Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 40 - Evidence
MONTREAL, Thursday, November 1, 2001
The Standing Senate Committee on Social Affairs, Science and Technology met
today at 9:00 a.m. to examine the state of the health care system in Canada.
Senator Yves Morin (Acting Chairman) in the Chair.
The Acting Chair: This morning, the Chair will be directing the
proceedings in French, given that our original Chairman, Senator Kirby, is
unfortunately unable to be with us for a while.
I would like to welcome the Quebec Association of Optometrists, represented by
Dr. Langis Michaud, President, in the centre; Ms Marie-Josée Crête, Assistant
Director General, on my right; and Mr. Clermont Girard, Advisor to the
Association, who is seated to my left. Welcome.
Mr. Michaud, I imagine you will be making a brief presentation. After that,
there will certainly by questions from members, since this is a topic of great
interest to us.
You have provided us with a document that we are currently distributing. Dr.
Michaud, please proceed.
Dr. Langis Michaud, President, Quebec Association of Optometrists: I want
to thank the Standing Committee for inviting the Quebec Association of
Optometrists to appear. It is a pleasure to meet with you today and present our
views on the health care system in Canada.
I would first like to take a few minutes to talk about the status of optometry
in Quebec. Based on my discussions with a number of politicians, it would seem
that they do not always have a clear understanding of the status of optometry in
In the 21st century, practising optometrists perform duties that go well beyond
simple eye examinations, dispensing glasses to patients and providing
eyewear-related services. They are top professionals, with a university degree
based on five years of study. One of the only schools of optometry in Canada is
located here in Montreal, at the University of Montreal. The other is in
Waterloo, Ontario. There are 40 graduates a year in Montreal, and 60, in
We are in fact the gateway to front-line oculo-visual care, both in Quebec and
across Canada. Our training relates to ocular pathology, recognition of the
signs and symptoms of ocular pathologies, as well as vision, visual training,
strabismus, crossed eyes and learning problems. These are services we provide on
a daily basis.
In Quebec in particular, we have, since last year, had the right to prescribe
medication to treat eye disease. Along with the Yukon, we are the fourth
province to have given optometrists the right to prescribe medication to treat
eye disease, which has been common all across the United States since 1976. So,
we are really front-line players, like general practitioners, when it comes to
providing eye care, in addition to playing our traditional role in terms of
performing eye exams and dispensing optic products such as eye glasses and
Despite this change in status in recent years, for the purposes of the health
care system in Canada, we are still considered to provide so-called
complementary services. As you know, the Canada Health Act and its extension to
Quebec go back a long way, to the point where the definitions set out in the
legislation no longer jibe with the current reality. As far as we are concerned,
"complementary services" under the Act no longer fits the reality of
modern optometry, as I have described it.
The fact that we are deemed to provide complementary services led the government
of Quebec, along with many other provincial governments, to de-list some of our
services in 1992-93. And last year, we faced the threat of complete de-listing
of our services, a threat that was withdrawn at the last minute, but is still
Because we provide front-line care to Canadians, we see this classification of
services as unfair, and the constant threat of de-listing of government-funded
services, even more unfair. This would deprive citizens, particularly in areas
where there are no other front-line services available. Ophthalmologists, who
provide other oculo-visual services, practice primarily in the major cities.
There 200 of us in Quebec City, and 1,200 scattered across the province. So, the
Gaspé, the North Shore and the Abitibi, for example, are regions where few
ophthalmological services are available. Optometry is the only access point. In
places like Trois-Rivières and Thedford Mines, which are semi-urban areas,
ophthalmologists are not taking any more patients. Services are therefore
provided by optometrists. So, the de-listing of these services would be
disastrous for the majority of the people living in these regions, since they
would be forced to go to urban areas, like Quebec City, Montreal or Sherbrooke,
to access them, or rely on university centers, where ophthalmological services
The de-listing of services in 1992-93 did not include services for children aged
0 to 18 or people 65 years of age and over. They continue to be insured. Since
people aged 19 to 64 have been deprived of insured services, we have noted a
decline in the frequency of consultations by patients in this age group. We are
no longer providing preventive services, even though we know that prevention is
the key to maintaining good health. We now provide strictly curative services.
People come to us when they have to, but consult us much less for preventative
Furthermore, successful re-entry into the labour force requires good vision and
good eye health. As regards eye emergencies, the current system is quite poorly
defined, which means that services are not necessarily insured. People aged 19
to 64 have to pay out of their own pockets to receive our services. To a certain
extent, that forces people to consult physicians in the hospital setting and at
emergency departments, which clogs the health care system even more and results
in longer waiting lists.
The current situation is unfair and has severely penalized practitioners in our
field, as well as limiting patients' access to services, particularly in the
regions I mentioned earlier.
That was a brief overview of the situation in Quebec. I am now available to
answer your questions, if you have any.
We have reviewed the report you released touching on some of your work,
including Volume 4, which has just been released. We agree with almost all your
I would like to focus on the three most important points we make in our brief.
First, we say that we endorse thefive conditions set out in the Canada Health
Act, including public administration, which is the basis for our health care
system. However, we believe that in order for these conditions to continue to be
met, adequate funding is needed. In the absence of adequate funding, it becomes
difficult, if not impossible, to force the provinces and health care
administrators to meet those five requirements. You cannot impose conditions
unless you're prepared to provide the financial support that is needed for those
conditions to be met.
Second, we believe the Canada Health Act should be amended. It focuses on
so-called medical services - in other words, those provided in the hospital or
by a physician. In optometry, as in many other areas, the most efficient way of
providing health care is not in physicians' offices and hospitals. There are
currently a number of players, including optometrists, providing such services.
Because our services are not consistent with the definition of medical services
or hospital services, we end up being lumped in with complementary services and,
depending on the vagaries of provincial budgets, services may or may not be
insured. We are of the view that at the very least, therapeutic services, eye
emergencies, eye care and treatment of eye disorders must be provided for under
the Canada Health Act. Here we are not talking about eye examinations and
eyeglass dispensing; we are talking about our actual workload, which includes
the medical aspects of optometry. We should be taking an approach based on the
services to be provided, rather than the person providing them. So, instead of
referring to physicians or hospitals, we should be talking about insurable
services, whoever the provider may be, as long as the person providing them is a
registered professional qualified to prescribe medications, with a university
medical degree or registered under the laws of the province or territory where
they apply. The other essential point is that the service is what must be
insured, rather than the physician or the hospital.
The third point we want to emphasize is that the administration of the health
care system must continue to be a provincial responsibility. The role of the
federal government is obviously important with respect to health, research,
standardization of services all across the country and, of course, financial
support. But the management and organization of services in the field must be
geared as closely as possible to the needs of citizens, and as far as we are
concerned, it must remain a provincial prerogative. That being the case, we
agree that our services must be partly funded by the federal government.
However, the way those services are organized in the field, as well as the
definition of insured services or otherwise, must be determined by the province.
The Acting Chair: Thank you, Mr. Michaud. Some of the members' questions
will be asked in English. However, we do have interpretation, if you care to use
it. You may answer in the language of your choice.
Before I give the floor to Dr. Keon, I would like to ask a question myself,
because you are the first optometrist we have heard from.
What is the current situation in terms of the prerogatives enjoyed by
optometrists and they way they organize their work? Could you give us a brief
overview of the way optometrists operate outside Quebec? Are there differences
from one province to the next as regards rights, health care system claims, and
Mr. Michaud: First of all, with respect to training, as I pointed out
earlier, there are two schools in Canada - one in Waterloo and one in Montreal -
where most Canadian optometrists receive their training. There are a certain
number of Canadian applicants who train in the United States, and because space
is limited in our universities, this gives an advantage to American schools.
Some students train in the United States and come back to Canada to practice.
Our two schools are recognized by the Council on Optometric Education, an
organization connected to the American Department of Education, which ensures
that optometrists receive standardized training throughout North America.
The school in Montreal is recognized as being in the top quartile of optometric
schools, which means that it can be considered among the top North American
schools. It is the same for Waterloo. Our Canadian schools have a very good
reputation in relation to American schools. All Canadian optometrists have the
same basic training, meaning that they have completed a five-year program.
Training for professional doctors of optometry focuses on traditional vision
problems, visual rehabilitation, binocular vision, the way both eyes work
together - in other words, strabismus, and so on. But their training also
focuses on recognizing eye pathologies and, now, on the treatment of such
The first province to legislate eye therapeutics in Canada was Alberta, in 1995,
followed by Saskatchewan and New-Brunswick in 1996. Yukon followed suit in 1998.
In 2000, Nova Scotia and Quebec passed similar legislation, giving optometrists
the right to prescribe drugs.
Some provinces still do not provide for eye therapeutics, but we expect that
within the next two or three years, most provinces will have passed legislation
to give optometrists the right to practice ocular therapeutics. Training has
already been provided. Optometrists are already trained to provide such
In the United States, the process was similar. It began in the Midwest in 1976,
and between 1976 and 1990, the 50 States passed legislation one after the other
to allow optometrists to practice ocular therapeutics.
With respect to government reimbursement, only two or three provinces have no
system in place to reimburse examination fees. Therefore, whatever their age,
people are required to pay their own examination fees. Most of the other
provinces, with the exception of Ontario, insure people aged 0 to 18, as well as
those over the age of 65. About two weeks ago, British Columbia de-listed such
services for people aged 19 to 64. In that province, it will therefore be more
difficult, for budgetary reasons, to have one's eyes examined. Again, according
to the federal Act, such services are deemed to be complementary. In Ontario,
everyone is insured, but people are limited to one eye examination every two
years. This creates problems because optometrists have to check with Ontario
Government authorities to determine whether their patient has been examined by
another Ontario optometrist over the last two years. Thus an authorization
number is needed for every patient. In terms of administration, that is an
extremely cumbersome system.
The Acting Chair: What provinces do not insure any of these services?
Mr. Michaud: If memory serves me, there are some in the Atlantic region -
Newfoundland and Prince Edward Island, if I am not mistaken. Nova Scotia has now
agreed to insure services related to medical emergencies, diabetes,
diabetes-related examinations, and eye emergencies associated with ocular
therapeutics. Other examinations are not insured.
The Acting Chair: Thank you very much.
Senator Keon: Would you lead me through the process of remuneration for
you for those services that are covered? How do you receive payment?
Dr. Michaud: Those people who benefit from the coverage of medicare, that
means those people under 18 years of age and over 64, just have to present their
medicard and I bill the government directly. I receive the payment from the
government. Other patients I charge directly, up front. They pay for their
examination immediately after the examination.
The only exception in those aged between 19 and 64 are those patients who have
security revenue, Welfare. They are entitled to one examination every two years,
and I charge exactly the same amount as I charge for those patients who have a
Senator Keon: What patients would be covered if they consulted an
ophthalmologist rather than an optometrist?
Dr. Michaud: All patients are covered for ophthalmological services,
except if the service is required only for a visual examination, the refraction.
We just completed a survey of ophthalmologists in our province. Many
ophthalmologists are too busy to perform only refraction and vision exams. In
that sense, all their services are covered because they intervene in only
Senator Keon: Could, for example, a person who becomes hypertensive use
that as a reason for seeing an ophthalmologist, and have the refraction paid
Dr. Michaud: Yes, but the patient will have to pay. More than that, if a
diabetic patient is seen by his general practitioner, and the general
practitioner wants to have an opinion on the ocular health of that particular
patient, he has to refer to an ophthalmologist or to an optometrist. We are
allowed to perform the fundus evaluation of a diabetic patient under dilation.
If the patient is seeing an optometrist, this is not covered by the medicare
program, and he has to pay for his examination. The same service, delivered by
an ophthalmologist, is covered by Canadian law, but the patient will probably
have to wait six months. However, he will be covered at that time.
It is certainly not fair, particularly for patients who live in rural regions or
for Aboriginal people, many of whom suffer from diabetic conditions. If they see
an optometrist on their reserve they have to pay. It is unfair.
Senator Keon: Do the insurance companies go by the same rules as the
Dr. Michaud: About one third of the patients are covered by private
insurance programs. However, that is part of the private sector-public sector
debate. If you consider the cost for a patient who requires ocular health
services, if he has to pay on the basis of his income tax, and you add to that
an insurance fee, it will cost more than it does to be covered by the public
Senator Michael Kirby (Chairman) in the Chair.
The Chairman: I have a supplementary question, and if this is unfair,
please do not answer it. Is the fee you get paid by the government for someone
over 65 the same as what you would receive if you performed exactly the same
procedure on someone who was paying for it himself or herself and who was, say,
50 years old?
Dr. Michaud: No. We charge higher fees for private patients.
The Chairman: That could be for one of two reasons: either you are
allowed to do that, or there are higher administrative costs and so on
associated with a private patient.
Dr. Michaud: What we charge to the "private patient" represents
what is our administrative cost to perform an examination. For some reason, we
are underpaid by the government. It is as a result of negotiations with the
Mr. Girard: There is another reason for that. You know, when you have a
public program and there is no fee barrier, the number of patients is assured,
that is, those under 18 and over 64. However the number of patients decreases
when they have to pay. Therefore, we see fewer patients, but we have the same
expenses. The volume is down, so to get the same income to cover your expenses,
you have to increase the fees on the private side.
The Chairman: That is helpful. Thank you.
Senator Pépin: I understand that costs are staying at the same level,
whereas the number of patients is declining. Is that why, when you consult an
ophthalmologist, even if you show your health insurance card, you are asked to
pay an additional $25 or $35, to cover administrative services?
Mr. Michaud: Yes, that is correct.
Senator Pépin: So, that is the reason.
Mr. Michaud: Some practicing ophthalmologists take certain liberties with
respect with incidental service costs. They may say they are charging for the
drops they use to dilate your pupil or they may apply so-called administrative
charges. Theoretically, if you look at the provisions of the Act carefully, it
does not give them the right to charge for drops. So now they talk about
administrative costs. As a result, the patient is required to pay twice, even
though the service is insured by the province.
Among optometrists, the practice at this time is not to ask insured patients to
pay for such things as drops. I believe only about 10 per cent of optometrists
have adopted such a practice. Ordinarily, we accept whatever the province pays
us for insured patients. Of course, the rates charged uninsured patients, given
that they are higher, include the use of drops and associated administrative
Senator Pépin: In the Abitibi, for example, or in other remote areas,
are your services insured by the government, or are they still provided
Mr. Michaud: No, it is the same thing.
Senator Pépin: Oh, I see.
Mr. Michaud: The insurance is exactly the same everywhere, whatever the
region, even if ophthalmological services are not available. Trois-Rivières is
the best example of that. Trois-Rivières is not part of the Third World. And
yet there are only three ophthalmologists left there, and one of the three is
only in private practice. He performs laser surgery and cataract surgery, but no
longer accepts patients insured under the provincial health care plan. The other
two ophthalmologists are so overloaded they cannot see any new patients.
So, if a patient develops glaucoma or an eye pathology that we are unable to
treat - because there are limits to our treatment capability - we have no choice
but to send that patient to Quebec City or Montreal. That only increases waiting
lists in Quebec City and Montreal. The system thus becomes overloaded, not to
mention the fact that the patients have to pay for their own travel costs, and
that these patients are often seniors. Frequently the spouse or a member of the
family provides transportation. Some have to take taxis or use public transit,
which still costs them a certain amount of money. These are insidious health
People say the system is expensive, but when we are looking at the overall
costs, we have to consider that the average citizen absorbs these kinds of
costs, which could easily be covered if there were fair access to our services
through public funding, and if no one were forced to travel.
Senator Pépin: I may be wrong, but perhaps your representations concern
the provincial government more than the federal government.
Mr. Michaud: We know that the federal government considers our services
to be "complementary." And in that sense, it is important to emphasize
that we are talking about prescription medical services - not about eye
examinations. So, because we are deemed to provide complementary services, the
province has the choice of insuring our services or not insuring them. As a
result of the budgetary pressures that all provinces have experienced, our
services were de-listed in 1992-93, meaning that only minimal insurance was
It is not even a matter of re-insuring medical services, because the province
does not have the money. That is why we are saying to the federal government
that it has two responsibilities: first, to broaden the definition of insured
services under the Canada Health Act, which is currently limited to physicians
and hospitals, and focus on insured services, rather than the prescribing
physician or facility; and second, to provide adequate funding of insured
services under the Canada Health Act.
The federal government has the responsibility to change the definition, and then
to provide adequate funding, once the new definition is in place. The
legislation still refers to medical services. Obviously, the current situation
could not have existed in 1970, when the Act was passed, because optometry as it
was practiced then did not include treatment of such disorders in 1970, and thus
was not the form of modern optometry we are referring to here. Such disorders
are currently being treated by optometrists. So, we believe the legislation must
evolve to jibe with the new reality. We are not blaming anyone.
Senator Pépin: And then there are the Aboriginal people.
Mr. Michaud: Yes.
Senator Pépin: You referred to the Aboriginal people. Are none of the
services provided to members of Aboriginal communities paid for?
Mr. Michaud: As regards Aboriginal communities, we have just finalized an
agreement with Health Canada. We are trying to get the Department to recognize
diabetes-related eye examinations and eye health assessments. We have said we
will do general examinations. They have agreed to pay for vision assessments.
The cost is about $43 or $44, which is about the amount charged a patient
privately. That is a little more than what the province gives us.
There can be partial examinations, as required, if the patient's condition
deteriorates further. For example, if a patient is diabetic and needs to have
specific types of examinations, then that is done by special request. This
always involves requesting an exemption or special authorization, and is always
dependent on budgetary contingencies.
And yet we did try to make the point that diabetes is a significant problem in
Aboriginal populations. We are now recognized by the Medical Council of Canada
as being able to examine cases involving diabetes, but not to provide laser
treatment, of course, since that is a secondary or tertiary service that must be
provided by an ophthalmologist. However, the assessment at least may be made by
an optometrist. So, we are asking to be paid for this service, which would
prevent Aboriginal people from experiencing a deterioration in their vision and
improve services on the reserves, so that they are not forced to take a plane
from Sept-Îles to Baie-Comeau to consult an ophthalmologist, an arrangement
that is costing the federal government a fortune.
Senator Morin: Could you summarize, please? I was trying to follow you.
The Aboriginal question is important to us. Could you just summarize in a few
words what you do not like about the current system?
Mr. Michaud: With respect to eye health, the key point is the need to
provide the necessary budgets for these services.
Senator Morin: Yes. But I understand you just signed an agreement, is
Mr. Michaud: Yes.
Senator Morin: Or at least you are in the process of signing one. What is
there about that agreement that you consider to be unsatisfactory?
Mr. Michaud: They have refused the eye health examination.
Senator Morin: Including special exemptions?
Mr. Michaud: They are available with special exemptions, yes, but we need
to have an earmarked budget for this service.
Senator Morin: It is costing us $7 billion.
Mr. Michaud: Yes, I agree with you. But still, we are always subject to
exceptions and the uncertainty that surrounds them. We never know - especially
if we happen to be number 22 on the list and they stop paying when they reach
number 20 - whether or not we are actually going to be paid for the services we
provide. We are always going to be asking for exemptions, even though diabetes
is known to be an issue in Aboriginal populations; it is a significant problem.
So, we really wanted there to be a specific examination focusing on that, and
that it be insured and officially recognized, without our having to go through
cumbersome administrative procedures.
If the physician treating the patient knows that the process will involve
several steps with no guarantee that any of it is insured, his preference will
be to refer his patient to an ophthalmologist 300 kilometers away and let him
take a plane there for his consultation, whereas if this service was included in
the agreement, such an arrangement would be easy enough to apply in the field.
Senator Morin: Then what you want is for this service to be included in
the agreement, rather than being subject to exemptions?
Mr. Michaud: For it to be statutory.
Senator Morin: Statutory?
Mr. Michaud: Yes, exactly. Because there are optometrists practicing on
every reserve. The services are provided on the reserves in the Lower North
Shore, in Chibougamau and James Bay. There are optometrists everywhere providing
Senator Morin: If I understand what you have explained, Mr. Michaud, you
essentially consider yourselves - probably rightly so - to be part of front-line
Mr. Michaud: Yes, exactly.
Senator Morin: On an equal footing with front-line service providers. You
are aware of the reforms that have been recommended. The Clair commission, the
Fyke commission - indeed, every commission that has looked at this has
recommended that front-line services be reformed and that interdisciplinary or
multidisciplinary - for some people, those terms mean different things - teams
be constituted that would be responsible for a given population and be
compensated based on a capitation formula. Do you also think there is a
responsibility to ensure that comprehensive care is provided to the population?
Do you see yourself as a potential member of this kind of team?
