Proceedings of the Standing Senate Committee on
National Finance
Issue 20 - Evidence - November 3, 2010
OTTAWA, Wednesday, November 3, 2010
The Standing Senate Committee on National Finance met this day at 6:45 p.m. to examine the Estimates laid before Parliament for the fiscal year ending March 31, 2011 (topic: transfer payments for health care).
Senator Joseph A. Day (Chair) in the chair.
[English]
The Chair: I call to order this meeting of the Standing Senate Committee on National Finance. Honourable senators, thank you for being here this evening to continue our examination of the Main Estimates 2010-11. An issue of ongoing interest to this committee, in our consideration of both estimates and legislation that we see from time to time, has been transfer payments to the provinces. In the discussion this evening, we will focus on transfers for health care to the provinces. In the Main Estimates at page 5, you will see the Canada Health Transfer in the amount of $25.4 billion. Also in the Main Estimates as part of the supply bills and not part of the statute, we have $198 million for various grants to the Mental Health Commission of Canada, the Canadian Institute for Health Information, Canadian Partnership Against Cancer, et cetera.
Honourable senators will appreciate that this is a huge part of annual government expenditures. We are very pleased to welcome representatives of the Canadian Medical Association, who will share their views with us. I welcome Dr. Jeffrey Turnbull, President of the CMA. He is accompanied by Mr. Owen Adams, Vice-president of Health Policy and Research.
Gentlemen, thank you for coming on short notice. We look forward to your presentation, followed by discussion, questions and comments. Dr. Turnbull, please proceed.
Dr. Jeffrey Turnbull, President, Canadian Medical Association: Thank you, Mr. Chair. I hope that all of you have the packages before you. I hope to work through those packages with you, after which we will have the opportunity for questions. This is a great honour to be before the committee today to present some of our perspectives.
Going to page 2, I will begin with a brief overview of the CMA's recently released Health Care Transformation action plan. I will then touch on the important role of the federal government within Canada's health care system. I will provide you with some key financing issues facing us as we move forward. Of course, there will be lots of opportunity for questions.
[Translation]
I look forward to our discussion on potential solutions to improve health care for all Canadians.
[English]
On page 3, you can see that Canada's doctors have been increasingly concerned and frustrated with the performance of Canada's health care for some time. In particular, we believe that there have been enough studies and that what we need now is action.
The Chair: I have on page 3, 2008 General Council motion: ``The CMA will develop . . .'' Am I looking at the wrong document?
Dr. Turnbull: No. Accordingly, the Canadian Medical Association's annual meeting in 2008 adopted the following general council motion.
The Chair: We are on the same page, so to speak.
Dr. Turnbull: That was the beginning of a long process that has brought us where we are today.
I will move to page 4 and talk about some of the steps we have taken. We began our study of the international fact- finding mission that includes some 75 key informants and five countries. Some of the findings for our examination of leading European health systems are listed on this page. There was a great deal of commonality, so we thought it would be important to highlight these for you.
The principle of universality is by no means unique to Canada. All systems examined made universality a cornerstone of their systems. What is different is how they went about it and the route they took to achieve universality.
Another area was poor access. This was the burning platform, if you will. Lengthy wait times stimulated each of these governments, in particular the U.K. and Denmark, into action. Given that, the public and the decision makers felt they had to move on. They had strong political and medical leadership to make that happen. As a result of their actions, wait times were no longer a serious problem and were reduced to wait times of weeks as opposed to what we experience — months.
They properly aligned incentives to improve quality and access, and they used things like activity-based funding for hospitals, which is rare in Canada but quite widespread in Europe and in many other industrial countries including Australia.
Every country had some sort of public-private mix that varied depending on the jurisdiction. For example, Belgium and France use copayments for most services, whereas the Netherlands has compulsory private insurance.
Having dealt with the access problem, these jurisdictions were moving on to a quality and safety initiative.
As a result of our review of the European health systems, we developed a series of frameworks to look at and sample through interviews other physicians, key opinion leaders and the public. That led to the five pillars that we think are essential in transforming the health care system.
The first pillar is building a culture of patient-centred care. We have to refocus our system so that it serves the needs of patients, not the system itself. To that end, the CMA has drafted a charter for patient-centred care. We believe there was a great deal of input for that. We had a great deal of community support for that, and it has been an essential part of our next step. We are proud of the work that has taken place as it relates to the first pillar.
The second pillar is that we have to align the incentives for enhancing access and improving quality of care. The first way to do that is to change the way we fund hospitals. We currently have a globally based system of funding a hospital so that a hospital gets a global amount of money. We have to change that to a system that rewards activity — in other words an activity-based funding system where patients are seen as a revenue source rather than as a cost to the system.
Colleagues may know I am the chief of staff at the hospital, and we feel that the best way to balance books in our area and have the most efficient hospital is to have a hospital with no patients. Because we get a global budget, we see patients in our context as a cost, and instead they should be looked at as a source of revenue. Then as a consequence one would align outcomes as a revenue source — hence better care for patients.
The second direction speaks to the proper use of incentives to improve the quality of care delivered, and there we are talking about pay for performance. These incentives can be used at an institutional level — for example, they have done that in hospital emergency departments in B.C. — and at the provider level, so as a provider you are actually provided incentives for doing the appropriate number of immunizations or for screening for breast cancer, et cetera. We incent individuals for things we know bring good outcomes for patients.
The third pillar is enhancing patient access across the continuum of care. This speaks to the fact that we have very significant gaps in what we consider medicare. In the Canada Health Act, in 1984, we covered hospitals and doctors' services, but now we have moved into a new health care environment where chronic care, long-term care and even health promotion and illness prevention are essential parts of the continuum of care. We wish now to consider the whole continuum, so as we look ahead we have to think of mechanisms to fund the continuum of care.
In particular, we have two crucial areas, out-of-hospital prescription drugs, and continuing long-term care and home care.
The fourth pillar is a critical area. It helps the providers to help patients, and two particular areas are there. We need timely access to an adequate supply of human health resources, and that is not just doctors but also nurses and all other essential health providers. We need faster adoption of the health information technologies to allow us to adopt a much more efficient health care system that focuses on quality and safety.
The fifth pillar is building accountability and responsibility at all levels. We suffer from a lack of accountability for a system in which we do not have the necessary tools to exert appropriate stewardship over the financing of our health care system. We need to have that if we are to pursue long-term stability and sustainability of our health care system. We have to know that we are getting value for money.
Page 7 outlines the fact that significant pockets of excellence exist in this country. There have been some good examples that are already in effect. Alberta had the recent Horne report, which recommended proceeding with the creation of an Alberta patient charter.
There is limited activity-based funding in Ontario, Alberta, and B.C. Alberta has discussed activity-based funding and the Performance and Diligence Indicator Fund under the trilateral agreement. That could be a good starting point.
Quebec has a universal prescription drug program. Models of collaborative care are developed in many different constituencies, and they are starting to grow.
