician who did not screen

we use them as therapy of a sort, giving hope to the patient that we will find an explanation for the symptoms instead of admitting that we do not know and might never know the exact cause of the problem

At the highest level, there needs to be a broader evaluation of guidelines. Such evaluation needs to have representation from policy thinkers and health economists in addition to family doctors, other specialists, patients, and the public.

the opportunity costs of deciding to implement widespread laboratory testing for healthy people, compared with adopting population-based policies, such as 24-hours-a-day, 7-days-a-week access to community recreation facilities and social housing, or free access to smoking cessation supports, should be debated.

Tests and repeat tests that are deemed to be of less benefit or not worth the opportunity-cost trade-off should be delisted.

Yet there is no guarantee that a hiring blitz will improve things, particularly because hospitals are releasing elderly patients faster than ever.

This is why Halifax, and its Extended Care Paramedic (ECP)Extended Care Paramedic (ECP) program, is so important.

Here, a paramedic — trained in the health needs of seniors — is assigned to a nursing home.

The presence of a paramedic onsite means that calls which once led to emergency rooms visits — falls, wounds and issues relating to palliative care are prime examples — are now dealt with at the nursing home

What is also important is that the ECP program has not required an extra infusion of money. Instead, the system was simply reorganized to give existing paramedics a new responsibility.

While impressive, this is only a pilot project, one that is based on a long-standing policy used in the United Kingdom, and the city of Sheffield in particular

The results proved so successful that an expanded program is now used throughout the U.K.

As a result, well over half of those seen are not sent to the emergency room or even the hospital.

And because of this, in the areas it is practised, ambulances are able to meet the U.K. standard call response time of eight minutes in the vast majority of cases. In Canada, nine minutes is the benchmark for cities but this is often missed.

As for costs, here, too, reorganizing the system rather than hiring a vast number of new staff has helped keep expenses in check. In fact, because emergency room and hospital admittances are down, money has actually been saved.

“Our focus is on expanding services being provided in the community through home care and by not-for-profit specialized clinics, contrary to what the OHC suggests,”

<bullet> 70 per cent of hospitals have seen increases (63 hospitals).

<bullet> About 81 per cent of hospitals have seen no more than a 1 per cent swing, up or down.

<bullet> The largest decrease that a hospital has received is 1.2 per cent and the largest increase is 2.8 per cent.

In smaller communities, the coalition says, the cuts range from 10 per cent to almost 50 per cent of existing hospital beds slated to be closed while in larger cities hospitals are reporting deficits of $20 million to $40 million.

"These are going to be very, very hard cuts to the hospital, but we have to do them to balance our books," said Dr. Robert Ting, president of the Scarborough Hospital's medical staff association. On Wednesday afternoon, staff at the hospital attended town hall meetings where they were told more cuts were coming. The hospital is looking at closing two operating rooms, a surgical wing with up to 20 beds and several outpatient clinics, including a rheumatology clinic for patients with arthritis. Earlier in the year, staff were told 98 positions were being eliminated.

Ontario

"The government's attempt to downplay their health-care cuts is demonstrably false. Hospital beds are being closed in significant numbers and these services are not being replaced in local communities," Mehra said.

But some insiders say the cuts are having a big impact. "People will notice for elective things. Things that are super-urgent will still get done, but non-urgent things like hernia repairs or gallbladder (surgeries) will definitely get pushed back," Ting said.

Matthews said the shift from hospital to community care, though bumpy, demonstrates the success of the transformation of Ontario's health system. "This is a deliberate strategy," she said.

Personal support workers in the home care sector can be paid as little as $12.50/hour compared to hourly rates of $18 to $23 for their hospital-based colleagues.

Similar disparities have also been observed for other care workers, including registered nurses.

In addition, home care workers often do not get steady hours

According to Stella Yeadon, a representative for the Canadian Union of Public Employees, this is largely because union organizing is very challenging in the home care sector. Unlike the hospital environment where workers are in a single building, home care workers rarely meet one another.

support for family caregivers was notably absent from both Ontario’s Action Plan for Healthcare and the year-one update released last month. Support for caregivers is part of Ontario’s new Seniors Strategy, but it remains to be seen how much of this strategy will translate into action.

According to a report from the Ontario Health Coalition, another contributor to lower wages is the Ontario government’s procurement policy for Community Care Access Centres (CCAC), which requires CCACs to contract out home care services. While competitive bidding for contracts has been somewhat successful in keeping costs down for CCACs, it has done so largely by “driving down wages,”

Low wages and limited benefits across an entire sector raise concerns about the possibility of recruiting skilled care workers. “

low wages could pose real barriers to recruiting and retaining staff.

