BLOGGED:
Seniors dying/burial/living in poverty $$$- IN CANADA-NOVA SCOTIA- Don't be afraid- God loves us old sinners- getting prepared-write ur own obit- find out $$$ 4 burial 4 poor folks/Women- ur rights/Pensions- Income- LIVING IN POVERTY HELP- One Billion Rising- girls and women matter Nova Scotia and Canada
----------------
BLOGGED:
CANADIAN SENIORS ARE GETTING RIPPED OFF-12 Monthly 4wk cheat 2 full weeks- same 4 poverty systems- O Canada- Nova Scotia?? This is soooo 60s and this is 2014!!1 Fix it or lose our votes in 2015/Sept 25- Holy Sheeeeet Sherlock -Linda McQuaing's IPOLITICS article- real war over inequality isn't between old and young- awesome/Sep. 25- OLD AGE... POPULATIONS GLOBALLY- AND YOUTH - GLOBAL MAPS OF AGES 2014... O Canada, Africa has all the young ones and a bit Middle East - world is changing
http://nova0000scotia.blogspot.ca/2014/09/canadian-seniors-are-getting-ripped-off.html
CANADIAN SENIORS ARE GETTING RIPPED OFF-12 Monthly 4wk cheat 2 full weeks- same 4 poverty systems- O Canada- Nova Scotia?? This is soooo 60s and this is 2014!!1 Fix it or lose our votes in 2015/Sept 25- Holy Sheeeeet Sherlock -Linda McQuaing's IPOLITICS article- real war over inequality isn't between old and young- awesome/Sep. 25- OLD AGE... POPULATIONS GLOBALLY- AND YOUTH - GLOBAL MAPS OF AGES 2014... O Canada, Africa has all the young ones and a bit Middle East - world is changing
http://nova0000scotia.blogspot.ca/2014/09/canadian-seniors-are-getting-ripped-off.html
----------------
BLOGGED:
SENIORS- PEOPLE WITH DISABILITIES- Nova Scotia Canada- Global hits-NOVA SCOTIA SENIORS How 2 prepare4disaster/International Disability and Senior Links/Mental Wellness/Wheelchair/coping with disabilities proudly- RECYCLE- how 2 separate your householdgarbage and electronic waste (thanks Kings Co. Nova Scotia) - let’s git r done Canada... and world.... Seniors and Disabled matter- all links provided- thx Canada-USA-UK-Aussies-Europe etc.
------------
CANADA- A PATIENT’S BILL OF RIGHTS
PATIENT'S BILL OF RIGHTS
– A COMPARATIVE OVERVIEW
Prepared by:
Margaret Smith
Law and Government Division
4 February 2002
Margaret Smith
Law and Government Division
4 February 2002
TABLE
OF CONTENTS
A. Canada
1. Rights and Entitlements in Relation to Health Care – Federal Initiatives
a. Health Charter for Canadians
b. Canada Health Act
c. Patients’ Bill of Rights
1) Private Member’s Bill
2) Senate Committee Proposal
2. Rights and Entitlements in Relation to Health Care – Provincial Initiatives
a. Alberta
b. Ontario
c. Quebec
d. Nova Scotia
e. New Brunswick
3. Rights and Entitlements in Relation to Health Care – Policy Proposals
a. IRPP Task Force on Health Policy
1. Rights and Entitlements in Relation to Health Care – Federal Initiatives
a. Health Charter for Canadians
b. Canada Health Act
c. Patients’ Bill of Rights
1) Private Member’s Bill
2) Senate Committee Proposal
2. Rights and Entitlements in Relation to Health Care – Provincial Initiatives
a. Alberta
b. Ontario
c. Quebec
d. Nova Scotia
e. New Brunswick
3. Rights and Entitlements in Relation to Health Care – Policy Proposals
a. IRPP Task Force on Health Policy
B. New Zealand
1. The Code of Health and Disability Services Consumers’ Rights
2. The Health and Disability Commissioner
1. The Code of Health and Disability Services Consumers’ Rights
2. The Health and Disability Commissioner
E. United States
1. Federal Proposals
a. Presidential Initiatives
b. Congressional Initiatives
2. State Initiatives
a. Patients’ Rights in Relation to the Provision of Health Care
b. Patients’ Rights and Protections in Relation to Managed Care
1. Federal Proposals
a. Presidential Initiatives
b. Congressional Initiatives
2. State Initiatives
a. Patients’ Rights in Relation to the Provision of Health Care
b. Patients’ Rights and Protections in Relation to Managed Care
PATIENTS’ BILL OF RIGHTS – A COMPARATIVE OVERVIEW
Concern about the
state of the Canadian health care system tends to centre on its long-term
sustainability. The focus is on rising costs, funding, human resource
shortages, the use of technology, and primary care reform. Recently, the
ambit of this concern has broadened to include an increasing interest in
patients’ rights which is being driven by a number of factors such as:
· evidence
of long waiting times for diagnostic tests, treatment for certain diseases and
conditions, and appointments with specialists;
· the
growing numbers of educated and knowledgeable patients who are less willing to
accept the status quo and are becoming more assertive in demanding information
from health care providers;
· the
increasing patient demand for a greater role in decisions affecting their care
and treatment;
· the
increasing complexity of the health care system; and
· the
growing perception that patients need to be active health care “consumers.”
Canada is not alone in experiencing these
developments. In an attempt to refocus the delivery of health care
services to patients, countries such as New Zealand, the United Kingdom,
Australia, the United States and Norway have seen the introduction of patients’
bills of rights and responsibilities, or patients’ charters, as they are
sometimes called.(1) In
some of these nations, patients’ rights have the force of law; in others, they
are statements of health policy. Regardless of the form they take, these
initiatives have two goals: to empower patients by providing them with certain
rights and entitlements as they interact with health care providers and
institutions; and to place the patient-health care provider relationship on a
more equal footing. By outlining what is expected of health care
providers, institutions and patients, they also serve as important guidelines
for the delivery of health care services.
This paper discusses recent initiatives regarding the
development and implementation of patients’ bills of rights in Canada, New
Zealand, the United Kingdom, Australia, the United States and Norway.
When discussing patients’ rights in the context of
the Canadian health care system, it is important to distinguish between
“collective” rights and “individual” rights and entitlements.
· Collective rights are broad principles relating to the general societal
obligation to make reasonable access to health care available for the entire
population. What is reasonable in terms of the number and range of
provided services depends on political, social and economic factors.
Collective rights also relate to equal access to health care for all those
living in a country or other geopolitical areas.
· Individual rights and entitlements, on the other hand, refer to the
application of the health care system at the patient or consumer level; in
other words, what individuals are entitled to and can expect at various stages
of the health care system when they interact with health care providers and
institutions. These rights include rights to information, privacy,
confidentiality, and consent to treatment.
The 1964 Report of the Royal Commission on Health
Services (Hall Commission) put forward a “Health Charter for Canadians.”(2) This
statement of collective entitlements was based on the assumption that the
“achievement of the highest possible health standards for all people must
become a primary objective of national policy....”(3)
The Charter states that this objective can be best
achieved through a “comprehensive, universal Health Services Programme for the
Canadian people” that would be:
· implemented
according to Canada’s evolving constitutional arrangements;
· based
on freedom of choice and on free and self-governing professions and
institutions;
· financed
through prepayment arrangements; and
· accomplished
through the full cooperation of the general public, health professions,
voluntary agencies, all political parties and levels of government.(4)
Certain principles
– which were to become the basis upon which the federal government would
contribute funding to provincial health care plans – were defined as follows:
· “Comprehensive”:
“all health services, preventive diagnostic, curative, and rehabilitative that
modern medical and other sciences can provide.”
· “Universal”:
“adequate health services should be available to all Canadians wherever they
reside and whatever their income, within limitations imposed by geographic
factors.”(5)
· “Health
Services Programme”: “legislative enactments and administrative
arrangements to organize comprehensive universal health care including
prepayment arrangements for financing personal health services introduced in
stages.”(6)
· “Freedom
of Choice”: a patient’s right to select a physician or dentist, and the
right of the practitioner to accept or not to accept a patient except in
emergency or on humanitarian grounds.(7)
From the federal perspective, the primary objective
of Canadian health care policy – to protect, promote and restore the physical
and mental well-being of residents of Canada and to facilitate reasonable
access to health services without financial or other barriers – is outlined in
the Canada Health Act.(8)
The fundamental collective principles underlying the Canadian health care
system are set out in the five program criteria found in the Act. They
are:
· public
administration;
· comprehensiveness;
· universality;
· portability;
and
· accessibility.(9)
“Public
administration” ensures that the health care insurance plan of each province is
administered and operated on a non-profit basis by a public authority that is
responsible to the provincial government.
“Comprehensiveness”
means that each provincial health insurance plan must cover all “insured health
services,” provided by hospitals, medical practitioners or dentists or similar
or additional services rendered by other health care practitioners where
permitted. The term “insured health services” is defined by the Act to include
medically necessary “hospital services,” medically required “physician
services,” and “surgical-dental services” when performed in a hospital.
To satisfy the
“universality” criterion, each provincial health insurance plan must cover all
persons resident in a province.
“Portability”
means that residents moving to another province must continue to be covered for
insured services by the home province during a minimum waiting period (not
longer than three months) imposed by the new province of residence for
insurance coverage, and that residents are insured for services outside their
province of residence if they are elsewhere in the country or outside Canada.
“Accessibility”
means that insured health services should be provided on uniform terms and
conditions and on a basis that does not impede or preclude reasonable access to
those services.
In order to
qualify for the full federal cash contribution for health care, provincial
health insurance plans must satisfy these criteria and must not allow extra billing
or user fees for insured services. When coupled with the prohibition on
extra-billing and user fees, these five program criteria establish the
principal collective right to health care in Canada – reasonable access to
medically necessary hospital and physician services without charge anywhere in
Canada.
Federal health care initiatives tend to focus on
collective, system-wide principles and objectives rather than on the rights and
expectations of individual users of the health care system. The absence
of a federal focus on individual rights stems largely from the constitutional
division of powers, which makes health care a provincial responsibility.
Recently, however, federal politicians have expressed
increased interest in patients’ rights. Mr. Greg Thompson (New Brunswick
Southwest) introduced a Private Member’s Bill – Bill C-261, An Act to establish
the rights of patients in relation to health, treatment and records (Patients’
Bill of Rights) – in the House of Commons on 12 February 2001. This bill,
if passed, would set out a number of rights with respect to the health care
system as a whole as well as a series of personal rights for patients.(10)
In addition to outlining specific patients’ rights,
the bill (clause 5) lists three health care responsibilities that patients
would undertake:
· provide
health professionals with full and accurate information relating to their
health and the public health services they have received;
· cooperate
with health professionals and to either follow their advice or indicate when
they have not done so; and
· exercise
due economy in using health services.
The rights
pertaining to the public health care system found in clause 3 of the bill
provide that all Canadians would have the right to “national collaboration
between governments” to assure:
(a) a
good-quality, dependable and accessible national system of health care;
(b) a
system of health care that is transferable and generally uniform across Canada;
(c)
the minimum amount of overlap and duplication in public health services between
different governments;
(d)
consistency in development of public health services between different
governments resulting in consistency in the timing of development of services
and innovation; and
(e)
regular consultation with the public about public health services in a forum
that is public, open and gives a reasonable opportunity to present views to
representatives of government, the House of Commons or a legislative assembly,
and the medical profession.
Clause 4 of the
bill outlines a substantial list of personal (individual) rights for users of
the public health care system, including:
(a)
the right to be fully informed about one’s medical condition;
(b)
the right to be advised of the available treatment options;
(c)
the right to be involved in treatment decisions;
(d)
the right to information on the qualifications and experience of the health
professionals from whom services are received;
(e)
the right to receive considerate, compassionate and respectful public health
services;
(f)
the right to confidential communications with health professionals;
(g)
the right to have access to and copies of personal health records and to have
them corrected, if necessary;
(h)
the right to have health records kept confidential and not used for any purpose
other than public health services without written consent;
(i)
the right to designate a person to exercise rights on the patient’s behalf if
the patient is not able to do so because of a physical or mental incapacity;
and
(j)
the right to be informed of all rights and responsibilities under the bill and
under other laws of Canada or a province with respect to public health
services.
Recognizing that
the provinces have primary responsibility for health care, the bill would
enforce these rights through federal-provincial agreements and make full cash
contributions to provinces under the Federal Provincial Fiscal Arrangements
Act conditional upon the conclusion of federal-provincial agreements
relating to patients’ rights.
In its September 2001 issues and options document on
the federal role in the Canadian health care system,(11) the
Standing Senate Committee on Social Affairs, Science and Technology put forward
a patients’ bill of rights as an option to address the problem of timely access
to health care services.
The Committee observed that adopting patients’ bills
of rights at the provincial level would accommodate differing provincial
situations and might even inject an element of competition into health care
delivery. At the same time, the Committee noted that because many
Canadians would not want to see substantial discrepancies among provincial
standards, the federal and provincial/territorial governments could participate
in the development of minimum standards for timely access to health care that
would serve as the basis for provincial patients’ bills of rights.(12)
In dealing with rights and entitlements to health
care, provincial governments have adopted a range of approaches: Quebec has
legislated certain entitlements; the current Ontario government has made a
commitment to enact a patients’ bill of rights; the Premier’s Health
Quality Council of New Brunswick has proposed a New Brunswick Health Charter of
Rights and Responsibilities; and other provinces have set health care goals,
objectives and expectations in planning and policy documents. Private
Members’ bills introduced in the Ontario and Alberta legislatures in the late 1990s
also sought to enact a code of patients’ rights and responsibilities.
A number of these initiatives are outlined below.
A Private Member’s
bill – Bill 201, Alberta Patients’ Bill of Rights – was introduced in the
Alberta Legislative Assembly on 28 January 1998. The purpose of the bill
was to:
(a) ensure
that patients were aware of their right to receive appropriate and timely care;
(b) ensure
that patients were treated with dignity and respect; and
(c) promote
and improve communication between patients and health care professionals.
The bill would
have provided patients with various rights, including the right to:
· receive
health services without discrimination;
· have
their personal and health information protected from disclosure;
· have
access to their health information unless, in the opinion of a relevant health
professional, the disclosure could result in immediate and grave harm to the
patient’s health or safety;
· refuse
consent to any proposed treatment; and
· receive
information relating to any proposed treatment and options.(13)
Bill 201 was defeated shortly after it was
introduced.(14)
The Ontario government has committed to introducing a
patients’ bill of rights and tying hospital funding to how well hospitals
deliver health care services.(15)
Prior to this commitment, at least three Private Members’ bills to promote
patients’ rights had been introduced in the Ontario legislature over a
three-year span.(16)
The most recent of these – Bill 18, Health Care Accountability and the
Patients’ Bill of Rights Act, 1999 – which was introduced in April 1998, would
have:
· codified
the rights (as listed below) of residents of Ontario who receive health care;
· provided
for the appointment of a Health Care Standards Commissioner who would promote
understanding of and compliance with the Patients’ Bill of Rights, participate
in setting health care standards and developing a complaints procedure, monitor
health care standards, and make recommendations to the Legislature for
improvements to the laws and policies related to health care; and
· established
whistleblower protection for health care providers.
The bill set out
the following collective and individual rights:
· the
right to receive all necessary health care services in a health care system
that:
a) is
accessible, universal, comprehensive and publicly administered and funded,
b)
offers freedom of choice,
c)
provides timely treatment,
d)
does not allow personal income to determine access to health care services, and
e)
recognizes that every provider of health care services is a valued member of a
multidisciplinary health care team;
· the
right to give or refuse consent to the provision of health care services;
· the
right to all information necessary to make fully informed health care choices,
including information about who will provide particular services and their
qualifications;
· the
right to receive high-quality, publicly funded health care in the home and in
the community as well as in health care facilities;
· the
right to receive information about choices that promote good health as well as
about measures that prevent illness and accident;
· the
right to be dealt with by health care service providers,
a)
with courtesy and respect,
b) n
a manner that recognizes individual dignity and privacy and promotes individual
autonomy,
c) in
a manner that recognizes and responds to individual needs and preferences,
including those based on ethnic, spiritual, linguistic, familial and cultural
factors,
d) without
mental, physical, sexual or financial abuse;
· the
right to participate in any assessment of personal care requirements and in the
development of plans for care;
· the
right to make complaints, raise concerns, and recommend changes without fear of
interference, coercion, discrimination or reprisal;
· the
right to be informed of:
a) the
laws, rules and policies affecting providers of health care services, and
b) the
procedures for initiating complaints about providers of health care services;
· the
right to confidentiality of health care records in accordance with the law.
None of the three
bills has become law.
Quebec’s Act regarding health services and social
services (Loi sur les services de santé et les services sociaux)(17) sets
out entitlements with respect to health and social services. Included
among these are entitlements to:
· be
informed of the existence of the health and social services resources available
in the community and the conditions governing access to the services;
· receive
health services in a continuous and personalized manner and which are
scientifically, humanely and socially appropriate;
· choose
the professional from whom or the institution from which health services are to
be received;
· receive
the care required when life or bodily integrity is endangered;
· be
informed of the state of one’s health and options for care prior to giving
consent to care; and
· participate
in decisions affecting one’s care.(18)
It should be noted, however, that the Act limits the
application of health and social services entitlements by tying them to
structural and economic constraints. The entitlement to health services
and to choose one’s health care professional and institution must be exercised
within the framework of the legislative and regulatory provisions relating to
the organizational and operational structure of the institution and within the
human, material and financial resources available to the institution.(19)
The Act also created a three-tier regime for dealing
with complaints against health care facilities and providers. Complaints
were to be made first to the relevant institution, then to the appropriate
regional board and finally to the government-appointed Complaints Commissioner
who examined complaints from persons who were dissatisfied with decisions made
by regional boards.(20)
Bill 27, an Act respecting the Health and Social
Services Ombudsman and amending various legislative provisions – which was
introduced in May 2001 – replaces the Complaints Commissioner with a Health and
Social Services Ombudsman (Health Services Ombudsman).(21)
The Act streamlines the complaints procedure by creating a two-tier
regime. In the first instance, local service quality commissioners and
regional service quality commissioners examine complaints in relation to
services and activities coming under their respective authorities. At the
second tier, the Health Services Ombudsman hears appeals from complainants who
are dissatisfied with decisions at the quality commissioner level.