At the federal level, good work is being done by the Canadian Institute for Health Information, CIHI, on case-mix costing that could support an activity-based funding system. That would be an essential building component to move with that type of activity.
Of course, we recognize the $500 million that has been invested recently in the electronic medical records. That $500 million should be aimed principally at the point of care, so that we get better utilization on the ground by primary providers and better integration of health systems at a local grassroots level.
I would like to talk about the federal role in many different areas. The point we would like to make is that we believe very strongly that the federal role is essential in health. Canadians continue to desire a strong co-stewardship approach with provincial and federal governments.
I wish to touch on the need for federal leadership in several areas. As you know, the federal government has an important role in providing health transfers to the provinces through the Canada Health Act to ensure that key services are provided. That enables it to provide some leverage to achieve national program standards.
The federal government has responsibility for the delivery of care for many different jurisdictions, for example First Nations, the military, RCMP and inmates. There is an opportunity for the federal government to implement best practices of its own systems to demonstrate leadership by showing that it provides the highest quality of care for others to follow.
Ensuring Canadians receive comparable levels of health care wherever they reside is essential. Canadians expect that when they move across the country, they will have a comparable level of care. At the same time, we should understand that diseases do not respect provincial boundaries, either. H1N1 was a perfect example of why we need national strategies and standards because that was a national problem. Equally, increased labour mobility in both health human resources and Canadian workers would be enhanced by national standards.
There is also a need for strong federal leadership to support the transformative changes that we have been talking about, for example, serving as a national focal point for the pan-Canadian and international exchange and promotion of best practices in the delivery and management of high-quality health care.
Finally, the last thing we have seen more recently is that it makes good sense from an efficiency perspective to have a national perspective. Bulk purchasing of pharmaceuticals and medical supplies improves the bottom line. From that perspective, that is another reason our national government needs to be actively involved.
However, as you will remember, after a series of freezes in the growth of the federal cash transfer, in April 1996 the federal government unilaterally cut cash transfers to the provinces and territories by $6 billion over two years. That soon resulted in great concern about access problems and growing wait times. Since 2000, the federal government has concluded three accords with the premiers and made four significant investments to support health care delivery.
The key takeaway is that the federal government has historically been a significant funder of health care in Canada, and recent funding has served to provide financial stability for the health care system.
However, there is unfinished business. Unfortunately, for the most part no strings were attached to these accords. In consequence, provinces and territories have not lived up to some of the commitments that were made. For example, in the February 2003 accord, they committed to identifying a basket of home care services by September of that year for which first-dollar coverage would be provided by 2006. Equally, they committed to ensuring catastrophic drug coverage by March of 2006. Neither of those has happened.
On a public reporting front, since 2004, only the federal government has lived up to its commitment to report on health indicators.
I would like to present to you data from Statistics Canada for the year 2008. They show the percentage of households spending more than 3 per cent to 5 per cent of net income on out-of-pocket prescription drugs. At either level, you will see a more than twofold variation across Alberta and Ontario, with those provinces having lower incidence of high drug expenditures and Saskatchewan and Prince Edward Island having the highest.
I can also tell you that from my perspective of looking after the poor in Ottawa, these individuals cannot afford to fill their prescriptions. Many of my colleagues who are primary care providers will also attest to the fact that more and more of our clients who are the working poor cannot afford a significant amount of expenditures for some of these medications. Some of them cost $200 to $300 per month, and some are as expensive as $20,000 a year. Not too many of the working poor can afford that type of expenditure.
I show this slide to emphasize that many Canadians are spending a considerable amount of money in out-of-pocket pharmaceuticals, and I also show it because it highlights the fact that there is wide variability right across our country.
On page 12, we believe that the federal government has a role to play in ensuring a more level playing field and access to necessary services. This slide shows the Canada Health Transfer as a share of estimated provincial and territorial health spending in 2010. Generally, it accounts for about one fifth of your spending. Alberta is a bit low because of writedowns, and the territories are low because of the amount of federal direct funding in that region. It is about one fifth, and that is not trivial.
Slide 13 shows the growing burden of health spending on provincial and territorial budgets. Overall, over the past decade, health has increased from just under 35 per cent on program spending to around 40 per cent. In 2009, four provinces exceeded 40 per cent, with Ontario heading towards 45 per cent. As I will indicate on the next slide, the challenges continue to grow.
Let us look at this. It is a bit challenging to understand, but let me give you a bit of an explanation of this particular slide. It shows that back in 1996 we projected what some of our costs would be as a percentage of gross domestic product. We had three different funding models — low, medium and high. You can see on the slide exactly what each one was. As you look across, you will recognize that we are tracking above the highest expenditure. I will explain that in a minute.
One of the first cautions about our sustainability came from Chapter 6 of Auditor General Denis Desautels' April 1998 report to Parliament, where he talked about the issue of an aging population and the concerns that would bring for supporting them later in life through health care. The report projected that public health spending as a percentage of gross domestic product could as much as double between 1996 and 2031, depending on the real growth rate in health spending. As I mentioned, we are tracking that.
The report recommended that the government should produce long-term financial projections on the basis of status quo policies and alternatives, to which the government replied that it would pursue a strategy of achieving long-run goals by setting and meeting realistic short-run targets.
I can tell you that, according to CIHI health information, which you may recall has recently been released, we estimated 8.3 per cent of GDP in 2009 — hence we are tracking the documents I have told you about — above the high range. The forecasted growth rates in public spending, according to the most recent report, are 6.2 per cent in 2009 and 5.1 per cent in 2010.
What does that relate to? It means that we are now spending 11.7 per cent of our gross domestic product on health, and that works out to be about $191.6 billion annually. This country spends a lot of money on health care. The question is, are we getting good value for money?
Slide 15 outlines the prospect of higher health spending that was raised by the Parliamentary Budget Officer, Kevin Page, in his Fiscal Sustainability Report of February 2010. According to his projections, total provincial-territorial government health expenditures could rise over 14 per cent of GDP by 2040 to 2041, mainly due to the increase in drug costs, which is the fastest-growing area in health expenditures. You can see on that slide the incremental aspect of drug costs.
What do Canadians think about the future of health care spending? This is on page 16. The Canadian public is quite worried about the future state of health care in Canada, in terms of both financing and being responsive to future needs. Data taken from our annual report card survey done by Ipsos Reid last summer found that an overwhelming majority of Canadians are concerned about the health burden they bear and the health costs they will be exposed to. Seventy-five per cent believe that urgent change to the health care system will be required to provide today's level of care to the baby boomer generation. Significant numbers of Canadians expect specific personal consequences associated with future health care costs.
For example, almost one in three expect to alter their retirement plans to help pay for their own future health care costs; one in four expect to dip into their retirement savings to support this and one in five expect to move their parents into their own home. These are concerns today. The baby boomer generation starts when they turn 65 next year.
The next slide indicates the cost of inaction. The argument we would like to make here is that we need a concerted effort at all levels of government to push this agenda ahead. The cost of inaction is too great, and more needs to be done to get this message out to citizens and governments.