Mr. Michaud: Yes, of course, and we are in fact discussing that very
issue with the Quebec Federation of General Practitioners. As you know,
following the Clair commission in Quebec, the Ministry of Health set up thirteen
groupings of family doctors, who are trail blazers for what will be the new way
of providing front-line services in doctors' offices. These doctors' groups,
according to the ministry's current definition, will include both physicians and
nurses whose role will be extended to include psychosocial services currently
provided by CLSCs. So, there will be liaison between doctors' groups and CLSCs.
What we are currently establishing as a template - and there is a real
willingness on the part of both physicians and optometrists to look at this -
involves including optometrists as an additional resource that a group of family
physicians could offer its patients.
Of course, we cannot be grouped in with the physician group per se, because that
would mean our work would be subordinate to that of physicians, which is
currently the case with nurses, when in fact we are an independent profession on
an equal footing with physicians. So, we are really trying to establish a
partnership between optometrist office in a given region and the physician group
that has been set up there.
Therefore, whether the patient consults an optometrist or a family physician,
there will automatically be a linkage between the two. When he goes to his
family doctor's office, the doctor will be able to treat the patient's
condition, and we agree with that. As is currently the case in regions where
there are no available ophthalmologists, if the physician wants a second opinion
on his diagnosis or proposed treatment, he can direct that patient to an
optometrist who could examine him that day or the next day. They would also
If the patient goes to see an optometrist who is registered with a family
medicine group, that optometrist would be required to forward his report to the
physician to make him aware of the patient's condition and the treatment he has
One of the shortcomings of this system, however, is that because we are not sure
our therapeutic services will be insured by the province, and therefore covered
by federal funding as well - since the federal government funds the health care
system - physicians are somewhat reluctant to get involved because they know
full well that if they refer a patient to the hospital or to an institutional
ophthalmological unit, even though it may take more time, the patient will not
have to pay, whereas if he comes to us directly, it will cost him money.
That is what is currently preventing this ideal front-line service model from
making headway. Once again, patients are being referred to institutions or
secondary services, where physicians pretty well feel they have no choice but to
go as far as they can in terms of the care they provide their patients, when in
fact it would be easy enough for their patients to consult an optometrist.
Senator Morin: Mr. Michaud, if that were the case, would you be prepared
to accept a capitation-based compensation system?
Mr. Michaud: All compensation systems are possible. We are prepared to
talk about anything. In terms of per capita based regimes, I guess that would
depend. It would also be possible to implement a hybrid system - in other words,
fee for service in some cases, and capitation payments in others. One thing that
is quite common in Quebec among optometrists - and which helps patients stay at
home - are visits to institutions or residences when patients are unable to get
We are still compensated on the basis of a fee-for-service system in such cases,
but that method really is not ideal under the circumstances, because they take a
lot more time and require portable equipment. Also, the dynamic is not
necessarily the same as in a private office.
Senator Morin: As part of the plan to reform front-line care, if we
establish the principle of responsibility for a given population, then a
capitation payment would be easier to set up as a method of compensation than a
Mr. Michaud: Yes, absolutely.
Senator Morin: Would members of your profession have any objection to
that form of compensation?
Mr. Michaud: No, not at all.
Mr. Girard: But capitation could not really be considered under a system
where certain groups of people are insured, but not others.
Senator Morin: What do you mean by insured and uninsured?
Mr. Girard: Well, such as people aged 0 to 18 at the present time.
Senator Morin: Yes. But under such a system, we could assume that the
entire population would be insured.
Mr. Girard: Yes. And that taking this kind of approach would have certain
Senator Morin: Yes, exactly. We would have to assume that the entire
population was covered for all types of services. What you are describing seems
Mr. Girard: Yes, it does.
Senator Morin: At the present time, people consult an optometrist
directly without having to be referred by a family physician.
Mr. Michaud: Yes, that is correct. And as regards red eye and eye health
problems, we are increasingly seeing that in those regions where optometrists
are abundant, that is how the system works. But there are always limits on the
cost of consultations.
Senator Morin: Yes.
Mr. Michaud: People have a choice between going to a hospital, seeing
their physician or consulting an ophthalmologist directly, in some cases.
I could cite the example of New Brunswick or Alberta, where the Therapeutics Act
has been in effect longer than it has here. Payment of eye therapeutics is not
insured in those provinces either, which effectively prevents cooperation with
optometrists within the health care system, as well as more efficient optometric
services. There is still the issue of the costs that patients are forced to
bear. The situation in Quebec applies equally to the other provinces. It is
important that those provinces insure therapeutic services. The reference is
always to eye care of a medical nature or emergency care.
Senator Morin: As far as Canada as a whole is concerned, all the
provinces currently grant the same privileges to optometrists. Is that what you
Mr. Michaud: Except with respect to therapeutics and the right to
Senator Morin: What provinces do not allow that?
Mr. Michaud: Newfoundland and Prince Edward Island - I am listing them
starting from the opposite end of the country - Ontario, Manitoba and British
Columbia. In all the other provinces, those services are currently insured.
Senator Morin: And you say there are negotiations underway in the other
Mr. Michaud: Yes.
Senator Morin: And do you think they are headed in the right direction?
Mr. Michaud: Well, we think it is inevitable. It is like in the United
States, where this is occurring gradually. Of course, some regions are more
reluctant than others. And every time legislation is introduced, a segment of
the medical lobby steps up to oppose any such progress in the way optometry is
practiced. In Quebec, we have made some headway. We are talking to
ophthalmologists and general practitioners, and we have a good agreement. There
is less reluctance here in Quebec than elsewhere, which is why legislation was
passed in this province somewhat before it was elsewhere.
Ideally, optometric therapeutic services would be available all across Canada
immediately. And in any case, it is inevitable: I believe that within five years
at the most, all provinces will be insured.
Having said that, if there was some assurance that these services would be
funded, the provinces might be more inclined to act quickly to make that happen.
Senator Morin: Thank you very much, Mr. Michaud,Ms Crête and Mr. Girard
for being with us today. We very much appreciate your contribution.
Our second witness, Mr. Paradis, was unfortunately unable to be with us.
I would like to welcome Dr. Yves Lamontagne, President of the College of
Physicians, and who is actually my boss now, since I am still a member of the
College. Dr. Lamontagne has played a pivotal role not only in terms of providing
policy direction to the College and its conduct of professional affairs, but
with respect to the organization of health care delivery here in Quebec. I
wanted to recognize his important contribution in this area before giving him
Welcome, Dr. Lamontagne and Dr. Garon. You have provided us with a document
which we will obviously read carefully. Perhaps you could make a short
presentation, after which we will have questions for you. Questions may be
addressed to you either in French or English. You may answer in the language of
your choice. Please proceed, Dr. Lamontagne.
Dr. Yves Lamontagne, President, Quebec College of Physicians: Mr.
Chairman, thank you very much for inviting us to meet with you this morning.
Senator Morin, you have already introduced Dr. André Garon, who is the Deputy
Secretary General of the Quebec College of Physicians, responsible for External
First of all, I want to say that the College has repeatedly made the point to
the Government of Quebec - and it is our sense that we may have a better chance
of being heard here since you are appointed, rather than being elected - that
what we advocate and have been saying for a long time is that it is time to stop
playing politics with health care and start developing good health care policy.
Let me give you two examples at the federal level. As you well know, a little
more than a year ago, Alberta passed legislation intended to allow the private
sector to deliver publicly funded health care services. And, of course, during
the last election campaign - probably to get votes, the federal Minister of
Health planted doubt in the minds of voters as to whether or not the Alberta
initiative was consistent with the Canada Health Act.
I also have no doubt that it was as a result of political pressure that the
federal government passed regulations, just a few weeks ago, on the therapeutic
use of marijuana. By so doing, it once again threw the problem back into the
physicians' court, in terms of the responsibility to determine the use of a
product that contains a number of substances, most of which are probably
injurious to health. By taking this action, he contravened his own legislation
by deciding to authorize the use of a so-called health product whose
effectiveness and safety have yet to be proven. Just to conclude my
introduction, I would remind you that the ultimate goal of a health care system
is to improve the health of all Canadians, and not to win votes.
Having said that, we have a very good idea of what the health care issues are in
Quebec. We laid them out very clearly before the Clair Commission, which in fact
accepted most of our recommendations. We agree with you about the need to
reorganize front-line care, review physicians' compensation, update the
professional system, and provide more home care and effective medications.
Today, our presentation will focus on a subject that particularly concerns the
federal government: the principle of financial accessibility set out in the
Canada Health Act.
In that respect, my first point is that the reason we have a public system, as
you know as well as I, is to guarantee access to health care, when needed, to
all citizens. The application problems we are currently experiencing are the
result of fairly strict interpretations of this principle which, paradoxically,
leads to accessibility problems as soon as governments start rationing the
service offer by cutting back budgets.
I would also remind you that when public insurance schemes were first
introduced, the federal government was responsible for 50 per cent of
hospitalization and health care costs. Basically, the federal government spent
one dollar for every dollar spent by the province. That is called bridge
funding, a mechanism linked to the spending power intended to stimulate the
introduction of social programs by the provinces. And that share was an
opportunity for the provinces to interpret the federal government's funding
role, through which it was intended that stable funding be provided to ensure
the viability of the health care system in Canada.
Once public systems were put in place all across the country, the federal
government gradually began to cut back its financial contribution, which now
amounts to 17 cents for every dollar spent in Quebec. Let's just say the bridge
has become considerably weaker, despite recent injections of funds by the
federal government. And unfortunately, I think that is contributing to a kind of
mistrust of the federal government when it comes to spending by the provinces -
or at least Quebec, but I will not say anything more about that.
In Quebec, in 1991, those doubts prompted the government to consider
introducing, not user fees but fees to guide people's use of the health care
system. In order to act on the problem of inadequate health care funding, there
was an attempt to establish a co-payment arrangement that would force citizens
who had bad consumption habits to behave more responsibly. That would have
injected new money into the system from the users, in addition to taxpayers'
money. Such a fee was never actually introduced, however, for fear of financial
In 2001, we believe it is absolutely necessary that we all agree on how the
accessibility principle is to be interpreted. Even though the financial
situation in Canada and Quebec is consistently improving, uncertainty about the
future suggests to us that we should consolidate our conception of collective
responsibility, particularly by strengthening individual responsibility. Thus,
the prohibition on co-payment arrangements for medical and hospital services
should only be maintained when the care provided and received is considered most
relevant, most effective and most efficient.
In Canada, unfortunately, we have an unfortunate arrangement whereby public
monies are used to pay either all medical and hospital services, or nothing at
all. It is the "all or nothing" formula: 100 per cent or zero. There
is no room for anything in between. And to be in good standing, a province that
wants to discourage a particular practice has to completely uninsure it, or
de-list it, rather than refunding only 50 per cent or 75 per cent of the cost,
for example. That "all or nothing" approach is part of the Act.
What we are saying is that the right to access publicly funded health care
services - and these services should certainly continue to be funded in this way
- does not mean that the user has no duty to contribute when his use of a
service is not what it should be. And there are a number of examples cited in
our brief. For example: X per cent of the cost of care provided to ambulatory
patients in a hospital emergency department will be borne by the patients. Y per
cent of the cost of care provided in a clinic to patients who are not registered
with a family physician who belongs to a clinic will be borne by patients.
Twenty-five per cent, rather than 100 per cent, of the costs of magnetic
resonance imaging tests provided in a private sector clinic will be borne by
It should also be noted that the Quebec Health Insurance Plan requires
co-payment, whereas the Canada Health Act prohibits co-payment under
hospitalization and health care insurance schemes. That is the kind of
inconsistency that we should be aiming to remove. To that end, the Canada Health
Act should allow the provinces to set up their own co-payment schemes based on
certain quality parameters.
As far as we are concerned, throwing public money at the system will not yield
adequate benefits if no other steps are taken. On the other hand, injecting
private money, as we see in the United States, to the point where health care
spending as a percentage of GDP increases from 9 per cent to 15 per cent, means
going from health care spending of $90 billion in Canada to $150 billion - only
to end up with poorer health care indicators and a segment of the population
with no protection whatsoever against health care emergencies.
We believe there is a happy medium that opting for one extreme - an all public
system - or the other - an all private system - cannot offer. So, we must find
that happy medium, because otherwise the federal government will have to cut
other expenditures and go back to paying the share of health spending it was
responsible for previously.
In conclusion, we read in your report that there was room to debate new options,
even though they may seem troubling. This morning, we tried to outline possible
avenues for change to ensure the long term viability of our health care systems.
Depending on whether the federal government is seeking a new contribution in the
health care system through actions that assist citizens in need, there is
currently one area where little is being done, and that is with respect to
compensation for victims of medical mishaps. The current rules relating to
professional third party liability mean that only some of the victims of medical
malpractice are compensated. The only insurance company to provide coverage, the
Canadian Medical Protective Association, has no mandate to protect the victims,
and even less so victims of medical mistakes that while they do not constitute
malpractice, cause harm to the victim. And that is both a serious and common
problem which provincial governments have really taken very little interest in
Mr. Chairman, have I exceeded my time?
Senator Morin: One of our witnesses could not appear at the last moment,
so you still have some time.
Mr. Lamontagne: I would like to make some very specific comments with
respect to parts of your Executive Summary.
On page 12, you say that the role the federal government plays with respect to
population health focuses on prevention, rather that treatment of disease. I
just want to make a comment on that. For some years, I have noticed that there
has been a lot of talk of prevention and promotion, as though that was all we
did and no one ever died. But we do need to provide treatment. And as
physicians, we are the persons responsible for providing treatment. But because
of the obsolescence of equipment, conditions in hospitals, and so on, we have a
long road ahead of us.
I think we should also be investing in treatments, mainly as they relate to
three conditions: the impoverishment of society, especially since we are in a
recession and we know that a poor society is one that generates more illness;
new diseases, such as AIDS, that cost more, are more complicated to treat and
require much more expensive medications; and finally, the aging of the
population. This results in multiple pathologies and far more complex forms of
I completely agree with you when you say, on page 12, that the health care
sector bears no resemblance to a modern industry. I will come back to that
later. And when you say the health care industry is very much like a cottage
industry, I must say I agree with you. There are three main issues: inadequate
funding, a system of management that does not jibe with the kind of management
practiced in the 21st century, and health care administrators who manage
expenditures rather than managing revenues and expenditures. If you want to
improve something, you have to cut something else. I've never seen a company
able to operate like that; it would go bankrupt within three months. On page 13,
... review the benefits of establishing specialized service units, an
important component of a modern system.
I fully agree with that. You know, I have the feeling - and I do not know what
it is like in the other provinces - that we have sprinkled money throughout the
system, creating kings all across Canada in small kingdoms, rather than valets
who are part of one large kingdom. I am very much in favour of local hospitals
providing basic services, regional hospitals providing more specialized
services, and university institutes and hospitals providing ultraspecialized
Senator Morin: That will make Dr. Keon happy.
Mr. Lamontagne: Really? Well, that's great.
Senator Morin: He is the Director of the Heart Institute in Ottawa.
Mr. Lamontagne: Oh, really! Then let's take the example of cardiology. As
regards cardiac surgery, in the Montreal area alone, there are eight different
centers operating; however, in Sweden, there are only one or two for the entire
country, if memory serves me. I think we could have one in Montreal and one in
Quebec City. And if those kinds of situations exist here, they must surely exist
in the other provinces as well.
Senator Morin: And one in Ottawa, of course.
Mr. Lamontagne: Yes, of course. But you know, I am not really talking
On page 15, you say:
Can the government continue to discourage the provision of private services
while prohibiting private insurance?
I think the answer to that is no. Let's look at the situation in Australia,
where they have supplementary insurance that costs about the same amount as a
driver's licence would cost us here - about 500 $ a year. And this is not for
the rich, but for people whose average income is about $23,000 CAN. That makes
it possible to inject additional funds into the health care system.
People here spend thousands of dollars a year on lottery tickets but cannot
spend $500 to insure that they have access to good services. There is something
wrong with that picture. I realize that lotteries bring in huge amounts of
money, but it seems to me we could be investing the money in the right places.
Two-tier medicine is a reality. In fact, I think there are two kinds of two-tier
medicine: private/public and a two-tier system that nobody talks about and that
does not bring in much money. I will use the same image I often use: if you want
to be well looked after in a hospital these days, it is really quite simple:
either you scream your head off and join a lobby group, or you have friends who
will make sure you are taken care of. There is not much of a financial return in
that. Maybe we should be organizing things so that at least we can make money
out of this.
Let me tell you a little story. I like telling stories. A Montreal hospital
provides - dare I say - check-ups to influential businessmen right in the
hospital. At one point, they said: "Listen, we are prepared to pay to come
in on Saturdays. We have no problem with your making a profit on that. So, we'll
just line up the limousines one after the other, and we'll pay you for your
But that arrangement was not accepted. So, they have to have their check-ups
during the week like everybody else. One businessman in particular gave a
Mont-Blanc pen to all the secretaries and technicians. I can assure you that he
gets an appointment on the day and at the time he wants.
It is very nice for the secretary who gets a beautiful Mont-Blanc pen ouf of it.
But what does the hospital get out of it? Nothing. If that were subsidized, we
would be able to talk about managers managing income and expenses.
On page 18, you say:
There is a need to increase efficiency and effectiveness and find new ways of
That is true. We have been injecting money into the health care system for
thirty years now. For thirty years we've been investing in the health care
system, assuming that things will get better, but things never get better. So,
there must be other problems. And that is basically what I was saying earlier.
There is a management problem. There is a private/public partnership problem,
but everyone is afraid to talk about it because they think the private sector
will gobble up the public sector and that we will end up with two-tier medicine,
when actually we would be able to afford to have a second tier of medicine. That
is the difference. So, we need both.
In Sweden, which is a much more social democratic country than Canada, the
largest hospital in Stockholm was sold to the private sector; it is now listed
on the stock exchange. And when people go to see their doctor, they are
responsible for a co-payment of $25 if they consult their doctor at his office,
or $35, if they visit an emergency department.
On page 19, you say:
All physicians should be required to work a certain number of hours in the
We agree with that. We think that would be possible if we have a private/public
partnership. And Bonin, an economist who wrote an excellent book on the
management of various government systems in Quebec, suggested that all
physicians should be forced to work 35 hours a week in the public system, and
then, if they wish to work additional hours in the private sector, they would be
able to do so.
There would be an advantage in doing that. With the ceilings in place in Quebec,
physicians only work as many hours as the ceiling allows, then after that, they
go and play golf. While that is happening, people are not being treated. The
people who would be treated under those circumstances would not be treated
within the public system. And it is highly likely that fewer physicians would
leave Canada to practice elsewhere because they are paid less here.
You also say that the public system could guarantee waiting times and that if
those were exceeded, the government would pay for the treatment to be provided
by a private facility. That is something that must really scare the government,
for two reasons.
First, we should not even be talking about waiting periods and waiting lists.
There are waiting lists for cardiac surgery, and so forth. That makes absolutely
no sense. And for breast cancer surgery, people are often required to wait a
number of weeks. But when you are sick, you do not want to wait weeks. You
should be treated immediately. So there is a danger in that kind of approach.
Of course, there would be a danger in indirectly subsidizing the private market,
which could clearly demonstrate that it provides better services, so we will try
to slow down the public system as much as possible to bring the money in that
On the same page, you say there is a need for:
an independent, mandated organization to ensure that technology used in the
public system is as advanced as that available in the private sector.
I believe we are way behind as far as technology goes. The danger I see is again
that we will just expand the bureaucracy by creating another organization. And
if there is not adequate funding to allow us to be as advanced as the private
sector, we clearly will not see any results.
The President of the Conseil des technologies du Québec told ministry officials
one day: I produced these great reports, but you never act on the
recommendations. Why do you pay us to write reports that you have no intention
of implementing, because you do not have the funds to do so?
On page 27, in relation to technology:
Modernize, purchase, operate...
What a great idea! In terms of information technology, you say it is a cottage
industry. That is terrible! We are not in the modern era here. Shareable
computerized medical records, patient medication, laboratory analyses that come
in by computer, diagnostic and therapeutic aids - all of this would save a great
deal of money. And it would mean that patients would receive better treatment.
The problem is that everybody is off doing his own thing, without telling
anybody else about it. If we computerize the entire system, I predict that in a
few years, we will face a great many problems. How will we ever be able to
harmonize all these small computer systems here and there, when we probably
should have developed a provincial or national plan? When someone gets sick in
Vancouver, using a computer, we could find out what medication the patient is
using in Montreal. I guess that is wishful thinking.
You refer to pilot projects. In Quebec - and I do not know what it is like in
the other provinces - it seems to me we have been overdosing on pilot projects.
At the College, we have assessed hundreds of pilot projects, some as ridiculous
as the one on the use of combi-tubes by ambulance operators, and things like
Instead of basing ourselves on research principles, we launch pilot studies,
show that something is effective, proceed to carry out a
"multi-center" study, and then apply it.