The Act also gives the Health Services Ombudsman the
power to intervene in circumstances where there are reasonable grounds to
believe that a person or group of persons has been or may likely be adversely
affected by an act or omission of an institution or a regional board.(22)
In Nova Scotia, the provincial government originally
tasked the Provincial Health Council with developing a Patient’s Bill of
Rights. However, the Council produced a set of “Expectations for Health
and Health Care in Nova Scotia” after concluding that a legislated patients’
rights document “would pose innumerable legal problems that might take decades
to resolve through the courts.”(23)
The expectations fall into three broad categories:
the attainment and maintenance of health for persons, families and communities;
the development of health care and related services; and the provision of
health care and related services. The latter two categories contain 10
expectations related to the development of the health care system and 21
expectations pertinent to the provision of health care.
The Expectations relating to the development of
health care deal largely with what Nova Scotia residents should reasonably
expect at the policy and system level. These include:
· a
health care system that reflects their values;
· the
development and delivery of service that reflects a commitment to the health,
general well-being and dignity of all residents;
· access
to health care and related services and supports, including: primary care,
acute care, long-term care and home care as well as emergency, palliative,
rehabilitative and preventive services;
· the
development and delivery of service guided by the best available qualitative,
quantitative and experiential evidence;
· support
for individual and community efforts to enhance the health and well-being of
residents;
· eradication
of intersectoral and other barriers to ensure better health and health care;
· equitable
allocation of resources;
· adequate
funding for, and wise management of, services that have an impact on health;
· continued
Government commitment to the spirit of the Canada Health Act and Nova
Scotia’s Health Goals (1992); and
· widespread
public input into major proposed changes to the health care system.(24)
The Expectations
for the provision of health care services, on the other hand, outline what
individual residents should reasonably expect in relation to their personal
health care. These include:
· providing
services that respect values, culture, language, religion, ethnicity and
individual ability;
· being
treated with respect, dignity and consideration;
· paying
attention to the individual’s views, preferences, observations and problems
regarding all aspects of care;
· providing
care in a manner that is free from abuse, neglect and prejudice;
· providing
care based primarily on individual need;
· receiving
safe, competent and ethical care by qualified providers;
· knowing
the names, qualifications and professional roles of the health care providers;
· providing
health care and related services with reasonable accommodation for the
geographic distribution of the population;
· being
cared for in a clean, safe and healthy environment;
· receiving
understandable information about one’s health care;
· participating
fully in all decisions related to one’s health care, either directly or where
circumstances dictate, through the use of an appropriate proxy or Advance
Directive;
· participating
in arrangements for discharge;
· honouring
requests for the withdrawal of treatment or the refusal of care except where
otherwise prescribed by law;
· honouring
refusals to participate in research or educational activities;
· being
informed of the relevant risks, benefits and reasonably foreseeable
consequences of any proposed intervention together with the risks and potential
consequences of refusing care;
· being
adequately informed of the rules, regulations, policies and limits associated
with the provision of health care and related services;
· receiving
a full explanation, in advance, for any charges for services not covered by the
provincial health care plan;
· being
assured of privacy;
· observing
confidentiality unless disclosure is authorized by law;
· receiving
an explanation of the requirements for disclosure of confidential information;
and
· having
reasonable and timely access to and copies of personal health care records as
well as the right to request changes to the records.(25)
In its January 2002 report,(26) the
New Brunswick Premier’s Health Quality Council outlined a New Brunswick Health
Charter of Rights and Responsibilities, the purpose of which is to set out what
New Brunswick residents can expect from the health care system and health care
professionals. The Charter, which sets out a number of specific rights
and responsibilities at three levels – the individual, the health professional,
and the health care system – addresses five broad classes of rights:
· access
to health services;
· the
making of one’s own decisions;
· good
communication and information;
· personal
consideration and respect; and
· the
addressing of issues and complaints.(27)
The rights
encompassed under “access to health services” include the right to:
· receive
publicly funded health services on the basis of need, rather than ability to
pay, lifestyle or any other factor;
· have
access to primary care in one’s local area;
· receive
health services from a family physician or collaborative practice team;
· have
equitable access to health services;
· obtain
a second opinion;
· have
continuity of care;
· receive
health services that respond to individual needs and preferences;
· receive
services in the official language of choice; and
· ensure
wheelchair accessibility.
Responsibilities
outlined under access to services include both individual and health system
responsibilities. The former include the responsibility to:
· learn
how to access health services;
· use
services appropriately and wisely; and
· live
a healthy lifestyle.
The corresponding
health system responsibilities include the responsibility to:
· respond
to patients’ needs in a timely manner based on established standards;
· provide
information about treatment and services;
· provide
a seamless continuum of care;
· deliver
services effectively and efficiently without compromising quality;
· spend
public funds prudently and wisely;
· provide
a clear policy about health care professionals reporting concerns about risks
for patients;
· provide
a safe working environment;
· respect
health care personnel; and
· ensure
wheelchair accessibility.
The rights under
“the making of one’s own decisions” deal with issues such as being informed,
refusing treatment, choosing treatment, participating in research, and
receiving information about the qualifications and experience of health
professionals. The health system’s responsibilities under this category
centre on providing information about treatments and procedures and their
implications as well as respecting health care decisions.
“Good
communications and information” covers rights to an explanation of proposed
treatments and risks, access to health records, information about new treatment
advances, and information on health services. Patients have a
corresponding responsibility to ask questions, follow instructions, understand
their treatment plan, and request information.
Rights under
“personal consideration and respect” focus on providing a clean and safe care
environment, being treated with dignity and respect, and protecting
privacy. The Charter also stresses that patients have a responsibility to
collaborate with health care personnel and to be courteous and respectful.
Finally, the
proposed Charter outlines rights to complain along with a corresponding
responsibility on the health system to provide mechanisms to address
complaints.
The Premier’s
Health Quality Council did not address whether the Charter should be entrenched
in legislation, noting, however, that it was up to the government to decide
whether the Charter should be legislated or made part of public policy.
In order to facilitate the rights outlined in the
proposed Charter, the Council recommended the creation of an advocate system
composed of Health System Advocates to facilitate access and
communications. Regional Advocates would be created in each regional
health authority along with one Provincial Advocate who would deal with
province-wide policy and communications issues. The Health System
Advocate system would also address patients’ concerns and complaints of a
defined scope.(28)
In 2000, the Institute for Research on Public Policy(29) (IRPP)
Task Force on Health Policy released a series of recommendations to Canada’s
first ministers on reforming Canada’s health care system. Among the
recommendations was a suggestion for increasing the accountability of health
organizations through mechanisms such as Patients’ Charters and a Health Care
Ombudsperson.(30)
The IRPP Task Force suggested that Patients’ Charters
should be adopted at the provincial level to permit patient entitlements to be
adapted to the particular circumstances of each province. In the
beginning, charters would focus on a short list of items and not include broad
statements dealing with all personal health services.(31)
Under the IRPP proposal, health organizations would issue a statement of
“patient rights, expectations and responsibilities with regard to the
appropriateness, quality and timeliness of care”(32) and
report annually on how hospitals and other health care providers were meeting
these entitlements. The overriding view was that Patients’ Charters would
result in improved health care services.
The Task Force argued that an effective Patients’
Charter must be built on the following premises:
· a
change in health services organizations;
· a
selective focus on quality of services;
· a
determination to commit incremental resources; and
· an
effective appeals process.(33)
The Task Force saw a number of benefits from creating
Patients’ Charters. First, they would “refocus the delivery of health
care services on the patient and on the quality of these services in each and
every community.”(34)
An emphasis on outcomes would result in a shift in decision-making to a
regionally managed system that could be adapted to meet the needs of particular
regions and patients. Second, because they are directed to individual
entitlements, Patients’ Charters would focus the measurement of quality on
individual contacts with the system rather than on aggregate numbers.(35) Third,
Charters would compel governments to allocate greater resources to the health
care system in order to live up to the entitlements provided.(36)
To overcome barriers imposed by the expense of the
litigation, and scepticism about the effectiveness of such charters, the Task
Force suggested that an administrative appeals process be established at local
and provincial levels, through an official such as an ombudsperson who would
monitor the system’s adherence to the principles of Medicare and the patients’
entitlements under provincial charters.(37)
New Zealand has legislated rights for consumers of
health and disability services in a Code of Health and Disability Services
Consumers’ Rights, created in 1996 as a regulation under the Health and
Disability Commissioner Act 1994.(38) The
impetus for the passage of the Act came from two factors: the widespread view
at the time that the law was inadequate to protect consumers of health and
disability services; and public concern about the imbalance in power and
knowledge between health care professionals and health care consumers.
This was documented by a commission of inquiry established by the New Zealand
government to investigate allegations relating to inadequate treatment of
cervical cancer in an Auckland hospital.(39)
The Act’s purpose is “to promote and protect the
rights of health consumers and disability services consumers, and, to that end,
to facilitate the fair, simple, speedy, and efficient resolution of complaints
relating to infringements of those rights” (s. 6). The aim is to achieve this
objective through: the Code of Health and Disability Services Consumers’
Rights; the appointment of a Health and Disability Commissioner to investigate
complaints against persons or bodies who providing health care or disability
services; and the education of health care providers and consumers.
The Code of Health and Disability Services Consumers’
Rights(40) sets
out ten rights relating to the patient-health care provider relationship.
These are:
· the
right to be treated with respect;
· the
right to freedom from discrimination, coercion, harassment and exploitation;
· the
right to dignity and independence;
· the
right to services of an appropriate standard;(41)
· the
right to effective communication;
· the
right to be fully informed;
· the
right to make an informed choice and give informed consent;
· the
right to have support persons present;
· the
right to accept or refuse participation in teaching or research; and
· the
right to complain.
The Code also
outlines compliance requirements for health care providers. Where the
rights cannot be met, the onus is on the provider to establish that it was
reasonable in the circumstances not to have done so.
The Health and Disability Commissioner appointed
under the Act has far-reaching powers. The Commissioner, whose initial
task was to prepare a draft Code, has ongoing responsibility to review the Code
in accordance with the Act. Other responsibilities include promoting the
rights of health and disability services consumers, investigating alleged
breaches of the Code,(42) and
making recommendations for resolving breaches. The Commissioner can also
advise the minister responsible for the Act and report on the need for action
to protect the rights of health consumers and disability services consumers.(43)
The Commissioner has the authority to refer a matter
under investigation to the Director of Proceedings, an independent statutory
officer under the Act, who can hold proceedings regarding a complaint.
Generally, proceedings can be brought before the Complaints Review Tribunal and
various health professional disciplinary bodies.
The Complaints Review Tribunal has the authority to
issue consumer remedies including:
· a
declaration that the action of the provider is in breach of the Code;
· an
order restraining the provider from continuing or repeating the breach, or from
engaging in, or causing or permitting others to engage in, conduct of the same
kind as that constituting the breach;
· damages;
· an
order that the provider perform any specified acts with a view to redressing
any loss or damage suffered by the consumer as a result of the breach; and
· any
other relief the Tribunal thinks fit.(44)
The Act also provides for advocates to assist
consumers in resolving their complaints or concerns directly with health and
disability service providers. Advocates neither investigate nor make
decisions on whether the Code has been breached. They also perform an
educational function by promoting awareness of the Code and the Act to
consumers and providers. Advocacy services operate independently of the
Commissioner, health care providers and disability services providers, but the
Commissioner can issue guidelines for the operation of such services.(45)
The United Kingdom (UK) introduced a patients’ bill
of rights in 1992 when the National Health Service (NHS) Patient’s Charter(46) was implemented to improve
the quality of care delivered to patients. Complaints about the NHS had
been rising steadily, patients were experiencing long waiting periods for
medical services, and concerns were being voiced about the quality of care and
the manner in which patients were being treated.
The NHS Patient’s Charter(47) was
composed of individual rights and service standards (known as
expectations). The rights comprised core principles such as access to
health care, the receiving of information to make informed choices about
medical care, and included the right to:
· receive
health care on the basis of clinical need, not on ability to pay, lifestyle or
any other factor;
· be
registered with a General Practitioner (GP), change GPs easily and quickly, and
have a medical checkup;
· be
prescribed appropriate drugs and medicines, and have free medicines if the
patient is within certain age categories;
· obtain
emergency medical treatment at any time;
· be
referred to an acceptable specialist and obtain a second opinion;
· choose
whether to take part in medical research or medical student training;
· have
a clear explanation of any proposed treatment, the risks involved and the
alternatives;
· have
access to personal health records;
· have
complaints about NHS services investigated; and
· receive
detailed information on local health services including quality standards and
waiting times.
The Charter
standards (expectations) were more specific and sought to address concerns
about the quality of health care services and waiting times for certain
procedures. These standards included:
· readmission
within one month if surgery was cancelled on the scheduled day for non-medical
reasons;
· a
maximum waiting period of 13 weeks for a non-urgent outpatient appointment in
90% of cases;
· patients
at outpatient clinics being seen within 30 minutes of their scheduled
appointment time;
· a
maximum wait of two hours for a hospital bed after admission to hospital
through an emergency department;
· immediate
assessment of patients arriving at an accident and emergency department;
· waiting
times for an ambulance not to exceed 14 minutes in urban areas, 19 minutes in
rural areas;
· clean,
safe hospitals with clear signs;
· pre-discharge
arrangements for necessary post-hospital care;
· provision
of a clear explanation of a hospital’s food, nutrition and health policy as
well as catering services and standards; and
· respect
for privacy, dignity, and religious and cultural beliefs.
The Charter
stressed the importance of GPs establishing their own practice charters and for
hospitals to set local standards for waiting times.
In June 1997, the UK Department of Health
commissioned a study to review the existing Patient’s Charter and develop
proposals for a new NHS Charter. Overall, the study gave the Charter
very low marks. Describing it as a “disconnected ragbag of so-called
service rights and aspirations,” the study concluded that the Charter was of
limited usefulness.(48)
The Charter was criticized on a number of fronts,
from the manner in which it was drawn up and implemented to its content.
It was described as a top-down initiative which staff saw as a “political”
document designed to assuage mounting complaints about health care services.
NHS staff believed the Charter engendered a blame culture by giving
patients rights without obligations.
Critics argued that the Charter encouraged cheating
to comply with admission standards. By measuring the process by which
patients travelled through the system rather than the clinical outcome or the
quality of the care prescribed, all the targets could be met but patients could
still be dissatisfied with their level of treatment and care.(49)
Despite these criticisms, however, the study found
that one of the most important impacts of the Charter was the more consumerist
culture it injected into the British health care system.
In the end, the study concluded that the NHS would
not benefit from the imposition of another national charter and proposed instead
that local charters be developed in trusts, primary care groups and other
community health services dealing directly with patients.(50)
It did not, however, recommend a complete abandonment of national standards,
and suggested a national framework containing some minimum national standards
that could be included in local charters.
In 2001, the Patient’s Charter was replaced by a new
NHS document, Your Guide to the NHS.(51)
The Guide sets out what patients can expect from the NHS in relation to current
and future waiting times for certain kinds of treatment, ambulance arrivals,
treatment in hospital emergency departments, and appointments with a GP or a
nurse practitioner. For example, by 2004, patients should not have to
wait more than four hours in an accident and emergency department from arrival
to admission, transfer and discharge. The Guide also provides a care
guarantee when a patient’s operation is cancelled on the day of surgery for
non-clinical reasons. In this case, the hospital is required to provide
another surgery date within 28 days or pay for treatment in a hospital of the
patient’s choice.
The UK government has also put forward a plan for a
Patient Advocacy and Liaison Service under which patient advocates will act as
independent facilitators to: (a) handle patients’ complaints about
service; and (b) guide patients through the complaints process.
An independent Health Service Ombudsman investigates
complaints about the NHS.(52)
The type of complaints examined include those relating to: poor service or
failure to provide a service; allegations that staff did not follow proper
procedures or were rude; and complaints about the care received from doctors,
nurses and other health professionals.
The Australian commonwealth government provides
financial assistance to the States and Territories for public hospitals and
other health services conditional upon the latter entering into agreements
(Australian Health Care Agreements). States and Territories must agree to
develop a Charter giving residents various types of information, including the
provision of health services, the process for making complaints, and how the
complaints will be heard. As a result, States and Territories have developed
Public Patients’ Hospital Charters(53) hat
include a number of rights, including the right to:
· receive
free public hospital services as a public patient;
· be
treated on the basis of health needs, regardless of financial or health
insurance status;
· have
access to public hospital services, regardless of place of residence;
· be
treated with respect, compassion and consideration of privacy, taking into
account the patient’s background, needs and wishes;
· participate
fully in health care decisions including admission, discharge and arrangements
for continuing care;
· receive
a clear explanation of proposed treatment including risks and alternatives, before
agreeing to the treatment;
· seek
a second medical opinion;
· give
informed consent (except in exceptional circumstances) before a procedure is
carried out, including consent to participation in undergraduate health
professional teaching or medical research;
· withdraw
consent or refuse further treatment;
· have
access to personal medical records;
· be
assured that personal information will be kept confidential, unless otherwise
provided by law;
· have
interpreter services when necessary; and
· complain
about health care and be advised of the procedure for expressing concerns.
Australia has also
developed a Private Patients’ Hospital Charter which sets out guidelines
relating to private patients in a public hospital, a private hospital or a day
hospital facility and what such patients can expect from doctors, hospitals and
health insurance funds.
Over the past decade, managed health care through
organizations – commonly known as health maintenance organizations (HMOs) –
proliferated in the United States as employers and governments sought to
contain rising health insurance costs.(54)
In their quest to contain costs, managed care organizations have garnered
numerous criticisms and complaints. For example, HMOs have been routinely
accused of improperly denying coverage or delaying care. As well, surveys
have reported patient problems such as difficulty seeing physicians, the
refusal to make referrals to specialists, restricted coverage for emergency
services, limits on the length of hospital stays and delays, and denial of
payment on the grounds that procedures are not medically necessary. In
some cases, these actions have resulted in health problems and significant
financial costs for patients.