The Centre for Spatial Economics estimated the economic cost of waiting in 2007 for treatment across four areas — hip and knee replacement, cataract surgery, cardiac surgery for narrowing of the arteries and diagnostic procedures — was $14 billion. That included a loss of over $2.2 billion in federal revenues and $2.2 billion in lost provincial government revenues.
Most agree that the pressure on our health care system will intensify due to the aging baby boomer generation. According to some demographic experts, we have a 10-year window to put our system in order so that we can properly manage the surge. If we do nothing, the system will continue to erode and lose the support of the Canadian people.
Finally, we need to appreciate that our health care system is an investment. A healthy workforce is a productive work force. Our health care system provides us with an economic advantage over our neighbours to the south.
On page 18, as you know, the federal government has said that it will honour the terms of the 2004 accord to the end of March 31, 2014. Its recent economic update projects the transfers at their current growth rates out for two additional years but stresses that they have not yet been negotiated.
Recently, there has been speculation about converting cash transfers to tax points, but I caution that the cash transfer is the only lever the government has to enforce the Canada Health Act.
Looking ahead to 2014 and the renewal of the health accord, our action plan has identified some core elements that we believe must be included. These elements include a stable and predictable funding schedule, one of the benefits of the 2004 10-year accord. That was a very welcome addition. We have certainly appreciated the federal government's commitment to this and to upholding the agreement for the next two years.
The financial strategy for addressing the continuum of care gaps has to be addressed, such as access to prescription drugs, with certain populations requiring enhanced need, particularly looking ahead for long-term care and the continuum of care. We have to think of those not covered by public or private plans to support their expenses, and we have to think about long-term care, institutional care, home-based care and palliative care.
We need meaningful accountability. The previous health accords have unsuccessfully tried to incorporate accountability mechanisms. We now have some time to begin to put those mechanisms in place before 2014.
Where are we going in the future? Looking ahead, we may be faced with the necessity of raising additional funds for health. This will necessitate a dialogue with Canadians about what they are willing to pay for and how. While Canadians remain committed to a universal approach based on need, not ability to pay, they are open to considering a variety of measures to finance health care.
There is a full spectrum of funding opportunities. They can be taxation-based, dedicated taxes, tax incentives, contributions similar to the Canada Pension Plan, CPP, approach or private insurance. In fact, I believe that one size will not fit all for all components of our ongoing support of health services delivery. We may look at pharmaceuticals and adopt one approach. We may look at long-term care and other techniques, and we may mix and match.
We must begin with a public dialogue on the fundamental principles Canadians support for their health care system going forward and the range of services they are willing to pay for.
[Translation]
Finally, we are not looking for a solution that will finance the status quo but rather a solution that will allow for a sustainable financing of our heath care system whereby patients will be able to access care in a timely and efficient manner.
[English]
The federal government must be involved.
This ends my formal presentation. I will be pleased to answer any questions. I appreciate that you have taken the time to listen.
The Chair: Dr. Turnbull, you have given us some interesting points to consider. Your presentation was very effective. We thank you and the team that helped to put this together.
Before we begin questions, would you tell us from where the Canadian Medical Association gets its funding? What relation, if any, do you have to government?
Dr. Turnbull: We receive all our funding from our membership. We have no formal affiliation with any government organization. We have projects that are supported from time to time through different initiatives, such as pharmaceutical companies helping us with educational components. However, we are almost 100 per cent supported and funded by our membership.
The Chair: What is your membership comprised of?
Dr. Turnbull: We have 73,000 Canadian physicians.
The Chair: Are any pharmaceutical-producing companies members?
Dr. Turnbull: They are not members. One or two of our educational programs have been co-funded and co- supported by pharmaceutical companies, but we have no direct funding relationship with the pharmaceutical or any other industry.
The Chair: Thank you. It is important to put that on the record so that we know you are an independent body acting in the best interest of the medical system for Canada.
Dr. Turnbull: That is the case.
Senator Marshall: Thank you for being here this evening. Your presentation was very interesting.
I would like to talk a bit about the future sustainability of the health care system. The material we were given indicates that the current funding arrangement between the provinces and the federal government ends in 2014. In your presentation you spoke about all the pressures on the system, which include the cost of prescription drugs, the cost of home care and community care, and the aging population. The sustainability of the system has been in question for a number of years. As you know, the federal government is facing quite a large deficit, which it is trying to get under control.
Could you give us your views on what can be done with regard to sustainability? Do you think we will be moving into an era of more private health care? In the last number of years there has been an attempt to slow the growth of the cost of health care. That has not been very successful, if successful at all.
Where do you see this going from a practical point of view? I think we are almost being pushed into private health care. I would appreciate your views on that.
Dr. Turnbull: Thank you very much for that question, senator. It is particularly topical.
Let me talk about two things. First, the Canadian Medical Association, the doctors of Canada, feel that Canadians should get health care independent of their ability to pay. Any system that we set up should not put vulnerable Canadians at an economic disadvantage. Second, Canadians support the principles of the Canada Health Act and medicare.
On the issue of sustainability, you might think us crazy if we want to consider more comprehensive coverage for Canadians at this time, especially when we have significant physical challenges ahead of us, which I think was the crux of your question.
We are very interested in looking at reframing the discussion of sustainability. Sustainability is value for money. We think that a sustainable system is not one that money has been taken out of, because our system now is challenged in almost every regard. To take more money out of the system will make it even more challenged. We believe that there has to be a fundamental restructuring of health care and that by doing so we can deliver more comprehensive universal care with timely access in a cost-effective fashion. We believe that can be done.
Will that require more money? There may be one-time costs. However, we are currently spending just under $192 billion, and our health care system is ranked the second-lowest in terms of value for money. We think much of this can be done by integration of care, focusing on quality, safety and better relationships and following good practice guidelines to ensure that Canadians get good value for money.
We must have a discussion with Canadians about the scope of services they want. Once we have had that discussion and have made every efficiency possible in the system, we can determine whether we need new investments. If we do need more money for health, we will have to think about how to pay for it.
I have been very concerned, as have we all, that as soon as we talk about private versus public the discussion stops. It is such a polarizing topic. That has not served us well. I would rather focus on the best health care system that we would all be proud to have. What does it look like? How would we design it and make it as efficient and as effective as possible, getting good value for money? After that, will we need one-time investments for retooling, or will we need continued investment? Finally, how will we pay for it? Within that there might be consideration of private health care or other things.
Senator Marshall: There have been attempts in the past to retool the system. When you look at the increasing costs in health care, you have to wonder how successful the retooling has been.
Dr. Turnbull: Yes.
Senator Marshall: The cost projections for the future are very concerning. The question is whether we will be able to contain the costs.
Dr. Turnbull: As I said, I am the chief of staff at one of Canada's largest hospitals. I just left our public board meeting. Our hospital is always at over 100 per cent occupancy. Yesterday we hit our record of 115 per cent occupancy.
The Chair: You do not mind promoting your hospital.
