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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

What does this mean? The economy will eventually recover and relax provincial health expenditure constraints, but federal health transfer growth will be reduced starting in 2017. This means that the new transfer formula may yet be a factor in forcing provinces to deal with costs in their respective health care systems.

When it comes to health care, Canada’s federal government enters the future with a role whereby the federal government will observe but not directly involve itself in provincial affairs.

Health regions in which the population has higher income on average are less efficient than those in which the population has lower income.

What can we do with such findings? First, we need to learn from the best health regions across the country how to monitor hospital stays (length and quality), guarantee access to family doctors for the poor, and make sure family physicians make up a reasonable proportion of the physician workforce. Secondly, we need to invest in public health -- not necessarily spending more -- finding ways to curb smoking rates, obesity rates, and to encourage physical activity.

Finally -- and perhaps, most importantly -- we need to re-think the way we allocate resources to regions in Canada. Not all regions require similar resources for the health of their populations. Regions who attract fewer immigrants, have more aboriginals in their population, and fewer individuals with higher education should receive more funding per capita because it costs more than in other regions to achieve similar levels of health gains. Conversely, regions with more immigrants, fewer aboriginals, and more highly educated individuals don't need the same health care dollars to get the same results.

Equality and equity are not the same thing where health is concerned. It's time we spread the health dollars where they are needed most.

Ontario’s number of hospital beds per capita is among the lowest, not only in Canada but across the developed world. The province makes no apologies for this. In fact, downsizing hospitals and diverting resources to home-, community- and long-term care — all cheaper alternatives — is central to the government’s strategy to transform the health system. But selling the idea to the public is another matter.

British Columbia Health Minister Terry Lake told The Globe and Mail on Tuesday that the current system, in which the federal money is allotted on a per-capita basis, ignores the fact that some provinces have much older populations than others.

That is about the point when the PBO says the provinces and territories will be in the best financial position, after which increasing health-care expenditures will force a long, steep slide toward deficits and, by 2034, their budgets will be chronically in the red.

"Provinces are responsible for health-care delivery," Melissa Lantsman, a spokeswoman for Finance Minister Joe Oliver, said in an e-mail. "Nevertheless, our government is increasing health funding at a higher rate than provinces are spending it.

"When an older province has higher health-care costs because we have older residents, that should be reflected in the Canada Health Transfer as a population-needs based approach," Mr. Lake said.

The universal child-care benefit, which was increased in this year's budget and resulted in the delivery of $3-billion in cheques to Canadians this week, will have only a minor impact on fiscal room because the cash transfers are not indexed to inflation, the report said.

The report also says the federal government is on track to eliminate its own net debt over the next 35 years.

Melissa Newitt, the national co-ordinator of the Canadian Health Coalition, an advocacy group for public health care, said the PBO report is more evidence that a new national health accord is needed. That accord, she said, should provide stable funding, set national standards and include a national drug plan and a national seniors plan.

Hundreds of thousands of patients on B.C. waiting lists know that role is not being fulfilled. The health minister and premier recently admitted that patients were waiting inappropriately long times, and a health region spokesperson reported some "life-saving" procedures were being delayed. Provincial health commissions were the brainchild of Tommy Douglas, who believed they should be chaired by doctors and never subject to political influence. But the MSC is always chaired by a politicallyappointed civil servant. Douglas supported premiums and felt they made the public cost-conscious, creating a sense of individual responsibility. He would never have condoned the practices of raising premiums to compensate for fiscal failures, nor reporting low-income earners, delinquent with their payments, to collection agencies. The commission is wasting health care funds as it displays contempt, in terms of its fiscal and social accountability, toward taxpayers.. In one example of carelessness and incompetence, I received cheques from them totalling hundreds of thousands of dollars, for services on patients that I had never seen. I also received confidential personal information on hundreds of patients unrelated to me or our clinic. When informed of their error, they responded: "Just mail them back." They were not inclined to investigate.

In Canada, health providers are compelled by law to share confidential patient files with government employees armed with the right to inspect and copy patients' files. Your health record is considered public property; you cannot block government access. Consent is not needed, and you are not notified when Big Brother is looking. Privacy rights have been legislated away. I witnessed a defeated provincial cabinet minister's medical file being reviewed by a newly elected government. In the 1989 tainted blood inquiry, Justice Horace Krever was "shocked by the inadequate laws, the abuses of confidentiality, and the fact that so many people - except the patient - had access to medical records." Little has changed.