In fact, there have been so many complaints and
criticisms that governments have felt it necessary to enact laws guaranteeing
patients’ rights in managed care situations. State governments were first
off the mark in enacting patients’ rights statutes to deal with the managed
care industry. Also, a variety of patients’ rights bills have been put
before the House of Representatives and the Senate; to date, however, none has
become law.
A number of these initiatives are discussed below.
In 1997, President Clinton created the Advisory
Commission on Consumer Protection and Quality of the Health Care Industry and
charged it with developing a patients’ bill of rights. Later that year,
the Advisory Commission issued the Patients’ Bill of Rights and
Responsibilities, which set out seven categories of rights and one set of
responsibilities:(55)
· the
right to information;(56)
· the
right to choose one’s health care providers, including access to qualified
specialists;
· the
right to access to emergency services;(57)
· the
right to participate in health care decisions;
· the
right to care without discrimination;(58)
· the
right to privacy;
· the
right to speedy complaint resolution;(59) and
· the
responsibility to maintain good health.
In 1998, President
Clinton directed the following bodies – the federal Department of Health and
Human Services as well as the departments of Labor, Defense and Veterans’
Affairs and the Office of Personnel Management – to bring their health
programs, including Medicare and Medicaid, into compliance with the consumer
protections proposed in the Commission’s bill by the end of 1999.
The U.S. Congress has been debating patients’ rights
issues since the mid-1990s. In the 106th Congress, the Senate
and the House of Representatives each passed a bill on this subject: the
Bipartisan Consensus Managed Care Improvement Act of 1999 (the Norwood-Dingell
Bill, H.R. 2723)(60) passed
the House of Representatives in October 1999; and Bill S. 1344 passed
the Senate in July 1999. However, Congress was unable to reconcile the
differences between the two bills.
The 107th Congress has also seen patients’
rights proposals. In June 2001, the Senate passed Bill S. 1052, the Bipartisan
Patient Protection Act,(61) while
the House of Representatives passed a patients’ rights bill, H.R. 2563, in
August of the same year.(62)
The bills have important similarities. Under
both bills:
· health
plans would have to reveal to enrollees how they operate;
· health
plans would have to allow enrollees to see specialists outside each plan’s
network when the network does not include the required physician;
· health
plans would be required to pay for emergency care provided to enrollees who
reasonably believed that they needed immediate medical attention;
· enrollees
who were receiving ongoing treatment would be able to continue to be cared for
by their health care provider for a limited period of time after the provider
had left a plan’s provider network;
· health
plans would be required to establish internal processes to review coverage
denials and other decisions.(63)
However, there are also notable differences between
the two bills. One key difference relates to the structure of an
independent system to review challenges to health care plan decisions.
Most states have established an independent review process to review decisions
unfavourable to health plan enrollees. H.R. 2563 would have federal
review procedures override state review processes while S. 1052 would establish
minimum federal standards, but allow states to have their own review programs.(64)
Another, and perhaps the most contentious, difference
relates to the extent of permissible litigation by enrollees against their
health plans. Both bills include provisions that would allow enrollees to
sue their health plans, but there are significant differences in the scope of
the liability provisions. S. 1052 would allow suits to proceed in state
courts under state laws for denial of benefits or quality-of-care issues and in
federal court for other matters. H.R. 2563 would also allow suits in
state courts but under stricter federal rules relating to burden of proof and
damages.(65)
The bills also differ on the amount of damages that an enrollee could
recover. The Senate bill would allow for the recovery of economic damages
(lost wages and medical expenses) and non-economic damages (pain and suffering)
without limitation and up to US$5 million in punitive damages in federal suits
where it was established that the health plan’s actions were in flagrant
violation of an enrollee’s rights and a proximate cause of the enrollee’s
injury or death. H.R. 2563, on the other hand, would allow for the
recovery of economic damages but would cap non-economic damages at US$1,500,000
and would allow punitive damages up to US$1,500,000 in limited circumstances.(66)
Although passed in 2001, these bills have not yet
proceeded to a conference committee for reconciliation. However,
patients’ rights are expected to be back on the legislative agenda in 2002.
State governments were enacting patients’ rights laws
well before legislation was placed before Congress. At the state level,
two forms of statutes predominate – laws that give patients certain rights in
relation to the provision of health care (particularly hospital services), and
laws that provide protections for patients in managed care situations.
Florida’s Patient’s Bill of Rights and
Responsibilities(67) is a representative sample
of state laws that establish patients’ rights in relation to the provision of
health care services. The Florida law requires health care providers and
health care facilities to recognize patients’ rights in the course of medical
care. It also requires patients to respect the health care provider’s or
health care facility’s right to expect certain behaviour on the part of
patients. Under the law, a patient has the right to:
· be
treated with courtesy and respect;
· have
their privacy protected;
· receive
a prompt and reasonable response to questions and requests;
· know
who is providing medical services and who is responsible for his or her care;
· know
what patient support services are available, including interpreter services;
· know
the rules and regulations applying to patient conduct;
· receive
information about diagnosis, planned course of treatment, alternatives, risks
and prognosis;
· refuse
any treatment, except as otherwise provided by law;
· be
given full information and necessary counselling on the availability of
financial resources for patient care;
· receive
a reasonable estimate of the charges for medical care prior to treatment;
· have
impartial access to medical treatment or accommodations, regardless of race,
national origin, religion, physical handicap, or source of payment;
· receive
treatment for any emergency medical condition that will deteriorate from
failure to provide treatment;
· have
access to any medical treatment that is, in the judgement of the patient and
his or her health care practitioner, in the patient’s best interests;
· know
if medical treatment is for purposes of experimental research and to consent to
or refuse to participate in such research; and
· express
grievances about any violation of the patient’s rights.
At the same time,
the law also outlines certain patient responsibilities, including
responsibility for:
· giving
health care providers accurate and complete information about their health;
· reporting
unexpected changes in their condition;
· indicating
whether they understand a contemplated course of action;
· following
the treatment plan recommended by the health care provider;
· keeping
appointments and notifying the health care provider or health care facility if
unable to do so;
· assuring
prompt payment of medical bills; and
· following
health care facility rules and regulations affecting patient care and conduct.
Patients’ rights laws in relation to managed care
differ across U.S. states; however, a number of common themes run through these
initiatives. Typically, patients’ rights initiatives deal with at least
some of the following issues: disclosure of information about medical coverage
to enrollees; mandated coverage of emergency services; utilization of
review/external review relating to the medical necessity of a procedure;
continuity of care; access to specialists; physician incentives; protection of
the doctor-patient relationship; and health care plan liability. These
themes are outlined in more detail below.(68)
· Consumer Information: Most states require HMOs to provide basic
information about their benefits and services to current and potential
enrollees in the plan. Failure to do so could result in fines and
penalties.
· Timely Service and Patient Access to Care: Most states require HMOs to
ensure that plan enrollees have timely access to benefits.
· Specialists as Primary Care Physicians: Many state laws allow plan
enrollees to name a specialist as their primary care doctor, particularly
obstetricians/gynecologists.
· Utilization Review: A number of state laws give plan enrollees the
right to discuss an unfavourable preliminary coverage decision with an HMO
medical director who has the authority to review and change or reverse the
decision.
· Point of Service Provisions: Many states require HMOs to
offer a point of service option or product in their plans that permit plan
enrollees willing to pay higher out-of-pocket costs to receive partial coverage
in relation to services obtained from health care providers outside their plan.
· Continuity of Care: State provisions mandating continuity of care
require an HMO to provide enrollees with the opportunity to continue to obtain
services covered by the HMO plan for a defined period of time (usually 90 days)
from a health care provider who no longer participates in the HMO’s network.
· Ability to Choose and Change Health Care Providers: Some laws require HMOs to
allow enrollees to choose their health care provider from any of the HMO’s
participating providers and to change providers.
· Privacy of Medical Records: State legislation provides for
patient access to, and the confidentiality of, medical records.
· Access to Emergency Services: Many state laws require HMOs to
allow enrollees to seek medical services at an emergency room without prior
authorization from the HMO.
· Physician Incentive Plans:A number of states regulate
“incentive plans” between HMOs and health care providers. State laws
typically provide that HMOs cannot use financial incentive programs to
compensate health care providers for requesting or providing less than
medically necessary and appropriate care. Where incentives are permitted,
HMOs may be required to disclose them to enrollees.
· Health Care Plan Liability: A number of state laws allow
enrollees to sue HMOs in relation to decisions that directly affect their
health; some permit litigation in connection with disputes over plan coverage.(69)
In addition to the kinds of individual rights
typically included within the scope of patients’ rights, Norway has enacted
patients’ rights legislation through The Patients’ Rights Act.(70) The
Act includes various rights, including the right to choice of hospital, the
right to treatment, and the right to get an evaluation from a specialist within
30 days after receiving a referral from a general practitioner.
The Act also sets out rights to:
· receive
emergency medical care;
· participate
in decisions relating to patient care;
· receive
information;
· be
assured that a patient’s medical information will be kept confidential;
· give
consent to treatment;
· have
access to medical records; and
· complain.
A “patient ombud” is established to safeguard
patients’ rights and interests in relation to health services.(71)
A number of countries have developed patients’ bills
of rights. In some nations, patients’ rights have been legislated; in
others, they have been promulgated in charters as non-binding policy
documents. These initiatives often provide for collective rights such as
equal access to health care as well as individual rights that pertain to the
relationship between patients and health care providers or institutions.
Examples of individual rights include: giving consent to treatment,
participating in health care decisions, receiving information about treatment
options and medical procedures, being assured of privacy and confidentiality,
receiving dignified and respectful patient treatment, and having a complaint
investigation and resolution process.
A 2001 paper(72) notes
that a patients’ bill of rights designed to promote understanding and better
enforcement of rights in health care services would improve patients’ ability
to deal with health care providers. However, the authors point out that
such a bill of rights would not address concerns about access to timely
care. They envisage an Ontario bill of rights that would include both
rights to health care by establishing guaranteed maximum waiting times for
health care services along with a Commissioner or Ombudsperson to investigate
complaints about access and timeliness as well as rights when receiving health
care services.(73)
The concept of a patients’ bill of rights is less
well developed in Canada than in a number of other countries. Only since
the late 1990s have proposals to create such bills in this country been
discussed. To date, the majority of Canadian proposals for patients’
bills of rights focus on certain collective and individual rights in relation
to the provision of health care services, but have not included waiting time
guarantees. One of the most detailed of these initiatives is the proposal
put forward in January 2002 by the New Brunswick Premier’s Health Quality
Council which sets out a number of specific rights and responsibilities at
three levels – the individual, the health professional, and the health care
system – and addresses five broad classes of rights. At the federal
level, the Private Member’s bill, Bill C-261, outlines a series of collective
and individual patients’ rights as well as patients’ responsibilities; the bill
proposes to develop these rights through federal-provincial agreements and by
making full cash contributions to provinces under the Federal Provincial
Fiscal Arrangements Act conditional upon the conclusion of
federal-provincial agreements relating to patients’ rights.
Patients’ bills of rights may well be part of the
future landscape of the Canadian health care system. Whether developed
through legislation or as statements of government policy, they can serve as an
important tool for recognizing patients’ rights, defining health care
objectives, and emphasizing the complementary nature of the rights and
responsibilities of patients and health care providers.
(1)
In the United Kingdom, the National Health Service (NHS) patients’ guide
(entitled Your Guide to the NHS) has replaced the Patients’ Charter.
This development is discussed in Section C.
(2)
Canada, Royal Commission on Health Services, Queen’s Printer, 1964, Vol.
1, pp. 11-12.
(3)
Ibid., p. 11.
(4)
Ibid.
(5)
Ibid.
(6)
The services would include: medical services; dental services for children,
expectant mothers, and public assistance recipients; prescription drug
services; optical services for children and public assistance recipients;
prosthetic services; and home care services.
(7)
Ibid.
(8)
R.S.C. c. C-6, section 3.
(9)
Ibid., section 7.
(10)
Bill C-261, An Act to
establish the rights of patients in relation to health, treatment and records,
First Session, Thirty-seventh Parliament, 49-50 Elizabeth II, 2001.
This bill was originally introduced on 7 February 2000 as Bill C-417 but
died on the Order Paper with the dissolution of Parliament for the 27
November 2000 federal election.
(11)
Standing Senate Committee on Social Affairs, Science and Technology, The Health of
Canadians – The Federal Role, Volume Four – Issues and Options,
September 2001.
(12) Ibid.,
p. 47.
(13) Legislative
Assembly of Alberta, Hansard, 24th Legislature, 2nd Session, 28 January
1998.
(14)
Bill 201 was defeated on 4 February 1998.
(15)
Ontario, Ministry of Health and Long-Term Care, Ontario Budget 2000.
(16)
Bill 41, Patients’ Bill of Rights, 1996 (Mrs. Caplan); Bill 50, Health Care
Accountability and Patients’ Bill of Rights Act, 1998 (Mrs. Boyd); and Bill 18,
Health Care Accountability and Patients’ Bill of Rights Act, 1999 (Mrs. Boyd).
(17)
An Act Respecting Health Services and Social Services, 1991, R.S.Q. c. S-4.2.
(18)
Ibid., sections 4-10.
(19)
Ibid., section 13.
(20)
Ibid., section 56.
(21)
Chapter 43, Statutes
2001, An Act respecting the Health and Social Services Ombudsman and amending
various legislative provisions, Royal Assent, 11 December 2001, in
force 1 January 2002, except for certain sections.
(22)
Ibid., section 19.
(23)
Nova Scotia, Provincial Health Council, “Expectations for Health and Health Care in Nova Scotia,”
18 May 2000.
(24)
Ibid.
(25)
Ibid.
(26)
New Brunswick Premier’s Health Quality Council, Health Renewal: Report from the Premier’s Health Quality Council,
January 2002.
(27)
The proposed Charter is outlined on pages 91-95 of the Report from the
Premier’s Health Quality Council.
(28)
Ibid., p. 85.
(29)
The IRPP is an independent, national non-profit public policy research
organization founded in 1972.
(30)
The Institute for Research on Public Policy, IRPP Task
Force on Health Policy Recommendations to First Ministers, 2000, p. 22.
(31)
Ibid., p. 27.
(32)
Ibid., p. 22.
(33)
Ibid., p. 27.
(34)
Ibid., p. 26.
(35)
Ibid., p. 27.
(36)
Ibid., p. 28.
(37)
Ibid.
(38)
Statutes 1994, No. 88.
(39)
S. Cartwright, The Report of the Cervical Cancer Inquiry, 1998.
(41)
One of the features of the right to have services that comply with legal,
professional, ethical and other relevant standards is that it allows the
standards of professional and other bodies to be enforced through the Code by
the Health and Disability Commissioner.
(42)
Under section 14(1)(e) of the Act, the Commissioner can investigate, on
complaint or on the Commissioner’s own initiative, any action that is or
appears to be in breach of the Code.
(43)
Health and Disability Commissioner Act 1994, s. 14.
(44)
Ibid., section 54.
(45)
Ibid., section 30.
(46)
National Health Service, Patient’s Charter.
(47)
England, Scotland, Wales and Northern Ireland have separate charters. The
information in this paper is drawn from the charter for England.
(48)
Greg Dyke, The New NHS Charter – A Different Approach, Report on the new
NHS Charter, December 1998.
(49)
Ibid., pp. 10-11.
(50)
Ibid., p. 16.
(51)
United Kingdom, National Health Service, Your Guide to the NHS.
Patient’s Charters continue to apply in Wales, Scotland and Northern
Ireland.
(52)
For additional information, see the Health Service
Ombudsman's website.
(53) Examples
include the Northern Territory Public Hospital Charter and the South Australia
Charter for Public Health System Consumers.
(54) Jill
A. Marsteller and Randall R. Bovbjerg, “Federalism and Patient Protection:
Changing Roles for State and Federal Government,” August 1999, Urban
Institute, p. 3.
(55) U.S.
Department of Health and Human Services, HSS Fact Sheet, The Patients’ Bill of
Rights in Medicare and Medicaid, 12 April 1999.
(56)
Patients have the right to receive accurate, easily understood information to
assist them in making informed decisions about their health plans, facilities
and professionals.
(57)
Health plans should pay for emergency services when a patient has: symptoms
that a “prudent layperson” would reasonably expect to place the patient’s
health in serious jeopardy; serious impairment to bodily functions; or serious
dysfunction of any bodily organ or part.
(58)
Patients have the right to considerate, respectful care and must not be
discriminated against in the marketing or enrolment or in the provision of
health care services based on race, ethnicity, national origin, religion, sex,
age, current or anticipated mental or physical disability, sexual orientation,
genetic information, or source of payment.
(59)
Patients have the right to a fair and efficient process for resolving
differences with their health plans, health care providers and health care
institutions, which includes an independent system of external review.
(60)
H.R. 2723 was folded into a health “tax and access” bill (H.R. 2990) and passed
the House of Representatives as part of H.R. 2990.
(61)
Bill S. 1052 was sponsored by Senators McCain (R-Arizona), Kennedy
(D-Massachusetts) and Edwards (D-North Carolina).
(62)
Bill H.R. 2563 was sponsored by Representatives Ganske (R-Iowa), Dingell
(D-Michigan) and Norwood (R-Georgia).
(63) Stephanie
Lewis, A Guide to the Federal
Patients’ Bill of Rights Debate, prepared for The Kaiser Family
Foundation, August 2001, p. 4.
(64) Ibid.,
p. 6.
(65)
Ibid., p. 7.
(66)
Ibid., pp. 8-9.
(68)
The themes listed have been summarized from: Douglas A. Hastings, “Patient Rights meet Managed Care: Understanding the Underlying
Conflicts,” reprinted from Journal of Health Law, 1999, pp.
4-7.
(69) For
an overview of state liability laws, see the paper entitled Key Characteristics of
State Managed Care Organization Liability Laws: Current Status and Experience,
August 2001, prepared by Patricia Butler for The Henry J. Kaiser Family
Foundation.
(70)
The Patients’ Rights
Act, Act of 2 July 1999, no. 63 relating to Patients’ Rights.