Dr. Turnbull: I am not sure that this would be promotion. We had 40 patients waiting in our emergency department, and we had no beds. We had five or six people waiting in hallways, getting care in hallways. Yesterday we cancelled five operations. We cancelled three more today, just to try to deal with the problem.
At the same time, we had 163 patients in the hospital awaiting long-term care. They did not need to be there. They would get better, more patient-centred care at a fraction of the price elsewhere, closer to home. That is what patients want. Yet we were paying $1,000 a day — that is $163,000 my hospital spent yesterday and will again today and tomorrow.
It does not take too long before you can think of some dramatic cost savings just by looking at this as an integrated health care system, but we have silos. Acute care is one thing; chronic long-term care is another thing, and you do not cross that border somehow.
We have to be much more creative. We have to think of how we transform this and look at the perception of what the patient sees. Patients do not see silos. They just have an illness that happens to be acute sometime and chronic sometimes, and they expect to have a smooth, uninterrupted flow of care.
Senator Marshall: The only other comment I can make is that in the past, we have put so much faith in retooling, and now we are looking at retooling again. Maybe we are putting all of our eggs in one basket, and maybe we should have a backup plan, which might be private health care or something else, in case our retooling does not work.
Dr. Turnbull: Let us make our best effort to retool.
Senator Marshall: I agree.
Senator Eaton: Talking about private-public care, to follow up on Senator Marshall, I think England and France have dual systems.
Dr. Turnbull: Yes.
Senator Eaton: You are not for any kind of opting out at present; is that correct?
Dr. Turnbull: In the present, we are not. That is our stance at the moment. We stand by those things that we have talked about: Everyone should get access to care, independent of his or her ability to pay. Canadians and Canada's doctors feel strongly about that.
In the future, as we look ahead, what we really want to see is a health care system that is effective and that provides wonderful care. If it requires some kind of private component, we are willing to consider that, but that is not our intention. At the moment, that is not the direction we are going.
Senator Eaton: That is fine, but just as a comment, I do not think then that you should compare us to other systems that have dual systems.
Dr. Turnbull: Yes.
Senator Eaton: I was privileged to work with Senator Keon on his health report, which is fascinating. The bottom line of the report claims that the least expensive and best way to get health care is not always in a hospital.
He was a strong advocate of creating community clinics that would provide much of the care that a hospital would provide, such as for arthritis and dialysis. For all the ongoing care, you would go to a community clinic, not to an expensive hospital.
Would you agree with that? Do you see that as a provision?
Dr. Turnbull: Very much so. Now that we are seeing so much more in the way of long-term chronic care, we have to have new paradigms for how we manage chronic care illness, and the hospital is not the place for that.
We have to decant our hospitals and use them for what they are most effective at doing, which is delivering acute services. We need to provide care closer to home, in the home, and get people cared for in that context in a much more patient-friendly and effective way. That saves you money.
Senator Eaton: It does, especially with diseases that we are suffering in Canada, such as diabetes and obesity — all those chronic care diseases. The community clinics could be geared to each neighbourhood they are in.
You talked about activity-based funding. Are not provinces, by the very strings they attach to each hospital, an impediment to the way hospitals are run? In other words, you know, as chief of staff, what your greatest needs are.
Dr. Turnbull: Yes.
Senator Eaton: You are told, are you not, how many beds you can have for this and for that?
Dr. Turnbull: Very much so. You are right. There was an attempt to try to look at greater opportunities of flexibility through regionalization of care, leaving that up to the regions and allowing the regions to make some of those decisions.
Again, much of this is scripted. At every level, we have a system that in many regards does not support innovation, does not allow for local solutions and does not connect the funding directly to the accountability and the outcomes we are looking for. We should be investing in health care knowing specifically that we will get a certain type of outcome, and we should have data systems that allow us to know that. We do not.
Senator Eaton: Hospitals should be run a bit like businesses; should they not?
Dr. Turnbull: Very much so.
Senator Eaton: Geared to your population in your neighbourhood.
Dr. Turnbull: They have a bottom line within the resources they have. I think they should be permitted to provide the services, as long as they do that in a collegial way amongst their colleagues, as part of a system. We could utilize our hospital much better.
The budget in my hospital is over $1 billion. That is one hospital in Canada. Granted, it is one of the biggest, but that is an awful lot of money. Despite that, we still are cancelling surgeries.
Senator Eaton: That is right, because you are not allowed to decide.
Dr. Turnbull: We, as a hospital, cannot deal with the problem that is jamming up our hospital, that is, people who are waiting to get into the long-term-care sector. As a hospital, we have no control over that aspect.
Senator Eaton: That is right.
The Chair: Do you contemplate new and innovative ways of compensating doctors and other service providers in a manner different from what we are doing now, a fee for service?
Dr. Turnbull: That is also a very good question. We have moved from a substantive reliance on fee for service, which historically was the normal way doctors were compensated. Now just under 50 per cent of physicians are remunerated through fee for service. We are moving to other payment systems, such as salaries or working within groups, and we pay a health care team a certain amount of money for the outcomes they might be getting.
In Ontario, for example, you have a health care team. Because of the number of patients you roster, you get a certain amount of money based on that. Then there might be some incentives in place in addition to that that would say that you are actually providing this number of pap smears or you are doing this number of breast screenings or checking for osteoporosis in so many patients, so we will give you a little bit more money.
We see that as an innovative way of supporting physicians. The reason for that is we are aligning our valuable investment from tax dollars to outcomes that we are looking to get in the system.
Senator Ringuette: This is all very interesting. I would like to start with your slide 10, where you indicate that some agreements have not been respected by the provincial governments in regard to what they were supposed to do with the money transferred or agreed to.
I distinctly remember our Auditor General, Ms. Fraser, appearing before this committee and my asking her, in regard not to the health transfer but to any kind of federal transfer to the provinces, what accountability mechanisms she could use. The answer is none, because she has to rely on her provincial counterpart to audit whether the provinces are using the money according to the agreements that were signed in the specified field.
In regard to your comments here, we have no mechanism federally to make the provinces accountable for those transfers to any area, including health. The federal Auditor General has no jurisdiction in the provinces.
The Chair: Dr. Turnbull, will you comment on that?
Dr. Turnbull: Yes, and perhaps Mr. Adams will have a comment. We recognize the sensitivity surrounding federal- provincial jurisdictional health issues. We understand the predicament of the federal government and the limitations within which we have to work.
Nevertheless, you are in for 20 per cent of their total health expenditures. As we head to 2014, it is reasonable to think about areas where we can make contributions federally that support the provinces and that do not infringe upon their jurisdictions. We know you are getting a good return on your investment. The hope would be that there might be structures in place as we move ahead toward 2014 whereby some of the commitments made in 2004 about accountability and reporting on outcomes would be followed through. I will ask Mr. Adams to comment.