Health care workers face substantial health risks as part of their work, due to their exposure to infectious diseases, violence from patients/residents with dementia, allergic reactions from chemical agents, and injuries resulting from lifting patients.

There is currently limited data on the occupational health risks of delivering care in the home. However, some care may be riskier in the home, where workers are more likely to be without either backup from other staff or mechanical assistance (such as patient lifts), as compared to workers in a hospital or a long-term care facility.

turnover as workers leave home care for higher paying jobs at hospitals is bad for patients

patients who need home care do not have families to care for them

there’s no one to care for them but me and they need more help.”

lower wages and riskier environments raise the possibility that the quality of care may be negatively affected as services are moved from hospital to community settings.

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.

Every year there has been an increase, but it's health care facilities and hospitals who make the decisions on how they're going to staff." "She is completely wrong," Hurley replied in a release. "Blame goes to her government's health policies and too low funding for hospitals. "Throwing hospital administrators under the bus for provincial government funding decisions is, in our view, unprincipled."

North Bay's hospital, built as a private-public partnership (P3) facility, is more expensive to operate than a typical hospital, Hurley said. During the 2003 election, the provincial Liberal's promised to cancel the North Bay P3 and to build the hospital as a publicly owned entity. "They reneged on that promise and yet have provided no special support for the significantly higher costs of this model. Now they are blaming them for cuts," said Hurley.

OCHU says successive Ontario Liberal health ministers have made no bones about downsizing hospital care. Since the Liberals were elected over a dozen years ago, funding for hospitals has fallen compared to other provinces. In the past several years, Ontario hospital funding "has lagged well behind the cost pressures associated with an aging population and inflation, OCHU says. This too low funding - well under the hospitals' real operating costs - has resulted in serious cuts to staff and services at North Bay and many other hospitals province-wide.

That's the root of blame for hospital staffing and program cuts," said Hurley. Provincial funding at its current levels has meant that in the past five years alone, North Bay has cut $20.7 million, OCHU says. The 2016 provincial budget gives hospitals a one per cent increase, it adds. However costs, driven by drugs and medical technologies will be closer to four per cent, "so another round of cuts is coming. It is completely unfair and below the premier to blame the managers of the hospital for this," said Hurley.

Wynne said the province is in the midst of a transformation of health care. "People want health care at home. People are looking for care for themselves and for their parents or grandparents. They want to know we are going to continue to invest in home care."

When asked what types of investment the province will commit to long-term care, Wynne acknowledged there are gaps in long-term care beds. "A review of the province's longterm care beds has been done by the Ministry of Health and Long-Term Care and decisions will be out soon." © 2016 Postmedia Network Inc. All rights reserved.

Kat Lanteigne, executive director for BloodWatch.org and writer of the play Tainted based on three-years of research about the tainted blood scandal, travelled to Alberta to help spread the message about concerns about private, donor-paid plasma collection. Lanteigne said these types of clinics had started to show up in Ontario in the last few years. "This is a big-pharma push," she said. "If they can build a clinic and get a licence from Health Canada then they can open without the province's permission." She said that the private sale and collection of blood and plasma introduces risk into the system. She also dispelled another myth that plasma is being imported into the country. She said that is not the case, as about 70 per cent of the drugs produced from plasma is what is being imported. When successful in the fight to get Ontario to legislate against private, donor-paid plasma collection at the end of 2014, and because Quebec has a similar law, Lanteigne said they made the mistake of thinking that because the largest provinces in Canada had done this, the rest of the provinces would follow suit.

Instead, as part of one of her first decisions, the new federal Liberal Health Minister approved CPR opening a clinic in Saskatchewan. Lanteigne says the Saskatchewan government, led by Premier Brad Wall, then approved the private, donor-paid plasma collection business to open in Saskatoon, "in between a pawn shop and a pay-day loan company." "This collection facility is a blood broker. They are literally a middle man Ñ a source to get profits. "We're asking the provinces and territories to pass voluntary blood donation acts which adds blood and plasma to their existing human tissue acts ..." Lanteigne explained. There is a lot of information on the BloodWatch.org website about the issue, including an informative timeline. The organization also has a Heart Watch rating system. Alberta currently has three hearts and Lanteigne would like to see that increase to five. "Saskatchewan has broken our hearts," she adds.

Kim Storebo, CUPE Local 46 president who works with Canadian Blood Services (CBS), also spoke at the event. She said CUPE supports a public, voluntary-based blood system in Canada, adding CBS needs to increase the number of its own plasma collection sites. The organization has been slowly closing locations since 2012. "There is no evidence the collection of plasma from paid donors will create self-sufficiency," she said. "Under no circumstances should there be payment of blood plasma donors with cash or cash-in-kind equivalents." The union wants to see blood and plasma collection remain the sole responsibility of Canadian Blood Services and for the organization to expand its plasma collection and its work hours and ensure stable and consistent hours for its employees. As part of the wrap-up of the Alberta tour officials with FOM, BloodWatch.org and CUPE presented an online SumOfUs petition with more than 15,000 signatures to provincial health minister Sarah Hoffman asking for all provincial governments to "implement legislation that ensures no for-profit, donor-paid blood plasma collection clinics are allowed to operate in Canada." Azocar assured those at the meetings that Friends of Medicare would continue to lobby the Alberta government this fall and next spring during the Legislature sittings.