(71)
World Health Organization, European Observatory on Health Care Systems, Health Systems in Transition: Norway, 2000.
This document gives a detailed overview of the health care system in
Norway.
(72)
Colleen Flood and Tracey Epps, “Can a Patients’ Bill
of Rights Address Concerns About Waiting Lists?” Draft Working
Paper, Health Law Group, Faculty of Law, University of Toronto, 9 October 2001.
(73)
Ibid., p. 23.
--------
CIR
94-4E
The Canada Health Act: Overview and
Options
Odette
Madore
Economics Division
Economics Division
Revised
16 May 2005
PDF (101 Kb, 27 pages)
TABLE OF CONTENTS
D. The Requirements Stipulated in the Act
1. Criteria
2. Provisions
3. Conditions
4. Insured Health Services and Extended Health Care Services
1. Criteria
2. Provisions
3. Conditions
4. Insured Health Services and Extended Health Care Services
THE CANADA HEALTH ACT: OVERVIEW AND
OPTIONS?
The Canada
Health Act (hereafter called the Act) received Royal Assent on 1 April
1984. Through this Act, the federal government ensures that the provinces and
territories meet certain requirements, such as free and universal access to
publicly insured health care. These requirements, or “national principles,”
have helped shape provincial health care insurance plans throughout the
country.
Since its
inception, the Act has been subject to debate. This debate focuses on the
national principles and is part of a broad picture involving factors that are
political (distribution of powers), fiscal (trade-off between health care and
other priorities), and economic (greater cost-effectiveness and efficiency). It
also addresses fundamental concerns about the public sector’s role, including
that of the federal government, in health care funding.
This document
gives an overview of the Canada Health Act. It does not set out to offer
a legal interpretation of the Act; rather, it seeks to take stock of the
evolution of the way it is implemented and examine its future prospects. The
first section reviews the justifications for government intervention in the
health care sector, while the second describes the respective roles of the
federal government and the provinces. The third section traces the historical
background of the Act, and the fourth presents an overview of the requirements
attached to it. In the fifth section, penalties for defaults under the Act are
described, and the sixth section discusses the imposition of penalties. The
seventh section examines the issue of privatization. In the eighth section,
some options are set out for maintaining the Act or improving it.
In Canada,
governments are the main source of funding for health care because they play a
key role in the insurance market. The proponents of government intervention in
this field generally cite economic and social equity factors, as well as
administrative efficiency. First, they explain that government intervention is
necessary to correct potential problems for social equity in the operation of
the private insurance market. They claim that private insurance companies could
refuse to insure high-risk clients or force them to pay a much higher premium
to offset the risk. They believe that government insurance can correct the shortcomings
in the private market by protecting the broadest possible cross-section of the
population and avoiding unreasonable premium hikes which ultimately effect no
improvement in the state of health. Second, they maintain that the private
insurance market does not have a regard for economic equity. They argue that in
a private insurance market, individuals with health problems and a low income
would be subject to the same fee structure as high-income individuals; thus,
economically disadvantaged individuals would have to assume a relatively higher
proportion of health care costs. Government intervention would, then, guarantee
increased access to insurance, regardless of the individual’s ability to pay.
And third, another argument in favour of public health care insurance is that
it yields more efficiencies than private insurers, in terms of lower
administrative costs and economies of scale. Public insurance eliminates costs
associated with the marketing of private health care insurance policies,
billing for and collecting premiums, and evaluating insurance risks. This is
one of the reasons cited for the relatively higher administration costs of the
American system relative to Canada’s.
For these
reasons, governments in Canada have favoured public health care insurance over
private insurance. This approach, which protects all people against risks
related to illness, is essentially based on income tax: all citizens contribute
in accordance with their income, rather than in accordance with the benefits
they expect to derive. Thus, since its introduction, public health care
insurance in Canada has stressed the principle of transferring resources from
the richer to the poorer and pooling the risks between the healthy and the less
healthy.
This does not
mean, however, that the private sector is totally absent from this field in
Canada. Private health care insurance exists, but its scope is limited. To be
more precise, the private market provides additional coverage for health
services that are not insured by the public plan or that are only partially
insured by it.
The fact that
government is present in the field of health care insurance does not mean that
it is also involved in the delivery of publicly insured health services.
Indeed, the delivery of health care in Canada is largely in the hands of the
private sector: most medical practitioners are in private practice (small
businesses) and hospitals are to a great extent private, non-profit
organizations (however, physician and hospital services and remuneration for these
are subject to government regulation). Laboratory and diagnostic services paid
for by public health care insurance are delivered by private for-profit
facilities in most provinces. Laundry services, meal preparation and other
support or ancillary services that are provided in publicly funded hospitals
are often delivered by private for-profit companies.
The federal and
provincial governments have very different responsibilities in health care.
Strictly speaking, the federal government cannot establish and maintain a
national health care insurance plan because it cannot regulate the delivery of
health care to individuals; under the Canadian Constitution and its
interpretation by the courts, health care is a field primarily under provincial
jurisdiction. The only explicit references in the Constitution to health care
issues give the federal government jurisdiction in matters relating to navy
hospitals and quarantine. In addition, the federal government is responsible
for delivering health services to groups that fall under its jurisdiction, such
as Aboriginal peoples, the Canadian forces, veterans, and inmates in federal
penitentiaries. Provincial governments are responsible for administering the
public health care insurance plan in their own province. They also have
responsibility for health care delivery. This includes, for example:
determining how many beds will be available in a province; deciding what
categories of staff will be hired; determining how the system will serve the
population; approving hospital budgets; and negotiating fee scales with the
medical association and other health professional organizations.
The federal government has
intervened in the provincial health care field by using its constitutional
“spending power,” which enables it to make a financial contribution to certain
programs under provincial jurisdiction, generally subject to provincial
compliance with certain requirements. Pierre
Blache, in an article published in 1993 in the Revue générale de droit,
indicates that in his opinion, it is the constitutional imbalance between
powers and responsibilities, together with inter-provincial equity factors,
that brought about federal transfers such as those to the health care sector:
The scale of transfer payments from the
federal government to the provincial governments has increased in Canada as a
result of the characteristics of the constitution and reality. It is because
Canadian provinces have been given the potentially most expensive
responsibilities in the modern state, while being limited to direct taxation,
and because many of them have found themselves faced with a tax base below the
national average, that recourse to the spending power has become so important
in the practical workings of Canadian federalism. … Against such a background,
it appeared unfair to leave it to the provinces to fund the social programs
demanded by the people, out of their own resources. (p. 38) [translation]
Consequently, the federal government has intervened in an
area under provincial jurisdiction, but without changing the division of powers
stipulated in the Constitution. Although the federal government is not
responsible for health care administration, organization or delivery, it can
exert considerable influence on provincial health care policies by using the
political and financial leverage afforded by the spending power. In fact, by
setting the requirements for providing federal funding, the Canada Health
Act has to a large extent shaped provincial health care insurance plans
throughout the country.
Public health
care insurance as it is known today, in which the federal government’s
financial contribution is linked to provincial compliance with specific
requirements, dates back to the late 1950s. Under the Hospital Insurance and
Diagnostic Services Act of 1957 and the Medical Care Act of 1966,
the federal government made an offer to the provinces to fund approximately
half the cost of all insured health services. In return for federal
contributions, the provinces – as part of their public health care insurance
plans – undertook to insure hospital and physician services and to comply with
certain requirements, such as universality. These two Acts did not prevent
provinces from demanding a financial contribution from patients; however,
because federal contributions were proportional to provincial government
expenditures, the provincial governments had nothing to gain from imposing
direct patient charges. In fact, the revenue from such charges would have
resulted in a reduction in the federal contribution. This implicit reduction
mechanism thus strongly deterred provinces from adopting any form of direct
patient charges, such as extra-billing and user charges.
In 1977, this
formula of shared costs was replaced by a method of block funding based on cash
transfers and tax point transfers as part of Established Programs Financing
(EPF). Both federal Acts on hospital services and medical care and the
requirements attached to them were retained. However, the implicit mechanism
for deducting federal contributions was eliminated with the EPF, because
federal funding was no longer linked to provincial government expenditures;
this resulted in a proliferation of direct patient charges. For example,
Newfoundland, New Brunswick, Quebec, Ontario, Saskatchewan, Alberta and British
Columbia levied user charges; and extra-billing was authorized in most
provinces. The federal government saw this situation as posing a threat to the
principle of free and universal access to health services throughout the
country. It was therefore anxious to reassert its commitment to the principle
of universal health care insurance; and it relied heavily on the criterion of
economic equity to justify its intervention. A document issued by Health and
Welfare Canada in 1983 stated:
The Government of Canada believes that a
civilized and wealthy nation, such as ours, should not make the sick bear the
financial burden of health care. Everyone benefits from the security and peace
of mind that come with having pre-paid insurance. The misfortune of illness
which at some time touches each one of us is burden enough: the costs of care
should be borne by society as a whole. That is why the Government of Canada
wishes to re-affirm in a new Canada Health Act our commitment to the essential
principle of universal health insurance.
This document paved the way for the Canada Health Act,
which, as stated earlier, was passed on 1 April 1984. The Act combined and
updated the two federal Acts of 1957 and 1966. The national principles were
reaffirmed in the Act, but extra restrictions were specifically added to deter
any form of direct patient charges and to provide citizens of all provinces
with access to health care regardless of ability to pay.
On 1 April 1996, the Canada Health Act was linked to
the Canada Health and Social Transfer (CHST), which merged EPF transfers with
Canada Assistance Plan (CAP) transfers. The method of calculation adopted for
the CHST was similar to that used for the EPF, and included both cash transfers
and tax point transfers. The provinces had to meet all the requirements of the
Act in order to be eligible for the full CHST cash transfer. Since 1 April
2004, the Canada Health Act is linked to the Canada Health Transfer
(CHT). The CHT resembles its predecessor; it is made up of both cash and tax
point transfers, and its cash component is subject to the requirements of the Canada
Health Act. In contrast to the CHST, however, the CHT is expressly
dedicated to health care.
The Canada
Health Act sets out nine requirements that provincial governments must meet
through their public health care insurance plan in order to qualify for the
full federal cash contribution under the CHT. These nine requirements include
five criteria, two specific provisions and two conditions. The five criteria,
which are often referred to as the
“national principles,” are public administration, comprehensiveness, universality, portability, and accessibility; they apply to insured health services. The two specific provisions relate to user charges and extra-billing for insured health services. The two conditions pertain to the provision of provincial information and provincial recognition of federal contributions; they apply to both insured health services and extended health care services.
“national principles,” are public administration, comprehensiveness, universality, portability, and accessibility; they apply to insured health services. The two specific provisions relate to user charges and extra-billing for insured health services. The two conditions pertain to the provision of provincial information and provincial recognition of federal contributions; they apply to both insured health services and extended health care services.
Section 8 of the
Act deals with public administration. Under this section, each
provincial health care insurance plan must be administered on a non-profit
basis by a public authority, which is accountable to the provincial government
for its financial transactions. This arrangement is largely explained by the
considerable amount of money devoted to the health care sector and the need for
governments to keep some control over the growth of these expenditures. It is
also designed to allow information to be consolidated. Perhaps more
importantly, the original policy objective of this criterion was to prevent
provinces and territories from using federal contributions to subsidize the
coverage of provincial and territorial residents by private insurance
companies. In Canadian literature, reference is frequently made to the concept
of “single payer” to describe the concept of administration of health care
insurance by a public authority.
Under the
criterion of comprehensiveness stipulated in section 9, the health care
insurance plan of a province must insure all services that are “medically
necessary.” The criterion of comprehensiveness refers in a way to a minimum
basket of services, because the Act neither mentions the quantity of services
to be provided nor gives a detailed list of what services will be insured;
provincial governments can define these. Thus, the range of insured services
may vary among provinces and from one year to the next.
Under section
10, the criterion of universality demands that all residents in the
province have access to public health care insurance and insured services on
uniform terms and conditions. Initially, the concept of universality focused on
two specific objectives. First, it sought to make insured services available to
everyone, everywhere. Second, it sought to pool the risks among those insured;
the more people the plan covered, it was said, the more the risk sharing would
be cost-effective.
As stipulated in
section 11, the criterion of portability requires provinces to cover
insured health services provided to their citizens while they are temporarily
absent from their province of residence or from Canada. For insured health
services provided in another province, payment is made at the rate negotiated
by the governments of the two provinces. For out-of-Canada services, the Act
states that the amount paid will be at least equivalent to the amount the
province of residence would have paid for similar services rendered in that
province.
The fifth
criterion, accessibility, is set out in section 12: insured persons must
have reasonable and uniform access to insured health services, free of
financial or other barriers. No one may be discriminated against on the basis
of such factors as income, age, and health status.
Free access to
insured health services is the key factor of the Canada Health Act. The
two provisions of the Act specifically discourage financial contributions by
patients, either through user charges or extra-billing, for services covered
under provincial health care insurance plans.
With respect to
the two conditions, provincial governments are required by regulation to
provide annual estimates and statements on extra-billing and user charges. They
are also required to provide voluntarily an annual statement describing the
operation of their plans as they relate to the criteria and conditions of the
Act. This information serves as a basis for the Canada Health Act annual
report. In addition, provinces are required to give public recognition of
federal transfers.
The Act makes a
distinction between “insured health services” (i.e., those that have been
deemed “medically necessary”) and “extended health care services.” So-called
medically necessary services are defined only in the broad sense of the term in
the Act. Section 2 states that insured health services – which must be
fully insured by provincial health care insurance plans – comprise:
· hospital
services that are medically necessary for the purpose of maintaining health,
preventing disease or diagnosing or treating an injury, illness or disability,
including accommodation and meals, physician and nursing services, drugs and
all medical and surgical equipment and supplies;
· any medically required services rendered
by medical practitioners; and
· any medically or dentally required
surgical-dental procedures which can only be properly carried out in a
hospital.
Section 2 of the Act also stipulates that extended
health care services include intermediate care in nursing homes, adult
residential care service, home care service and ambulatory health care
services. Because these services are not subject to the two provisions relating
to user charges and extra-billing, they can be charged for at either partial or
full private rates. Similarly, extended health care services are not subject to
the five criteria of the Act. As such, they do not have to be publicly administered,
universal, comprehensive, accessible or portable. In addition, provincial
health care insurance plans may cover other health services, such as optometric
services, dental care, assistive devices and prescription drugs, which are not
subject to the Act, and for which provinces may demand payment from patients.
The range of such additional health benefits that are provided under provincial
government plans, the rate of coverage, and the categories of beneficiaries
vary greatly from one province to another.
Penalties under
the Canada Health Act are linked to federal transfers to the provinces.
More precisely, each provincial health care insurance plan must comply with the
requirements of the Act before the province receives its total entitlement of
cash transfers. If a province fails to comply, the federal government may
impose a penalty and withhold part or all of the transfers. Between 1984-1985
and 1990-1991, this financial penalty was applied to that portion of EPF cash
transfers earmarked for health care. Between 1991-1992 and 1995-1996, financial
penalties were not limited solely to federal cash transfers for health care. In
fact, the government expanded the penalties to cover other cash transfers. It
had become necessary to extend the financial penalty to transfer payments in
other fields because of the federal government’s continued restriction on the
growth rate of EPF transfers and its specific impact on cash transfers. Studies
such as those conducted by the National Council of Welfare in 1991 and Jenness
and McCracken in 1993 had predicted that EPF cash transfers to some provinces
would be non-existent by the year 2000. These additional withholdings or
deductions were not stipulated in the Canada Health Act, but were
specifically set out in paragraphs 23.2(1), 23.2(2) and 23.2(3) of the Federal-Provincial
Fiscal Arrangements Act, the legislation that established the EPF and then
governed the CHST. These provisions apply as well to the CHT under paragraphs
25.6(1), 25.6(2) and 25.6(3).
By introducing
the CHST, the federal government moved to prevent the erosion of its power to
enforce compliance with the Canada Health Act across the country.
Obviously, if a province were to decide to forgo its cash entitlement under the
CHST, it would no longer be required to comply with the requirements of the Canada
Health Act. Although the Act is now linked to the new CHT, the penalties
still apply to total cash transfers to the provinces for health and social
programs, as well as to other federal cash transfers.
The financial
penalties stipulated in the Act vary depending on whether a default is directly
related to extra-billing and user charges or involves failure to satisfy any of
the five criteria or the two conditions. Sections 18 to 21 of the Act, which
describe the provisions relating to penalties for extra-billing and user
charges, stipulate that the federal government may withhold one dollar of cash
transfer for every dollar collected through direct patient charges. In the case
of failure to satisfy the criteria or conditions, section 15(1)(a) of the Act
stipulates that the cash value of the penalty is left to the discretion of the
Governor in Council, who sets the amount depending on the “gravity” of the
default. As Sheilah L. Martin suggested in a paper published in 1989, the
discretionary nature of this penalty does not require the federal government to
impose a fine, but leaves it the option of doing so. At one extreme, Cabinet
could decide to withhold all CHT cash transfers, and even reduce federal
contributions paid as part of other programs. At the other extreme, the federal
government could decide not to impose any financial penalty and to confine its
action to persuasion and negotiation.
The Act also
includes a conflict resolution mechanism for cases where a province violates
the requirements of the Act. It is a long process, however, with the result
that federal contributions are not reduced immediately. In the event that
Health Canada deems that a provincial plan is failing to satisfy any one of the
five criteria or the two conditions, under section 14(2) it must inform the
province of the problem, obtain its explanations, draft a report on its
concerns and, if the provincial Health Minister so requests, hold a meeting to
discuss the issue. Section 15 states that where the Governor in Council is
convinced that a province no longer meets the criteria and conditions of the Canada
Health Act, the Minister of Health may direct by order that federal
contributions be reduced or withheld.