I am not very keen on pilot projects.
Senator Morin: I want to be sure I understand your point, Dr. Lamontagne.
What you're saying is that rather than carrying out pilot projects where there
is not proper control and verification, we should be doing
"multi-center" studies. Is that what you mean?
Mr. Lamontagne: It seems that every time we launch a pilot project, we
are out to discover something new. But take the informatics sector, for example.
There are a great many things that have already been discovered and applied
throughout the world.
Let me give you an example relating to computerized medical records:
There is currently an excellent program in place in Australia, which could
easily be translated into French. In Quebec, we are carrying out pilot projects,
when in fact we would simply have bought that program from Australia, started
applying it in English immediately, and then had it translated into French. Ten
years from now, we would have to update it. But let's stop doing research in
areas where it has already been carried out. There are a lot of companies
developing very interesting things. We seem to find that rather scary.
The same applies to tele-health. Because of the size of our country, we really
need to develop tele-health. I'd like to cite a very personal example of that.
Two years ago, my daughter got a concussion while skiing in New Hampshire. There
is a small hospital there serving a population of about 20,000 that had aCAT
scanner; they did the CAT scan and when I asked where the radiologist was, they
told me they didn't have one, but that Tele-health Boston would provide an
answer within a half hour.
Three quarters of an hour later, we were told that it was not serious. I left
the hospital with a bill of $935 US. But that is real efficiency! And they are
saving money, because they do not need a radiologist and everything is carried
out using tele-health.
In terms of resources, we have a shortage of physicians. A long time ago, we
must have done some serious miscalculations with respect to physician manpower.
We are starting to have a clearer idea now and are realizing that there is in
fact a shortage all across Canada. I will not dwell on that any further.
The current rules define what various professionals can and cannot do. We can
talk about this more later. We are also currently considering the idea of
shareable procedures, which I will address later.
Indeed, we have to review our entire system of shared procedures. This goes back
to what the optometrists were saying earlier. But we also need to be careful: we
have to avoid replacing one health care provider with another and thus driving
our health care system down to the lowest common denominator.
In Quebec, the Bernier Committee considered this. We have to avoid turf wars, or
giving something to Pierre that we then take away from Jacques, to the point
where we end up with lower quality medicine.
At the political level, this could result in savings and increased access. In
terms of economics, there is a chance that costs would be reduced. However, I am
not so sure that services would be as good.
And finally, the good stuff: physicians' compensation. Everyone agrees on the
need to review fee-for-service - at least in Quebec. It all began in Quebec with
this business of a lump sum based on a percentage of procedures performed.
Actually, with capitation, it is about the same thing; there is a lump sum and a
percentage of procedures. I think that is most likely the best approach.
The most important factor in decreased productivity is without a doubt salary,
because physicians really become public servants.I have seen that happen in
certain European countries.
In last Monday's La Presse, a doctor was saying that he was leaving the
CLSC for private practice, because he was only seeing patients about eight hours
a week. We should not be paying physicians to go to meetings on public health;
we are paying them to see patients. So that is certainly a problem. And perhaps
individually based compensation would be helpful in that respect.
I should say that my former specialty is psychiatry. As long as physicians -
indeed, like other people - see themselves as entrepreneurs - and let's not kid
ourselves, they are - we have to provide for enhancements - hence the need, in
my view, for a mixture of forms of compensation for physicians.
Senator Morin: Senators' questions will be addressed to you either in
French or English. You may answer in the language of your choice.
Mr. Lamontagne: No problem.
Senator Keon: Dr. Lamontagne, you certainly covered the entire
waterfront, and you covered it very well. You threw out all kinds of dilemmas
that are confronting everybody.
I want to bring you back to the physician remuneration system. Mr. Claude
Castonguay was here yesterday morning, and I mentioned to him that, when the
CLSCs came in, my brother was a general practitioner in western Quebec and he
thought this was a great idea because it, for example, provided social workers
who would deal with non-medical problems that were taking up about 30 per cent
of his time. That left him free to deal with medical problems. However, you have
pointed out some of the pitfalls of the system.
You also mentioned tele-health. The Heart Institute in Ottawa has been involved
in tele-health for quite a long time. We have installations in Baffin Island and
other remote area so that the local people can transmit their medial information
to Quebec and Ontario. The major barrier to setting this up is that there is no
way of paying the doctors. At the Heart Institute, where physicians are salaried
and they share the total pot of money according to formulas, there is no problem
at all. If a physician has to spend time on a tele-health clinic, it does not
hurt his income any more than teaching or research. However, in the small
communities, the doctor will not be paid for that service. You have to ask the
doctor to work for nothing for a morning so that this can be done.
I feel very strongly that the medical profession has to lead the way in advising
government about alternate payment plans. I agree with you in that I do not
think there should be a universal plan. However, we have to assist government in
developing payment plans that can make the system work in primary care, in
academia, and so forth.
You covered this area to a degree. You said very forcefully that you do not want
to see doctors become civil servants, and I agree with that. We want to leave
some incentives. The fee-for-service system does not work in many systems. Maybe
you could go through that a little slower than you did on your first run at it,
because you covered so much material. Could you give us your thoughts on the
various systems of payment that could solve the problems in primary care, in
academic institutions where people have to devote a lot of time to teaching and
research, and in leading edge programs where there is no fee in the fee
schedule? It appears there will not be one for four or five years with some of
the new things that come out. There has to be a way of remunerating doctors so
that we get leading edge health care to the patients. Tele-health is a good
example of that.
What kind of a system do you think could be implemented? Let us limit it to
Quebec now because you know the scene in Quebec very well. What kind of system
do you think could be implemented in Quebec that would solve some of these
Dr. Lamontagne: I will make two comments. The first is related to the
CLSCs that you talked about. I will give you an example of this partnership.
When this all started there were physicians in private practice in one building,
and suddenly the CLSC was at the next corner. They were practising medicine and
then more and more they began to treat social problems rather than medical
problems. Of course, they stopped talking to those people in private practice,
and it was the same the other way around.
That is an example of one partnership that could be formed. You could combine
the CLSCs with doctors working in private practice. Hopefully, doctors working
in CLSCs would work very closely with those in private practice so that they
would have a connection to treat psychological and social problems. As it is
now, physicians in private practice and CLSCs do not communicate.
Of course, there would be one major problem. If, as a CLSC salaried doctor I am
working eight hours a week and I am very satisfied with that, I would not be
very happy to start seeing patients 35 hours a week. You would certainly have to
find some new reinforcers that would encourage these people to get into the new
On the subject of payment, I believe that what you have at your hospital is what
we would call the pool system. In university hospitals I think operating with a
pool system is a very good idea. However, people always become worried when
there is any suggestion of changing a routine. You have to give them some
reinforcers to get them into a new system. I might also add the there may be a
cultural element because, in Montreal, the pool system is working much better in
the English university hospitals than in the French hospitals.
However, I think it is a good idea. I have been teaching at a university for 25
years. As in a private business, at the end of the year, if you are in the pool
system you have to show what you have done during the year in terms of teaching,
research, publishing, grants, clinical services, and so on. That creates very
good competition. If you do not meet certain criteria, you are fired. That
encourages entrepreneurship and leadership. In my opinion, the pool system is a
good thing for university hospitals.
However, in primary care, I think that a mixture of "forfait" as they
say in French, that is, a flat rate or fixed sum, and a percentage of the fee
for service is not a bad thing. Doctors working in an isolated region where they
are expected to undertake all sorts of new activities could be paid on a forfait
basis. If the task is related to clinical work, then you would add to that a
percentage of a fee for service. Of course, that is not part of the
responsibility of the College of Physicians and Surgeons. That falls on the
shoulders of the federations, which are really the unions. They would have to
discuss with the government, what work would be paid for.
Our college prepared a report on télé-médicine. When tele-health started
there was no provision for payment for a consultation by tele-health. Nobody was
paying for that service.
I think a mixture of "forfait" and a percentage of fee for servide
would be appropriate for doctors in outlying regions. Of course we have the
whole problem of trying to keep physicians in the regions.
Senator Keon: Do you think part of the problem is that we have two
separate pools of funds? Tele-health or télé-médicine is, perhaps, a
framework within which to discuss this. There is a pool of funds to remunerate
physicians, and there is a pool of funds to pay for institutions, fundamentally.
There are no funds for anything else. There are, of course, piecemeal little
bits of money for this and that.
The problem is that, when a new program is approved in the institutional sector
there is not, at the same time, approval to remunerate physicians from the pool
of funds, because they are already short of funds. On an annual basis, they try
to decide how to equitably divide the funds they have. They must decide whether
specialists are making too much, and family physicians are making too little,
and all of these problems. To include a new program in the fee structure is
One of the major barriers is the fact that we have thesetwo pools of funds.
Perhaps what is needed is the creation of a development fund that would fund
programs both from the institutional sector and from the personal sector until
an appropriate mechanism for funding them from both pools of funds comes about.
We have nothing like that right now. This is a tremendous barrier to the
development of new and efficient programs.
Mr. André Garon, Deputy Secretary General, External Affairs, Quebec College
of Physicians: We have in fact noted the problems that would result from
having two sources of funding, two programs that would be complete and utterly
separate from one another. Before the Clair commission, and more recently before
another parliamentary committee in Quebec, we argued for what we call a health
care "hydro". Basically what we would like is an insurance system
where one manager would oversee all insurance schemes to ensure that there is a
We realize that as part of the negotiations between the Minister and physicians'
representatives, we could certainly agree on methods of compensation and rates.
That works in favour of certain kinds of practices rather than others, and
focuses on one approach; however, the public system, the funding of the public
system and hospital funding focus on another approach. Insurance systems do not
talk to each other. That results in mixed messages, inconsistencies, wasted
energy, wasted money and everything else. If it were possible to develop bridges
between these different funding schemes, we think that could be an attractive
I want to come back to the question you asked earlier, to add something about
compensation, and particularly physicians' compensation. We believe that one
method or the other each has its benefits but also enormous disadvantages. The
method involving fixed honoraria, lump sum honoraria, and salaries has
advantages, but also significant disadvantages. The same can be said about the
fee-for-service method. We believe it is time to consider some combination of
the two, both for specialists with teaching and research duties and general
practitioners providing front-line care.
What is most important at this stage in Quebec is to determine how we could
combine the concept of client registration with a method of compensation that
would introduce a form of capitation or a certain percentage of capitation
payment. Perhaps 66 per cent of a physician's compensation could be based on
capitation and33 per cent on the procedures performed. You immediately see what
the effect of that would be. And the capitation portion would be modulated on a
basis of the patient base registered with the family physician.
There is no doubt that caring for a 35 year old man is ten times less onerous,
in terms of the workload, than caring for a 60 year old suffering from multiple
pathologies. So, the compensation has to be modulated on that basis. However, we
do think there are some very promising avenues that are worth exploring, in
addition to the one you seem to support, which would involve interface between
public insurance schemes.
The Acting Chair: I think that's excellent. I really think your
suggestion about 66 per 100 being based on capitation and 33 per cent on
procedures performed an excellent one. Did you arrive at that figure after a
Mr. Garon: I cannot tell you whether it stems from a study or not, but
the idea or principle behind it is to ensure that more than 50 per cent of the
compensation is paid for the fact of being responsible for a patient group. And
that is fundamental. The fee-for-service system does not include a procedure
called case management for which there is a charge, does it?
The Acting Chair: That is exactly our thinking. Senator Keon, do you have
any other comments?
Senator Keon: I did want Dr. Lamontagne to expand on co-payments.
Let me try to present something that we discussed with other people across the
country. We are in a situation now where hospital care and the doctors' charges
are pretty well covered in the system, but then there items at the front end, in
preventive health, and so forth, where there is no coverage at all. For example,
in the Heart Institute we run smoking cessation programs, primary prevention
programs, and so forth. We are able to fund these out of our global budget
because of efficiencies, but the programs are not as large as we would like them
In terms of preventive programs, what happens is that American hot-shots out of
California come up, set up shop in town, give cooking lessons, and they charge
people to go to these classes. Of course, only the richer people can afford to
go to these classes.
At the other end, when you talk about home care and custodial care of various
kinds, including physiotherapy at home and other things, the funding runs out
and the patient has to pick up the tab. This has become a serious problem,
particularly for older people where their government payments run out and their
insurance runs out. The family is left to pick up the tab for some kind of care,
and it almost wipes them out financially.
As I read your remarks, you say that you see a co-payment system existing across
the board. In other words, the government pays part of everything and the
individual pays the other part. Am I correct in my understanding?
Dr. Lamontagne: Yes, but there is a problem with that. What will happen
to the poor people? If they cannot pay, they will not seek medical care and, if
they do not do that, then they may die. It will be like it is in the States: If
you have no money you can die on the street. I do not know the answer to that.
Perhaps we would consider a system that is equivalent to Legal Aid which assists
people who cannot afford to pay their legal fees. It applies to people whose
income is, say, less than $20,000 a year. People who earn more than that have to
pay their own legal costs. If we can do that for legal aid purposes, why can we
not do that for medical purposes? If you have money, you pay; and if you have
more money, you pay more. It is quite easy to check income against annual income
tax reports. We must remember that there are poor people, and they have to be
treated as well as those who are rich.
I would agree with there being a co-payment for everything. If we start charging
$5 for this and $10 for that and $25 for something else, then we will be back to
a bureaucratic sysem. How are we going to deal with that? What is worth $5 and
what is worth $25? It could take years to come to decisions on that. I think
that doing it across the board would be the best way to proceed.
To come back to my example in Sweden, if a patient goes to see his doctor with
cold symptoms or because he has pneumonia, that costs $25. If the patient goes
to the emergency, for whatever reason, it costs $35. That applies as long as a
person can pay. I would agree with you that. It should be as simple as possible.
You talked about the Americans giving cooking lessons to those people who will
pay for that. Well, that is quite nice, but I would say it is also very
American. I quite agree with that. People should pay for that type of thing.
However, I think that they shouldfirst pay into the system when they are sick.
Minister Trudel will be coming forward with the suggestions made by the Clair
commission about what might be called old age security. Of course, on a
political level, you will not win an election on that platform because lots of
people would vote against that. Personally, I think it is a very good idea. On
one side things are becoming so expensive and, on the other side, salaries are
not increasing. If we get sick, we will not be able to afford any medical
services. We also have to think about what our children will have to pay for us
20 years from now. There will be more old people than young people around 2016.
That is why we should bank some money for that type of eventuality. I know that
governments make a lot of money on lotteries, but they do what they want with
that money. They certainly do not put it into health care. If you put some money
aside, you know it is there and, when the time comes, there will be money to
I agree with that but, politically, it is very tough to sell that to the
The Acting Chair: Dr. Lamontagne, before I recognize Dr. Keon again, what
you are saying seems to be somewhat contradictory to what you said in your brief
about co-payment. You said that co-payment should be prohibited for medical and
hospital services except where the services provided and received are considered
relevant, effective and efficient. You said we should prohibit co-payment, and
then you gave a series of examples.
The example I really liked, and which we will certainly be focusing on, relates
to the percentage of care provided in a clinic to patients who are not
registered with a family doctor. In other words, patients have the choice of
registering or not registering. You certainly cannot force people to do it. But
where they aren't registered, there would be a co-payment for any care they
receive outside of the front-line medical care team. That is on page 4, under
"Y". I really like that one, and this is the first time I've seen it.
We are always talking about reforming front-line care, saying that patients have
to be registered, and so on.
At the same time, we know that we cannot force people to register if they do not
want to, nor can we force things on patients. As you point out on page 4,
patients that refuse to register with a front-line medical team, for all sorts
of different reasons, would have to bear a percentage of the costs, if they want
to consult their pediatrician, gynecologist or psychiatrist directly. I think
that's an excellent idea.
Mr. Lamontagne: I would like to elaborate on that for a moment, Dr.
Morin, and then I will let Dr. Garon comment, because he is the one that wrote
the brief. My first comment would be that we have to make this as simple as
possible. Because as it currently stands, the system is complicated. If we could
make it as simple as possible, at least in terms of co-payment, we would avoid
the problem of additional bureaucracy.
If we charged a fee that would be the same for everyone, we would at least avoid
a major administrative problem. We all know how expensive it is to administer
the public system.
Now, when you talk about registered users, well, I guess I am going to play the
devil's advocate here. If we introduce a capitation-based system in Quebec and
ask people to register, there will be more people registering than the people
who vote in municipal elections next Sunday.
It is pretty difficult to find a doctor. If we were to decide that people who do
not register will have to pay, I am pretty sure 98 per cent of the population
would line up to register.
Senator Morin: I would like to talk about direct access to a specialist
to whom one has not been referred.
Mr. Lamontagne: I will let Dr. Garon answer.
Mr. Garon: As I am sure you understand, Dr. Morin, the idea here is to
encourage healthy behaviour, behaviour that fosters efficiency and
effectiveness, and to discourage other kinds of behaviour both among consumers
or users and providers of care. We do not feel it is desirable for patients to
be able to consult specialists directly, without having to go through the family
doctor they are registered with. That being the case, we have to find some way
to discourage conduct that we consider to be undesirable.
With respect to pharmacare, Quebec currently has a co-payment scheme which makes
it possible to ascertain electronically what portion of the costs the patient
has to defray and what portion is covered by the government. Management of this
co-payment system involves very little bureaucracy. The system is computerized
and works electronically. And an individual purchasing medications immediately
knows what his or her share is. There is always a ceiling. The payment can never
By using this kind of co-payment system, we would be fostering good behaviour on
the part of the prescriber as well. For example, good old penicillin could be
100 per cent insured, but Cipro might only be 25 per cent insured.
Senator Morin: I do not know why you chose the example of Cipro.
Mr. Lamontagne: I am sure you will have noticed that I skipped that
paragraph in the text.
Mr. Garon: All of this to say that modulation must be something each
province can do. In Quebec, in the 1990s, preventive dental care for children up
to the age of 12 was not insured. We went from 100 per cent to 0 per cent. We
aren't always smart about the way we do things. When we took that action, we
lost all information on consumption of such services. We could have maintained a
formula whereby 25 per cent or50 per cent would be paid by the government for
such care. The other costs would then have been borne by the family. But no. We
went right from 100 per cent to 0 per cent.
In Canada, our basket of health care services is not all that wide. But it is
certainly deep. It is 100 per cent. In European countries, however, it is wide.
It includes much more than medical services - things like optometric services,
drugs, or physiology. It is much broader, but it isn't based on a 100 per cent
formula. We do not need to have a fixed standard of either 25 per cent or50 per
cent. It can vary depending on efficiency.
Senator Morin, I think you know what I mean. Medicine is not always practiced on
the basis of meaningful information. And consumers do not always make their
choices based on what is most desirable.
Senator Morin: Thank you very much.
Mr. Lamontagne: Dr. Garon's example of dental care is an excellent one.
As you can see, we could have gone half and half. At that point, people with
average incomes could have continued to benefit from some assistance, in order
to access this care, whereas average families that can no longer afford to pay
for it have completely written it off. And ten years from now, we will be
dealing with major dental problems in these children whom we completely ignored,
because it had to be 100 per cent or0 per cent.
The other point Dr. Garon made earlier relates to the need to encourage positive
behaviours and discourage negative behaviours. I know something about this
because my training is in behavioural science. All health systems discourage
negative behaviours, but positive behaviours are never encouraged.
And yet we know that in behavioural therapy, positive reinforcement is much more
effective than negative reinforcement. So, we have to steer the train back onto
the right track, whether we are talking about physicians' compensation or the
contribution we are asking people to make, either financially or in terms of
system organization. But there has to be positive reinforcement somewhere. I
believe we have to re-think our whole approach and focus more on positive
reinforcement, rather than always providing negative reinforcement.
Senator Keon: I think I have taken too much ofDr. Lamontagne's and
Garon's time. I will give the floor to somebody else for a while.
Senator Pépin: Dr. Lamontagne, I really appreciated your article.
Mr. Lamontagne: I must admit there are some in Quebec who appreciated it
a lot less.
Senator Pépin: I want you to know that if you were Minister of Health, I
might consider running again.
Mr. Lamontagne: I do not want to be.
Senator Morin: I just realized that we did not receive that article.
Senator Pépin: Well, I cut it out of the magazine. It was published in L'Actualité,
and it is an excellent article. It says that we need a health care system that
operates like Hydro-Québec.
Senator Morin: We should have it photocopied.
Senator Pépin: Yes. I will provide it to you so that you can distribute
it to all the members.
I agree with what you said in your presentation about focusing on treatment and
not just on prevention. You said that there have been no studies of aging. We do
not know what the impact of it is or all the needs associated with it. That is
something we may want to do in the near future.