Owen Adams, Vice-president, Health Policy and Research, Canadian Medical Association: Some of it might have to do with the specificity of the commitment. The 2003 accord said there would be access to catastrophic coverage, but it was not that well defined. In the 2004 accord, they were more specific because there was a $4.5 billion wait time reduction fund. They had to come up with specific agreements on wait time standards. We were pleasantly surprised when, in late 2005, they agreed on national standards. Similarly, Prime Minister Harper promised in Budget 2007 $612 million if they came up with one wait time guarantee by 2010. Pretty well all jurisdictions did that.
Some of the commitments were met, and it was likely the ones that were explicit. Perhaps that is some indication of a way forward.
Senator Ringuette: Exactly. It has to be written clearly in stone that the money is dedicated specifically with that outcome in mind.
Dr. Turnbull: At the CMA's annual meeting, we heard from the Auditor General who highlighted to us the essential requirement that you have to have accountability structures in place at all levels, including for the federal transfer.
Senator Ringuette: The situation in hospitals in New Brunswick is no different from the one you described.
Hospital beds are occupied by long-term-care patients. Every statistician in Canada and North America has said that the baby boomers are retiring and will need prolonged health care. Yes, we need to plan, but there have been many words but no actions to meet that challenge. Now, we are faced with the situation you describe.
That being said, your five pillars make a lot of sense. This is all fine and should work. What plans do you propose for the organizational changes needed for the five pillars in the way you operate under the entire health care system in Canada?
How will you promote this? Will you meet with provincial premiers? There are many stakeholders: the CMA membership; nurses; unions; health managers; the provinces, et cetera. How will you manage to meet all these people and get their concurrence to do this?
Dr. Turnbull: That certainly is the challenge. Our plans over this coming year are to enter into a process of dialogue. That involves bringing these issues to many different jurisdictions and hearing their comments to determine whether we are on the right track and what the scope is. We will have a national dialogue with Canadians, other health care providers and decision makers. We will reach out to key informants — everyone we can think of. Ultimately this will not be decided by doctors only but rather by all jurisdictions. We have to recognize that while we may have started the process, we alone will not finish it. We recognize that we have to take a wide, consultative approach.
The second approach is to ask the following question: If those are the services we want and these are the principles under which we will provide those services in Canada, how will we make up the gap between where we want to be and where we are right now, recognizing that we have this challenge of an aging population in need of increased services? If that is to be the approach, then we would need to have another constituency at the table — governments, funders and the economic community to discuss various funding models. We have to talk about the model, bring all partners together and have discussions just like we are having tonight. We will go to doctors' offices or a church basement or anywhere to have that conversation with decision makers. Then, we will have another discussion on how it is to be funded. We would then like to submit that discussion to the committee.
Senator Ringuette: Have you ever thought of taking on a pilot project? For instance, I believe in the concept that small is beautiful. Could PEI be a pilot project for the rest of Canada to re-engineer the medical constituency?
Dr. Turnbull: We would like to see that recommendation. We would like to see the federal government as part of the accord. How do we foster innovation? It could be at the community level or a whole government. How do you take that innovation and transfer that to other jurisdictions? There should be some kind of health transformation innovation agenda with financial support. That would be a very good role for the federal government, recognizing that it wants to enhance a new type of health care that serves Canadians.
The Chair: It illustrates the open-mindedness of senators when a senator from New Brunswick recommends PEI as a model. Well done, Senator Ringuette.
Senator Neufeld: That would be a big nut to crack. Having spent quite a few years in the provincial government, I know that it does not matter what province you live in — they have all have similar problems. The parallel system has already been talked about. I am a bit of an advocate. The baby boomers are up on the graph and then the line goes down. The spike in the population will decrease at some time. If you can take someone off the waiting list for hip or knee surgery because they can afford to pay for it privately, I do not have a problem. However, when you try to talk to the public about that, it is the end of the world. From the CMA's standpoint, do you have a problem with a kind of parallel system? We have quite a bit of private health care in B.C. that seems to be working quite well, but it is hindered by the Canada Health Act.
Dr. Turnbull: There are several components to this. This is on the lips of many people as a potential solution, the private-public debate. I will highlight that it is very divisive, and people feel strongly about it, so I sympathize with your thoughts.
The issues are concerns about a parallel system. As background, remember that we have a very privately delivered health care system. Over 70 per cent of our health care is privately delivered. We have a principally publicly funded health care system, with 70 per cent coming from the public purse.
If you are talking about opportunities for taking into consideration the use of the private sector in the way we deliver services, I think there are lots of opportunities, and I think we could engage Canadians in that discussion.
If you are thinking about a two-tiered system where you actually allow people to be billed directly for the services you give, such as total knee joint replacements done in a private hospital, for example, and the patients have the money to pay for it themselves or through insurance, the challenge we have in that regard is that we have one workforce. In other jurisdictions where this has been successful, there has been a surplus of nurses and physicians.
I would say that, on the surface, I would have no difficulty with it at all as long as it did not take away from the public system. However, every time this has been introduced, we see, in terms of the payment component, that you pull away from the public system; you move people from a publicly funded health care system into a privately funded health care system, to the detriment of the publicly funded system and those people who do not have the resources. This is a challenge.
Senator Neufeld: This is a challenge, and it is not a challenge that politicians can do on their own. This needs to be done by organizations like yours, starting to talk about how we will deal with these issues. It is a poison pill when a politician goes out and starts talking about changing health care. You want to die right there on the stage. We need organizations to go out there and talk about this.
I live in Northern British Columbia. At one time in B.C., one government tried to say they would give out billing numbers in correlation to the population so that they could get doctors into underserved areas. The doctors took that to the Human Rights Tribunal and they won. We have lots of doctors in British Columbia, but most of them reside in Vancouver. They attract a whole bunch of people so they can do some billing.
In rural areas, the doctors are run off their feet — they cannot keep up, and they finally give up. We have good luck bringing people in from other countries, such as South Africa, who will actually come to those rural areas and serve.
Tell me how you start serving the public who live all over Canada, not just in the major centres. I just used B.C. as an example.
Dr. Turnbull: Trying to provide services to our rural areas is an issue right across Canada, since we have such a diverse geography. I would also highlight to you that there are underserved people in downtown Ottawa and Vancouver, too.
Senator Neufeld: Nothing like the North, though.
Dr. Turnbull: No. The underserved I see are the homeless. They actually get very poor services.
There are several things to think about. There have been success stories related to how we train physicians, and British Columbia is doing this as well. We will start taking physicians from the North and training them in the North so that they practise in the North. That is the mantra. Schools that have adopted those types of approaches have had success.
Senator Neufeld: We have done that in B.C. and it works, but I was wondering if you had some kind of magic bullet.
Dr. Turnbull: There are a couple of other components.
Senator Neufeld: It takes a long time, though.
Dr. Turnbull: It takes a long time. You have to train these people. You are exactly right. I worry a bit about the solution of having our medical graduates working in rural settings, especially now with the Agreement on International Trade that allows them increased flexibility around where they will move and end up practising. The concern might be that they now have been given the opportunity to move from a rural setting to an urban setting in another province, and that will be a challenge we will see over the next several years.