Since April 2002, the conflict
resolution mechanism embodied in the Canada Health Act is facilitated by
a Dispute Avoidance and Resolution (DAR) process. The purpose of the DAR is to
formalize and make transparent the process that the federal Minister of Health
must follow prior to forming an opinion as to whether a provincial or
territorial health care insurance plan has ceased to satisfy any of the Act’s
criteria, provisions or conditions. As a first step, the federal Minister of
Health invokes, in a letter to the province(s) or territory(ies) concerned, the
DAR process in relation to a potential case of non compliance with the Canada
Health Act. Within 60 days of the date of that letter, the governments
involved in the dispute will jointly: collect and share all relevant facts;
prepare a fact-finding report; negotiate to resolve the issue in dispute; and
prepare a report on how the issue was resolved.
If, however, there is no agreement
on the facts, or if negotiations fail to resolve the issue, any Minister of
Health involved in the dispute may undertake to refer the issue to a
third-party panel by writing to his or her counterpart. Within 30 days of the
date of that letter, a panel will be struck. The panel will be composed of one
provincial (or territorial) appointee and one federal appointee, who, together,
will select a chairperson. The panel will assess the issue in dispute in
accordance with the provisions of the Canada Health Act, will undertake
fact-finding and provide advice and recommendations. The panel will then report
to the governments involved on the issue within 60 days of appointment.
The final authority to interpret
and enforce the Canada Health Act remains with the federal Minister of
Health. In deciding whether to invoke the penalty provisions of the Act, the
Minister will take the panel’s report into consideration.
On three occasions, the federal
government has resorted to mandatory penalties and reduced its contributions to
some provinces that were authorizing extra billing or imposing user charges.
First, it deducted more than $244,732,000 from EPF transfers to all the
provinces from 1984-1985 to 1986-1987.
However, it also complied with section 20(6) of the Act, under which a province
was able to recover these funds if it terminated all forms of direct patient
charges within three years after the Act came into force, i.e., before 1 April
1987. Because all provinces complied with the Act within this timeframe, the
amounts withheld were all reimbursed.
Second, from
1992-1993 to 1995-1996, the federal government withheld some $2,025,000 in EPF
cash transfers to British Columbia because approximately 40 medical
practitioners in that province had opted out of the province’s health care
insurance plan in 1993 and resorted to extra-billing. These doctors have since
discontinued this practice.
Finally, since
1995-1996, the federal government has imposed penalties on provinces that
permit private clinics to demand facility fees from patients for medically
required services, having determined that such facility fees constitute user
charges. These penalties have applied to five provinces. By the time the
deductions from transfers to Alberta ended in July 1996, a total of $3,585,000
had been deducted from that province. Similarly, a total of $284,430 had been
deducted from Newfoundland, which started to comply with the Act in January
1998. The penalties imposed on Manitoba ($2,355,201 in total) were discontinued
as of 1 February 1999. A total of $372,135 was deducted from transfers to Nova
Scotia, which was deemed in compliance with the Act in November 2003. Between
2002-2003 and 2003 2004, a deduction totalling $173,385 was made to British
Columbia’s CHST cash transfer in respect of instances of user charges levied in
private surgical clinics. Although no other deductions have been made, the
issue of imposing user charges at private facilities is still ongoing in
British Columbia.
Until now,
however, there has been no discretionary penalty for failure to comply with the
five criteria stipulated in the Act, despite some complaints regarding, for
example, portability and comprehensiveness.
There are claims
that several provinces are violating the criterion of portability. For example,
in 1988, Quebec refused to sign the reciprocity agreement whereby other
provinces would be reimbursed according to their own rates for services they
provided to Quebeckers outside Quebec. Moreover, Canadians must increasingly
resort to private insurance when abroad: New Brunswick, Quebec, Saskatchewan,
Alberta and British Columbia have reduced their coverage for emergency hospital
services obtained outside Canada. Some experts, who accuse the federal
government of inaction in this area, explain that the scope of the portability
criterion is clearly defined in the Act, where the terms and conditions for
reimbursement of out of-province services are stipulated. For its part, the
Commission on the Future of Health Care in Canada (Romanow Commission)
recommended that the criterion of portability be limited to guaranteeing
portability of coverage within Canada.
Likewise, some
people believe the criterion of comprehensiveness is not being observed in
practice, because provinces do not necessarily cover the same basket of insured
health services or medically required services. They also believe that cutting
government expenditures could compromise this principle even further and that
the process of de-insuring begun in recent years could lead to the
balkanization of provincial health care insurance plans. Federal legislation
defines only the major outline of insured services and leaves each province
complete freedom to determine what services its public plan will provide.
However, de insurance emphasizes the gaps between provinces in their coverage
of health services; these discrepancies are likely to become increasingly
difficult to justify. Moreover, de-insurance with the sole purpose of reducing
public health expenditures could ultimately undermine the criterion of free
access, inasmuch as it has not been proved which services are or are not
medically necessary. This raises the thorny problem of how to determine when a
service is medically necessary. It could prove difficult to determine the
limits of any list of medically necessary health services. Furthermore, it is
hard to know how far the federal government can intervene in defining insured
services, without encroaching on provincial jurisdiction.
It is important
to note that, although discretionary penalties have never been applied, a
number of cases of non-compliance have been resolved through discussion,
negotiation and persuasion. Although this approach may lead to less friction in
federal-provincial relations, it does not lead to a speedy resolution of
violations to the Act. In his November 1999 report (Chapter 29), the Auditor General
of Canada pointed out that six cases of non-compliance had been resolved
through discussion and negotiation; however, four of them took 14 to 48 months
to resolve, while the remaining two went on for as long as five years without
any penalty. In her September 2002 report (Chapter 3), the Auditor General of
Canada identified twelve new possible cases of non compliance that had arisen
since 1999; Health Canada once again attempted to resolve them through means
other than penalties. Only two of these cases have been resolved.
This section
attempts to shed some light on the current confusion over the concept of
privatization and its implications in terms of the Canada Health Act.
Privatization is
the process whereby the government transfers some of its activities or
responsibilities to the private sector. With respect to health care,
privatization of financing is not the same as privatization of delivery.
Privatization of financing is achieved by shifting the burden of funding away
from public health care insurance plans and towards patients and/or their
private insurance companies. Privatizing the delivery of health care implies
greater reliance on individuals and institutions outside government for the
production and provision of health services. In Canada, difficulties with
respect to privatization revolve primarily around the financing of health care,
because health care delivery is already largely private in nature. In fact,
governments deliver relatively few health services directly. Most health care
providers (e.g., physicians, physiotherapists and pharmacists) are in private
practice; they are not government employees. The vast majority of hospitals and
long-term care institutions are not for-profit and are privately owned;
although they are funded by government, they are not owned by government.
Privatization of
health care financing can be achieved in two ways: either actively, by
containing public health care costs; or passively, by shifting the care outside
traditional settings. Active privatization is the direct result of the partial
or total de-insurance of publicly funded health services. In the 1990s, in an
effort to reduce public health care costs and to balance their budgets, most
provinces limited the coverage provided under their health care insurance
plans. A list of de-insured services by province is presented in the following
table. For the most part, medically required hospital and physician services
remain covered by provincial health care insurance plans. In fact, public
funding accounts for approximately 91% of hospital expenditures, while 99% of
total physician services are financed by the public sector (according to data
from the Canadian Institute for Health Information). Nevertheless, de insurance
has generated disparities in provincial health care coverage. For example, the
removal of warts is no longer covered in Nova Scotia, New Brunswick, Ontario,
Manitoba, Alberta, Saskatchewan and British Columbia, but it remains publicly
insured in Newfoundland, Quebec and Prince Edward Island. Although stomach
stapling is covered in most provinces, it is not insured in New Brunswick, Nova
Scotia and the Yukon, and patients in these provinces/territories must pay for
this procedure. In addition, coverage varies widely across the country in the
areas of reproductive services.
Passive
privatization mainly refers to the gradual shift towards non-institutional care
provided in the home and the community. Less invasive medical techniques and
shorter hospital stays have allowed Canadians to receive more medical care in
their homes and in the community. As a result, many services that are deemed
medically necessary today are not publicly insured because they are not
provided in hospitals or by physicians. Consequently, many commentators contend
that the realities of health care have shifted considerably since 1984, when
the Canada Health Act, with its focus on hospitals and physician
services, was passed. In other words, the definition of “medically necessary
services” has not kept pace with the way services are now delivered. The
National Forum on Health subscribed to this view when it stressed that it would
be essential to “fund the care, not the institution.” Accordingly, it
recommended that public health care insurance be expanded to cover a wider
range of services and, in the first instance, home care and prescription drugs.
It is believed that the scope of the Canada Health Act could be broadened
without challenging in any way the requirements embodied in that Act. The
report of the Romanow Commission supported this view and made very similar
recommendations.
DE-INSURED HEALTH CARE SERVICES BY PROVINCE
|
|
Services*
|
Province
|
Routine circumcision of newborn
|
Nfld, PEI, NS, NB, Ont, Alta, Yk
|
Xanthelasma excision
(removal of fatty spots on eyelids) |
Nfld, NS, Ont
|
Hypnotherapy
|
Nfld
|
Removal of impacted teeth
|
Nfld
|
Otoplasty
|
Nfld, PEI, NB, Ont, Alta
|
Gastroplasty (stomach stapling)
|
NB, NS, Yk
|
Tattoo removal
|
Sask, Man, Ont
|
Reversal of sterilization
|
PEI, NB, Ont, Man, Sask, Alta, Yk
(uninsured service in NS and BC) |
Penile prosthesis
|
NS, Ont, Sask
|
Psychoanalysis
|
Man, QC
|
Eye examination (people aged 19 to 64)
|
PEI, NS, NB, QC, Man, Sask, Alta
|
Wart and benign skin lesion removal
|
NS, NB, Ont, Man, Alta, Sask, BC
|
Second or subsequent ultrasounds in uncomplicated pregnancies
|
NS, BC
|
In vitro fertilization
|
Ont, Man (uninsured service in Nfld,
NS, NWT |
Simple sclerotherapy
(removal of varicose veins) |
QC, Ont, Man (uninsured service in NS)
|
Artificial/intrauterine insemination
|
NS, NB (uninsured service in Alta)
|
Ear wax removal
|
NS
|
Anaesthesia associated with
a non-insured service |
NB, Sask, Alta
|
Chiropractic services
|
Sask
|
Epilation of facial hair
|
PEI, Ont
|
Eye refractions
|
Nfld, Sask
|
Cosmetic surgery
|
Alta (uninsured service in Nfld, NS, PEI, NB, QC, Man, Sask, BC, Yk,
NWT)
|
Breast reduction/augmentation
|
NS, NB, Ont, BC
|
*Some exceptions may apply.
Source: Canadian Medical Association, Uninsured Medical Services - A Canadian Perspective, February 1997.
Source: Canadian Medical Association, Uninsured Medical Services - A Canadian Perspective, February 1997.
In the Canadian context of health care, the main concern
with respect to privatization is that it can lead to a “two-tier” system – one
that allows some patients to pay privately and receive priority access to
health care, while the rest of the population who use the publicly funded
health services must face longer waiting times. The issue over privatization surfaced
in 1995, when the federal government implemented its policy on private clinics.
There are two categories of private clinics: semi-private
clinics and fully private clinics. Semi-private clinics are facilities that
receive public funding for medically required services under a provincial
health care insurance plan, but also demand payment (“facility fees”) from the
patient. For the federal government, facility fees present a problem because
people who can afford to pay them get faster access to services. In 1995, the
federal Minister of Health stated that such semi-private clinics fall under the
Canada Health Act because: (1) they are included in the definition of
“hospitals” set out in the Act; (2) they provide medically necessary services;
and (3) they receive public funding. Therefore, semi-private clinics contravene
the Canada Health Act because the facility fees they require from
patients constitute a form of user charges.
Fully private clinics are facilities that receive no
government funding: the physicians are not reimbursed by the provincial health
care insurance plan and their patients must pay the full cost of the services
rendered to them. The creation of such clinics does not result in a reduction
in provincial transfers, and the provisions relating to extra-billing or user
charges do not apply in such cases. It is, however, possible that the federal
government might decide to intervene by invoking the Act’s criterion of
accessibility should it be decided that fully private clinics threaten access
to the insured services provided by the public system. This could happen if
these clinics were to offer financial incentives to health care providers that
might draw them away from the public system.
In practice, few physicians leave the public system because
it is hard to attract a sufficient number of patients who want to pay full
health care costs when they also have access to the public system. Private
insurance for medically necessary services is discouraged, by both federal and
provincial legislation. The Canada Health Act requires provincial health
care insurance plans to be accountable to the provincial government and to be
non-profit, thereby effectively preventing private insurance plans from
covering medically required services. Moreover, the majority of provinces
(British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Quebec, New
Brunswick and Nova Scotia) prohibit private insurance companies from covering
services that are also guaranteed under public health care insurance plans.
Concerns over privatization were raised again in 2000, when
the Alberta government enacted legislation (Bill 11) with respect to
contracting with the private sector for medically necessary surgical services.
This legislation allows Regional Health Authorities (which are publicly funded)
to contract with a private provider – either a for-profit or a not-for-profit
entity – for the provision of surgical services. The patient is not supposed to
incur any out of-pocket expenditures, as the costs related to the surgery will
be fully insured by the provincial health care insurance plan. Regional Health
Authorities are also responsible for coordinating the delivery of uninsured
surgical services requiring an extended stay by the patient. The Alberta
government believes that contracting with privately operated facilities for
surgical services will reduce waiting lists in the public system, improve
access, and enhance efficiency. Private providers will be required to operate
within the requirements of the Canada Health Act. The Alberta government
believes that the Act does not prevent a public health care facility from
contracting out any of its services to the private sector.
Nonetheless, the then federal Minister of Health expressed
concerns over the long-term impact of the Alberta legislation. Among other
things, he questioned whether private providers would provide faster or more
cost-effective services than would existing public hospitals (if these were
receiving the additional funding). He also raised the issue of whether the
expansion of private for-profit facilities would help sustain the delivery of
health care, or would undermine the letter and spirit of the Canada Health
Act.
In some provinces, the operation of private clinics that
offer magnetic resonance imaging (MRI), X-ray, ultrasound and computed
tomography (CT) scanning services also raises concerns over the accessibility
criterion of the Act. Queue jumping is one of the dangers of these clinics. For
example, individuals who can afford to pay may be able to get their diagnostic
tests done more quickly. They then return to the publicly funded system for
treatment one step ahead of patients awaiting diagnostic tests. In September
2000, the federal Minister of Health wrote to his counterparts in Alberta and
Quebec to obtain more information on private diagnostic imaging clinics
operating in those provinces. In July 2003, the Minister wrote again to four
provinces to outline concerns about private MRI and CT scan clinics. Although
consultations with provincial officials followed, these discussions were
postponed at the request of the provinces.
Once
again in April 2005, the federal Minister of Health wrote to Alberta, British
Columbia, Quebec and Nova Scotia to express concerns over private for-profit
diagnostic imaging clinics that operate in those provinces. The concerns relate
to medical necessity (comprehensiveness), private payment (user charge
provisions) and queue jumping (accessibility) and the potential for
non-compliance under the Canada Health Act. Should consultations with
the four provinces prove inconclusive, the DAR process could be initiated with
the view of ensuring that private clinics delivering diagnostic imaging
services do so in compliance with the Canada Health Act. This process
could yield useful information and clarification concerning the role and impact
of private for-profit health care delivery.
In the current context of
structural health care reform, it has often been asked whether the Canada
Health Act can be maintained or whether it would be wiser to amend it.
Some analysts
believe the Act should be kept as it is. In their view:
· any
change in the five criteria on which public health care insurance is based
would undermine the greatest achievements of the health care system in Canada;
· the need to contain public health care
costs should not be used to justify overhauling the Act;
· the five criteria of the Act can be
maintained while the system is reorganized to improve clinical and economic
effectiveness;
· effective allocation of public funds,
together with a more judicious use of staff and medical care, would enable the
government to reduce overall public health care expenditures and fund a wide
(or even wider) range of effective and necessary services; and
· the status quo is to some extent
preferable, given that most provinces have already reformed their health care
delivery system by focusing on greater efficiency.
For a growing number of experts, however, the status quo
is unacceptable. They say the Canada Health Act must be amended. Some
suggest clarifying what is meant by “comprehensiveness” or “medically necessary
services.” Those who believe the criterion of comprehensiveness in the Act is
vague and imprecise point out that clarification in this area would produce
many benefits. First, the services for which the public sector must be
responsible would be clearly set out; second, greater uniformity in the range
of services throughout the country could be achieved, thus ending the
balkanization of provincial health care insurance plans. Clarification could
also help define medical necessity, taking into account important factors such
as clinical, economic and ethical considerations.
The Act could be clarified in three different ways. First,
a definition of the term “medically required” could be added to section 2.
Second, also in section 2, definitions relating to physician services, hospital
services and extended health care services could be given. Third, the
provisions in section 22 could be invoked, under which the federal government
may establish by regulation: (1) a definition of extended health care services;
and (2) the list of hospital services that would be excluded from all insured
services. The Act stipulates that such regulations cannot be made unilaterally,
without the agreement of each province.
However, there is no general agreement on these three
options. Some analysts claim that until now the Act has given the provinces the
latitude they need to interpret these terms in keeping with their own economic,
political and social conditions. They believe that excessively specific
definitions might limit the options of provincial governments to address the
specific needs and values of their own residents.
Some experts favour the imposition of direct patient
charges for services covered by government health care insurance plans. They
explain that such action would help limit the abuse of health care by some
patients, while reducing public health care expenditures. The effects of user
charges on the use of health services and on public expenditures have been the
subject of lively debate for some time and will not be discussed here. However,
it should be pointed out that many analysts believe user charges are a step
backwards, because the Act was adopted with the express purpose of discouraging
such fees.
Finally, some people believe the Act creates inflexibility
by limiting the options available to provincial governments in their fight to
reform the delivery of health care and increase effectiveness and efficiency in
this sector. Their solution, which is undoubtedly the most radical, would be to
repeal the Act. It is difficult to foresee the consequences of such an action.
For example, it might have no effect: if the vast majority of Canadians remain
satisfied with the current system, pressure from voters might in itself be
sufficient to force provincial governments to maintain the requirements of
public health care insurance across the country. On the other hand, repeal of
the Act might result in a large number of experimental systems in Canada;
provincial health care insurance plans would undoubtedly vary greatly,
especially among provinces with very different tax bases.