However, until now no federal government has had the nerve to take on serial offender Quebec. Quebec has been allowing its doctors and clinics to charge extra user fees since 1979. The province's current health minister, Gaetan Barrette, freely acknowledges this. In some cases, these fees were truly exorbitant. The Montreal Gazette reported last year that some colonoscopy clinics were charging patients an extra $600 for medications - on top of the publicly paid medicare fee. Many Quebecers were outraged. The provincial Liberal government's somewhat peculiar response was to pass a bill codifying the practice of extra-billing but giving itself the authority to regulate it. In March 2015, the then-Conservative government in Ottawa formally notified Quebec that it would be looking into the issue. This March, Liberal Philpott sat down with Barrette to discuss the practice. On Sept. 6, she sent her provincial counterpart a letter threatening cutbacks to Quebec's health transfer. A few days later, Barrette announced that extra billing will end as of next January.

It is hard to gauge the importance of Philpott's threat. User fees have become widely unpopular in Quebec. That alone may have been enough to drive the provincial government to disavow them. Still, it was bracing to see a federal health minister publicly standing up for the principles of medicare. It is not an everyday occurrence. It is particularly interesting that she targeted a province that is notoriously touchy about what it sees as federal interference. Perhaps she will do more. Certainly, more needs to be done. The latest annual report on the Canada Health Act filed with Parliament notes that private MRI clinics in British Columbia, Alberta, Quebec, New Brunswick and Nova Scotia are charging user fees to patients. It says some hospitals are avoiding the ban on charging for drugs by routing the sick through outpatient clinics - which do charge. It also notes that the portability requirement of medicare, which allows Canadians to receive care outside their home provinces, is routinely ignored.

Quebec routinely refuses to fully reimburse other provinces that provide health services to Quebec residents. Yet it has never been penalized by Ottawa for this. Nor have an unspecified number of other provinces that, at one time or another, did the same. Except for Prince Edward Island, the report says, no province appropriately reimburses residents who obtain medical care outside Canada. Such patients aren't necessarily entitled to the full cost of their out-of-country care. But they are entitled to be reimbursed for the amount it would have cost them to be treated in their home province. To work as a national program, Canadian medicare needs two things. First, the federal government must put up enough money to give it a real financial role in the system. The 2002 Romanow royal commission suggested that Ottawa provide at least 25 per cent of medicare funding. That figure still makes sense. Second, Ottawa has to use its financial clout to enforce those few national standards that do exist. A former Liberal health minister, Diane Marleau, tried to do this back in the 1990s. She was sandbagged by Jean Chrétien, the prime minister of the day. Let's hope Philpott has better luck.

It was bracing to see a federal health minister stand up for medicare principles, writes Thomas Walkom.

Reportedly, Dr. Philpott wrote to her counterpart earlier this month, intimating Ottawa would start withholding transfer payments if extra-billing is not addressed. Now Dr. Barrette is making the typical spluttering noises about Ottawa invading provincial jurisdiction and claiming credit. In recent years, the provinces have tended to treat the federal Health Department as a cash machine; the extra-billing skirmish may end up being part of a broader negotiation over a likely reduction in federal transfers.

Let's hope Quebec's decision, and Dr. Philpott's role in it, signal a new era of robust federal defence of publicly funded medicare. With the British Columbia Supreme Court hearing arguments this week in a case that challenges some key pillars of the Canada Health Act, such robustness is needed.

Though Canadians’ public health care costs are down, we still spend a lot, $155 billion last year. And when you include private spending – all your out-of-pocket and private-insurance health costs – the total was $219 billion.

Frightening Canadians about “unsustainable” health care might be nonsense, but not pointless. If you frighten people enough they’ll even cheer a government that cuts health care. It’s been successful before.

The 5% shift was good news for private health companies. It gave Chretien room to make big corporate tax cuts. Everybody wins – except Canadians. And among us, sick, older, poor and working class Canadians were surely hit hardest.

But now at 71% publicly-paid, Canadian health care is more private than Germany (76% public), France (79% public), Japan (83%) or the UK (87%).

Remember, Trudeau’s first act in the Commons was to spend $4 billion a year on a tax cut with maximum benefit to incomes between $90,000 and $200,000.