Third, there are many opportunities for us to think of new models for the delivery of health services in a rural setting. We can look at poly-clinics around the small, rural, remote hospitals; excellent referral systems; an Urgi clinic that provides excellent emergency care with transportation systems back and forth. The point is that there are models, but if we have scarce resources, such as a physician or a nurse, in some of these rural settings, we have to use them for the absolute best they can be doing, and use that scarce resource. That might give us some time to build up through training systems or immigration.
Senator Neufeld: You also touched on the issue of people waiting for long-term care in hospitals. I have had the opportunity to access some of the information from the hospitals I am familiar with, and often I am told those people are in there because a doctor has ordered them to be in there, not because they are just taking up a bed in a hospital to go to long-term care. I know there is some of that; I appreciate that. However, I think we put a bit too much emphasis on that, because if a doctor has said an elderly person should be in hospital care, then that is where that person should be. I am not saying that it does not go both ways, but that has been my general experience in the few times I have tried to access that.
With regard to one-time costs, you say we have to have a conversation with Canadians; we have to change the system, and there might be some one-time costs. I have heard one-time costs in relation to health care year after year. Tell me what those one-time costs might be, in a nutshell.
Dr. Turnbull: Those are good questions. Let me attack them.
With regard to those patients in hospital who are awaiting long-term care, I am a general internist, so I end up caring for many of these people. It is true that we deem those people incapable of returning home because of their underlying ability for self-care or care provided by other health care providers or family. We do say that person is unable to go home. We make that decision with them, if they are competent, and otherwise with their family.
As soon as the acute component of the care is over we designate them as ALC, awaiting long-term care. As soon as someone has an ALC designation, that means the physician has made a decision that had there been a bed out in the community, this person could have been discharged. The physician has formally said this person can go home. However, he or she cannot go home because there are insufficient resources. The ALC number is the number I have referred to, the number that we live by, and those are people who have been designated capable to return if there is a bed. However, physicians did say, right at the onset, with the family and the individual involved, that under these circumstances the person cannot go back home; self-care is not possible, and the person would be unsafe.
With regard to one-time costs, there are several things we could think of. The one that comes to mind most prominently is to continue the investment in the electronic medical record. That is a one-time cost. If we had a health information system that allowed physicians to practise better and provide care, we would see that there would be improvements in both safety and quality. Whenever you have a safety and quality agenda, you save money. I think that one-time investment is a good one.
I think the discussion about one-time investment in IT infrastructure that allows us to find out if we are getting value for money would allow us to manipulate the system much more quickly.
Another one-time investment would be the wider dissemination of practice guidelines, which allow physicians like me, when I am seeing someone, to say, ``Do you know the best practice for here is to do this, this and this? You can still do something else, but the best practice is to do this.'' The best practice would be shown to be cost-effective. That would allow us better care, and I think we would find perhaps less utilization of expensive pharmaceuticals, for example.
I am very sensitive to your issue that we come and ask for one-time dollars that always become recurring dollars, and the next thing you know, we have another billion dollars added on to our health care budget.
Senator Runciman: It is a hugely interesting topic. You talk about one-time investments, and I guess, being from Ontario, we do not consider eHealth Ontario as a one-time investment, given the Ontario experience. There was a federal contribution related to that. Briefly, how do you see eHealth impacting costs with respect to the challenges we are facing?
Dr. Turnbull: If we were to invest in the eHealth agenda, how could we save some money? One could think of several ways. One would be pharmaceutical prescribing. In the electronic medical record, if we had an opportunity for prescribing, we could then have medical records that relate to the total number of prescriptions; we could make sure there are no redundancies; we would have some record of double-doctoring; we would know if someone went to another jurisdiction and got the same medications. Equally, if they came to the hospital after that, I could access at the hospital what medications this person was on. Through the electronic medical record, we could also ensure we follow practice guidelines, as I mentioned. For example, if a patient has pneumonia, the minute you enter that into the electronic record you could see that for pneumonia the best drug being prescribed with good outcomes and that is cost- effective would be this medication. Equally, you could look for drug-drug interactions to make sure that your patient is not getting two drugs that affect each other.
There is a convenience component; there is a cost component; and there is certainly a quality component to the electronic medical record.
Senator Runciman: You referenced a report that came out a few days ago from the Canadian Institute for Health Information. One of the comments made in here is that physicians account for the rise in insured health dollars for the fourth year in a row. Growth in physician spending has outpaced growth in hospital and drug spending. It is expected to grow by an estimated 6.9 per cent this year.
From my experience in Ontario, we talked about the scope of practice. There was Ontario legislation relating to scope of practice. There has always been resistance from the physician community related to that issue. If you talk to nurse practitioners, for example, they still feel there is unnecessary resistance with respect to scope of practice. Do you have any comments relating to that?
Dr. Turnbull: There are two components to that. One is the rising cost of physicians, and one component of that, and I will recognize that it is just one component, is that we are now starting to see an increasing number of physicians who are practising. They are delivering services, so it is not unanticipated that you will see a rising cost as they deliver more services.
Physician expenses are going up. They are going up in part, I will grant you that, because there are more doctors now. I would anticipate that we will start to see increasing expenditures that relate to physician services as we have more and more doctors. That is what we want. We want them to deliver more services. That is why we increased enrolment in the medical schools upwards of 20 per cent, 30 per cent in some jurisdictions.
The scope of practice is another challenging and vexing issue. It sometimes pits one provider versus another, and that should not happen. We should be working together. More and more, we are working in teams, as I mentioned earlier. Physicians now are getting more comfortable — I would not say are more comfortable but are getting more comfortable — working in a multidisciplinary team environment, working with allied health professionals and recognizing this is an effective way. The more you look at it, you will see, certainly in Ontario, many of my colleagues working on these teams, and it is just recognizing that that is a good way to practise.
Senator Runciman: I am looking at your five pillars for health care transformation. Maybe I am misreading this, or maybe you do not feel this fits the formula here, but when we talk about control of health care costs right across this country, we have heard governments of all political stripes talking about prevention. I do not see prevention as part of your five pillars. Do you not see that fitting in? You are talking about mostly patient-centred care and dealing with timely treatment and those issues. Keeping folks from requiring your services is a significant key to getting costs down.
Dr. Turnbull: That is a good point. I know it is an important initiative for the federal government, looking at health promotion and illness prevention. The Canadian Medical Association very much supports that. In the document, we outline the importance of looking at the continuum of care and the continuum of health. An important component of that, even though we highlight just long-term care and pharmaceuticals because those are a big gap, is for us to get into meaningful health promotion strategies, recognizing, however, that those will have a delay, so there will be a period of time before wait reduction minimizes the amount of diabetes we are seeing. It is very important to address that, no question, but we also have immediate issues in front of us that we would also like to address.
Health promotion is very important. It is part of that continuum we have talked about.
Senator Runciman: You raised some revenue options. We talk about a deductible, for example. Deductibles are in place in the Ontario Drug Benefit Program. You pay the first $100.