You also talked about the importance of having a team in place to manage both
revenues and expenses, instead of just expense managers. I agree with you on
I also agree with your views with respect to local, regional and university
To make our hospitals and health care facilities more efficient, we could have
them operate seven days a week. If we combined public and private services, that
would put money into the system and probably make it a lot more efficient.
You talk about work being performed in teams. I would like you to tell us how
you see that working, because we are talking about physicians. I find that
pretty serious that a doctor would only be seen patients eight hours a week. But
it there were teams made up of doctors, nurses, lab technicians, social workers
and ophthalmologists, how would you actually design that team to ensure it would
be functional and worked to the advantage of each team member, according to his
or her particular discipline?
You referred as well to computerized medical records. In that regard, there is
one thing that concerns me, and that is confidentiality. Thus far, no one has
been able to reassure us with respect to confidentiality. There are a couple of
issues we really have to look at.
Mr. Lamontagne: Senator Pépin, your first question had to do with team
work, did it not?
Senator Pépin: Yes. Hours of work.
Mr. Lamontagne: Well, because there are a lot of us, we have to work
together using an interdisciplinary approach. The number of disciplines has
increased. In the 1950s, the approach was based on the physician-nurse-patient
triad, where all three worked hand in hand. Obviously the team has expanded. Now
we have all kinds of technologists. From a human standpoint, the issue is that
everyone has started to "peck" at patients - taking pieces of skin,
blood, urine, et cetera. And the patient feels as though he is kind of lost in a
jungle where everyone is jumping all over him but he has no idea who is really
looking after him. I think that sort of describes the current situation.
Senator Pépin: You get the feeling that the patient is at the bottom.
Mr. Lamontagne: Yes. So I think we have to reinstate concepts such as
team spirit and strengthen the linkages between different health care
professionals. Now that I am no longer president of a union association, I can
talk about money. I think that way of doing things would be helpful and have the
effect of improving relations with other health care professionals. It is an
interesting idea from the standpoint of the way in which society has evolved.
In the 1950s and 1960s, when there were still enough physicians, there was no
question of relinquisking certain duties to nurses or anyone else. But now we
are facing a shortage, and all of a sudden, I see young doctors who are ready to
hand over all sorts of responsibilities to others.
Senator Pépin: But they would have to increase nurses' salaries in that
Mr. Lamontagne: Oh! I do not want to get into that. As I say, now I am a
professor. But I do think that something can be done. In that sense, I would say
we are well on the way, and we will be meeting with the ministry again to talk
about what we referred to as "shareable activities."
Senator Pépin: Yes.
Mr. Lamontagne: So, we are fully aware of the fact and support the idea
that as physicians, we need to have highly specialized nursing personnel. In
terms of hemodialysis, intensive care, and neonatalogy, for example, we have
described all of these tasks and are prepared to let nurses provide such care
based on a medical protocol, insofar as they have adequate training, which means
more than Cegep level.
Senator Pépin: I agree.
Mr. Lamontagne: Secondly - and this does not concerns me - they need to
be paid for the work they do, and relieve physicians as much as possible of
those tasks that other health professionals are able to perform.
For example, why does a doctor have to administer vaccines, when a nurse is
perfectly capable of doing so? Every year, as soon as a new vaccine becomes
available, we have to revisit this issue and delegate the task to nurses once
again. And I must admit the delegation process takes so much time that sometimes
the vaccination date is past before we are actually able to delegate that task.
We are talking about specific duties here. We have looked at the various
processionals. We are in the process of reaching an agreement with associations
of specialized physicians to determine to what extent they can delegate certain
tasks to an inhalation therapist or physiotherapist - not just a nurse.
We have to do that, first of all, in order to improve our cost-benefit ratio
and, secondly, to release the physician from certain duties. Some people with
better training are now able to do things that doctors had to do previously. So,
let's let them. That was my comment in answer to your first question.
Now let's talk about computerized medical records and confidentiality. Last
week, I gave a lecture before the Quebec Hospital Association as well as one at
a symposium organized by the Access to Information Board. At one point, we
brought an ethics advisor into the College to discuss the issue of computerized
medical records. He had some wonderful slides to show us on his computer. I said
to him: "Mr. Péladeau, if we take your advice, by the year 3000, we still
will not have computer-based diagnostics."
I realize there are certain concerns with respect to confidentiality. Protection
of computer systems is not adequate. As for paper records in hospital - and this
is my argument - the housekeeping staff have access to them. When a nurse is not
at her station, any visitor can go behind the desk, access the files and take
whatever he wants.
Senator Pépin: Yes, but there is less likelihood that people will see
this information on a screen.
Mr. Lamontagne: Yes. But, as I say, computer systems are sophisticated
enough now that there are ways of blocking access. And with smart cards, two
cards are needed. If you do not give me your card, I cannot access your records.
When you come to my office for a consultation, you insert your card; then, to
let the system know that you can get in, I insert my card and access your
records. It works very much like a credit card. If you do not give me the card,
the payment cannot go through.
And in cases where records are shared among several professionals, I am told
that as far as the computer system is concerned, I could decide that only the
physician, nurse and psychologist would have access. I may not want the social
worker or pharmacist to see that information. So, it is possible to configure
the system so that only certain people have access to the records, but not
others. The technology does allow that to happen.
Senator Pépin: I see.
Mr. Lamontagne: There will be pilot projects in this area. IBM has
started to develop shared files. Other companies are also getting on board,
because there is a market for this, isn't there?
They give you the equipment, because there are some very, very attractive
potential clients out there. It starts up in one place and moves to another. At
some point, we will want to be able to talk to each other across the province.
If my computerized records are in Montreal and I fall into a coma in Chicoutimi,
how are we going to set up the system in Montreal, which is a pilot study, with
the one in Chicoutimi, which is also a pilot study? How are we going to make all
I must admit I would be very pleased, if I'd been involved in a serious traffic
accident in Chicoutimi, to know that the physician in Chicoutimi could simply
take the card out of my pocket and use it to find out what drugs I am taking,
and so on. So, the day is coming when that will be a reality. I think it will
allow us to save lives.
Senator Pépin: The other thing you talked about is tele-health.
Mr. Lamontagne: Yes.
Senator Pépin: We know that there are significant problems in remote
areas. If we could work out an appropriate system of payment for Aboriginal
communities, tele-health would be a really attractive solution to some of their
Mr. Lamontagne: You are absolutely right. I am not as familiar with
Aboriginal communities, but remote regions can just as easily be Chibougamau as
elsewhere. These people are paying taxes like everybody else and they are
entitled to medical services. At the same time, we have to be realistic. We
cannot implement this kind of system everywhere, as I said earlier. The best
examples are the famous scanners. Everybody wants a scanner. But four years
later, it is already obsolete. It seems to me that only the hospitals that
really need one should have a scanner.
Let me give you another political example. In one region of Quebec, we have a
traumatology unit in one riding, and a scanner, in the neighbouring riding.
Politically, that works really well. The patient arrives at the hospital in a
thousand pieces, but we practically have to put him on a dolly to give him a CAT
scan 60 miles away. That is not medicine. That is just plain ridiculous!
Those are the kinds of things that simply make no sense, from a clinical
standpoint. Why? Because they never asked a physician whether it was important
to have a scanner at the traumatology unit.
With tele-health, it is the same thing. I was telling you earlier about my
daughter's experience in a small hospital in New Hampshire, in the middle of
nowhere. There was no need then to pay for a radiologist, was there? Thirty
minutes later, the results were there. But do not worry: the radiologist who
looked at the pictures was well paid. He got most of the $835 or $935 I paid. It
is a good thing I had insurance!
In Quebec, we have started a project in pediatric cardiology. There are now
seven centers that are linked by cable, and it is working very well. We want to
develop more such systems.
At the same time, there is a management problem. There are seven centers linked
by cable for pediatric cardiology, with wonderful rooms, equipment and so on. I
would be willing to bet that it operates from 9 to 11 in the morning, and then
the key is in the door. In the afternoon, there are psychiatric consultations
with other professionals until 3 p.m. Then from 3 to 5 p.m., there are
endocrinology, internal medicine or other consultations. Then at8 o'clock at
night, it is something else - just to keep the machine running.
I lost a good friend who used to live across from me - a surgeon who went to
practice in New York. He worked very little. One day a week at Hôtel-Dieu, one
day a week at Victoria, and the three other days, he would schedule his patient
visits; that was it.
We have patients who have to wait a year for surgery. Our system so exasperated
him that we ended up losing him. It was not a question of money. He used to say
that the reason he had trained to be a doctor and surgeon was to be able to
We communicate by e-mail. Once he said to me: "Here, I could operate 24
hours a day, seven days a week, if I wanted to, ask for any kind of instruments,
and it wouldn't be a problem." But he also told me: "I miss
Quebec." If only we had that here.
Senator Pépin: I would like to address a more touchy subject: women
physicians. We read that the President of the Quebec Federation of General
Practitioners declared, following a poll, that women physicians worked fewer
hours than their colleagues because they have children and have to look after
them. And I recently read another article to the effect that in gynecology and
obstetrics, 38 per cent of those admitted are women, and that their number is
Do you think that this trend will have consequences? And what would the impact
be on the overall availability of services?
Mr. Lamontagne: You are leading me onto a very slippery slope, Senator.
Senator Pépin: That is why I said it was a touchy subject.
Mr. Lamontagne: There is no doubt that women physicians work fewer hours
than men, for obvious reasons that I understand, and it clearly is a good thing
that they look after their children. But the end result is that they work fewer
hours. Also, they see fewer patients than male physicians. That is a good thing.
They are more human, have a closer relationship with their patients and feel
more empathy. That is a good thing.
From an economic standpoint, women physicians also earn less money than male
physicians. At the beginning of their career, they work less than men. But when
they reach their 50s, because they have already raised their family, they
increase their work hours. It is men who begin to work fewer hours then. So,
over time, things balance out.
About 40 per cent of physicians in Quebec are women, compared to about 30 per
cent in the other provinces. That is why when making comparisons between
provinces, it is important to pay attention to the women physician ratio, and
the number of hours worked, because of the number of female physicians.
Women physicians do not work less than men: they work just as much and often
they work better. But if you look at the long term, they may well work fewer
hours while they are raising their children, then work more hours when their
children are grown up, whereas men tend to work fewer hours after the age of 50.
Senator Pépin: So, things do balance out.
Senator Léger: You talked about cultural differences between
English-speaking and French-speaking Canada in the way health problems are
resolved in Canada.
If I understood you correctly, English-speaking hospitals adopt a different
solution to a given problem than French-speaking hospitals do. I am wondering
how a culture can actually have its own approach to issues?
Is that the case all across Canada? Is there a difference in problem-solving
because of cultural differences?
Mr. Lamontagne: It is a question of culture. We are not making this up.
The Anglo-Saxon culture is a highly practical one; in our Latin culture, we are
more emotional. That is just the way it is.
What can be done about this? Well, as I see it, Anglo-Saxons tend to manage
their hospitals based on a much more business-like approach than is the case in
Second, they have more guts. They are not as afraid. Let me give you an example:
The Director General of an English-speaking hospital got the hospital to pay his
mortgage and make his car payments, and everything was fine and dandy. But a
Francophone hospital fired some guy because the hospital had paid for four
baseball tickets and the cost of cleaning three suits. So, somebody somewhere
just does not get it.
We have to stop putting a collar on these people, and instead say to them:
"We are paying you to administer, so administer as efficiently as you
possibly can." We should stop splitting hairs.
The Chairman: I am sorry I missed your presentation. However, I did pick
up on an answer you gave Senator Pépin. When Duncan Sinclair was conducting the
study for the Government of Ontario, like the Clair commission in Quebec, by
looking at a sample of billings to the government - and my numbers are
approximate - he found that two thirds of the services billed for by general
practitioners could have been provided by some other health professional, and
roughly one third of the services provided by specialists could have been done
by the family practitioner.
Has a similar type of study been done in Quebec? In other words, are the Ontario
numbers totally unique, or is it reasonable for us to assume that that is the
state of affairs?
Dr. Lamontagne: I would say that, although Ontario is much richer than
Quebec, yes, you have the same problem as we do here, and in that regard, there
is no cultural difference. It is the same thing.
The Chairman: It is the same thing. Thank you.
Senator Pépin: Maybe the solution is to have women heads of department
Senator Morin: Senator Pépin always has to throw that in at the end of
the discussion. Before we let you go, Dr. Lamontagne and Dr. Garon, there is one
extremely important issue our Committee has not looked at: compensation for
victims of medical mishaps or malpractice. That constitutes a significant part
of our health costs. Has the College looked at that? Have you carried out a
study of the issue? Are you aware of any study relating to that question?
Mr. Lamontagne: Dr. Morin, you raise a very important point. And I am
going to ask Dr. Garon to answer that question, because he sat on the ministry
committee looking at obvious medical mishaps.
Mr. Garon: Yes, a report was recently submitted to the Quebec Minister of
Health regarding the prevention of medical mishaps in the clinical setting. I
would invite you to read it.
As you know, under the current system of liability in delict or tort, in order
for a victim to be entitled to compensation, there has to have been malpractice
and harm caused, and you must be able to show a connection between the two.
Obviously, for the person who feels he or she has suffered harm, this can be a
difficult test to meet.
I believe both American and Australian studies show that only a tiny fraction of
those who are victims of a medical mishap actually receive compensation in the
final analysis. The question is: How do we measure the performance of a
compensation scheme? Based on the fact that it isn't too expensive or on the
fact that it does compensate the victims?
If we can measure that at some point, we will probably start questioning the
limitations of the current medical mishaps compensation plan. And maybe we
should be looking at alternatives.
Senator Morin: Perhaps my question was unclear. Has there been any
assessment or evaluation of the costs?
Mr. Garon: No.
Senator Morin: Because they could be huge. Every time a patient suffers
the side effects of a drug, he could present a claim.
Mr. Garon: In other countries, studies have been done. Sweden has a
Senator Morin: Sweden?
Mr. Garon: Yes. Sweden has a no-fault system, and it is self-financing.
Of course, I imagine that, as is the case for automobile insurance, the payment
schedule must not be very generous.
Senator Morin: I see.
Mr. Garon: That said, the problem is that we lack information about
medical mishaps. Thus it is difficult to assess the feasibility of a system
other than the one we currently have.
Senator Morin: In closing, I would like to express my thanks to Dr.
Lamontagne and Dr. Garon. I think we tested your patience by asking you so many
questions. You have seen how much interest your comments and brief have
generated. Thank you very much. It is possible we will ask you for additional
information or clarification with respect to specific points. Again, thank you.
Mr. Lamontagne: Thank you very much.
Senator Morin: Senators, Dr. Battista was unable to attend at the last
minute. I would therefore invite our next witness, Mr. Robert Dorion - a witness
to whom I extended a personal invitation - to come forward. Mr. Dorion
represents patients. We have heard from a lot of professionals and
representatives of governments, hospital and regional administrations. Mr.
Dorion represents the patients who receive care. He is appearing as an
individual. I have asked him simply to tell us his story in his own words.
Mr. Dorion - and this has nothing to do with his testimony - is an engineer who
resides in Quebec City. It is primarily as a patient that he is testifying this
morning. I thought it was important for Committee members to hear his testimony.
Mr. Dorion, thank you so much for being with us. I know that you have travelled
here from Quebec City to give your testimony. It isn't really that far, and you
have come from one beautiful city to another.
Mr. Robert Dorion: Yes, exactly. And by chance, I travelled all across
Canada last month on business. It was an opportunity for me to talk to fellow
citizens in every region of the country. So I tried to prepare a short paper
setting out some of my thoughts.
Senator Morin: Please proceed then, Mr. Dorion.
Mr. Dorion: I prepared a short text. Did you receive it?
Senator Morin: Yes. Perhaps you could summarize it for us. We will read
it in full as a follow-up.
Mr. Dorion: Certainly. With going into detail, my brief first talks about
my perception of the system, and the personal journey I have made, largely as a
result of my father's death while he was still on a cardiac surgery waiting
list. When he died, he was only a few days away from his surgery and had already
had the surgery postponed three times, probably because of other emergencies.
Obviously, that is a terrible disappointment because when your father is ill,
and you know his case is being managed by the system and that he is about to
have surgery, you think to yourself: he'll be around for another twenty years.
You are just so happy that his health problem has been identified and that the
health care system is looking after him and he can get better - but then, you
find yourself experiencing exactly the opposite feelings several days later.
My own experience got me thinking about a number of things. The first thing I
asked myself was, why do we care so much about our health care system? Why do we
spend so much time trying to define it? Last month, I was surprised to see that
Canadians in a number of large cities - Toronto, Winnipeg, Ottawa - send their
children to immersion programs or French schools. These are parents who didn't
know a word of French but wanted their children to learn how to speak the
language. And I thought to myself: I am really happy to see you making this
Their response was: this is what allows us to be different. This is what allows
us to distinguish ourselves from Americans. It is a type of knowledge that helps
us to define our identity.
I think Canadians like their health care system because it is open, generous and
is one of the things that defines us as a country. There are reasons for that,
as I explained in my brief. And I think it is time we faced reality.
Based on my training and my experience as an economist involved in municipal
affairs and realty, it is clear to me that as a result of the aging of our
population, demand for health care among people aged 60 and over is going to
double in the next twenty years. In the real estate sector, that is how you do
your measurements. So, we will be facing a rapid increase in demand. It is time
we face reality.
What will Canadians think if this institution, which is one of their primary
concerns and part of their fundamental Canadian identity, becomes inefficient
and unable to cope with demand? That may result in Canadians feeling less
strongly about their country and its institutions. So, it is important to be
proactive and show that our country is able to question and challenge, and take
courageous and enlightened action.
Currently, if supply is inadequate to meet the demand and we cannot afford to
increase it in future, we run the risk of facing a sequence of events of which
we are already starting to see the signs. In 1993, when my father died, people
were very careful not to talk openly about the funny business surrounding
waiting lists. Yesterday, I happened to be with some friends, one of whom is a
cardiologist at Laval Hospital and whose wife is an oncologist at Hôtel-Dieu,
and I can tell you that now there is no doubt that this sort of thing is
happening - indeed, nobody even tries to hide it anymore because unfortunately
there simply is not enough room for anybody. And, as is often the case in life,
it is the wheelers and dealers who end up in the front of the line.
This is of great concern to me because as a Canadian, if I am in need of a
bypass or other type of operation one day - well, I know a lot of people in
Quebec City. It is a small town and people know each other. It would be easy
enough for me to make a few phone calls. But now I am wondering: what am I going
to do? Am I going to let someone else die instead of me by taking that kind of
action? Maybe that's what happened to my father; I have no reason to believe it
did, but it is certainly a possibility. If supply is not adequate to meet
demand, and people behave in this fashion, then morally, we have a big problem.
But some have no problem with it. Some are used to getting mileage out of the
people they know and there is something very human about that, but the fact
remains that is what we are heading towards.
It is this message and this sentiment that brings me here today. I suffered when
I lost my father and if there is any way reflection can lead to change, then I
will be very happy if that is the result.
In my view, if we do not restore some balance between supply and demand within
the public system, simply because we cannot afford to, we will have to be
innovative and find new solutions. We have to be prepared to challenge what we
do now and thoroughly examine all the issues.
In the meantime, I have resolved the problem weighing heavily on my conscience,
since I decided to take out insurance in the United States in the event I become
seriously ill, get cancer, et cetera. I brought the insurance policy papers with
me. Dr. Morin, I can provide them to you. If I get sick I automatically receive
a certain amount, and the insurance company finds me the best available spot in
the United States where the services of specialists can be accessed. With the
money I receive, I can travel to wherever I am to be operated on and return
home. This is a very individualistic approach that I do not like much.
However, the alternative of being caught in a system that I no longer trust,
given the rules it operates by, led me to the conclusion that it was probably
more humane to take this action, if I had the opportunity to do so, than to make
use of my many friends and acquaintances, at the appropriate time, to avoid the
fate that awaited my father.
Senator Morin: Thank you very much, Mr. Dorion, for your testimony. I
would like to ask you a couple of questions. We do not know much about the
insurance policy you have taken out. Is this American insurance?
Mr. Dorion: No, Canadian.
Senator Morin: Could you tell us - provided you have no objection to
giving us this information - how much this insurance is costing you? As I
understand it, your policy allows you to receive treatment in the United States
immediately if you require a bypass, surgery or treatment for cancer or similar
conditions. Could you elaborate a little more on the insurance you have taken
Mr. Dorion: Basically, this insurance policy automatically gives me
access to an amount of money corresponding to the amount for which I am insured
when a symptom appears. And the way it is presented and marketed, it is almost
like salary insurance - in other words, staying at home and receiving money
because of illness. Or - and this is what I opted for - the company offers
services which involve finding physicians in the United States.
Senator Morin: And how much is it costing you?