The federal government has already made its position known.
By introducing the Canada Health and Social Transfer and its successor, the
Canada Health Transfer, it has taken steps to maintain an adequate level of
funding as well as the authority conferred upon it by the Canada Health Act.
Moreover, the 1995 federal policy on private clinics and the successive letters
of concern related to private diagnostic imaging clinics (2000, 2003, 2005)
suggest that the federal government is prepared to initiate the DAR process to
ensure compliance with the Canada Health Act.
In Canada,
governments have intervened in health care in order to promote social and
economic equity in this area. First, with the adoption of the Hospital
Insurance and Diagnostic Services Act in 1957, and then with the Medical
Care Act in 1966, the federal government used its spending power to
transfer funds and attach requirements it considered important, but without
regulating this sector, which is under provincial jurisdiction. By passing the Canada
Health Act in 1984, however, Parliament did affect the provincial health
care insurance plans in that it imposed nine requirements, including five
specific criteria. These criteria guarantee all Canadians access to medically
necessary physician and hospital services, free of financial or other barriers,
within a system publicly administered on a non-profit basis. They also
guarantee reimbursement for insured health care services received anywhere in
Canada or abroad.
The five
criteria stipulated in the Canada Health Act are not new: they were
already set out in previous legislation on medical and hospital care. What was
new in the 1984 Act was the provision of penalties for defaults, i.e., for the
failure of provincial governments to comply, as part of their health care
insurance plan, with the criteria stipulated in the Act. Federal cash transfers
made as part of the EPF, CHST or CHT, as well as other transfers to provincial
governments, were or are conditional on the province’s compliance with these
criteria.
In the years
since the Act was adopted, the provinces have complied to a great extent with
the five criteria and other provisions of the Act, although the federal
government has had to intervene to ensure compliance with respect to extra-billing
and user charges. The federal government has not, however, imposed penalties
for some of the failures to comply with the five criteria of public health care
insurance. It has preferred to limit its action, at least so far, to persuasion
and negotiation. Some people have criticized this approach and have referred to
the federal government’s inaction and inability to enforce the criteria. Given
the division of powers between the two levels of government, it can be expected
that intervention by the federal government in this area could lead to conflict
with the provincial governments and that warnings alone might not be enough to
secure the provincial governments’ cooperation.
Overall, any proposal for reforming
the Canada Health Act will inevitably have to consider factors that are
constitutional (distribution of powers), political (feasibility and voter
approval), and economic (cost effectiveness).
1 April 1984 -
The Canada Health Act received Royal Assent.
May 1994 - In
accordance with the Act, the Governor in Council withheld $1,750,000 in EPF
transfer payments from British Columbia because some medical practitioners in
that province had withdrawn from the government health care insurance plan and
resorted to extra-billing in 1993.
September 1994 -
Federal/provincial/territorial meeting of Health Ministers in Halifax, Nova
Scotia. All Ministers present, except the Alberta Minister, agreed to “take whatever
steps are required to regulate the development of private clinics in Canada,
and to maintain a high quality, publicly funded Medicare system.”
January 1995 -
The federal Health Minister, the Honourable Diane Marleau, sent her provincial
counterparts a letter informing them of the federal government’s intention to
impose financial penalties on provinces whose private clinics demand extra fees
from patients in addition to the amount reimbursed by health insurance. The
provinces had until 15 October 1995 to comply with this new interpretation of
the Act.
June 1995 - Bill
C-76, under which EPF transfers would be combined with CAP transfers to create
a new form of block funding, received Royal Assent.
Section 6 of the
Canada Health Act was removed as a consequential amendment to Bill C-76.
Despite this repeal, extended health care services continue as part of the Act
in the same manner they have since 1984. As such, they still remain subject
only to conditions related to the provision of information and recognition of
federal transfers, as set out in section 13 of the Act.
November 1995 -
The federal Health Minister, the Honourable Diane Marleau, stated that the
federal government had begun imposing cash penalties on all provinces in which
semi-private clinics charged user fees. These provinces were Alberta, Manitoba,
Nova Scotia and Newfoundland.
April 1996 - The
new CHST came into force, combining EPF and CAP transfers.
July 1996 -
Health Canada lifted the penalties imposed on Alberta when that province began
complying with the Act.
January 1998 -
The penalties imposed on Newfoundland with respect to private clinics were
lifted.
February 1999 -
Health Canada discontinued the penalties imposed on Manitoba with respect to
the federal policy on private clinics.
September 2000 -
The federal Health Minister, the Honourable Allan Rock, wrote to his Alberta
and Quebec counterparts to obtain more information on private MRI clinics
operating in these provinces.
July 2003 - The federal Minister of
Health, the Honourable Anne McLellan, wrote to Alberta, British Columbia, Nova
Scotia and Quebec to communicate her objection to the queue jumping that
results from private diagnostic imaging clinics.
April 2005 - The federal Minister
of Health, the Honourable Ujjal Dosanjh, wrote to the same four provinces to
express concerns about private MRI and CT scan clinics.
Alberta Health
and Wellness. Policy Statement on the Delivery of Surgical Services.
Government of Alberta, 17 November 1999.
Auditor General
of Canada.
· “Federal
Support of Health Care Delivery.” November 1999 Report. Chapter 29.
· “Health Canada – Federal Support of Health
Care Delivery.” September 2002 Report. Chapter 3.
Blache, Pierre. “Le pouvoir de
dépenser au cœur de la crise constitutionnelle canadienne.” Revue générale
de droit, Vol. 24, No. 1, 1993, pp. 29-64.
Boothe, Paul, and Barbara Johnston. “Stealing the Emperor’s
Clothes: Deficit Offloading and National Standards in Health Care.” C. D.
Howe Institute Commentary, No. 41, March 1993.
Brooks, Janet. “Alberta’s Private MRI Clinics One Sign of
Move away from Cash-free Medical Care.” Canadian Medical Association Journal,
Vol. 151, No. 5, 1 September 1994, pp. 647 648.
Canadian Bar Association. What’s Law Got To Do with It?
Health Care Reform in Canada. Report of the Canadian Bar Association Task
Force on Health Care. Ottawa, August 1994.
Canadian Healthcare Association. The Private-Public Mix
in the Funding and Delivery of Health Services in Canada: Challenges and
Opportunities. Policy Brief. Ottawa, 2001.
Canadian Institute for Health Information. National
Health Expenditure Trend (1975-1999) Report – Executive Summary. 16
December 1999.
Canadian Medical Association.
· Toward
a New Consensus on Health Care Financing in Canada.
Discussion Paper. Ottawa, July 1993.
· Core and Comprehensive Care Services: A
Proposed Framework for Decision-Making – Executive Summary.
Ottawa, 13 May 1994.
Canadian Public Health Association. Caring about Health.
Issue Paper on Federal/Provincial/Territorial Arrangements for Health Policy.
Ottawa, 1992.
Commission
on the Future of Health Care in Canada (Roy J. Romanow, Commissioner). Building
on Values – The Future of Health Care in Canada. November 2002.
Courchene, Thomas J. Social Canada in the Millennium –
Reform Imperatives and Restructuring Principles. C. D. Howe Institute,
Ontario, 1994.
Evans, Robert G., Morris L. Barer, Greg L. Stoddart and
Vandna Bhatia. It’s Not the Money, It’s the Principle: Why User Charges for
Some Services and Not Others? Discussion Paper No. 94-06. Centre for
Research on Economic and Social Policy, University of British Columbia, January
1994.
Federal, Provincial and Territorial First Ministers. A
Framework to Improve the Social Union for Canadians. 4 February 1999.
Flood, Colleen M., and Sujit Choudhry. Strengthening the
Foundations: Modernizing the Canada Health Act. Discussion Paper No. 13.
Commission on the Future of Health Care in Canada, August 2002.
Godbout, Gilles. “Les
transferts fédéraux aux provinces : une réforme nécessaire.” Policy Options,
Vol. 14, December 1993, pp. 40-44.
Gray, Charlotte. “As Ottawa Reduces Stake in Health Care
System, Does It Open Door for Private Sector?” Canadian Medical Association
Journal, Vol. 151, No. 5, 1 September 1994, pp. 643-644.
Health and Welfare Canada. Preserving Universal Medicare.
Ottawa, 1983.
Health Canada.
· “No
Two-Tier Medicine under the Canada Health Act Says Diane Marleau.” News
Release, 6 January 1995.
· Canada Health Act – Annual Report.
Ottawa, various years.
· CHA Dispute Avoidance and Resolution, Fact Sheet, 25
November 2002.
· Affidavit of Gigi Mandy, Director of the Canada Health Act
Division, Health Canada. Federal Court, Trial Division, Court File No.
T-709-03, October 2003.
Jenness, R. A., and M. C. McCracken. Review of the
Established Programs Financing System. Informetrica, Paper No. 2. Prepared
for the Ministry of Intergovernmental Affairs, Government of Ontario, 29
October 1993.
Kennedy, Mark. “Is There a Cure for Medicare?” Ottawa
Citizen, 3 September 1994, pp. B1-B2.
Leeson, Howard. Constitutional Jurisdiction Over Health
and Health Care Services in Canada. Discussion Paper No. 12. Commission on
the Future of Health Care in Canada, August 2002.
Madore, Odette. Federal Support for Health Care Under
Bill C-28: The Budget Implementation Act, 2003. PRB 03-20E. Parliamentary
Research Branch, Library of Parliament, 21 November 2003.
Martin, Sheilah L. Women’s Reproductive Health, The
Canadian Charter of Rights and Freedoms and the Canada Health Act. Canadian
Advisory Council on the Status of Women, Ottawa, September 1989.
Moran, Terry. “Province’s Former Health Minister Brings
Private Sector MRI to BC.” Canadian Medical Association Journal, Vol.
151, No. 5, 1 September 1994, pp. 645-646.
National Council of Welfare.
· Health,
Health Care and Medicare. Ottawa, Fall 1990.
· Funding Health and Higher Education:
Danger Looming. Ottawa, Spring 1991.
National Forum on Health.
· The
Public and Private Financing of Canada’s Health System: A Discussion Paper.
Ottawa, 1995.
· Canada Health Action: Building on the
Legacy. Ottawa, 1996.
Rachlis, Michael. “Le bistouri sur la gorge – Medicare, la pièce maîtresse des programmes
sociaux canadiens est en danger.” Les Cahiers de l’Agora,
Vol. 1, April 1994, pp. 17-20.
Sormany, Pierre. “La médecine
privatisée.” Affaires Plus, No. 15, September 1992, pp. 18-21 and
24-25.
Standing Senate Committee on Social Affairs, Science and
Technology (Hon. Michael J. L. Kirby, Chair). Volume Six: Recommendations
for Reform. Final Report on the State of the Health Care System in Canada,
October 2002.
Thomson, Alistair.
· Federal
Support for Health Care – A Background Paper. Health Action
Lobby (HEAL), June 1991.
· Getting to the Core of Comprehensiveness –
A Discussion Paper. Health Action Lobby (HEAL), March 1994.
------------
-------
Canada Health Act- FEDERAL GOVERNMENT
R.S.C., 1985, c. C-6
An Act relating to cash contributions by Canada and
relating to criteria and conditions in respect of insured health services and
extended health care services
Preamble
WHEREAS the Parliament of Canada recognizes:
—that it is not the intention of the Government of Canada
that any of the powers, rights, privileges or authorities vested in Canada or
the provinces under the provisions of the Constitution Act, 1867, or any
amendments thereto, or otherwise, be by reason of this Act abrogated or
derogated from or in any way impaired;
—that Canadians, through their system of insured health
services, have made outstanding progress in treating sickness and alleviating
the consequences of disease and disability among all income groups;
—that Canadians can achieve further improvements in their
well-being through combining individual lifestyles that emphasize fitness,
prevention of disease and health promotion with collective action against the
social, environmental and occupational causes of disease, and that they desire
a system of health services that will promote physical and mental health and
protection against disease;
—that future improvements in health will require the
cooperative partnership of governments, health professionals, voluntary
organizations and individual Canadians;
—that continued access to quality health care without
financial or other barriers will be critical to maintaining and improving the
health and well-being of Canadians;
AND WHEREAS the Parliament of Canada wishes to encourage
the development of health services throughout Canada by assisting the provinces
in meeting the costs thereof;
NOW, THEREFORE, Her Majesty, by and with the advice and
consent of the Senate and House of Commons of Canada, enacts as follows:
SHORT TITLE
Marginal note:Short title
1. This
Act may be cited as the Canada Health Act.
· 1984,
c. 6, s. 1.
INTERPRETATION
Marginal note:Definitions
2. In this Act,
“Act
of 1977”
“Act of 1977”[Repealed, 1995, c. 17, s. 34]
“cash contribution”
« contribution pécuniaire »
“cash contribution”
means the cash contribution in respect of the Canada Health Transfer that may
be provided to a province under sections 24.2 and 24.21 of the Federal-Provincial
Fiscal Arrangements Act;
“contribution”
“contribution”[Repealed, 1995, c. 17, s. 34]
“dentist”
« dentiste »
“dentist” means a person lawfully entitled to
practise dentistry in the place in which the practice is carried on by that
person;
“extended health care services”
« services complémentaires de santé »
“extended health care services”
means the following services, as more particularly defined in the regulations,
provided for residents of a province, namely,
· (a) nursing
home intermediate care service,
· (b) adult residential care
service,
· (c) home care service, and
· (d) ambulatory health care
service;
“extra-billing”
« surfacturation »
“extra-billing” means the billing for an insured health
service rendered to an insured person by a medical practitioner or a dentist in
an amount in addition to any amount paid or to be paid for that service by the
health care insurance plan of a province;
“health care insurance plan”
« régime d’assurance-santé »
“health care insurance plan”
means, in relation to a province, a plan or plans established by the law of the
province to provide for insured health services;
“health care practitioner”
« professionnel de la santé »
“health care practitioner”
means a person lawfully entitled under the law of a province to provide health
services in the place in which the services are provided by that person;
“hospital”
« hôpital »
“hospital” includes any facility or portion thereof
that provides hospital care, including acute, rehabilitative or chronic care,
but does not include
· (a) a
hospital or institution primarily for the mentally disordered, or
· (b) a facility or portion thereof
that provides nursing home intermediate care service or adult residential care
service, or comparable services for children;
“hospital services”
« services hospitaliers »
“hospital services” means any of
the following services provided to in-patients or out-patients at a hospital,
if the services are medically necessary for the purpose of maintaining health,
preventing disease or diagnosing or treating an injury, illness or disability,
namely,
· (a) accommodation
and meals at the standard or public ward level and preferred accommodation if
medically required,
· (b) nursing service,
· (c) laboratory, radiological
and other diagnostic procedures, together with the necessary interpretations,
· (d) drugs, biologicals and
related preparations when administered in the hospital,
· (e) use of operating room,
case room and anaesthetic facilities, including necessary equipment and
supplies,
· (f) medical and surgical
equipment and supplies,
· (g) use of radiotherapy
facilities,
· (h) use of physiotherapy
facilities, and
· (i) services provided by
persons who receive remuneration therefor from the hospital,
but does not include services that are excluded by the
regulations;
“insured health services”
« services de santé assurés »
“insured health services” means hospital
services, physician services and surgical-dental services provided to insured
persons, but does not include any health services that a person is entitled to
and eligible for under any other Act of Parliament or under any Act of the
legislature of a province that relates to workers' or workmen’s compensation;
“insured person”
« assuré »
“insured person” means, in relation to a province, a
resident of the province other than
· (a) a
member of the Canadian Forces,
· (b) [Repealed, 2012, c. 19, s.
377]
· (c) a person serving a term of
imprisonment in a penitentiary as defined in the Penitentiary Act, or
· (d) a resident of the province
who has not completed such minimum period of residence or waiting period, not
exceeding three months, as may be required by the province for eligibility for
or entitlement to insured health services;
“medical practitioner”
« médecin »
“medical practitioner” means a person
lawfully entitled to practise medicine in the place in which the practice is
carried on by that person;
“Minister”
« ministre »
“Minister” means the Minister of Health;
“physician services”
« services médicaux »
“physician services” means any
medically required services rendered by medical practitioners;
“resident”
« habitant »
“resident” means, in relation to a province, a
person lawfully entitled to be or to remain in Canada who makes his home and is
ordinarily present in the province, but does not include a tourist, a transient
or a visitor to the province;
“surgical-dental services”
« services de chirurgie dentaire »
“surgical-dental services”
means any medically or dentally required surgical-dental procedures performed
by a dentist in a hospital, where a hospital is required for the proper
performance of the procedures;
“user charge”
« frais modérateurs »
“user charge” means any charge for an insured health
service that is authorized or permitted by a provincial health care insurance
plan that is not payable, directly or indirectly, by a provincial health care
insurance plan, but does not include any charge imposed by extra-billing.
· R.S.,
1985, c. C-6, s. 2;
· 1992, c. 20, s. 216(F);
· 1995, c. 17, s. 34;
· 1996, c. 8, s. 32;
· 1999, c. 26, s. 11;
· 2012, c. 19, ss. 377, 407.
