What it means to be a colonial, federal, constitutional monarchy
Canada is…
-a colonial country
-a constitutional monarchy: head of state is king/queen, elected parliament passes legislation, prime minister is head of government
-a federation: central federal government, ten provincial/three territorial governments (both equal in power with different responsibilities)
Primary, secondary and tertiary prevention
-Primary prevention: intervention before there’s evidence of disease e.g. vaccines, educational programs
-Secondary prevention: Intervention after a disease process has begun but before it’s symptomatic e.g. cancer screening
-Tertiary prevention: interventions after disease occurs e.g. chronic disease management programs
Primary, secondary and tertiary care
Primary care: first point of consultation, GP/family physician, walk-in clinics some emergency departments
Secondary care: Medical specialists and acute care for brief/serious conditions e.g. childbirth
Tertiary care: more specialized consultative care usually in hospital e.g. cancer treatment, surgery
Types of health care (e.g. mental health care, rehabilitation, home care) and whether or
not services are by-in-large publicly or privately paid
- Emergency care
-Emergency department: public
-Emergency medical services: some out of pocket - Specialist physician and hospital care
-Specialist physician ambulatory services: some for profit
-Hospital services: some private (not for profit), some public - Rehabilitation
-Inpatient rehab (Surgery): public
-Outpatient rehab (PT/OT): workers compensation, private health insurance, out of pocket - Pharma
-Inpatient prescription: public
-Outpatient prescription: some public insurance, some private insurance, out of pocket - Mental health care
-Family physicians: public
-Psychologists/counselors: private (health insurance/out of pocket) - Home and long-term care
-Home, assisted living, chronic care institutions: mix of public, non-profit, for profit - Informal caregivers
-financial support = tax, benefits - Dental care
-private health insurance or out of pocket
Attributes of primary care as described by Starfield
-Access: first contact care for each health concern
-Continuity: patient rather than disease focused
-Coordination: follow up when services needed elsewhere
-Comprehensive: broad range of services, referral where needed
How policy is defined
Set of interrelated decisions taken by political actor or group concerning selection of goals and means of achieving them within specified situation where decisions should be within power to achieve
-decision makers consider: beliefs, evidence, elections, stakeholders
-Not a linear process
-can involve deciding to not change anything
The distinction between policy and legislation
Health legislation: body of rules regulates health promotion, services, equitable distribution, legal position of all parties
Most policies aren’t legislation/law meaning they can be easily changed if not supported as policy objectives in legislation
The two-by-two table describing public vs. private delivery and public vs. private financing
Roles and responsibilities of the different levels of government with respect to health care
Federal
-Financing provincial/territorial healthcare services through fiscal transfers
-set standards/principles upon which transfers contingent
-deliver healthcare services to specific groups
-fund other health-related functions
-e.g. Health Canada, Public Health Agency of Canada, Canadian Institutes of Health Research, Patented Medicine Prices Review Board, Statistics Canada, Indigenous Services Canada
Provincial
-administer health insurance plans
-delivery of hospital and physician care
-to some degree provide institutional and community care, drug plans for those w/o private health insurance
-negotiation of fee schedules with health professionals
The Canada Health Act: Five criteria
- public administration
-the health care insurance plan of a province must be administered and
operated on a non-profit basis by a public authority appointed or designated
by the government of the province
-Applies to health care insurance plan, not service delivery - comprehensiveness
-the health care
insurance plan of a province must insure all insured health services provided by
hospitals, medical practitioners or dentists, and where the law of the province so
permits, similar or additional services rendered by other health care practitioners.”
-Provinces allowed but not required to insure additional services
Provinces decide beyond physicians what “other health care practitioners”
qualify for payment under the Act E.g. midwives, nurse practitioners - universality
-the health care insurance plan of a province must entitle one hundred per cent of the
insured persons of the province to the insured health services provided for by the plan on uniform terms and conditions.
-Only applies to “insured persons” and “insured health services” - portability
-the health care insurance plan of a province must not impose any minimum period of residence in the province, or waiting period, in excess of three
months before residents of the province are eligible for or entitled to insured health services; must provide for and be administered and operated so as to provide for the payment of amounts for the cost of insured health services provided to insured persons while temporarily absent from the province; Residents moving will be covered by previous province for 3 months before new province picks them up - accessibility
-must provide for insured health services on uniform terms and conditions and on a basis that does not impede or preclude,
either directly or indirectly whether by charges made to insured persons or otherwise, reasonable access to those services
by insured persons
-Reasonable access and reasonable compensation are NOT defined (not just about cost), supposes that provincial negotiations with provider groups satisfy condition of reasonable compensation
The Canada Health Act: 2 conditions
- Information
The provincial and territorial governments are required to provide information
to the federal Minister of Health as prescribed by regulations under the Act. - Recognition
The provincial and territorial governments are required to recognize the federal
financial contributions toward both insured and extended health care services.
The Canada Health Act: what’s NOT addressed
-doesn’t define medically necessary (defined by provinces and medical physician colleges)
-CHA sets terms and provinces must meet these to receive funding
-Doesn’t mean provinces can’t cover other services (services outside CHA inconsistent)
-doesn’t address health services outside medicare
-doesn’t deal with private insurance coverage
-doesn’t encourage interdisciplinary approaches + health facility ownership
3Is framework
- Interests: agendas of societal groups, elected officials, civil servants, researchers, policy entrepreneurs
- Ideas: knowledge or beliefs about what is, what ought to be
- Institutions: formal/informal rules, norms, precedents, and organizational factors that structure political behavior
Reasons healthcare is not a normal economic good
-Need not a want: Inelasticity of demand (Price does not influence demand, People generally will not have treatment if they don’t need it)
-Asymmetry of information: (May not be easily understood by patients, Health care providers act as agents in patients’ best interest)
The concept of moral hazard
If something is free (or subsidized) you are more likely to consume it than if you had to pay for it yourself
-Pros: encourages use of services by the people who need it, regardless of ability to pay (and thereby improves health), encourages use of prevention by all (and thereby improves health)
-Cons: encourages use of unnecessary services (and thereby increases costs), encourages use of expensive/inappropriate services (and thereby increases costs)
Types of (private) insurance
-supplementary: covers services that are excluded from public plans
-complementary: pays for “extras” in the public system
-most controversial: duplicative/parallel, pays for services that are also covered under the public system
The four major financing models
- General taxation: patients do not pay when they receive services;
revenue is collected through various forms of taxation (e.g. sales tax) - Social insurance: typically employment-based insurance that is
mandatory and not-for-profit - Private insurance: the policy holder chooses a policy; not mandatory
- Out-of-pocket payment
Many combinations of these mechanisms are possible
The pros and cons of financing models
- General taxation
* Pros: best at pooling risks, low admin costs, progressive
* Cons: no natural incentive to limit demand - Social insurance
* Pros: politically feasible (in Europe), more information to consumers about care costs
* Cons: less risk pooling, administratively complex, no coverage for unemployed
3/4. Private insurance and out-of-pocket payment
* Pros: consumer choice
* Cons: regressive, high admin costs
How financing models are used in Canada
- General taxation:
◦ Provincial public health insurance plans that cover hospital and physician
services - Supplementary private insurance:
◦ Dental care, vision care, pharmaceuticals - Out-of-pocket payment:
◦ Over-the-counter pharmaceuticals and whatever you don’t have private
insurance to cover