The MSC is also charged with defining what services are "medically necessary" - and therefore publicly insured. They have never created a definition, but have arbitrarily designated clearly essential services such as ambulance, drugs, physiotherapy, artificial limbs, and dentistry as unnecessary, creating a true two-tier structure of care. The government's last action in delaying our constitutional challenge on patient rights resulted from a "last minute" discovery of 300,000 documents they were legally bound to provide. After a delay of more than seven years, the plaintiffs in the coming June trial will confirm that the Supreme Court of Canada's 2005 finding - that patients are suffering and dying on waiting lists - applies in B.C. Supporters of a system that limits timely access are complicit in such outcomes.

Our public sector health system (MSC included), is grossly overstaffed with non-clinical workers. A 2011 study revealed that Canada has 11 times as many public health bureaucrats per capita as Germany, where there are no waiting lists. Canada has 14 ministries of health, each with bloated bureaucracies and commissions scavenging dollars that should go to patient care. The mentality that cost inefficiencies can be balanced by increased taxes or "premiums" is responsible for our escalating charges. Independent health groups in Europe rated Canada as last in value for money compared to hybrid public-private systems that have accessible public systems. The Commonwealth Fund, a non-profit foundation focused on issues affecting lowincome groups, ranked Canada 10th of 11 health systems in developed nations.

What specific changes would I incorporate if I were minister of health? Apart from incorporating the best practices of other hybrid systems (including private-sector competition), I would dismantle the ministry and its committees and commissions. Then I would resign. The finance ministry could fund patients directly (thus empowering them), and also assign budgets to the newly emancipated, self-regulated health organizations, allowing them to cater directly to patient needs. Maybe our June constitutional court challenge will point us in that direction. Dr. Brian Day is an orthopedic surgeon, medical director of the Cambie Surgery Centre, and a former president of the Canadian Medical Association.

Dr. Brian Day says bureaucrats at the Medical Services Commission sent him cheques totalling hundreds of thousands of dollars for services on patients he had never seen.

This government needs to stop letting bankers like Ed Clark drive the bus. They don't have the best interest of Ontarians at heart," said Hahn. Instead, he said, the government should restore corporate tax cuts, which former Premier Dalton McGuinty bragged amount to $8 billion a year. They should invest in public services that create good jobs and stimulate the economy in every community across the province. "The Liberals have a choice to make," said Hahn. "Stop the cuts that are dragging our economy down, or face the thousands of people they've left unemployed during the next election." CUPE is Ontario's community union, with more than 250,000 members providing quality public services we all rely on, in every part of the province, every day. CUPE Ontario members are proud to work in social services, health care, municipalities, school boards, universities and airlines.

Craig Saunders (416) 576-7316

Dr. Isabelle Leblanc, president of the pro-medicare group Médecins québécois pour le régime public, said the survey results show that radiologists in Quebec are increasingly choosing to work in the private sector to the detriment of the public system. "For us, this is the best example of how mixing the public and private systems can lead to decreased accessibility for most patients and increased accessibility for those who have the money to pay," Leblanc said. "Radiologists have no incentive to increase access in the public system, and in fact, they're draining resources from the public system." Leblanc explained that radiologists can earn more money charging patients for scans in private clinics than they would if they worked exclusively in hospital and billed the Régie de l'assurance maladie du Québec. Leblanc's group warned in a report three years ago that wait times for MRIs in hospital would increase.

"We're the province that has the highest number of MRI and CT scan machines per capita in the country - with a third of the machines in the private sector - and yet our public wait times are going up," Leblanc added. Health Minister Gaétan Barrette, a radiologist by profession who had worked in a private clinic before entering politics, was unavailable for comment. Officials with the Association des radiologistes du Québec could not be reached for comment, either. The Fraser Institute report observed little progress in cutting wait times for medically necessary surgery or treatments. The median wait time in Canada for treatment inched up to 18.3 weeks from 18.2 weeks last year. In Quebec, the median wait time for treatment by a specialist rose to 16.4 weeks from 7.3 weeks in 1993, when the Fraser Institute first started compiling such data. The median wait time denotes the midpoint for those waiting, as opposed to an average. In Quebec, the median wait time to see a medical specialist following referral from a general practitioner rose to 7.3 weeks from 7.1 weeks last year. The survey found that the longest median waits in Canada were for orthopedic surgery at 35.7 weeks, or almost nine months.

"These protracted wait times are not the result of insufficient spending but because of poor policy," Bacchus Barua, the author of the Fraser survey, said in a statement. "In fact, it's possible to reduce wait times without higher spending or abandoning universality. The key is to better understand the health policy experiences of other more successful universal healthcare systems around the developed world." aderfel@montrealgazette.com Twitter.com/Aaron_Derfel

The median wait time in hospital for a magnetic resonance imaging (MRI) scan in Quebec jumped to 12 weeks this year from eight in 2014, a survey has revealed. Wait times also increased slightly for other medical imaging. ALLEN McINNIS-MONTREAL GAZETTE FILES • MONTREAL GAZETTE / Source: Fraser Institute