· Help
· Speeches
· Facebook
· RSS
· Twitter
· YouTube
Laws
Search
Resources
Help
· FAQ
· General
· PDF
Help
· Printing
· Glossary
----------
Dental Health
Services in Canada Facts and Figures 2010
-----------
-------------------
Health Care System
Canada's Health Care System
Table of Contents
- Introduction
- Background
- The Role of Government
- Health Expenditures
- How Health Care Services Are Delivered
- Timeline
- Additional Reference Sources
- Online Resources
Introduction
Canada's publicly funded health care system is dynamic--reforms have been made over the past four decades and will continue in response to changes within medicine and throughout society. The basics, however, remain the same--universal coverage for medically necessary health care services provided on the basis of need, rather than the ability to pay.Background
The basic values of fairness and equity that are demonstrated by the willingness of Canadians to share resources and responsibility are displayed in Canada's health care system, and have been reflected in the modifications and major reforms made to the system since its inception. The system has been and continues to be modified as the country's population and circumstances change, and as the nature of health care itself evolves.Evolution of Our Health Care System
In general, Canada's Constitution sets out the powers of the federal and the provincial and territorial governments. Under the Constitution Act, 1867, the provinces were responsible for establishing, maintaining and managing hospitals, asylums, charities and charitable institutions, and the federal government was given jurisdiction over marine hospitals and quarantine. The federal government was also given powers to tax and borrow, and to spend such money as long as this did not infringe on provincial powers. The federal department of Agriculture covered federal health responsibilities from 1867 until 1919, when the department of Health was created. Over the years the responsibilities of both levels of government have changed.Before World War II, health care in Canada was, for the most part, privately delivered and funded. In 1947, the government of Saskatchewan introduced a province-wide, universal hospital care plan. By 1950, both British Columbia and Alberta had similar plans. The federal government passed the Hospital Insurance and Diagnostic Services Act in 1957, which offered to reimburse, or cost share, one-half of provincial and territorial costs for specified hospital and diagnostic services. This Act provided for publicly administered universal coverage for a specific set of services under uniform terms and conditions. Four years later, all the provinces and territories had agreed to provide publicly funded inpatient hospital and diagnostic services.
Saskatchewan introduced a universal, provincial medical insurance plan to provide doctors' services to all its residents in 1962. The federal government passed the Medical Care Act in 1966, which offered to reimburse, or cost share, one-half of provincial and territorial costs for medical services provided by a doctor outside hospitals. Within six years, all the provinces and territories had universal physician services insurance plans.
From 1957 to 1977, the federal government's financial contribution in support of health care was determined as a percentage (one-half) of provincial and territorial expenditure on insured hospital and physician services. In 1977, under the Federal-Provincial Fiscal Arrangements and Established Programs Financing Act, cost sharing was replaced with a block fund, in this case, a combination of cash payments and tax points. A block fund is a sum of money provided from one level of government to another for a specific purpose. With a transfer of tax points, the federal government reduces its tax rates and provincial and territorial governments simultaneously raise their tax rates by an equivalent amount. This new funding arrangement meant that the provincial and territorial governments had the flexibility to invest health care funding according to their needs and priorities. Federal transfers for post-secondary education were also added to the health transfer.
In 1984, federal legislation, the Canada Health Act, was passed. This legislation replaced the federal hospital and medical insurance acts, and consolidated their principles by establishing criteria on portability, accessibility, universality, comprehensiveness, and public administration. The Act also added provisions that prohibited extra billing and user fees for insured services (see this brochure's section on the federal government for further details).
Federal legislation passed in 1995 consolidated federal cash and tax transfers in support of health care and post-secondary education with federal transfers in support of social services and social assistance into a single block funding mechanism, the Canada Health and Social Transfer (CHST), beginning in fiscal year 1996-1997.
An agreement on health reached in 2000 by the federal, provincial and territorial government leaders (or first ministers) set out key reforms in primary health care, pharmaceuticals management, health information and communications technology, and health equipment and infrastructure. At the same time, the federal government increased cash transfers in support of health.
In 2003, the first ministers agreed on the Accord on Health Care Renewal, which provided for structural change to the health care system to support access, quality and long-term sustainability. The Accord committed governments to work toward targeted reforms in areas such as accelerated primary health care renewal; supporting information technology (e.g., electronic health records, telehealth); coverage for certain home care services and drugs; enhanced access to diagnostic and medical equipment; and better accountability from governments.
Under the Accord, federal government cash transfers in support of health care were increased, and the CHST was split into the Canada Health Transfer for health and the Canada Social Transfer for post-secondary education, social services and social assistance, effective April 2004.
Further reforms were announced by first ministers in A 10-Year Plan to Strengthen Health Care in 2004. The federal, provincial and territorial governments committed to a health care renewal plan that included work toward reforms in key areas such as: wait times management; health human resources; Aboriginal health; home care; primary health care; a national pharmaceutical strategy; health care services in the North; medical equipment; prevention, promotion and public health; and enhanced reporting on progress made on these reforms. To support the Plan, the federal government increased health care cash transfers including annual increases to the Canada Health Transfer from 2006-07 until 2013-14 to provide predictable growth in federal funding.
In spring 2007, all provinces and territories publicly committed to establishing a Patient Wait Times Guarantee in one priority clinical area by 2010 and to undertaking pilot projects to test guarantees and inform their implementation. A Patient Wait Times Guarantee is the offer of alternative care options (e.g., referral to another physician or health care facility) to patients whose wait times exceed a defined timeframe when medically necessary health services should be provided.
For more detail on the history of our health care system, refer to the resources at the end of this brochure: the Timeline, Additional Reference Sources and On-Line Resources.
The Role of Government
The organization of Canada's health care system is largely determined by the Canadian Constitution, in which roles and responsibilities are divided between the federal, and provincial and territorial governments. The provincial and territorial governments have most of the responsibility for delivering health and other social services. The federal government is also responsible for some delivery of services for certain groups of people.Publicly funded health care is financed with general revenue raised through federal, provincial and territorial taxation, such as personal and corporate taxes, sales taxes, payroll levies and other revenue. Provinces may also charge a health premium on their residents to help pay for publicly funded health care services, but non-payment of a premium must not limit access to medically necessary health services.
There is more to health than the health care system. The responsibility for public health, which includes sanitation, infectious diseases and related education, is shared between the three orders of government: federal, provincial/territorial and local or municipal. However, these services are generally delivered at the provincial/territorial and local levels.
The federal government
The federal government's roles in health care include setting and administering national principles for the system under the Canada Health Act; financial support to the provinces and territories; and several other functions, including funding and/or delivery of primary and supplementary services to certain groups of people. These groups include: First Nations people living on reserves; Inuit; serving members of the Canadian Forces; eligible veterans; inmates in federal penitentiaries; and some groups of refugee claimants.The Canada Health Act establishes criteria and conditions for health insurance plans that must be met by provinces and territories in order for them to receive full federal cash transfers in support of health. Provinces and territories are required to provide reasonable access to medically necessary hospital and doctors' services. The Act also discourages extra-billing and user fees. Extra-billing is the billing of an insured health service by a medical practitioner in an amount greater than the amount paid or to be paid for that service by the provincial or territorial health insurance plan. A user charge is any charge for an insured health service other than extra-billing that is permitted by a provincial or territorial health insurance plan and is not payable by the plan.
The federal government provides cash and tax transfers to the provinces and territories in support of health through the Canada Health Transfer. To support the costs of publicly funded services, including health care, the federal government also provides Equalization payments to less prosperous provinces and territorial financing to the territories.
Direct federal delivery of services to First Nations people and Inuit includes primary care and emergency services on remote and isolated reserves where no provincial or territorial services are readily available; community-based health programs both on reserves and in Inuit communities; and a non-insured health benefits program (drug, dental and ancillary health services) for First Nations people and Inuit no matter where they live in Canada. In general, these services are provided at nursing stations, health centres, in-patient treatment centres, and through community health promotion programs. Increasingly, both orders of government and Aboriginal organizations are working together to integrate the delivery of these services with the provincial and territorial systems.
The federal government is also responsible for health protection and regulation (e.g., regulation of pharmaceuticals, food and medical devices), consumer safety, and disease surveillance and prevention. It also provides support for health promotion and health research. In addition, the federal government has instituted health-related tax measures, including tax credits for medical expenses, disability, caregivers and infirm dependants; tax rebates to public institutions for health services; and deductions for private health insurance premiums for the self-employed.
The five Canada Health Act principles provide for:
Public Administration: The provincial and territorial plans must be administered and operated on a non profit basis by a public authority accountable to the provincial or territorial government.
Comprehensiveness: The provincial and territorial plans must insure all medically necessary services provided by hospitals, medical practitioners and dentists working within a hospital setting.
Universality: The provincial and territorial plans must entitle all insured persons to health insurance coverage on uniform terms and conditions.
Accessibility: The provincial and territorial plans must provide all insured persons reasonable access to medically necessary hospital and physician services without financial or other barriers.
Portability: The provincial and territorial plans must cover all insured persons when they move to another province or territory within Canada and when they travel abroad. The provinces and territories have some limits on coverage for services provided outside Canada, and may require prior approval for non-emergency services delivered outside their jurisdiction.
Public Administration: The provincial and territorial plans must be administered and operated on a non profit basis by a public authority accountable to the provincial or territorial government.
Comprehensiveness: The provincial and territorial plans must insure all medically necessary services provided by hospitals, medical practitioners and dentists working within a hospital setting.
Universality: The provincial and territorial plans must entitle all insured persons to health insurance coverage on uniform terms and conditions.
Accessibility: The provincial and territorial plans must provide all insured persons reasonable access to medically necessary hospital and physician services without financial or other barriers.
Portability: The provincial and territorial plans must cover all insured persons when they move to another province or territory within Canada and when they travel abroad. The provinces and territories have some limits on coverage for services provided outside Canada, and may require prior approval for non-emergency services delivered outside their jurisdiction.
Top of PageThe provincial and territorial governments
The provinces and territories administer and deliver most of Canada's health care services, with all provincial and territorial health insurance plans expected to meet national principles set out under the Canada Health Act. Each provincial and territorial health insurance plan covers medically necessary hospital and doctors' services that are provided on a pre-paid basis, without direct charges at the point of service. The provincial and territorial governments fund these services with assistance from federal cash and tax transfers.
Medically necessary services are not defined in the Canada Health Act.
It is up to the provincial and territorial health insurance plans, in
consultation with their respective physician colleges or groups, to
determine which services are medically necessary for health insurance
purposes. If it is determined that a service is medically necessary, the
full cost of the service must be covered by the public health insurance
plan to be in compliance with the Act. If a service is not considered
to be medically required, the province or territory need not cover it
through its health insurance plan.
The roles of the provincial and territorial governments in health care include:- administration of their health insurance plans;
- planning and funding of care in hospitals and other health facilities;
- services provided by doctors and other health professionals;
- planning and implementation of health promotion and public health initiatives; and
- negotiation of fee schedules with health professionals.
Although the provinces and territories provide these additional benefits for certain groups of people, supplementary health services are largely financed privately. Individuals and families who do not qualify for publicly funded coverage may pay these costs directly (out-of-pocket), be covered under an employment-based group insurance plan or buy private insurance. Under most provincial and territorial laws, private insurers are restricted from offering coverage that duplicates that of the publicly funded plans, but they can compete in the supplementary coverage market.
As well, each province and territory has an independent workers' compensation agency, funded by employers, which funds services for workers who are injured on the job.
Health Expenditures
Within the publicly funded health care system, health expenditures vary across the provinces and territories. This is, in part, due to differences in the services that each province and territory covers and on demographic factors, such as a population's age. Other factors, such as areas where there are small and/or dispersed populations, may also have an impact on health care costs.According to the Canadian Institute for Health Information (CIHI), in 1975, total Canadian health care costs consumed 7% of the Gross Domestic Product (GDP). Canada's total health care expenditures as a percentage of GDP grew to an estimated 11.7% in 2010 (or $5,614 CDN per person).Footnote 1 In 2010, publicly funded health expenditures accounted for seven out of every 10 dollars spent on health care. The remaining three out of every 10 dollars came from private sources and covered the costs of supplementary services such as drugs, dental care and vision care.Footnote 2
Total Health Expenditures by Source of Finance, 1975
Note: Although the
graph notes that provincial/territorial governments pay for 71% of
health expenditures in Canada, the federal government supports
provincial/territorial expenditures through fiscal transfers.
Source: Canadian Institute for Health Information. National Health Expenditure Trends, 1975 - 2010.
Source: Canadian Institute for Health Information. National Health Expenditure Trends, 1975 - 2010.
Total Health Expenditures by Source of Finance, 2010 Forecast
Note: Although the
graph notes that provincial/territorial governments pay for 65% of
health expenditures in Canada, the federal government supports
provincial/territorial expenditures through fiscal transfers.
Source: Canadian Institute for Health Information. National Health Expenditure Trends, 1975 - 2010.
Source: Canadian Institute for Health Information. National Health Expenditure Trends, 1975 - 2010.
Total Health Expenditures by Use of Funds, Annual Average, 1975-2010
Source: Canadian Institute for Health Information. National Health Expenditure Trends, 1975 - 2010.
Though the share of health care expenditures accounted for by hospitals declined to 29% in 2010 from approximately 45% in the mid-1970s, hospitals continue to account for the largest share of health care spending. Spending on drugs has accounted for the second-largest share since 1997, making up 16% of spending in 2010. The third-largest share of health care expenditures is accounted for by spending on physicians, which made up 14% of spending in 2010.Footnote 3
How Health Care Services Are Delivered
Canada's publicly funded health care system is best described as an interlocking set of ten provincial and three territorial health systems. Known to Canadians as "medicare," the system provides access to a broad range of health services.What Happens First (Primary Health Care Services)
When Canadians need health care, they most often turn to primary health care services, which are the first point of contact with the health care system. In general, primary health care serves a dual function. First, it provides direct provision of first-contact health care services. Second, it coordinates patients' health care services to ensure continuity of care and ease of movement across the health care system when more specialized services are needed (e.g., from specialists or in hospitals).Primary health care services are increasingly comprehensive, and may include prevention and treatment of common diseases and injuries; basic emergency services; referrals to and coordination with other levels of care, such as hospital and specialist care; primary mental health care; palliative and end-of-life care; health promotion; healthy child development; primary maternity care; and rehabilitation services.
Doctors in private practice are generally paid through fee-for-service schedules that itemize each service and pay a fee to the doctor for each service rendered. These are negotiated between each provincial and territorial government and the medical professions in their respective jurisdictions. Those in other practice settings, such as clinics, community health centres and group practices, are more likely to be paid through an alternative payment scheme, such as salaries or a blended payment (e.g., fee-for-service payments plus incentives for providing certain services such as the enhanced management of chronic diseases). Nurses and other health professionals are generally paid salaries that are negotiated between their unions and their employers.
When necessary, patients who require further diagnosis or treatment are referred to other health care services, such as diagnostic testing, and health care professionals, such as physician specialists, nurse practitioners, and allied health professionals (health care professionals other than physicians and nurses).
Health Human Resources
In 2006, just over 1,000,000 people in Canada worked directly in health occupations; this represented 6% of the total Canadian workforceFootnote *.
Health care providers may be regulated (through professional colleges or other bodies) or non-regulated, unionized or non-unionized, employed, self-employed or volunteer.
Most doctors work in independent or group practices, and are not employed by the government. Some work in community health centres, hospital-based group practices, primary health care teams or are affiliated with hospital out-patient departments.
Nurses are primarily employed in acute care institutions (hospitals); however, they also provide community health care, including home care and public health services.
Most dentists work in independent practices; in general, their services are not covered under the publicly funded health care system, except where in-hospital dental surgery is required.
Allied health professionals include: dental hygienists; laboratory and medical technicians; optometrists; pharmacists; physio and occupational therapists; psychologists; speech language pathologists and audiologists.
In 2006, just over 1,000,000 people in Canada worked directly in health occupations; this represented 6% of the total Canadian workforceFootnote *.
Health care providers may be regulated (through professional colleges or other bodies) or non-regulated, unionized or non-unionized, employed, self-employed or volunteer.
Most doctors work in independent or group practices, and are not employed by the government. Some work in community health centres, hospital-based group practices, primary health care teams or are affiliated with hospital out-patient departments.
Nurses are primarily employed in acute care institutions (hospitals); however, they also provide community health care, including home care and public health services.
Most dentists work in independent practices; in general, their services are not covered under the publicly funded health care system, except where in-hospital dental surgery is required.
Allied health professionals include: dental hygienists; laboratory and medical technicians; optometrists; pharmacists; physio and occupational therapists; psychologists; speech language pathologists and audiologists.
- Footnote
- Health Personnel Database, Canadian Institute for Health Information.
What Happens Next (Secondary Services)
A patient may be referred for specialized care at a hospital, at a long-term care facility or in the community. The majority of Canadian hospitals are operated by community boards of trustees, voluntary organizations or regional health authorities established by provincial/territorial governments. Hospitals are generally funded through annual, global budgets that set overall expenditure targets or limits (as opposed to fee-for-service arrangements) negotiated with the provincial and territorial ministries of health, or with a regional health authority or board. Although global funding continues to be the principal approach for hospital reimbursement in Canada, a number of provinces have been experimenting with supplementary funding approaches.Secondary health care services may also be provided in the home or community and in institutions (mostly long-term and chronic care). Referrals to home, community, or institutional care can be made by doctors, hospitals, community agencies, families and patients themselves. Patient needs are assessed by medical professionals, and services are coordinated to provide continuity of care. Care is provided by a range of formal, informal (often family) and volunteer caregivers.
For the most part, home and continuing care services are not covered by the Canada Health Act; however, all the provinces and territories provide and pay for certain home and continuing care services. Regulation of these programs varies, as does the range of services. The federal department of Veterans Affairs Canada provides home care services to certain veterans when such services are not available through their province or territory. In addition, the federal government provides home care services to First Nations people living on reserves and to Inuit in certain communities.
In general, health care services provided in long-term care facilities are paid for by the provincial and territorial governments, while room and board costs are paid for by the individual. In some cases, payments for room and board are subsidized by the provincial and territorial governments.
Palliative care is delivered in a variety of settings, such as hospitals or long-term care facilities, hospices, in the community and at home. Palliative care focuses on those nearing death and their families and includes medical and emotional support, pain and symptom management, help with community services and programs, and bereavement counselling.
Additional (Supplementary) Services
The provinces and territories provide coverage to certain people (e.g., seniors, children and low-income residents) for health services that are not generally covered under the publicly funded health care system. These supplementary health benefits often include prescription drugs outside hospitals, dental care, vision care, medical equipment and appliances (prostheses, wheelchairs, etc.), and the services of other health professionals such as physiotherapists. The level of coverage varies across the country.As noted earlier, those who do not qualify for supplementary benefits under government plans pay for these services through out-of-pocket payments or through private health insurance plans. Many Canadians, either through their employers or on their own, are covered by private health insurance and the level of coverage provided varies according to the plan purchased.