Mr. Dorion: At the time I signed the contract, I was smoking about four
or five cigarettes a year so I did not want to take any chances; I got the
"smoker's" policy. But it costs about $100 a month for a non-smoker,
which I will be when I renew it. My four cigarettes a year were expensive; it
was costing $150 a year. And that is for a face amount of $100,000.
Senator Morin: Thank you very much.
Mr. Dorion: I would like to make a few other comments about the system.
Senator Morin: Yes, please do, Mr. Dorion. This is your opportunity to
make your arguments.
Mr. Dorion: I do not want to abuse.
Senator Morin: Absolutely not; we are very interested in hearing what you
have to say. You represent the average citizen.
Mr. Dorion: Yes. My expertise is in municipal services and utilities
economics at the municipal level. I was listening to discussions about the
information highway and confidentiality; those are services offered by my firm.
When I was reading the documentation, much to my surprise, I saw that there was
quite a lot of overlap between what we are trying to do at the municipal level
and concerns at the national level with respect to the health care system.
Having said that, I certainly do not claim to be an expert.
Senator Morin: Well, please give us the benefit of your comments on the
Mr. Dorion: Well, we are in the midst of a veritable revolution. I could
send you other papers I have written specifically about the computer revolution.
The fact is that all services are gradually melting, sort of speak. It is
helpful to see it as a candle. The base of the candle is the Web. Above that are
the operating systems, data bases and applications. Then, above the applications
are the services, that may be medical services articulated around a specific
Gradually, the entire candle is starting to melt away because everything is
moving down to the Web level.
That means greater centralization of information, but also the possibility of
decentralizing information and providing it to every individual. That has a
major impact on the way we will be providing services in future. There will
always be a bit of a race between those who want to poke holes in
confidentiality rules and the others. But that is not an issue. We are already
very advanced in terms of security. The banks are very open. And this will have
a major impact on the way we provide services.
As a business manager, the day I was able to provide pharmacare, I said to the
employees: if you want to continue to benefit from 100 per cent coverage, it
will cost you so much per month, whereas for 75 per cent coverage, the amount
drops. They all opted for 75 p. 100 coverage. And I noticed that there was a
dramatic drop in the use of drugs among company employees.
But this sort of thing is well known. Installing water meters in homes resulted
in a drop in consumption of about 20 per cent. And it is the same with highways.
Nowadays, some highways are being funded through private sector participation.
With respect to the funding options that you laid out, mention was made of an
annual statement that would be appended to the income tax return. I think that
is absolutely essential. According to what I've been told, no other health care
system is as open as ours is when it comes to refunding expenses. And we have no
knowledge of those costs. We pay, but we do not know what we are paying.
I think we would appreciate those benefits more and strengthen Canadians'
attachment to Canada if people were told what the country is doing for them,
even though they cannot see it. We are receiving health care services, but we do
not know how much they cost.
I think that is preferable to taxing people. The way the principle works, you
levy taxes to make people think, and I believe Dr. Lamontagne explained this
very clearly earlier. There is one possible tax option that was not addressed in
your paper: estate tax.
When the health care system was put in place forty years ago, our society was
not as rich as it is now and family wealth was certainly much less considerable.
Wealth has been created in this society but is not being taxed. It will be
passed on to future generations after our death. The following generation does
not need it yet because it does not have it right now. But when the current
generation dies, it will not need it either because these people will be dead.
I think there is an opportunity here, not to levy excessively high taxes but a
reasonable amount, such as 5 per cent. That represents more than $1 trillion.
And on $1 trillion, we are talking about $50 billion; over twenty years, that's
$2.5 billion per year. That is pretty well the percentage of GDP, the 0.5 per
cent we are lacking to properly fund health care.
So I do not think we should shy away from challenging our young people and
showing them that they will have to be as hard working as their parents have
been. And even if they receive less of an inheritance, I do not think that is a
Senator Morin: Perhaps we should leave it at that, Mr. Dorion. I am sure
there will be questions about your testimony.
The Chairman: Thank you. I have two questions. One is, does an insurance
policy in the United States cover everything, or does it only cover procedures
for which there are major waiting lines such as heart and cancer surgery, and
Mr. Dorion: What attracted me to this policy, was that it was targeted to
those kinds of diseases.
The Chairman: Let me just digress for a moment to say that I was very
sorry to hear about your father.
Mr. Dorion: Thank you.
The Chairman: Let me go back to the issue. Essentially, what happened
when governments cut back on health care budgets is that they basically rationed
the supply of health care services.
Mr. Dorion: Yes, I explained that in my paper.
The Chairman: There are only two solutions to that problem, because the
demand will stay the same.
Mr. Dorion: It will increase.
The Chairman: There are two solutions. First, you try to make the system
more efficient so you can handle more people. However, at some point you will
need more money. There are two ways to get that money. The government can raise
taxes and put it into the health care system, or individuals can put money
directly into the health care system by paying for services.
Mr. Dorion: Yes. That would be a major shift in our society.
The Chairman: Exactly. In you view, which of those alternatives is best?
Mr. Dorion: You have to work on several fronts. On one hand, you have to
rationalize the demand at all levels of services. If I start charging $40 for a
consultation the demand would be cut back by 60 per cent. Because the service is
free, people have no hesitation in going to the doctor`s office. We have to
discourage that. People have to think about it. When you put
"tarification" on water, the water demand is cut by 20 per cent. We
have to be available, but we have to work on that front.
I would suggest that inheritance tax would be justifiable if those monies are
identified for health care and not put into a general account. Perhaps there
could be an additional income tax. If you have insurance then perhaps the first
$500 or the first $1,000 would be added to income. In that way, people who do
not receive that revenue will not pay. I am sure I do not have to remind you
that it is important to keep that in mind.
On the other hand, if somebody receives a health care bill, and he does not pay
taxes, it could be used as a tool to find people who are not paying their fair
share of taxes. It would tie income tax to health care. It is an additional
I am not at all shy about saying that everybody should pay his or her share of
taxes. As an assessor, when somebody tried to fool me with his false
information, I send it right into court. I jack up the assessment to make sure
that he will file a complaint. I have no sympathy for people who do that. We set
the rules, and we must live with them.
We must remember that the supply is fixed. I did not touch on that in my paper,
but I do want to make a point of the fact that we have a strong culture in the
hospital environment. We are good at educating and encouraging competent people
in the health care system. However, if it were a private business, we would do
two or three times as well. We would be servicing the world with our talents.
Now we are rationalizing it. We are good, we are competent, we have dedicated
people, and we control their "formation" because we cannot afford to
We must remember that there are people who are willing to pay for medical
services. While he was on the waiting list, I am sure my father would have been
glad to pay $25,000 to have the doctor who would have otherwise been watching
T.V. in the evenings perform his heart surgery. Instead of that I inherited
money that I did not really need.
The Chairman: Thank you.
Senator Morin: Mr. Dorion, thank you very much for being with us. Your
testimony was greatly appreciated and extremely useful. We will be looking
carefully at your brief. Thank you once again for travelling to Montreal to
present your views today.
Mr. Dorion: It was a pleasure.
Senator Morin: It has been very useful for us.
The meeting suspended.
The meeting resumed.
The Chairman: Senators, our first witnesses this afternoon are
representatives from Canadian Life and Health Insurance Association, CLHIA. May
I remind you that, when they testified before us at an earlier time, we got into
a lengthy discussion with them about the gaps in drug coverage for Canadians. We
asked them to think about the question of how to design a drug plan that, at the
very least, would cover the catastrophic end of the business. By "the
catastrophic end of the business," I mean that it would cover the kind of
situation, which our report documents, where an employee, with an employer with
a very good drug plan, nevertheless would end up having to pay $12,000 or
$14,000 a year as his part of the co-payment because his wife had a terminal
The industry was kind enough to use some of their experts to do some program
designs for us. We are delighted to hear from them today. Mr. Mark Daniels, the
president of the association will open. Would you introduce the people with you,
Mr. Mark Daniels, President, Canadian Life and Health Insurance Association
Inc.: Honourable Senators, my colleagues and I very much appreciate the
opportunity to participate in your deliberations on this very important work
related to Canada's health system. With me today are Mr. Greg Traversy,
Executive Vice-President; and Mr. Yves Millette, Senior Vice-President, Quebec
Over the next few minutes each of us will address different aspects of your
recent "Issues and Options" paper. First, I will focus on its overall
vision of the roles of the public and private sectors; second, Greg will comment
on your paper's drug insurance options, basically to look at the question
Senator Kirby just raised; and third, Yves Millette will briefly review our
industry's real world experience with one of the public-private partnership
options for drug insurance which your report puts forward. We thought that Yves
joining us, Mr. Chairman, would be helpful because he is very familiar with the
plan here in Quebec. In fact, he had a great deal to do with helping the
industry work with government to put it together.
At the outset, however, let me just make a general point about the "Issues
and Options" report. It is an excellent piece of work, and we are pleased
to be able to contribute to it. It is an impressive piece, which demonstrates
candour, open-mindedness and a willingness to think, if it is not too hackneyed
to say these days, "outside the box." In that sense, it is a
refreshing contribution to a vitally important debate which is too often
characterized by, from our point of view, incivility, intolerance, and downright
demonization from time to time. It is a pleasure for us to be asked to comment
on some of these issues.
The Chairman: Thank you for that.
Mr. Daniels: Our submission paper, which relates to your "Issues and
Options" report, may be relevant in other ways to your ongoing work.
One aspect of the committee's approach which we admire is that your vision of
Canada's health system encompasses, among other things, complementary and
constructive roles for both the public and private sectors, both in the
financing of health care as well as in its delivery. In our view, that vision
captures both the current reality of Canada's health system since medicare's
inception, as well as its best hope for future sustainability.
Our industry's role is focused almost exclusively on the financing side,
providing funding to meet Canadians' health care needs through supplementary
health insurance plans. Our submission examines the role of supplementary health
insurance plans in Canada's health system. Most of it will not come as any
surprise to this committee. Indeed, the profile set out there very much confirms
the validity of this committee's vision of constructive partnership between the
public and private sectors in Canada's health system.
As it indicates, supplementary health insurance plans, first, complement our
public health insurance plans by picking up where public plans leave off.
Second, they provide funding to meet important health needs such as prescription
drugs, dental care, artificial limbs, wheelchairs, and many other valuable
services simply not covered by public plans. Third, supplementary plans protect
about 20 million Canadians. They paid out $10.6 billion in 2000, the latest year
for which we have comprehensive data. This makes supplementary plans in Canada,
Mr. Chairman, a significant direct payer for health services.
Indeed, in 1998, supplementary plans accounted for 11 per cent of direct total
health spending in Canada, thus placing fourth after the Ontario government,
which handles 23.9 per cent. Out-of-pocket spending by individuals on health
related products and services accounts for 16.4 per cent, and the Quebec
government is responsible for 15.4 per cent. Supplementary plans handle a good
chunk of the total bill. As part of these total expenditures, supplementary
plans provide $1 billion a year in payments to our hard-pressed hospitals.
On balance, as this committee is obviously well aware, there is no question that
supplementary health insurance plans are a major partner with our public health
insurance plans in providing funds to meet our health care needs. They play a
vital role in averting and reducing pressures on our public health insurance
plans. Over the next few years as public policy in the health area evolves, it
will be critically important to ensure that the capacity of supplementary plans
to continue to play that major partnership role is maintained. Indeed, many
expect, ourselves included, that that role might have to be significantly
broadened in the years ahead. If the role of supplementary plans is not at least
maintained, the result will be a massive further increase in the already huge
pressures on our public health insurance plans.
Sustaining the capacity of supplementary health insurance plans will require
dealing with some major challenges. One of these, which your report highlights,
is the fact that provincial governments have loaded a tax burden of $1 billion a
year in premium taxes and retail sales taxes on supplementary health insurance
plans. Moreover, the province of Quebec takes a further $200 million in income
taxes from supplementary group insurance plan members since employee
contributions to group plans in Quebec are taxed as income in the hands of
Another challenge is rising costs, particularly drug costs, which impact the
vitally important drug insurance component of supplementary health insurance
I will now ask Mr. Traversy to comment on your report's drug insurance options.
Mr. Greg Traversy, Executive Vice-President, Canadian Life and Health
Insurance Association Inc.: Mr. Chairman, as Mark indicated, drug expense
insurance is a central element of supplementary health insurance plans and, as
your report notes, it is also of greatly increasing importance in the context of
Canada's public health insurance plans.
Your paper's options with respect to drug insurance raise four approaches:
first, a comprehensive public program; second, a comprehensive public-private
partnership; third, a public-private partnership initiative to protect against
financial hardship due to high drug expenses; and, fourth, a tax based
initiative to protect against high drug expenses.
With respect to option one, given that the great majority of Canadians already
have some form of coverage for drug expenses through federal or provincial drug
programs, and/or through private supplementary health insurance plans, it would
seem terribly wasteful to proceed as if no Canadian had any drug coverage
whatsoever by putting in place a new comprehensive program from the bottom up.
This would amount to bulldozing into the ground a highly developed system of
public and private drug programs which already cover the vast majority of
Canadians. One immediate consequence of dismantling the drug insurance component
of supplementary health insurance plans would be that the new public program
would face the $4.3 billion in drug costs currently covered by private plans.
Mr. Chairman, it would seem far more sensible to leave the bulldozer approach of
option one aside and to focus instead on how to use our country's scarce
resources most efficiently to adjust the current system to deal with the
remaining public policy challenges. As your report notes, the current system is
by no means perfect from a public policy perspective. Hundreds of thousands of
Canadians simply do not have any drug insurance coverage at all. There are
significant regional disparities in coverage. Even among those who have drug
coverage, many are exposed to at least some risk of undue financial hardship if
they or their loved ones should require one of the high cost blockbuster drugs.
Indeed, your report cites an example which very clearly illustrates that even
the co-payment portion of a $50,000-per-year drug requirement can be a very
heavy financial burden indeed.
Could options two, three or four address these challenges more effectively and
efficiently than option one? My colleague Yves will be addressing option two in
a moment. Option three would require a public-private partnership approach which
would involve the federal government providing the financial support required to
permit provincial drug benefit plans and private supplementary drug insurance
plans to put an upper limit on the out-of-pocket expenses of individual plan
members at some threshold such as, say, $1,000 a year. Special emphasis would be
placed on "incenting" provinces and private plans to extend protection
to those who currently have no drug coverage whatsoever.
Under option three the federal government would essentially absorb the risks
associated with the relatively rare but extremely costly cases where individuals
require very expensive drug therapies.
It would be premature to come to any final conclusion on option three, or any
other option, perhaps, but there is every reason to believe that more work on
option-three-type approaches would be a very worthwhile investment of the
committee's efforts, and we would certainly be delighted to contribute any
information that you wish, if that proves to be an area you want to further
Finally, with respect to option four, the taxed-delivered approach, as your
report notes, there are, no doubt, some real opportunities to use our tax system
more creatively to address the public policy challenges facing Canada's health
system. However, given the backwards-looking, one-year-in-arrears nature of tax
filing, it is very difficult to foresee the tax system alone dealing effectively
with undue financial hardship due to high drug expenses. On balance, Mr.
Chairman, option four certainly appears to have far less potential than option
Senator Morin: Do we have a document with this information? It seems we
do not. Could we have the options again?
The Chairman: Correct me if I am wrong. I am going to do this from
memory. Full national primary care is option one. Option two is a mixed
public-private system. Option three relates to catastrophic coverage. It would
kick in when the total cost of drugs to a particular individual or family
exceeds some threshold amount.
Senator Morin: Do we have caps on Canadian insurance? Do we have private
drug plans in Canada where there are maximums?
Mr. Traversy: Yes. There are drug plans in both the public plan area, as
well as supplementary private plans that have caps. For example, the universal
drug program in Quebec which my colleague Yves will address, has a cap on
individual out-of-pocket expenses of, I believe, $750 a year.
Senator Morin: I am not talking about that. I am talking about a cap
after a certain amount of coverage.
Mr. Traversy: Do you mean where they do not pay beyond a certain amount?
Senator Morin: Yes, say, $20,000.
Mr. Traversy: Not that I am not familiar with.
Senator Morin: It exists in the U.S.
Mr. Yves Millette, principal vice-president, Corporate (Québec) of the
Canadian Life and Health Insurance Association: It is true, that type of
program is quite rare in Canada.
Senator Morin: In Canada, but you do find it in the United States.
Mr. Millette: You might find it more often in the United States, but here
in Canada you have almost nothing but group policies with unlimited coverage
underwritten buy employers.
Senator Morin: That means that a person covered in Canada under a private
plan will not need special catastrophe insurance. Plan number 3 will therefore
not apply to people covered by private insurance in Canada.
The Chairman: No, because the example we use in the report is the person
who had a $70,000-a-year income, and a very good plan, like the federal plan,
and whose wife had $50,000-a-year drug costs, for which he had to pay 20 per
cent so, on a $70,000, income he was paying $10,000 a year in drug costs.
Therefore, even in a co-payer system, at the catastrophic end, even someone with
a good health plan, let alone a bad health plan - I mean, a 50-50 plan would be
worse - can still run into problems.
Senator Morin: Does the Quebec plan have a cap on the co-payments?
Mr. Millette: Yes, it has, but we still have problems. We need a pooling
system in Quebec because, if you do not have a certain pooling fund, it will
become too expensive for small enterprises, small employers.
The Chairman: Is that in option four?
Mr. Millette: No.
Senator Maheu: What is option four?
The Chairman: That is the tax incentive system.
Mr. Daniels: Our comment on the tax system is simply that it pays in year
one for expenses incurred in year zero. However, for those who have had to deal
with a catastrophic situation, it will not help them much to get the money back
the next year. They still face a real problem.
The Chairman: In other words, you would get to the end of the tax year
and you would claim a deduction on your tax form. The problem is that you file
your tax return in April and you might have incurred the expenses in January of
the previous year. You might be out of pocket for 15 months, which is something
you cannot afford.
Senator Morin: Should we exclude option four?
The Chairman: They are suggesting we exclude option four.
Mr. Millette: I am sorry about that.
The Chairman: You can tell we are interested in the subject, because we
started asking you questions before you finished your presentation. Please go
Mr. Millette: Mr. Chairman, the second option outlined in your report
would be a partnership between the public and private sectors to create a
universal drug insurance plan.
In Quebec, our industry has been working together with the government since 1997
in order to offer this type of general drug insurance plan. In Quebec, everyone
must be covered by this type of insurance.
Those who are part of a private group plan set up by their employer must
subscribe to it with their dependents.
Self-employed people and their dependents also have to subscribe to a private
group plan set up, for example, by some professional body they belong to.
The insurance companies have to include drug insurance in all group health and
disability insurance plans offered to the public, to employers or to
associations in Quebec and no potential subscriber may be turned down on medical
Those who do not have access to an employer or association-run group plan must
subscribe to the plan set up under Quebec's health insurance plan. The annual
QHIP premium is $385.00, but private plans are free to set their own premiums.
On average, the private plans' pre-tax premium is roughly the same as the
government plan's. All the private plans as well as the Quebec Health Insurance
Plan must include the following conditions: The deductible part of drug expenses
must be no higher than $100.00 a year. The insured person must not have to pay
more than 25 per cent of his or her drug expenses.
Furthermore, no insured person should have to disburse more than $750.00 per
year for medicine. The idea is to relieve insured persons of the financial
burden of high drug costs.
Senator Morin: Would you repeat the figures, since they might be new to
some of us here.
Mr. Millette: There is a $100.00 deductible per year. Under the
government plan, since it is a monthly deductible, it comes to $8.33 a month.
No insured person has to cover more than 25 per cent of his or her drug costs
and none has to disburse more than $750.00 annually for drug purchases.
With the $100.00 deductible and the 25 per cent ceiling, you get an annual
maximum of $750.00 no matter what the cost of the drugs required that year.
All the drugs listed in regulations must be covered. And if I am not mistaken
that includes something like 93 per cent of the drugs generally prescribed by
Senator Morin: Very generous of Quebec.
Mr. Millette: Yes, very generous. The QHIP also include a financial
assistance scheme which extends both to premiums and to drug expenses.
This assistance is pegged to a person's income but is not offered to people
insured under a private plan.
Since 1997, people living in Quebec are therefore covered under various
combinations of private plans and the government plan according to their
From the industry point of view, the general drug insurance plan works
reasonably well. Compared with other universal drug insurance plans, Quebec's
plan is flexible enough to dovetail with the coverage offered by insurance
The establishment of this plan has had little permanent impact on the day-to-day
activities of most group insurance providers.
For example, when this plan came into effect, there was no need to modify
policies since the law did not require the officialization of provisions.