You do not take a firm position on those issues; you just put them out in front as a possible consideration for government?
Dr. Turnbull: At the moment, we would like to think about the variety of different options that are available. We would like to go to Canadians and hear what they think, but what we would like to do next as part of our strategy is to think about what are the principles we think are important; what are the services we want; think of all of the different options and then say this particular option into this particular setting provides these advantages but these disadvantages.
Senator Runciman: My next question is related to a deductible as well. You talk about the clogging up in emergency rooms. We have heard these horror stories for many years.
Friends of my family use emergency rooms constantly when they should not be using an emergency room. How frequent is it that folks go there when they do not have emergencies? Do you have any personal views, let alone the association's view, with respect to a deductible having an impact on that?
Dr. Turnbull: There are two components to that. Could we use user fees or deductibles as a way to direct the delivery of health services so that people keep out of emergency departments, and will it generate revenue for a struggling health care system?
I should say right at the beginning that the CMA does not support user fees. The reason for that is twofold. We think we should be innovative about how we look at it, and we are willing to reconsider all of this, but user fees do deter people from using the emergency department. The trouble is that evidence shows us that they deter equally people who do not need services and people who do need services. As a result, we are deterring people who perhaps are the most vulnerable, the people with the greatest amount of illness, and we know that those people often have the greatest difficulty to pay, and user fees deter them from utilizing essential services.
The second thing we know is that these are very cumbersome processes to implement, and the revenue stream you get is often less great than the expenditures you would have to have in place to administer them. There are more efficient ways to get money if that is what you are looking for.
Senator Runciman: I was seeing it as a gatekeeper.
Dr. Turnbull: Yes.
Senator Runciman: That is what I was thinking.
Senator Callbeck: Thank you for coming this evening. There is no question that health care is a huge challenge.
Under the common theme of the European health system, you talk about incentives to improve access and quality, which is one of your pillars. You mentioned global-based funding for hospitals to go into activity-based funding. What other incentives do the Europeans used?
Dr. Turnbull: Perhaps I will ask Mr. Adams to answer that.
Mr. Adams: That has certainly been one. Dr. Turnbull mentioned pay for performance in the U.K. to incent prevention screening, which started in the 1990s. They have used that since then.
There have also been disincentives in certain cases. If people remain in hospitals for too long, if another level of care is available, there would be some sort of a disincentive for the county to pay for that.
The one lesson we learned was that activity-based funding in hospitals was absolutely the key thing they told us.
Senator Callbeck: Will that work in a hospital with 150 or 250 beds?
Mr. Adams: I will defer to Dr. Turnbull on that.
Dr. Turnbull: We do not advocate complete activity-based funding but more a 60-40 mix, so that 60 per cent of the budget would be global and 40 per cent would be activity-based, recognizing that small hospitals need infrastructure and would have to come up with some kind of a guaranteed resource base. That 40 per cent would be an incentive for them to deliver care based on the activities they see.
I am not sure whether this is in Senator Runciman's riding, but I can tell you that right now, when we are at a capacity of about 115 per cent, there are two smaller rural hospitals within 25 minutes' drive from here that are often about 80 per cent occupied and see a fully stocked, fully equipped emergency department with 2.1 patients between eight o'clock at night and eight o'clock in the morning.
If they could be incented to see more patients and use some of their creative ability to have the flexibility to see more patients so they get more revenue, that would be positive. However, at the moment there is no disadvantage for them. We hope that system will be better aligned to outcomes.
Senator Callbeck: Do you think it would work in smaller hospitals on a 60-40 basis?
Dr. Turnbull: Yes. You could not go to 100 per cent. They would not be able to get by.
Senator Callbeck: The other area I want to ask about is catastrophic drug coverage. In 2006, I believe, the federal government committed money to the provinces to do something about catastrophic drugs. I know there were meetings, then there was activity and then everything seemed to stop. Where is that now?
Mr. Adams: There was an interim progress report in 2006 on the nine points of the National Pharmaceuticals Strategy. I am not sure what happened because not much has been heard since, but there were high cost estimates of catastrophic coverage. Senator Kirby recommended around $1 billion, and there was a lot of consensus around that figure. The estimates in that 2006 report were high.
With respect to the last statement that was made on that, in 2008, the provincial and territorial health ministers provided an estimate that the cost would be roughly $5 billion, and they suggested that that be equally cost-shared between the provincial and federal governments. That was their estimate, but not much has happened since then, so it is hard to say. Laterally, it seems like the provinces have been giving up because at their recent meeting they talked about doing a common purchasing agreement, and there was not much mention of a federal engagement on that, I am sorry to say.
Senator Callbeck: I read the press release about bulk purchasing. Back in 2006 it seemed so promising, and now it seems to have completely stalled.
Dr. Turnbull: Some cost savings could accrue also because of moving to catastrophic drug coverage. Sometimes we bring into hospital people who cannot pay for their biologics, such as REMICADE, for instance, which costs $20,000 per year. People cannot afford that. We bring them into hospital at $1,000 a day just to administer the drug. It makes no sense.
Senator Dickson: Thank you for the excellent presentation. When I was appointed to the Senate, someone asked me what my number one priority would be, and I said health care. I am slowly understanding that I said that too quickly.
On reflection, and going back to the Kirby-LeBreton report, I remember one line in one of the volumes of that report that talked about taking one step at a time. After your excellent presentation, if we adopted the principle of one step at a time, what would be your first step?
Dr. Turnbull: That is a very good question. Which one of these issues would we attack first? We have a process going ahead where we will have a dialogue, and I have mentioned all of those things.
If I were to choose one of those things to attack first — this is personal, and my colleagues behind me and I have not had a discussion about what it would be — I think we have to address both access and long-term care. That is two, but to be perfectly honest, it is really just one. We will solve many of our access problems if we deal with the continuum of care.
Senator Dickson: In the speech you made when you were inducted into your office, you said that we all recognize that if we are to have full responsibility, we must support and embrace the principles of the Canada Health Act, which I do. You said you might make certain recommendations to add to them so that they can create a sustainable health care system. I recall that Dr. Keon, during discussions in the Senate, mentioned the lack of a system.
Would you like to comment on what has to be done to bring about a sustainable health care system? I know it is impossible to provide a short answer. Where do we start to bring about a sustainable health care system? It seems to me the system does not exist. As you said earlier, there are many silos. How do you get it together?
Dr. Turnbull: You are exactly right. I have spoken about the sustainability piece, so I will not go on about that.
With respect to the system piece you are referring to, we have to start to look at this as an integrated whole and see it from the point of view of what the patient experiences. That means there will be significant challenges in the way we deliver, organize and fund services.
We might be starting to think now of mental health across this continuum and malignancy, cancer and cardiovascular disease across the continuum. That is what the patients experience, rather than suddenly going from acute care to chronic care, with all of the difficulties of moving between jurisdictions.