Trends/Changes in Health Care
The Canadian health care system has faced challenges in recent years due to a number of factors, including changes in the way services are delivered, fiscal constraints, the aging of the baby boom generation and the high cost of new technology. These factors are expected to continue in the future.Since publicly funded health care began in Canada, health care services and the way they are delivered have changed--from a reliance on hospitals and doctors to alternative care delivery in clinics, primary health care centres, community health centres and home care; treatment using medical equipment and drugs; and a greater emphasis on public health and health promotion.
Medical advances have led to more procedures being done on an out-patient basis, and to a rise in the number of day surgeries. Over the past several decades, the number of nights Canadians spent in acute-care hospitals on a per capita basis has declined, while post-acute and alternative services provided in the home and community have grown.
Beginning in the mid-1990s, most provinces and territories worked to control costs and improve delivery by decentralizing decision-making on health care delivery to the regional or local board level. Such regional health authorities are managed by appointed members who oversee hospitals, long-term care facilities, home care and public health services in their area. However, in recent years, some provinces have moved away from a decentralized model of health care delivery in favour of consolidating the number of health authorities and centralizing decision-making structures.
Primary Care
The episodic and responsive traditional primary health care model has served Canadians well. However, the aging population, rising rates of chronic disease, and other changing health trends have emphasized the need for the health care system to maintain and continue to develop the capacity to respond to the changing needs of Canadians.Reforms have focused on primary health care delivery, including setting up more community primary health care centres that provide on-call services around-the-clock; creating primary health care teams; placing greater emphasis on promoting health, preventing illness and injury, and managing chronic diseases; increasing coordination and integration of comprehensive health services; and improving the work environments of primary health care providers.
eHealth
Advancing eHealth has been a focus of attention in Canada and several other countries. Electronic health technologies (such as electronic health records and telehealth) are significant drivers of innovation, sustainability and efficiency in the health care system by improving access to services, patient safety, quality of care, and productivity. The implementation and use of electronic health records contributes to primary health care renewal by facilitating the effective coordination and integration of services amongst care providers.Wait Times Reduction
Provincial and territorial efforts to reduce acute care wait times in accordance with the priorities of their individual systems include: training and hiring more health professionals; clearing backlogs of patients requiring treatment; building capacity for regional centres of excellence; expanding ambulatory and community care programs; and developing and implementing tools to better manage wait times.Patient Safety
Patient safety, including the avoidance of medical errors or adverse events, is one of the most significant issues facing health systems globally, and is a growing aspect of Canada's efforts to improve the quality of health care provided across the health care system.The federal, provincial and territorial governments are continuing to work with health care professionals, organizations and institutions to better understand and mitigate the risks involved in the delivery of health care. This includes the development and implementation of a range of measures to improve patient safety and the quality of care.
Timeline
- 1867
- British North American Act passed: federal government responsible for marine hospitals and quarantine; provincial/territorial governments responsible for hospitals, asylums, charities and charitable institutions.
- 1897 to 1919
- Federal Department of Agriculture handles federal health responsibilities until Sept. 1, 1919, when first federal Department of Health created.
- 1920s
- Municipal hospital plans established in Manitoba, Saskatchewan and Alberta.
- 1921
- Royal Commission on Health Insurance, British Columbia.
- 1936
- British Columbia and Alberta pass health insurance legislation, but without an operating program.
- 1940
- Federal Dominion Council of Health created.
- 1942
- Federal Interdepartmental Advisory Committee on Health Insurance created.
- 1947
- Saskatchewan initiates provincial universal public hospital insurance plan, January 1.
- 1948
- National Health Grants Program, federal; provides grants to provinces and territories to support health-related initiatives, including hospital construction, public health, professional training, provincial surveys and public health research.
- 1949
- British Columbia creates limited provincial hospital insurance plan. Newfoundland joins Canada, has a cottage hospital insurance plan.
- 1950
- Alberta creates limited provincial hospital insurance plan, July 1.
- 1957
- Hospital Insurance and Diagnostic Services Act, federal, proclaimed (Royal Assent) May 1; provides 50/50 cost sharing for provincial and territorial hospital insurance plans, in force July 1, 1958.
- 1958
- Manitoba, Newfoundland, Alberta and British Columbia create hospital insurance plans with federal cost sharing, July 1. Saskatchewan hospital insurance plan brought in under federal cost sharing, July 1.
- 1959
- Ontario, New Brunswick and Nova Scotia create hospital insurance plans with federal cost sharing, January 1. Prince Edward Island creates hospital insurance plan with federal cost sharing, October 1.
- 1960
- Northwest Territories creates hospital insurance plan with federal cost sharing, April 1. Yukon creates hospital insurance plan with federal cost sharing, July 1.
- 1961
- Québec creates hospital insurance plan with federal cost sharing, January 1. Federal government creates Royal Commission on Health Services to study need for health insurance and health services; appoints Emmet M. Hall as Chair.
- 1962
- Saskatchewan creates medical insurance plan for physicians' services, July 1; doctors in province strike for 23 days.
- 1964
- Royal Commission on Health Services, federal, reports; recommends national health care program.
- 1965
- British Columbia creates provincial medical plan.
- 1966
- Canada Assistance Plan (CAP), federal, introduced; provides cost-sharing for social services, including health care not covered under hospital plans, for those in need, Royal Assent July, effective April 1. Medical Care Act, federal, proclaimed (Royal Assent), December 19; provides 50/50 cost sharing for provincial/territorial medical insurance plans, in force July 1, 1968.
- 1968
- Saskatchewan and British Columbia create medical insurance plans with federal cost sharing, July 1.
- 1969
- Newfoundland, Nova Scotia and Manitoba create medical insurance plans with federal cost sharing, April 1.
Alberta creates medical insurance plan with federal cost sharing, July 1.
Ontario creates medical insurance plan with federal cost sharing, October 1. - 1970
- Québec creates medical insurance plan with federal cost sharing, November 1. Prince Edward Island creates medical insurance plan with federal cost sharing, December 1.
- 1971
- New Brunswick creates medical insurance plan with federal cost sharing, January 1. Northwest Territories creates medical insurance plan with federal cost sharing, April 1.
- 1972
- Yukon creates medical insurance plan with federal cost sharing, April 1.
- 1977
- Federal-Provincial Fiscal Arrangements and Established Programs Financing Act (EPF) federal cost-sharing shifts to block funding.
- 1979
- Federal government creates Health Services Review; Emmet M. Hall appointed Special Commissioner to re-evaluate publicly funded health care system.
- 1980
- Health Services Review report released August 29; recommends ending user fees, extra-billing, setting national standards.
- 1981
- Provincial/territorial reciprocal billing agreement for in-patient hospital services provided out-of-province/territory.
- 1982
- Federal EPF amended; revenue guarantee removed, funding formula amended.
- 1983
- Royal Commission on Hospital and Nursing Home Costs, Newfoundland, begins April, reports February 1984.
Comite d'étude sur la promotion de la santé, Québec, begins, ends 1984.
La Commission d'énquête sur les services de santé et les services sociaux, Québec, begins January, reports December 1987.
Federal Task Force on the Allocation of Health Care Resources begins June, reports 1984. - 1984
- The Canada Health Act, federal, passes (Royal Assent April 17), combines hospital and medical acts; sets conditions and criteria on portability, accessibility, universality, comprehensiveness, public administration; bans user fees and extra-billing. Provincial/territorial reciprocal billing agreement for out-patient hospital services provided out-of-province/territory.
- 1985
- Health Services Review Committee, Manitoba, begins, reports November.
- 1986
- Federal transfer payments rate of growth reduced. Health Review Panel, Ontario, begins November, reports June 1987.
- 1987
- Premier's Council on Health Strategy, Ontario, begins, ends in 1991.
Royal Commission on Health Care, Nova Scotia, begins August 25, reports December 1989.
Advisory Committee on the Utilization of Medical Services, Alberta, begins September, reports September 1989.
All provinces and territories in compliance with the Canada Health Act by April 1. - 1988
- Provincial/territorial governments (except Québec) sign
reciprocal billing agreements for physicians' services provided
out-of-province/territory.
Commission on Directions in Health Care, Saskatchewan, begins July 1, reports March 1990.
Premier's Commission on Future Health Care for Albertans, Alberta, begins December, reports December 1989.
Commission on Selected Health Care Programs, New Brunswick, begins November, reports June 1989. - 1989 to 1994
- Reductions in federal transfer payments.
- 1990
- Royal Commission on Health Care and Costs, British Columbia, begins, reports 1991. Report of the Commission on Directions in Health Care (Murray Commission), Future Directions for Health Care in Saskatchewan, released
- 1991
- National Task Force on Health Information, federal, reports; leads to creation of Canadian Institute of Health Information. Task Force on Health, Prince Edward Island, begins June, reports March 1992.
- 1994
- National Forum on Health, federal, created to discuss health care with Canadians and recommend reforms, begins October, reports 1997.
- 1995
- Federal EPF and CAP merged into block funding under the Canada Health and Social Transfer (CHST), to support health care, post-secondary education and social services.
- 1996
- Federal CHST transfers begin April 1.
- 1998
- Health Services Review, New Brunswick, begins, reports February 1999.
- 1999
- Social Union Framework Agreement (SUFA) in force; federal, provincial and territorial governments (except Québec) agree to collective approach to social policy and program development, including health. Minister's Forum on Health and Social Services, Northwest Territories, begins July, reports January 2000.
- 2000
- First ministers' Communiqué on Health, announced September 11.
Canadian Institutes of Health Research established
Commission of Study on Health and Social Services (Clair Commission), Québec, created June 15, reports December 18.
Saskatchewan Commission on Medicare (Fyke Commission), Saskatchewan, begins June 14, reports April 11, 2001.
Premier's Advisory Council on Health for Alberta (Mazankowski Council), Alberta, established January 31, reports January 8, 2002.
Premier's Health Quality Council, New Brunswick, begins January, reports January 22, 2002. - 2001
- Standing Senate Committee on Social Affairs, Science and
Technology review (Kirby Committee), federal, begins March 1, publishes
recommendations October 2002 in report entitled The Health of Canadians -
The Federal Role, Volume Six: Recommendations for Reform.
Commission on the Future of Health Care in Canada
(Romanow Commission), federal, begins April 4, reports November 2002 in
report entitled Building on Values: The Future of Health Care in Canada. Canada Health Infoway established.
British Columbia Select Standing Committee on Health (Roddick Committee), begins August, reports December 10.
Action Plan for Saskatchewan Health Care released, December 5.
Northwest Territories Action Plan, begins November, reports January 2002.
[Health] Consultation Process, Ontario, begins July, results released January 21, 2002.
Health Choices - A Public Discussion on the Future of Manitoba's Public Health Care Services, Manitoba, begins January, reports December. - 2003
- First ministers' Accord on Health Care Renewal, announced February 5.
Health Council of Canada established to monitor and report on progress of Accord reforms, December 9.
Canadian Patient Safety Institute established. - 2004
- Federal CHST split into two transfers: the Canada Health Transfer (CHT) and the Canada Social Transfer (CST), April 1.
Commitment to the Future of Medicare Act, Ontario, adopted June 7.
Creation of the Public Health Agency of Canada established, September.
First Ministers' A 10-Year Plan to Strengthen Health Care, September 16. - 2005
- Wait times inquiry and consultation (Postl report) begins, July 2005, reports in June 2006, (Final Report of the Federal Advisor on Wait Times).
- 2006
- Standing Senate Committee on Social Affairs, Science and Technology (Kirby) report, Out of the Shadows at last: Transforming mental health, mental illness and addiction services in Canada released, May.
Getting on with better health care: Health Policy Framework, Alberta, released August 15.
Conversation on Health, British Columbia, launched September 28, summary of submissions report released November 2007 - 2007
- Mental Health Commission of Canada established, March.
Canadian Partnership Against Cancer Corporation established, April 1.
The federal and provincial/territorial governments' Patient Wait Times Guarantees initiative introduced, April 4. - 2008
- Strategic Plan 2008-2011. Department of Health and Community Services, Newfoundland and Labrador, released.
Changing Nova Scotia's Health Care System: Creating
Sustainability Through Transformation. System Level Findings and Overall
Directions For Change From the Provincial Health Services Operational
Review, Nova Scotia, released, January 17.
Report of the Manitoba Regional Health Authority External Review Committee released, February.
Report of the Task Force on the Funding of the Health System, Getting Our Money's Worth, Quebec, released February 19.
Transforming New Brunswick's Health Care System: The Provincial Health Plan 2008-2012, New Brunswick, released April 1.
Health Action Plan, Alberta, released April 16.
Parliamentary Review of A 10-Year Plan to Strengthen Health Care (2004 Accord) by the House of Commons Standing Committee on Health, June.
Report of the Yukon Health Care Review Committee released, November 13.
An Integrated Health System Review in PEI: A Call to Action: A Plan for Change, Prince Edward Island, released November 18.
Vision 2020: The future of health care in Alberta released December 1. - 2009
- Patient First Review report, For Patients' Sake, Saskatchewan, released October 15.
Additional Reference Sources
Accords
2000 - First Ministers' Communiqué on Health- 2003 - First Ministers' Accord on Health Care Renewal
- 2004 - First Ministers' A 10-Year Plan to Strengthen Health Care
Commission Reports
- Commission on the Future of Health Care in Canada (Romanow)
- Standing Senate Committee on Social Affairs, Science and Technology (Kirby)
Reports
- Canadian Institute for Health Information, Health Care in Canada (annual)
- Canadian Institute for Health Information, National Health Expenditure Trends (annual)
- Health Canada, Report on Plans and Priorities
- Health Canada, Departmental Performance Report
- Canada Health Act Annual Report
- Healthy Canadians: A Federal Report on Comparable Health Indicators
- Federal Healthcare Partnership, Annual Report
- OECD, Health at a Glance (biennial)
Online Resources
- Federal Departments and Agencies
- Health Organizations
- Canadian Agency for Drugs and Technologies in Health (CADTH)
- Canadian Institute for Health Information (CIHI)
- Canada Health Infoway
- Canadian Health Services Research Foundation (CHSRF)
- Canadian Partnership Against Cancer Corporation (CPACC)
- Canadian Patient Safety Institute (CPSI)
- Health Council of Canada
- Mental Health Commission of Canada
- Provinces and Territories
- Newfoundland and Labrador - Department of Health and Community Services
- Prince Edward Island - Department of Health and Wellness
- Nova Scotia - Department of Health and Wellness
- New Brunswick - Department of Health
- Quebec - Ministry of Health and Social Services
- Ontario - Ministry of Health and Long-Term Care
- Manitoba - Manitoba Health
- Saskatchewan - Saskatchewan Health
- Alberta - Alberta Health and Wellness
- British Columbia - Ministry of Health Services
- Yukon - Yukon Health and Social Services
- Northwest Territories - Department of Health and Social Services
- Nunavut - Department of Health and Social Services
- Canadian Health Stakeholder Organizations
- Accreditation Canada
- Association of Canadian Academic Healthcare Organizations
- Canadian Alliance for Sustainable Health Care (CASHC)
- Canadian College of Health Leaders
- Canadian Healthcare Association (CHA)
- Canadian Medical Association (CMA)
- Canadian Nurses Association (CAN)
- Canadian Pharmacists Association (CPhA)
- National Aboriginal Health Organization
- Royal College of Physicians and Surgeons of Canada
- International Organizations
Footnotes
- Footnote 1
- Canadian Institute for Health Information. National Health Expenditure Trends, 1975 - 2010. Ottawa: the Institute, 2010, p. xi.
- Footnote 2
- CIHI, National, p. xi.
- Footnote 3
- CIHI, National, p. xi.
Share
Terms and Conditions on Hyperlinking and the Official Languages Act.
Email this page
Email to a friend
Hotmail
Gmail
Yahoo! Mail
Twitter
Facebook
Delicious
Digg
Google Bookmarks
StumbleUpon
MySpace
reddithttp://www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/2011-hcs-sss/index-eng.php
--------------------
Use the Services Directory to quickly access information on all of the services provided by the NS Department of Finance and Treasury Board.
|
Pensions
Eventually, we all turn our attention to planning for retirement.
There are many factors to consider when you retire and a lot of
information to absorb. If you are about to retire, or have recently
joined a pension plan, and you would like to learn more about pensions,
this site provides information on workplace pensions and personal
retirement savings.
If you work for the private sector or municipal government in Nova Scotia, and you are a member of a pension plan, your plan is monitored and protected by the Nova Scotia Office of the Superintendent of Pensions. This Office supervises over 490 registered pension plans to ensure they are well managed and adequately funded in order to meet their obligations to pension plan members. |
Resources:
YMPE : $53,600 Max LIF Temp Income (50% of YMPE): $26,800 Financial Hardship Program Low Income Cutoff: $35,733 LIF Reference Rate: 6% | ||||
-------------------------
Blogged:
CANADA MILITARY NEWS: Most Militaries of Nato 65% retirement age- and youth aren't interested/ Pope Francis/ Global News/Military News/F**KING PAEDOPHILES/if colonization was such a bitch, why are so many children, aged, disabled all nationalities still worse off 2da/Environment matters folks/Mexico steals First Peoples-Indigenous lands/O Canada/july 15-JUST IN WIKILEAKS Pacific Rim
http://nova0000scotia.blogspot.ca/2015/07/canada-military-news-most-militaries-of.html
------------------
BLOGGED
CLIMATE CHANGE- PARIS- Heads up- Nov 30 Canada News-
USA/CHINA/RUSSIA/JAPAN/INDIA/PAKISTAN- Big 5 will NOT SIGN ENFORCEABLE
INTERNATIONAL CONDITIONS- WTF??? Paris- CLIMATE CHANGE-From Canada with love:
Newage Climate Changers- a new breed of environs- community based-smart and
savvy no more hippies and $$$$protests- and American Reality Show hype- World’s
humanity are all trying 2b truly green- and pls. remember to honour France as
the world mourns- human dignity and respect is courage and global children need
to see the world Climate Change meeting strong and
respectful...imho./BLOGS-LINKS our beautiful Canada/Climate Change NewAgers
show respect for our Paris with shoes and global rallies- so children can see
RESPECT!
No comments:
Post a Comment
Note: Only a member of this blog may post a comment.