Nor did the plan's coming into operation complicate the processing of insurance
And finally, the most difficult thing we had to do was to put into effect a
system of mutualization where you provide for catastrophic risk in a way that
enables small and mid-size businesses to keep offering their employees coverage
even when one of them has to take a particularly expensive drug.
Because of this mutualization of risk, the premiums remain affordable even for
small and mid-size businesses.
The industry's input in solving the mutualization issue creates the basis for an
even greater cooperation in the future in terms of catastrophe insurance, which
is option 3 outlined by your committee.
I cannot speak for the Quebec government, but I believe that from their point of
view the results attained thus far may not be entirely satisfactory but the
government has attained some of its key objectives.
First of all, everyone in Quebec can now be covered under an insurance plan
which, as you were saying earlier on, is relatively generous.
Everyone has standard coverage. Everyone is also covered in case of financial
hardship. And, what is significant in terms of tax dollars, elderly people and
people receiving social assistance now, depending on their income, pay a larger
part of their drug costs than before.
On the other hand, the government is faced with a number of difficult
challenges. First of all, the rapid increase in the QHIP's drug expenses. That
is obviously also a problem for private insurance plans considering the rise in
the cost of medicine.
The government is perpetually trying to keep health insurance plan premiums
affordable while at the same time assisting low-income people.
The costs underwritten by Quebec's Treasury Board are continually going up and
each year the health insurance plan loses money.
Furthermore, the cost to high-income elderly people has gone up, since the plan
was put into effect, from a few dollars per prescription to a $385.00 annual
premium, and this has caused a measure of discontent among the people concerned.
The premiums paid by this category of policy holders is, however, to a large
degree subsidized, for a retired person's participation in a private group
insurance plan actually costs about $1,200.00 a year.
Experience has taught us, Mr. Chairman, that the second option outlined in your
report is workable. We suggest, however, that your committee take into account,
in considering this second option, the costs that might have to be borne by the
The putting into effect of a universal plan can obviously weigh on the public
purse, even if the private sector plays an important complementary role,
especially with an aging population.
Mr. Chairman, this concludes our testimony. We will now gladly answer any
The Chairman: We do not have a copy of your opening statement. We have
the red book you gave us. If you can pull all your papers together and leave us
with a copy of your opening statement, that would be helpful.
You will remember that, in our volume 4, we had some data which indicated, that
97 per cent of Canadians had some form of drug coverage, and so on. A number of
witnesses do not accept that data. Can your staff and our staff ger together and
come up with an agreed set of numbers? I am not suggesting that your numbers are
wrong. During your first presentation to the committee we had a discussion as to
whether or not the numbers were right. We must get a handle on the data so we do
not get into factual arguments with people.
Mr. Daniels: We would be happy to share our information with you. We are
currently undertaking an update of that data so you will have more. We have seen
some preliminary runs, and the general trend of this data is not changing at
Mr. Traversy: That is absolutely correct, Mr. Chairman.
The Chairman: We would like to be able to respond to the critics.
My next point concerns the one that, in fact, Senator Morin raised. If you look
at the history of pension plans, you will remember defined benefit plans. Of
course, you are familiar with those. A defined benefit plan is one where your
pension is based on so much per year times the number of years worked. Over the
last 10 years, as those types of plans became very expensive, the move was
towards so-called defined contribution plans, in which the employee and the
employer put a certain amount of money into an RRSP every year. How much the
pension is worth at the end is a function of how well the RRSP does. If the
markets go down, the pension does not pay as good a pension as it would
We have some anecdotal evidence which suggests that the same kind of switch is
now starting to occur with respect to drug plans. In other words, as opposed to
a drug plan like the federal one, where the federal government pays 80 per cent,
the employee pays 20 per cent, and there is no cap, there is a trend towards
paying a maximum amount per year. This is because it is becoming very expensive
for employers, particularly as biotech drugs are put on the list.
There is no question that is occurring in the United States, but I happen to
know of some employers who have made such a switch in Canada. I need not
identify them here. I am trying to understand the extent to which that is an
aberration. In 10 years from now, is that where we will be?
Mr. Traversy: I would not want to hazard a guess as to where we will be
10 years from now.
The Chairman: Make a try.
Mr. Traversy: I am certainly aware of plans in which non-drug benefits
are being replaced by, or at least somewhat substituted by, what are sometimes
called "health spending accounts." For example, previously, an
employee might have had entitlement to eye glasses or whatever, but now, rather
than adhering to a long schedule of health related items, they give him a
certain amount, say, $500, and the employee can purchase whatever health related
items he needs.
I am not aware that that is a significant phenomenon with respect to the drug
component of supplementary health insurance plans at this time. Certainly, in
our recent discussions with our member companies and other very knowledgeable
persons, I have not heard that that is commonplace yet, although I stand to be
The Chairman: As biotech drugs kick in with their very large costs,
perhaps thousands of dollars a shot, is there any anticipation that that might
Mr. Traversy: There is no doubt that high-cost drugs are a real concern
for plan sponsors now. You are quite right, Mr. Chairman, to raise the prospect
that plans will have to adapt. The adaptation you have just suggested, I am
sure, would be one of the options that will be considered, and perhaps sooner
rather than later. There is no question that they really are a problem for
employer-sponsored drug plans.
The Chairman: Think of the example where the individual with an income of
$70,000 is paying $10,000 a year in his co-payments. To some of us, if not all
of us on the committee, that is wrong in a country that believes an individual
should not suffer undue financial hardship as a result of being sick,
particularly in view of the fact that, if the person were hospitalized, he would
get the drugs for nothing and the government would, in addition, incur a cost of
$1,500 a day, or whatever it costs to keep him in the hospital.
How would we go about designing a proposal, which is close to your option three,
that is aimed at dealing with those kinds of cases? In other words, not disrupt
anything that is going on now, but deal with a situation where the drug burden
became very heavy. I recognize that we would have to define "very
heavy", and that would depend on someone's income. I mean, "very
heavy" would be a much smaller number if a person's income is $20,000 a
year as opposed to $200,000 a year. How do we go about designing a plan that
would pick up all of those people and would solve Yves' problem in the sense
that, if it is a national plan, the sample would be big enough that it would be
easy to manage? I am not suggesting that is the answer; I just want to know what
process we should follow.
Mr. Daniels: Senator, I would make the very general comment that the
burden of our testimony here is that option three is eminently doable.
We are already, in this province, dealing with an option two, although it is not
The Chairman: Option three deals with the catastrophic situation.
Mr. Daniels: A catastrophic drug plan is doable. It will be for the
governments of the day to judge whether the costs are manageable. In our view,
they are within the kind of envelope that would be manageable.
The Chairman: I am sorry to press you, but it will take a lot of
technical knowledge that does not exist on this committee or in our staff to
come up with a precise proposal that would define, for government and for the
people, what is too much and relate it to income. People can then argue about
that. The concept to me is very clear, but I do not know how I go from the
concept to suggesting that someone ought to buy a certain plan or a version of
it. That is where the input of industry will make a difference. You people have
all this information.
Mr. Traversy: Mr. Chairman, your committee has already taken a very
important step in that you now have an approach on the table that has obviously
galvanized attention in circles like our industry, and others. We would be
delighted to contribute anything we can, should your committee want to pursue
this. We know you have at least one more report to prepare. In the months ahead,
should you want to delve into this more fully, we will certainly bring whatever
we can to the table. As Yves has mentioned, there are a number of approaches you
can take. In the context of the Quebec experience, the whole problem of high
drug expenses had to be dealt with in order to put the $750 cap in place and
make it affordable, even in small work places.
Mr. Millette: Yes, we may have limited experience with this, but our
first true encounter with catastrophe coverage was with the mutualization scheme
we had to set up in order to preserve insurance coverage for small businesses.
The experience has been interesting up to now since it has enabled us to group
the calamity claims and spread them out over the whole of the population. That
might be something that could be taken over by government.
Except that under the system as set up by the industry, at the present time only
some of the claims are mutualized. I think the annual figure is currently around
15 million dollars. But I know that is increasing very quickly, by some 30 per
cent a year.
Let me recall, for the sake of example, that this week we submitted a report to
the minister of Health outlining our experience thus far since the plan started
to pay out claims exceeding various amounts depending on the number of employees
in a given company. But, for example, in the drug insurance plan's first year of
operation in Quebec, that is to say 1997, the Compensation Fund did not have to
pay out anything. In that year, there were no claims for expenses over
In 1998, there were 46 such claims. And 76 in 1999, the last year we have the
figures for. You can see that the numbers are going up very quickly. I mean the
claims for amounts over $20,000.00.
If you scale that back and look at the $10,000 claims, you begin to see minimum
payouts of $5,000.00 per year, and that builds up very quickly.
A cursory examination shows that in 1999 there were 8 claims for amounts in
excess of $50,000.00, both private plans and the government plan.
If we bring that down do $20,000.00, the number of claims is 72, but that is for
a limited group only.
If you take all the various plans together, that is to say companies with at
least 125 employees, plus the government plan, you get a much higher figure,
with around $700,000.00 worth of claims in excess of $50,000.00 this year.
If we look at the $20,000.00 claims, we estimate that the total amount would be
in the tens of million of dollars.
If you come down to $10,000.00, then you are looking at hundreds of million of
dollars. And if you go down to $6,000.00, you get, just for Quebec, calamity
compensation of around 1 billion dollars in compensation for catastrophe claims.
So the more generous your catastrophe coverage is, the higher the costs, with an
exponential rate of increase.
Mr. Traversy: Mr. Chairman, I have a supplementary piece of information
on the incidents of these very high drug expenses. Recently, someone who has
been conducting a national study of the frequency distribution of high drug
expenses was telling me that the cases where an individual patient requires
drugs exceeding the $5,000 per year threshold, constitute between 1 per cent and
2 per cent of all patients. However, those 1 per cent to 2 per cent of cases
account for 15 per cent to 20 per cent of the overall drug cost in the system.
Senator Morin: That is true of every situation in health care costs.
The Chairman: That absolutely confirms the need for a catastrophic plan.
You are saying that that 1 per cent or 2 per cent are having to absorb 15 per
cent to 20 per cent of the cost. They are exactly the kind of people government
ought to be helping.
Might I suggest that some time in the next couple of weeks your staff and our
staff get together and figure out how we can put a real plan together? That
group should include Yves, because it is important to have someone who
understands the Quebec model.
Mr. Daniels: We would be happy to do that. However, I just want to make
it clear that the broad outlines of a catastrophic plan already exist. A lot of
thought and work has already gone into this. We are not starting at ground zero.
Quite apart from the critical, practical information that we have learned out of
the Quebec milieu, we have done a lot of work on a catastrophic plan.
The Chairman: Thank you.
Senator Morin: How many provinces do not have a catastrophic plan? I am
referring to the situation where a a citizen may have to pay out-of-pocket drug
expenses of $5,000. My impression is that that would be a relatively small
number of provinces.
Mr. Traversy: I believe there are five provinces in which that would be
the case. The four Atlantic provinces and the province of Alberta have a program
which is voluntarily accessible to any citizen who wants to go into it. However
some do not go in and they could be exposed to these high costs.
Senator Morin: That is a special issue. They make that choice.
Am I correct in saying that Alberta subsidizes a private company?
Mr. Traversy: Yes.
Senator Morin: It would be ridiculous not to take advantage of that. What
percentage of the Canadian population do the Atlantic provinces represent?
Mr. Daniels: Less than 20 per cent.
Senator Morin: Catastrophic insurance applies to less than20 per cent of
The Chairman: Just so that we are clear: the people in the Atlantic we
are talking about have no coverage. My suggestion was that the catastrophic
insurance would apply in the case of the example in our report, where someone
has a drug plan, but the co-payment portion of the drug plan is still
catastrophic. It is the 1 per cent or the 2 per cent that I am worried about.
Senator Morin: I am certain that this would not apply to Quebec, and that
it would not apply to those people in Alberta who are covered. At least two
provinces are out.
The Chairman: I am sorry, but that is wrong. Please understand the
difference. The difference is whether you have no coverage, or whether you have
to pay a co-payment. Under the Alberta Blue Cross plan it is a co-payment
Senator Morin: There is no cap on the co-payment.
The Chairman: That is the problem.
Senator Morin: Is Quebec the only province with a cap on the co-payment?
Mr. Daniels: No. I think B.C. may have a cap on total exposure. They have
just raised it from $800 to $2,000. However, if I recall correctly, it does not
kick in until quite late in the day.
Mr. Traversy: Ontario has the Trillium Plan which is intended to assist
those who face expenditures above 4 per cent of their total income. That is not
a plan, however, that is necessarily universally known. In a number of provinces
you could find public programs that have an upper limit. That, as the Chairman
has mentioned, is not the same as saying that all citizens would have knowledge
of and/or access to those provincial plans. People can be in a very good private
plan, but still face a significant burden through co-payments and whatnot.
Senator Morin: Even if we do have a catastrophic plan, we must consider
what the various provinces are already offering.
Mr. Traversy: Absolutely.
Senator Morin: What is the industry position on the Alberta plan? Here we
are subsidizing private industry. That is not one of our options. What is your
opinion of that, Mr. Daniels?
Mr. Daniels: Mr. Chairman, the industry is quite comfortable with the
arrangement in Alberta. Alberta deals effectively with its own company on this.
Of course, you can find us quarrelling about the fact that the majority of my
members do not get to compete.
Senator Morin: Would you favour that? Can you compare that to a mixed
plan like the one that Mr. Millette was describing?
Mr. Daniels: I do not think it makes sense to make changes in a system
that is working relatively well. Overall, as we have said, we have a good
complementarity between the core public programs and the envelope of private
programs that fit around that. Our companies try to make the systems we have in
place now work better, which is what gave rise to the situation in Quebec. I am
not quite sure, in historical terms, what gave rise to the Alberta model. I do
not know what it was that led Alberta to want to deal with a local company, but
I can guess what it was, and that is not an unfamiliar situation in Canada.
By and large, we want to use mechanisms that are already in place, mechanisisms
that we understand, and that, quite frankly, work. I cannot recall a time when
our industry councils have suggested that we toss out a system and start with
Senator Morin: I have one last question for Mr. Millette. You gave us a
clear description of the advantages of Quebec's drug insurance system. The major
drawback that people find is that a contribution is also required of people
receiving social assistance and of elderly people with low incomes.
Perhaps more will be said about this later, but research does point to a decline
in the health of elderly people, since they began to contribute in a way that
was not required of them before this plan went into effect.
I would like to have your thoughts on that matter and also on the fact that
although government expenses are going up, these expenses are not increasing as
quickly now that low income social security recipients and elderly people have
seen their premiums go up under the co-payment system.
In the first year of operation, the government of Quebec made a significant
profit because of the $100 deductible and the co-payment scheme for elderly
Mr. Millette: We believe that the main problem with the Quebec's plan is
that it includes under one program both drug expense refunds and an assistance
We believe that Quebec's plan should keep those two aspects separate. We feel
that the financial assistance plan should come under a tax program instead of
being funded under the drug insurance plan since that completely distorts the
figures and prevents us from knowing exactly how much is being paid out for drug
What most people criticize in Quebec's plan however is the insufficient level of
assistance, at least as far as certain people are concerned.
The support given to social assistance recipients is significant, however. The
great majority of them will end up not having to pay the premium themselves and
most will have to pay not $750.00 a year, but $200.00 only.
So the premium is subsidized as are some of the drug expenses incurred by people
What people most dislike about the drug insurance plan, I think, is the $8.33 a
month that they have to pay. But there might be a way of overcoming that.
Senator Keon: Can I shift the focus, gentlemen, to another area of
catastrophe, and that is out-of-country health catastrophes that are causing
tremendous problems for people now? I am talking about someone who has been
buying supplemental insurance, has a heart attack, and has to travel out of the
country often and cannot get appropriate insurance coverage. That person faces
financial ruin if he is caught with a health catastrophe in a foreign country.
In your executive summary you mention that supplementary health insurance plans
can deal with out-of-country health care. They can certainly deal with most
circumstances, but they cannot deal with a catastrophic situation. Where does
the solution lie?
Mr. Daniels: I will make a couple of remarks, and I will ask my
colleague, Mr. Frank Fotia, Vice-President of Group Insurance and Pensions, to
speak to the details of group plans.
It is my understanding of the characteristics of most group plans that they do
not put any limits on pre-existing conditions. If a retiree with a heart
condition has a group plan with no limits, he can pretty much travel. However,
if there are limits on the group plan, and he has to buy private coverage then,
as costs go up abroad, the costs of getting coverage like that will be higher.
In some cases it is impossible to get that coverage.
Mr. Frank Fotia, Vice-President of Group Insurance and Pensions, Canadian
Life and Health Insurance Association Inc.: For the most part, as Mr.
Daniels mentioned, in a group plan this is not an issue. The issue that you
raised deals primarily with retirees who no longer have access to coverage
through a group plan. Having some experience in the travel insurance industry, I
can say that most people over 65 who are at least medically stable have access
to out-of-country medical insurance through a variety of providers, albeit their
assessed premium is based on their individual risk. The greater the risk factor
that they present, the greater the premium.
A very small percentage of travellers, because of their pre-existing health
conditions, are virtually uninsurable. It is extremely difficult for that small
percentage to get coverage simply because of the risk factors and the enormous
cost that would be associated with a medical emergency. I can assure you that
they represent a very small minority.
Senator Keon: However, a fairly significant group of people falls into
that category. I am thinking of the small businessman who is self-employed, who
is not part of a large corporation and a group plan, and who has to travel for
his livelihood. I am also thinking of the seniors that I have come in contact
with, many of whom are women who were housewives and who raised their families
in the traditional way. They were buying supplemental insurance when they
travelled but, if they suddenly got a serious diagnosis, they could not get
insurance. I believe that this is a serious problem that we, as a society, have
Mr. Daniels: You certainly raise an issue of real importance. The
question of out-of-country medical insurance did not become an issue until
provincial plans starting dropping. You will recall that, in the province of
Ontario, that at first it was unlimited and we were a cash cow for the Florida
hospital system. Then we moved to $400 a day, and now we are at $100 a day, or
whatever it is. Of course, into the breach step the private carriers.
That did not present a problem for the group plan holders. Of course, when
dealing with individual coverage, then the carriers do not have experience
ratings, so they will price as best they can. The dimension of the problem that
you have raised, senator, put in a demographic context, means that the problem
will not go away. It will get bigger.
Not to beg a question, because I certainly have no answer for it, but I thought
you were going to ask me about terrorism insurance. It is a huge issue. There
are terrorism exclusions in most travel contracts. They are not being enforced
this time around, but they certainly will be in the future. I cannot imagine
that new contracts that are being written that have such exclusions will not
have meaning. It is not just the 65-year-old man with a heart condition who has
to travel that we have to think about, we also have to think of the 35-year-old
person who is travelling abroad and cannot get terrorism coverage.
If you push, Mr. Chairman, you will see how integral to the fabric of society is
not just coverage for this sort of thing, but perhaps, more broadly, the huge
issue of property and casualty, and the whole issue of how much we depend upon
being able to offset risk with insurance. If there are risk categories that all
of a sudden become uninsurable for one reason or another, then you have a real
issue. You have, for example, the move that the United States Congress is
currently taking to underwrite terrorism clauses. We will see many moves like
that. A piece of this concerns the issue that caused you to raise the first
I am not aware of any comprehensive fix for all this. There is none. There is no
question that the industry is certainly seized by these issues.
Senator Robertson: Gentlemen, we talked about single seniors who find it
difficult to obtain coverage because of age and illness, or identifiable
illness. What percentage of those single seniors is rejected?
Mr. Fotia: My understanding is that it is less than 10 per cent. These
coverages are individually underwritten based on a risk factor.
It is a very competitive industry. There are many providers. Even though a
person may have a pre-existing health condition, provided that they have
demonstrated a period of medical stability where they are physically capable of
travelling, and have a good likelihood of travelling and enjoying themselves and
remaining well, they will get coverage, albeit it will be a fair bit more
expensive than a healthy individual of the same age group, or someone younger.
Mr. Daniels: May I just add parenthetically, that I think it is also true
that the companies are dealing with this in part by limiting the amount of time
you can spend out of the country. There are various ways of shaving down the
exposure. As you know, some companies will not insure a traveller for more than
a few weeks.
Senator Robertson: I am asking this because next week the president of a
group of "snowbirds" will undoubtedly raise this question before our
You mentioned that the recipients of social assistance were looked after by the
department. How do you handle the large number of seniors who have very limited
incomes in Quebec? Most of their revenues would come from the federal government
and not the provincial government.
Mr. Millette: The same scale of revenue is used for the seniors as for
people in the welfare system.
Senator Robertson: They would have to apprise the federal government,
since their social security comes from the feds.
Mr. Millette: The disclosure is made when the senior first buys drugs at
the the pharmacy. Otherwise it is made in the tax return.