How could we do this? We do it with all of the partners in the room. It can be done, and I think we can get an integrated system. I would agree with you 100 per cent that we do not have a system. We have a series of silos. There are good examples out there of regionalized services that are done at a systematic level. I can think of some in my own jurisdiction, how we organize cancer care and stroke, for example. Those are models that we can do more of and do much better.
Senator Dickson: I am fully supportive of your going across the nation. Having originated this discussion, have you thought about partners that can join in this discussion with you, such as the Health Council of Canada, for example, or other partners?
Dr. Turnbull: Yes. We have already started to reach out to those partners, partners at an institutional level, at an allied health professional level and the public. The public, patient advocacy groups and consumer groups have to be instrumental in making this happen. As I said earlier, it will not be only doctors making this happen.
Senator Dickson: Last but not least, how can we help?
Dr. Turnbull: That is a fantastic question. You can help by being participants with us and joining this discussion. Many different views have been expressed tonight, and every one of them is legitimate. Let us think about the evidence and move beyond the rhetoric. With groups like this around the table, I think we will be very successful. I think we can do it.
Senator Dawson: I do not agree with Senator Callbeck about who should be designated as the pilot project. Since we are the federal Senate and we are responsible for federal issues, we should be giving a lesson with how the federal government is doing health care. The federal government has the responsibility for the Inuit, the RCMP and others.
If the federal government did a pilot project and did things well, we could preach to the provinces. However, if we are not handling our responsibilities well at our level, we cannot preach.
There is a big federal-provincial elephant in the room that we are not talking about. Delivery is a provincial responsibility. Your members do not work in the federal environment but in the provincial environment. They are members of your federal association, but they work in the provincial environment.
There is a digital world out there. You know that the technology exists to deal with pharmaceuticals electronically. You know that we could have our medical files stored on a USB card, but we are not doing that, because it is not our responsibility to do it — it is the provinces' responsibility.
The federal level has been preaching for years. We could be doing it at our level with the clients we serve and prove that this can be done more efficiently. If we did that, we would have more credibility to tell the provinces what they should be doing.
Your membership is provincially based. I am in favour of as much federal participation in the health sector at the provincial level as possible, but how do you deal with your membership on that?
Second, the technology exists and is being used in many countries, including Estonia, which is not a big or modern country. Why are we not using it?
Dr. Turnbull: Those are two fantastic points. On the issue of our membership and their provincial affiliation, like the federal government we are a national organization, but we have provincial affiliates. We work hand in glove with our provincial affiliates. When we reach out, we reach out to the provincial medical associations. When we try to get this to happen, it will be in concert with our provincial colleagues.
We also believe in the co-stewardship model with a federal, a provincial and a territorial mandate. We have the same challenges you do.
With regard to the federal level doing it better, if you can look after Aboriginal health and use it as a model for others to follow, that would be fantastic.
With regard to the digital era, we lag embarrassingly behind many jurisdictions that have a fraction of our GDP. It is not because the technology does not exist. I can go to my vet or dentist and get better electronic medical records than I can get from my doctor. It is almost embarrassing that doctors write charts in this era.
I do not think the holdup is doctors being unwilling to be earlier adopters of the technology, although there is some of that. However, we support them and help them. One third of doctors currently have electronic medical records, and that has to be 100 per cent. We do have a five-year plan to get electronic medical records to 100 per cent. There is a culture that opposes this, and we have to break it down. We have to work with the slow adopters, but we have some easy wins that we can work on.
You are right. If Estonia can do it, why is Canada not doing it? It is embarrassing.
Senator Gerstein: In her opening question to you, Senator Eaton suggested that you, as chief of medicine of your hospital, would know better how to spend the monies that you receive from the ministry than does the ministry. You agreed, and made the point that it comes with strings attached.
Dr. Turnbull: Yes.
Senator Gerstein: In your opening comments, you said that federal transfers to the provinces come with absolutely no strings attached. I suspect that if there is a transfer from the federal government for wait-time guarantees, catastrophic drugs or home care, it comes in an envelope and is deposited into the province's bank account, and it might go to those services or it might go to education or roads.
You are talking about efficiency, value for money and cost-effectiveness. As these are provincial issues, how do you suggest approaching this? Your presentation to us was excellent. How does it differ from what you would be saying to the provinces? The issue rests with the provinces. As Senator Ringuette said, once the federal government transfers the money, there is no accountability for how much of it goes to the service for which it was designated.
I am not quite clear what you are saying about this.
Dr. Turnbull: We are arguing that cash transfers made by the federal government in 2014 should be reported on very specifically with regard to outcomes and should be targeted toward actual objectives.
I appreciate that it is a challenge, but you have already set out some of those at the federal level. In fact, the federal government said it would provide $600 million to address wait times if the provinces provided a plan and a report. You did set targets, objectives, and accountability structures to ensure that your investment was a wise one. If they chose not to apply for the money, that was their business, but everyone did.
Senator Gerstein: However, we have no assurance of where the money ended up.
Dr. Turnbull: In most circumstances they did report on how the funding was spent, although not in all. You are right.
Senator Gerstein: Could you expand a little on how you view your role as the national group, the Canadian Medical Association, as distinct from the role that you expect your provincial counterparts to play?
Dr. Turnbull: We hope to initiate that discussion in concert with our provincial counterparts.
They will have unique provincial issues that we respect. At the same time, many of the jurisdictional issues we are challenged with are the same across the country. We believe our provincial associations are telling us that the electronic medical record, establishing effective policy, pandemic preparedness and health promotion strategies are common to all of us. In that context, why are we discovering that 13 different ways? Could we not all get together, from a provincial and federal CMA perspective, and say, ``Let us all advocate together, nationally, but in concert with our provincial partners''? We feel we will be more successful in that regard.
The analogy applies as well to how we could look at co-stewardship of the health services delivered across this country.
I hope I have answered your question.
Senator Gerstein: I hear what you are saying, but I still have trouble blending that with the fact that health delivery services are the responsibility of the provinces.
Dr. Turnbull: Absolutely, they are.
Senator Gerstein: Absolutely, and it is not a question of how to work better together. This is their responsibility, and it has been since 1867.
Dr. Turnbull: At the same time, however, we believe that the federal government can facilitate or assist the provinces with health care transformation through an innovation fund. The question is how we can help you develop this national standard.
At the same time, we believe in the importance of a national standard, and we believe that if you are investing in health, you should be investing in a way that you ensure there is a national standard that is common throughout Canada. Let the provinces find their own route to getting to that standard. They can do whatever they want, but we believe Canadians expect that when they go from one jurisdiction to another, they will get roughly comparable outcomes.
The Chair: This discussion has been very interesting, and it is obvious that we could carry on for some time. We may in the future want to discuss where we might go with this particular subject.
At this time, I am pleased, on behalf of the Standing Senate Committee on National Finance, to thank the Canadian Medical Association. Dr. Turnbull and Mr. Adams, thank you very much for a most enjoyable evening of discussion on an issue that is extremely important and that we know will be on the agenda for some time to come.
Dr. Turnbull: Thank you very much for your attention.
The Chair: The meeting is now concluded.
(The committee adjourned.)