Senator Robertson: Does the industry have any problems with travellers
buying more than one single protection plan from more than one insurance
company? Is that legal, or is that limited?
Mr. Fotia: There is nothing illegal about ensuring that you have as much
protection as possible, Senator. However, there is a coordination of benefits
clause in these agreements so that, if there is duplication of payments, the
companies will work together to ensure that they are not all paying the same
loss, and that they are coordinating their payments.
Senator Maheu: I have a brief question on snowbirds coverage.
Senator Morin: You can see where our interest lies.
The Chairman: It says something about our age.
Senator Maheu: We happen to be well protected right now. With snowbirds I
have heard that some snowbirds who are travelling to the United States are not
insuring for the full length of their stay. They are starting to insure the last
three months of their six-month stay. Is that legal? I know that is happening.
Mr. Fotia: People buying the insurance may be buying it for that period
of time because they are declaring that that is the period of time they will be
travelling. I would strongly advise them not to do that because it raises a
misrepresentation issue. For their own protection, they should be forthright and
honest on their application form as to when they are travelling, and for how
long they are travelling.
Senator Maheu: I know of some who are doing it because of the cost
Mr. Fotia: The potential costs at the other end would be far greater than
the few extra hundred dollars of premium they may have to pay at the outset.
Mr. Daniels: This is important counsel from a former practitioner. It
makes no sense at all for people to ever misrepresent their intentions because,
when they do that, the companies will clamp down on them. They do it not to be
mean, but because, when they price these things, they price them for everybody
and, if they independently start veering away from the terms of the contract,
they will be putting all their policyholders at risk.
The Chairman: In closing I would just note that, when we meet, the more
you can tell us about who the 1 to 2 per cent are who are costing 15 to 20 per
cent of the cost, the better. We need to identify them, because they would be
our target group.
I completely buy Mr. Millette's point, which is that we want to separate an
income support program from an insurance program. We are in the insurance
business, not the income support business.
Finally, just to put the generosity of the Quebec program in perspective,
because Mr. Millette said the maximum payment anybody pays for drugs is $750 a
year; in Saskatchewan seniors pay a premium - not a maximum - of $1,600 a year,
going up to $2,000, for drug coverage. That is paid twice a year - $800 up to
$1,000 every six months. Effectively, that is an insurance premium that seniors
I want to put that in perspective with respect to Saskatchewan, where you would
expect, intuitively, the number to be lower. I want to point out how effective
or generous - and I do not mean "generous" in a pejorative sense - the
Quebec plan is. We were quite startled by the Saskatchewan numbers, and stories
about people having to decide whether they were going to buy food or pay their
insurance premium at the end of the month.
Do you have any last comments?
Mr. Daniels: I just want to thank you and your colleagues for giving us
the opportunity to flight-test some of these really important ideas today. I
would also thank you for this opportunity to inform you on these issues that
will be a matter of critical public policy and industrial policy. This forum is
as good as it always was.
The Chairman: Thank you for coming. We will have many more conversations
with you. Yves, it was nice to meet you.
Senators, our next panel consists of Dr. Margaret Somerville, a professor of Law
at McGill, and acting director of the McGill Centre for Medicine, Ethics and
Law. As some of you will recall, she has testified before us before; Dr. Robyn
Tamblyn, associate professor of the Faculty of Medicine at McGill University;
and Mr. Kevin Skilton, the Director of Policy Planning forMerck Frosst.
Professor Somerville is an ethicist.
If we have time at the end, there is one question I want to ask you which does
not relate to this. Alternatively, I will phone and ask you my question.
Mr. Skilton will begin.
Mr. Kevin Skilton, Director of Policy Planning, Merck Frosst Canada Ltd.:
I want to thank you, Mr. Chairman, and the committee at large for the efforts
and the energies that you are putting into this process, a process which is very
important for Canadians, and very important for industry.
Mr. Chairman and honourable senators, I just want to echo some of the comments
made by the previous panel.
I read your "Issues and Options" paper with great interest. It is an
outstanding piece of work. I was particularly pleased to note the emphasis that
the committee has placed on the use of evidence to guide decision making. I was
also intrigued to see the word "behaviours" being used in the
"Issues and Options" paper because I believe it shows an awareness of
the complex interplay between what it is we aim to achieve and the policies that
we work with, and the intended and unintended behaviours that happen at the end
of the day.
It also shows a deep understanding and appreciation for the need to carefully
think through both the issues and the options, and the need to rally
stakeholders around a common goal. If, at the end of the day we do not find a
way to work together, we will continue to do what we have been doing for the
last several years, which is really working against one another.
The content of my presentation is reflected in its title, "Towards
Evidence-Based Pharmaceutical Policy." My goal is to contribute to the base
of evidence that the committee needs for its deliberations. I believe that the
evidence presented may persuade the committee to expand, if not redirect, the
options presently being considered.
The committee has chosen to focus on two areas: one, a need to contain cost,
contrasted by, two, the need to expand coverage. The committee has stated that
its present direction is to increase regulation and controls in the drug
industry. Rather than debate whether this is right or wrong, I would like to
ensure that the committee has a clear understanding of the regulatory
environment in which drugs are managed in Canada. If I were to conclude my
presentation at this moment, I would conclude with the following:
From an economic perspective the regulatory and policy environment is hindering
Canada's ability to compete internationally for investments in pharmaceutical
research and development.
From a health care perspective, the management of new drugs is contributing to
sub-optimal outcomes for patients, and sub-optimal value for the health care
Finally, solutions do exist that can unite the interests of patients, providers,
payers and industry in a collective effort that drives toward a proper focus on
cost rooted in a culture of evidence. This is what we call patient health
The Chairman: Are you going to read the whole brief?
Mr. Skilton: No, I am not.
The Chairman: I want to make absolutely sure we have time for questions.
Mr. Skilton: In each of your packages is all of the evidence to which I
will refer. I will proceed to the conclusions that are based on the evidence.
There is, however, one part that I would like to deal with before I dive into
the health care aspect, and that is the industrial policy aspect and the concept
of integrating health and economic policies.
The benefit of ensuring that Canada's health and economic policies are
synergistic and not combative is becoming increasingly clear. Changes to the
Patent Act in 1987 and 1993 have opened our eyes to what is possible. Today, the
innovative pharmaceutical industry invests over $1 billion a year in R&D,
and the industry, clearly, is a cornerstone in the knowledge-based economy in
We built the Merck Frosst Centre for Therapeutic Research in 1991. We employ
over 300 world-class scientists in our facility in Kirkland. Important
discoveries have already been made in the field of asthma with our product
Singulair, and in arthritis with our product Vioxx.
We have also built a world-class manufacturing facility, which by 2002 will
export over 80 per cent of its production.
Under the head of "A competitive knowledge-based and global economy,"
we believe that to attract investments requires that we benchmark ourselves on
the enabling conditions that position Canada to compete favourably with other
Mr. Chairman, I would draw your attention to a report that was recently launched
by the United Kingdom in which they have tabled their competitiveness and
performance indicators. They are clearly benchmarking themselves against other
countries and positioning their country to compete aggressively for their share
of investment of pharmaceutical research and development funds. I will leave
that with you.
Similarly, Australia, with its action agenda, is set up to develop key
industries including pharmaceuticals. Dr. Henry Friesen who appeared before you
earlier said that he thinks the role of the federal government is to articulate
the vision for Canada's health care system broadly and in an inspired way, and
that we are part of an effort to say that there is so much opportunity in Canada
if we can get it right and work together.
The challenge that the federal government has is one of coordination in the
development of health and economic policies as we move forward towards a common
goal of prosperity for Canada. It is not an easy task, but if you look at the
way the United Kingdom is set up, even administratively, they are set up to be
somewhat more efficient. That is something that we will have to compete with and
try to manage in our own system.
We now get down to the task at hand. The question that the committee posed is:
What, if anything, can be done to contain the rate of increase of prescription
drug costs and publicly funded plans? It is important to be clear on what the
question implies, and what options are open to us as we approach the question
from different perspectives. Is the rate of increase of prescription drug costs
appropriate, or, put differently, is the use of drugs appropriate?
Let us look at two scenarios. One scenario is: If the evidence supports the
appropriate use of drugs and stakeholders conclude that the rate of increase of
prescription drug costs is still not sustainable, then clearly this leads down
the path of rationing, and perhaps provides the rationale for increased
regulation and control. The other scenario is that the evidence supports the
appropriate use of drugs and stakeholders conclude that the need to find ways to
accommodate growth in this rapidly growing area of health care is important. I
believe that this was previously proposed to the committee by the Canadian
Institute of Actuaries.
Of course, buried in here is the more salient question for the time. What can we
do to ensure that providers and patients have a proper focus on cost benefit,
while remaining rooted in evidence? A solution contains the benefits of
minimizing the need for rationing, slowing the rate at which prescription drug
costs will increase, and optimizing the value that new medicines bring to
savings in other parts of the health care system.
As an aside, members of this committee would agree that it is in everyone's
interest to work together to achieve this aim. From the perspective of the
innovative pharmaceutical industry, realizing revenue growth from the overuse or
inappropriate use of medicines is not a viable sustainable strategy for growth.
I would like to emphasize that we are willing partners to cost-effective,
evidence-based pharmaceutical care.
Clearly, the approach we must take to arrive at a set of options that reflect
the challenges of our environment, as well as the needs of Canadians, involves
the following few items which I will list.
It involves taking stock of current regulations. If the proposition is that we
need increased regulations, then we must be mindful of what is out there today.
It involves reviewing how pervasive and how aggressive the current cost benefit
management practices are, and whether they achieve the cost-benefit management
goals that they are meant to achieve.
It also involves considering the evidence on appropriate use, the question
being: Do physicians' prescribing practices reflect a proper focus on cost
benefit and clinical evidence, or is it what many perceive it to be, a total
disregard for cost?
Considering the evidence on the impact of coverage decisions on decisions at
point of care, do coverage decisions, or the decisions that are made by payers,
contribute to inappropriate prescribing?
In the package, Mr. Chairman, I provide the evidence to support the conclusions
around those questions.
I will conclude on those points now.
The evidence shows that aggressive cost-benefit management already pervades
public drug plans, as evidenced by the majority of provinces that do not list
new medicines. Mr. Chairman and members of the committee, it may surprise you
that, over the last several years, six provinces have chosen not to list over 40
per cent of new medicines. This results in de facto un-insurance. On the one
hand we are trying to look at the need to expand coverage, and coverage is
important if it covers what you need, and on the other hand there is evidence to
show that prescribing practices do reflect a focus on cost benefit when the
clinical criteria that defines coverage is rooted in the clinical evidence that
guides care. What happens when the two do not coincide is you get friction with
There is evidence that drug plan coverage decisions impact at point of
prescribing and, when not rooted in evidence, we believe this poses a risk to
patient health and to unnecessarily increasing overall system costs.
You will hear from Dr. Terry Montague that there is also evidence which
indicates that, when stakeholders are immersed in an integrated health care
system that is based in partnership and that provides easy access to measurement
and feedback on care, stakeholders converge naturally towards a proper focus on
cost benefit that is consistent with the evidence.
I will conclude there. I know you will have questions on reference pricing and
other issues. I will be happy to respond to those questions later.
The Chairman: Thank you. Dr. Tamblyn?
Dr. Robyn Tamblyn, Associate Professor, Faculty of Medicine, McGill
University: Mr. Chairman, I will be making a slide presentation.
I read with interest the committee's report. I wish to commend you for your
thoughtful review of the issues. I am highly supportive of many of the thoughts
contained in the report - primary care reform, specialized care units, a
national health commissioner, a very interesting idea, the federal role in
health promotion-disease prevention and, most important, an infostructure and
infrastructure for health care delivery.
I wish to specifically highlight two issues. Let me first address issues and
options for the financing role. In your report, you refer to the option of user
fees. User fees, in one form or another, are a total tax on service utilization,
a point-of-source fee in terms of collecting from patients who are using the
system. This is a policy of making the sick pay for their health care. I am not
sure that that has really been an underlying value of our health care system to
this point in time.
The second area I want to talk about is disease prevention and health promotion.
This is a very important goal, a laudatory goal, but the report does not suggest
mechanisms for putting this action in place. The federal government could
definitely play a role here, one that probably the provinces may not be able to
take in that way.
The next slide discusses user fees - unsubstantiated assumptions and unintended
impacts. The user fee option is based on a set of unsubstantiated assumptions;
it is not strongly evidence-based. The first assumption is that free care will
lead to a lot of unnecessary use by many people. It assumes that people will
hang out in emergency rooms, rather than going down to the bars on Crescent
Street. The next assumption is that consumers know when less expensive
medications can be substituted and know about surgical interventions. It assumes
that consumers will have the knowledge to make those decisions, even though we
license health professionals because we believe they and only they can make
The third unsubstantiated assumption is that user fees will reduce only
unnecessary services. The fourth is that income-indexed user fees will be the
answer. Quebec was a bit ahead of its time, because they tried that out, and as
such can provide a prototype for you.
The next slide has two graphs on it. The Quebec government commissioned a study
to look at their new policy of coinsurance and deductibles for elderly and
welfare recipients that allowed them to bring in the universal health pharmacare
plan, which in itself is a laudatory goal, but they increased user fees for
previously insured in order to finance this plan.
A large, random sample of the population - taking into account history of
medication use three years prior and one year after the policy - revealed, not
unexpectedly, that user fees reduces utilization. Usually, people stop there and
say, "Well, this is exactly what we wanted. We have cut our costs. People
use less." They jump to the conclusion that there was unnecessary use.
User fees will of course target people who are heavy service users. In terms of
prescription drug use, which is what this study is looking at, this graph shows
that after the policy was implemented there was a large drop in consumption in
people who used a lot of drugs.
The next slide shows the effects of user fees on prescription drug use among the
elderly. The study looked at three groups: those who received a full guaranteed
income supplement, those who received a partial supplement, and those who
received no supplement. Those who receive no supplement have an annual income in
excess of $14,000 and are in the $750 maximum zone for prescription drugs.
The first piece of good news is that income-indexing did produce a somewhat
equitable distribution of reductions across the income spectrum in the elderly.
The interesting thing you will see here is that the very poor - those are the
people at the top, the red line - are those who are using a lot of prescription
drugs; also interesting - and you may be aware of this Statistics Canada
evidence - is the fact that they die on average about 10 years earlier. So, they
are sicker, they are using more drugs, and they are going to die earlier. By the
way, we are talking, in large part, about elderly women. This group is about 70
per cent elderly women, probably most of them single.
The next slide tells us about the unintended impact of user fees - and this has
been studied on two occasions. The question we are trying to answer here is
this: "Do user fees reduce both essential and less essential drug use? Now
to the bad news: Across the board, user fees reduce the use of essential
medications - medications for asthma, for mental illness, for hypertension, for
cardiac disease. Those are the medications we looked at. The other bad news is
that in populations of welfare and elderly citizens, the ratio is 2:1,
two essential medications for every one less essential medication. The other
piece of bad news is that essential drugs are more costly than less essential
Hence, when a co-insurance plan is put in place, there is an incentive to reduce
essential drug use. This true both for the elderly and - as the next page will
show - for welfare recipients, who made even more dramatic reductions.
The consequences are outlined in an accompanying paper. I will not go into them
in detail here, but there were downstream impacts, even in the short term.
Emergency room visits and hospitalizations were up. I do not think that is the
type of consequence we want.
The last bit of news, really the most unfortunate, I think, involves the
mentally ill. Special programs to reduce the burden of user fees in people with
severe mental illness -schizophrenia and psychosis - did not eliminate
reductions in essential drug use. Under the program, there would be a maximum
payment of $16.67 a month for people with severe mental illness. The graph at
the bottom of page 5 demonstrates the impact of the special program on that
population. There was a very rapid reduction in the use of anti-psychotic,
anti-schizophrenic medication. One of the biggest challenges in managing the
mentally ill is managing compliance. Hence, any extra burden on them in terms of
a financial disincentive is very counterproductive.
The graph on the final page, page 6, shows that utilization of health care
services rose dramatically. For example, emergency room visits climbed by 457
per cent, followed by medical visits and hospital admissions, even at a time
when hospitals were closing and there was reduced access. This was a very severe
impact. To the credit of the Quebec government, however, they changed the policy
and allowed free medication in this group. The government was incredibly
responsive, essentially, to its own requisitioned evaluation.
Based on this information, I would hope that user fees is not something that you
will consider. In my mind, they penalize the very sick, and they will penalize
the poor, even with income indexing.
The final point I want to touch on involves the issue of health
promotion-disease prevention. One thing we have learned from the Whitehall
studies, from studies here in Canada, is that many of the determinants of health
are outside the health care system. The health care system is like the final
resting point, the graveyard of what you did or did not do right in your life or
the conditions in the environment, et cetera.
Many of the things that will allow you to creatively and effectively bring in
place things that will promote health and prevent disease will be outside of the
health care system. I want to discuss an example of that - and that is injury
prevention. Injuries are the first leading cause of death for people aged 1 to
40. For the most part, many of these injuries are preventable. There has been a
fair bit of epidemiological research in terms of injuries prevention, et cetera.
Injuries can be prevented by implementing product safety standards, by building
better roads, by implementing environmental standards.
Nevertheless, it is not easy to make those changes. The health care sector is
waving a red flag, but with no real model for how Consumer and Corporate Affairs
and Transport Canada, for example, can implement changes. We need models for
cross-jurisdictional action plans. There has been some success in terms of
cigarette smoking, but the battle has been uphill.
Hence, if we are really serious about health promotion-disease prevention, we
will have to come up with some creative models for cross-jurisdictional
The Chairman: You are absolutely correct. Our paper did not contain
mechanisms for implementing the population health role, partly because we were
hoping that people would suggest mechanisms to us. Therefore, if either today or
at some later point you have some thoughts on how we should do that, we would
love to hear them.
Dr. Margaret A. Somerville, Acting Director, McGill Centre for Medicine,
Ethics and Law, McGill University: Thank you for asking me to appear. I have
submitted a brief written report.
I wish to preface my remarks by saying - as have the other speakers - that your
report is to be strongly commended - although that does not mean that I do not
find anything wrong with it. What I have done in my written presentation is to
pull out some of the issues in your report that I would see as raising values,
ethics issues, because, as you know, that is the area I work in. I shall go
through them quickly.
You make the statement that the report is "factual and
non-ideological." My concern, although not huge, about that is that the
health care system and decisions about it must be based on values, and some of
those values will fit with certain ideological positions and contravene others.
It is very important for us to recognize that to make those decisions ethically
we have to justify the value choices that we make. I do not think that that kind
of approach is outlined anywhere in the report.
The second purpose of the report is to "launch a public debate," and
again I commend you on doing that. I have, however, attached to my written
presentation an appendix, which is an outline of a research project entitled
"Ethics in the Public Square." Much as we talk about putting ethics
into public policy, and we talk about having the public involved in this very
important decision making - in fact, we even speak about it being an ethical
imperative to have the public involved in decision making about things such as a
health care system - we do not have the developed mechanisms to do it. As well,
we have a very inadequately developed system of ethics at the organizational,
institutional and societal levels. Most of the ethics that we have worked out in
relation to health care are at the physician/patient or health care professional
This leads me to the third point, where you point out that in order to make good
public policy you have to know what the objective of that public policy is.
Again, I would query the report in terms of its articulation of the values that
the health care system upholds. I know you wanted to avoid ideology, but it is
extremely important that you state values. I would suggest to you that many of
the problems, certainly the ones that we see in ethics in the health care
system, are not simply that people have perceived that they may not get the
health care they want, or as quickly as they want, but also have to do with the
fact that that goes to the heart of what we think are important as values both
for ourselves individually and for Canadian society.
I have attached as appendix B a list of features that shows, depending on how
you characterize and make the decisions that have an impact on values - and all
decisions in the health care system come into that category - that you can have
a very different impact. If I may, there is a typographical error in the
third-to-last line. The first and second groups should be reversed: It should
say, "...the decision making will have the second group of features and not
the first," rather than the way it is at present. In other words, the
decision making impact can be manipulated by doing things like hiding who makes
I was involved in a survey approximately 18 months ago to try to find out who
decided what treatments were available for certain cancer care in Canada, and in
some of the provinces we could not find out who made those decisions. If you
look at this chart, you will see that that's - I am assuming intentionally that
those decisions come into that second category so that they do not seem to
offend values in the same way.
One feature I did not find in the report was the impact of political advantage
and disadvantage in making decisions about health care, and the mechanisms that
might need to be put in place to deal with that. We have not considered that in
nearly enough depth.
As well, the report focuses mainly on macro-level decision making. That is
extremely important, but the health care system operates essentially, as far as
an individual Canadian is concerned, at the individual level. Hence, most of
your impression of the health care system, and certainly the complaints that
come to me, come from that individual level.
The reality is that what is ethical at the macro level might not be ethical at
the individual level. That is not addressed in the report at all. You will find
that I have explained this in my written presentation. For instance, a physician
has a primary obligation of personal care to every patient. The physician can
only take efficiency and effectiveness in saving the health care system
resources into account as a secondary objective, when it does not directly harm
the patient. You do say in your report somewhere that it is very hard to get
physicians to take efficiency and effectiveness into account. The reason for
that is that physicians have ethical and legal obligations not to do that. We
have to understand those obligations, and in doing so I hope we do not decide to
abrogate them. Nevertheless, they are the features that are causing that sort of
As well, there are problems with definition as to what constitutes timely health
care or medically necessary. Those are not new problems, but they are ones that
need to be addressed in greater depth.
With respect to evidence-based health care decision making, I agree that we need
it, but I was somewhat concerned in reading the report that it might be seen as
not only necessary, but also sufficient, and I do not believe that that is
sufficient. There is a saying that sometimes the measurable excludes the
essential. I would suggest to you that if we are concerned about healing and
caring, as well as curing, then we have to be concerned about some very
important intangible factors, not the least of which are the values that we
uphold or we contravene in making decisions about the health care system.
Again, I did not see in the report enough of the recognition of what I would
call the necessary ambiguity in some of these decisions that we have to make. We
cannot expect a linear decision-making model, where we will arrive at a
successful hard-based cognitive conclusion that we have to build in spaces where
these other very important human factors operate and, among those, to ensure
that we have a caring health care system and not simply an efficiently run one.
I would then come to the point about health care being an industry, which is
emphasized in the report. The report talks about - and I thought somewhat
disapprovingly - primary care medicine as being a 19th century cottage industry
rather than a 21st century service industry. What that brought to mind for me
was that while cottage industries do have negative features, that description
also brings to mind caring personalized interaction and personal knowledge of
the people - and I would emphasize to you that that should be included.
In conclusion, let me say that while there is much to be praised in the report -
I thought it was thoughtful, insightful, open-minded and open-ended - my major
concern is that the issues are addressed only at the macro level. The issues
also need micro-level analysis. When conflict exists between those levels, and
those are some of the most difficult ethical issues we face, we have to decide
how we will handle that conflict - and that is true for even each of us. As
Canadian taxpayers and citizens, what we decide should be available as health
care often differs radically from what we want, and what we want for those we
love when they need it.
I applaud the national ethical conversation that you have proposed. It will
certainly help, but it will not solve all the problems. As well, it has to be an
Finally, I would urge you to recognize not only medicine's curing role, and what
we need to do to support that, but also its healing and caring roles, and to
accept that it is worthwhile to spend even economic resources to uphold those
roles. Thank you.
The Chairman: Thank you for your usual provocative statement.
Dr. Terrance Montague, Executive Director, Patient Health, Merck Frosst
Canada Ltd.: As a leading health care company, Merck Frosst's core business
is discovering new and efficacious drug therapies for important diseases and
demonstrating their value to patients and payers. I think perhaps we are all in
the business of demonstrating the value of health to the patients at the moment.
Recent clinical and econometric analyses across many disease states, not just in
cardiology where they began, but in many disease states, have demonstrated
strong positive relationships among the utilization of the innovative
pharmaceutical therapies, increased longevity and national productivity, which
has usually been measured in these studies by gross domestic product measures.
However, repeated research studies carried out by groups such as the Clinical
Quality and Proven Network, CQIN, of which I was a founding director, and the
patient health management team at Merck Frosst indicate that the optimal social
rate of return of this innovation is not being realized in this country or in
other parts of the developed world.
This is primarily caused by a significant remaining gap between best care and
usual care. In this context, best care is defined as the accumulated body of
evidence from clinical trials; usual care is defined as the level of provision
of this efficacy knowledge in real-world practice. Narrowing of this care gap is
difficult and complex; however, my firm premise, and that of my colleagues, both
previously in academia and now in a combination of business, academia, and the
community level, is that it is possible, that is, that patient care, patient
outcomes, and the productivity of the nation can all be better.
In addressing the care gap over the course of the last decade, my colleagues and
I have championed an approach anchored in governmental, industry, professional,
and community partnerships. These partnerships are the focus of what I am
suggesting to you is a possible option worthy of your consideration here and in
your deliberations across the country. These broad-based partnerships have
utilized the principles of evidence-based and cost-efficient care and many of
the tenets of total quality management, particularly the use of repeated
measurement and feedback to drive continuous improvements in care and outcomes.
Our most advanced initiative so far, at least in the last five years, since I
have been involved with Merck, is ICONS - improving cardiovascular outcomes in
Nova Scotia. ICONS is a province-wide initiative. It was designed and launched
in 1997 with a view to improving cardiac care from the bottom up, that is, from
the community up. It has a very large community face, including a 70-member
steering committee representing all the health managerial districts in Nova
Scotia. Participating community physicians, both primary care and specialist,
nurses and pharmacists are providing regular feedback on local practices and
outcomes. ICONS is much more outcomes oriented than some of the discussions I
have heard today, which are so input focused. From the beginning, ICONS was
designed to be outcomes focused.
The first phase is nearing completion now, with more than 40,000 patients
screened and 13,000 enrolled and followed up. There has been a consistent,
year-over-year improvement in utilization of efficacious drug therapies, which I
have tried to highlight for you in some of the accompanying slides, with
diseases like acute myocardial infarction and congestive heart failure. In the
management of heart failure, which affects 450,000 people in our country, the
ICONS data demonstrated that patients on proven therapies have a significantly
lower risk of death and hospitalization, which are obviously important outcomes
for the patients and for society. The improvement in these clinical end points
is also associated with accompanying cost savings to the health system, even
when the component cost of increased drug use are factored into the
calculations. The system cost efficiencies contribute to the overall
sustainability, I believe, of Nova Scotia's health system.
The ICONS clinical and methodological data have also begun to enter the
scientific domain. There were 24 ICONS abstracts presented at the recent
Canadian Cardiovascular Society meetings in Halifax. This represents a
significant incremental component of the entire new gain in cardiovascular
knowledge, and outcomes-research knowledge, in our country this past year .
The timely provision of data that ICONS is making available now is very
important to the government partner in ICONS because it alleviates one of the
enduring frustrations of public health management - the lack of comprehensive
outcomes data on which to base policy decisions. The combination of clinical and
component cost data is particularly powerful, since it allows an estimate not
only of what we are buying for our health expenditures, the money that is spent,
but also across the whole health system.
Because of the success of practice improvements, as well as the creation of
innovative administrative processes to deal with access inequities to cardiac
care in Nova Scotia, the ICONS partnership is now entering a new phase. It has
become the platform for the development of a provincial cardiac program. The
evolution of this program will be sustained with funding from the Nova Scotia
Department of Health. The program will enter the fabric of everyday health care
for citizens and patients of that province.
Certainly, ICONS has shown that things can be better. It has demonstrated that
the promise of the best health, for the most people, at the best cost is a
vision that is achievable and that, indeed, it can be realized.
If you asked me to choose the single most important contributing factor to
ICONS' success, I would vote for the partnership's rigorous focus on
measurement, particularly outcomes-oriented measurement. Perhaps the importance
of the partnership-measurement interrelationship is best captured in a quote
that I have read by Charles Deutsch, a Harvard educator, who said of
We talk about them as if they were exhilarating, but they are usually
exhausting and sometimes maddening. They have to focus relentlessly on results
or they are likely to get lost attending to process.
Each time I read this and think about it, I realize that it is has to do with
more than education or health care; it might even extend to marriage. It strikes
me repeatedly as I read it.
In several other provinces and in several other disease states, as indicated in
that last slide in the enclosure, including diabetes, asthma, arthritis and
osteoporosis, which are enormous burdens for the society - 75 per cent of our
health expenditures are being now spent on chronic disease, which affects nearly
50 per cent of our entire population at any given time - we are now working with
additional partners from our own society, Canada's innovative pharmaceutical
community, using a template similar to that pioneered by the ICONS group. It is
our anticipation, and certainly our hope, based on all of the available
evidence, that the outcomes improvements and the innovative administrative
infrastructures and processes modeled by ICONS can be replicated and improved
upon. As always, our mantra in this partnership and measurement model of
evidence-based health and disease management is the belief that things can be
The challenges to that view of health care are not insignificant, as I am sure
you are very much aware as you listen to people across the country. Leadership
is required to propagate the opportunities promised by the options of ICONS and
projects like ICONS. The Government of Canada is well-positioned, I believe,
through initiatives like this committee's work, to assume a very important
leadership role and leadership position in the country.
Let me close by emphasizing that Merck Frosst remains committed to the
principles of ethical and effective health care partnerships across disease
states and across the nation. We look forward to the future.
Thank you very much for allowing me to make this presentation to you today.
Senator Keon: Dr. Somerville, you raised the old doctor's dilemma. Have
you seen Shaw's play, The Doctor's Dilemma?
Dr. Somerville: No, I have not.
Senator Keon: You really must see it. When you do, I would like to talk
to you after. Things have not changed.
The doctor's dilemma of our time is that if doctors are not involved in health
care policy and health care management the system will go forth. There is a
conflict there. Some doctors feel strongly that their total commitment is to be
a patient advocate. I think they have to learn to deal with responsibility to
the system as a whole, because what they are advocating for most patients is an
entry into the system, at least the primary care physician is, and then he or
she loses control of what happens next. If the primary care physician is not
making a meaningful contribution to that, the system is not going to get better.
I am just going to tease you a bit. Frequently, that might superficially appear
like compromise, that the system cannot be all things to all people, and
frequently the solution is the best possible compromise.
Dr. Somerville: Well, "compromise" tends to be a dirty word.
There was a car advertisement that said, "We make convertibles, not
However, I would like to respond to your very important question.
First of all, the physician, I think, has two roles today, and one is as the
individual protector and advocate of the individual patient. The grave danger
comes when that role becomes confused with the physician's role as a policy
advisor, sometimes policy maker-policy decider. We must be very careful to keep
thosetwo roles operating separately, even though the physician might, at various
times, play one or the other role.
Actually, at the risk of doing a bit of advertising here, I refer in my written
presentation to a chapter in a book I have just written, The Ethical Canary.
There is a chapter on the ethics of access to health care resources, and in it I
go at some length into the very question that you have asked. One option would
be to relieve the physician of that primary obligation of personal care to the
patient. Personally, I think that would be a total disaster. It is the absolute
foundation, the traditional base, of the trust relationship between the
physician and patient.
As my written brief says, it is true that health care features similar to other
industries in our society, but it is an industry like no other industry. One of
the important respects in which that is true is that a physician has a
relationship with a patient and power over a patient, indeed, even a kind of an
intervention on a patient, that no other member of our society is privileged to
have. It would be a very dangerous thing to change or damage that in any serious
way. The big challenge for us is to keep those traditional and, I believe,
necessary attributes of the physician-patient relationship, so that a patient
knows the physician is acting in his best interest, free of conflict of
interest, and, at the same time, to be able to organize our health care system
so that it is viable, "sustainable," as it says in the report.
Senator Keon: Thank you for expanding on that.
Dr. Tamblyn, you just superficially touched, because of time constraint, on
population health. I want to ask you what population health means to you, and
before you answer I want to ramble on a bit.
I think because the health care delivery system only affects a small segment -
the estimates are about 25 per cent, usually - of population health, and all the
other forces are social forces, the wealth of the group concerned, the
geography, et cetera, population health has not been used as the instrument it
should be in the ongoing assessment of the performance of our health care
delivery system. Since the Lalonde report, I have always felt - and I have not
seen anything to convince me otherwise since that time - that the only way we
will ever get a handle on accurate measurements of our performance in the health
care system is using the basis of population health.
So, with that bit of a harangue, will you tell me what population health means
to you, and then would you comment on its use as an instrument in the ongoing
assessment and monitoring of the health care delivery system.
Dr. Tamblyn: We are just beginning to understand the determinants of
health - "population health" to me is a bit of a slang word; it could
mean many things to many people. In my mind, what you are trying to tackle is
the fact that there are many things that influence people's health. It is not
the health care system, it is not within its jurisdiction, it is not within its
mandate, it is not within its responsibility.
With regard to the arena of injuries, in fact, most of it is outside the health
care system. Related aspects are safe products, roads and their condition,
driving speed and whether or not drinking and driving is happening. Those
aspects are not within the health care domain. The health care domain relies
heavily on jurisdictions outside of it, bureaucratic environments outside of it,
in fact, to influence what ultimately they will get as the final graveyard of
health problems, where they are going to have to spend money. If you really want
to start much earlier in the process to determine people's health, then you will
have to effectively deal with all these other sectors that will impact on
For example, if the Ministry of Transport decides to increase the driving speed
- I was just in France, where the driving speed was 199 kilometers an hour; at
least, that is how fast people were driving. If in fact that is the allowed
speed, the issue is one of unnecessary motor vehicle accidents and one of energy
Let's take the example of genetically modified foods. No one really knows the
consequences of GM foods. That issue is in the agricultural arena. There is also
the issue of antibiotic use in agricultural animals and the extent to which that
influencing resistance in humans.
Let's look at education. We do not quite understand the relationship between
socio-economic status and health, but we do know that there is a relationship
between having poor health and being less well off and being poorly educated.
Why? Are there environmental influences? Could, for example, it be that
something like a big steel refinery coughing out pollution produces negative
effects on the health of those living near the factory? Or is it other things?
Let's look at one specific example. We now know that exercise has a positive
influence on cardiovascular "wellness."
Maybe I should not say that. Dr. Montague is sitting next to me; I am sure he
could tell us more.
In any event, we know that exercise influences glucose metabolism. Hence, the
epidemics of diabetes and obesity in younger kids are related to exercise
programs. At the same time, the Ministry of Education is cutting education
budgets and teachers are refusing to get involved in extracurricular activities.
What are we doing? We are ignoring an opportunity to encourage and teach
physical fitness. This will have downstream negative effects on health. We are
choosing to ignoring this and instead to make immediate cuts in education, in
order to not achieve the final goal of influencing the determinants of health.
Population health to me is influencing the determinants of health before you
ever get into the health care system. It is one of the things that will make
people healthy, keep them healthy, and that is what I am talking about.
Senator Keon: What about secondary prevention?
Dr. Tamblyn: Secondary prevention is equal - are you talking about
earlier detection of disease and secondary prevention of complications?
Senator Keon: No, I am talking about after the hit has been made, after
the 31 year old has had a heart attack and he is enrolled in a good secondary
Dr. Tamblyn: Right.
Senator Keon: Where does that fit into population health?
Dr. Tamblyn: Secondary prevention, by and large, is in the health care
system. It involves approaches that are put in place within the health care
system. In some diseases, secondary prevention is very effective, and oftentimes
underused. For example, with stroke, the biggest predictor of another stroke is
your first stroke. The biggest predictor of another heart attack is your first
heart attack. The biggest predictor of another injury is your first injury.
Hence, it is important in those instances to have effective intervention,
secondary prevention. If those are available but are not being used, and the per
case cost may be in the neighbourhood of $20,000 per episode, that is a problem.
There is an orientation, culturally speaking, in the health care system to worry
about today, the urgency of today, and not about tomorrow.
Senator Keon: The ICONS study is dealing with the health care delivery
system, the 25 per cent that, in my opinion, is drastically affecting population
Dr. Montague: Yes.
Senator Keon: When we measure population health, we get distracted and do
not look at the interventions in the health care delivery system itself.
What I want to steer you into is whether you have looked at the population
health in the geographic area that that study applies to, and whether you have
noticed any effect in population health.
Dr. Montague: Thank you very much, Senator Keon.
I do not have a definitive answer for Nova Scotia, in terms of longevity over a
long period of time; we have not been doing it long enough. However, my sense is
to define population health by something that we can get our hands around.
There is evidence from some constituencies, certainly Alberta, that the money
spent on health care per capita from 1975 to 1995 drove well-accepted population
health outcomes like longevity in that province. Some people say that the money
we are spending on health care is not buying us anything; however, there is
countervailing evidence, even in ICONS, which is now over five years. You see a
year-over-year increase in the utilization of the proven therapies; you see an
increasing or a decreasing morbidity and mortality around the end points that
they are measuring in acute ischemic syndromes and heart failure.
Therefore, there is value, if you are defining population health around the
whole provincial HMO, if you will. If you are looking at major burdens of
illness like arthritis or cardiovascular disease, where there are a lot of
endpoints that are occurring quickly, I think you will be able to see your
interventions having an impact in a secondary prevention setting in a very short
period of time.
Let's take a disease like osteoporosis - which affects older women, who are
traditionally undermanaged and undertreated in our health system, whatever their
disease. With respect to a disease like osteoporosis, which takes a long time to
manifest its final clinical occurrence, despite long presence at risk, it may
not be as easy to see the outcome impact of the investments that are being made.
Certainly when we have presented programs like ICONS across the nation in
various forms, one of the criticisms we get from audiences is that we do not
have a primary prevention arm. We cannot take on everything all at once. It is
not that we are going for the low-hanging fruit, but I think, senator, as you
have rightly pointed out, in cardiovascular disease that low-hanging fruit is
our number 1 killer; it is a very worthwhile target.
Given time, we will get into the things that Dr. Tamblyn is making apparent to
us are very important. I know that those things are contributing to the overall
risk, but we will get more bang for our buck going for the high-burden
illnesses, where there are so many, unfortunately, still occurring endpoints.
Hence, that is where we have elected to go, and to go with partners.
In summary, my concept of public health definitely has an envelope that includes
projects like ICONS, with a community face and a whole province trying to be
involved with all of the patients as a target with that disease. Perhaps we will
have an impact starting the secondary prevention.
Senator Morin: I have one comment and two questions. Mr. Chairman, I
think it is important to realize that Dr. Montague is the leading Canadian
authority on disease management programs. I know your own interest on this, and
I think it is a very important issue. It is unfortunate that Dr. Montague had
only six minutes to develop that very important issue.
I would suggest that Dr. Montague be invited to discuss generally what it is
exactly. I understand what you have been doing - I am quite familiar with your
own work - but what I think is important is for us to have an idea about what
disease management is. I know you do not call it that, but let's call it a
disease management program for a minute.
Dr. Montague: We call it that, senator, because that is what everybody
else calls it.
Senator Morin: For diabetes, arthritis, and so on, there are problems of
underuse and overuse of medication, and I think this would help us. Perhaps at
some time, Mr. Chairman, we could re-invite Dr. Montague, who spent most of his
professional life dealing with these problems, to deal specifically with that.
The Chairman: Certainly.
Senator Morin: Dr. Tamblyn, I am very much interested in your study. I
remember very well the introduction of pharmacare in Quebec. It was a real mess.
There was a lot of negative publicity surrounding the program. The government
was always changing user fee levels; there were problems with computer programs,
and then computers kept crashing; pharmacists did not want to fill in
prescriptions. I remember calling Merck to send me all sorts of samples, to give
to my patients. The program was an administrative mess.
I am amazed that the government has not been sued over that. Some of my patients
stopped taking their medications. They were under the impression that they could
not have their drugs at all anymore. Your study found that mentally ill patients
were the most affected; of course, they are the most fragile in a situation like
There is no doubt there were undesirable effects; I saw them.
However, I am not sure that it was a study of user fees; I think it was more a
study of a terrific mess that went on for months. There was real turmoil.
I think you should repeat your study, see the same group today. I cannot recall
the amount, $4 or $5 a month, but I am sure these people are back taking their
I would caution you not to apply this study of user fees to the health care
system or to every country in the world. I am not proposing that we should bring
in user fees - but let's fact it, almost every country in the world has user
fees today. In Canada, most private insurance programs have user fees. Hence, I
would be very careful.
All of that was by way of a comment, not a question.
I should like to move to Mr. Skilton.
Dr. Tamblyn: I agree that it is important never to take a single study,
as you point out, by itself. However, the difficulty we have is that every
single study that has ever looked at this has shown exactly the same thing. It
may be that the implementation of user fees always produces chaos in the
consumer population, but the basis and rationale for user fees is essentially
not substantiated by any evidence.
What is the evidence to suggest that the mentally ill, for example, were
misusing their medication?
Senator Morin: No, you did not get my point. They were not taking it
because they are more fragile; understand? When the program was introduced and
the administrative mess ensued, for all sorts of reasons people did not take
their medications. I just spoke about pharmacists - in any event, I do not want
to get in an argument here.
Mr. Skilton, tell us a bit about reference pricing.
Mr. Skilton: Reference pricing really hinges on the assumption that all
chemical molecules in a given class are the same. It also depends, however, on a
price differential, and I would say a meaningful price differential between
those molecules in the same class. Without that, it is a price control
mechanism, or a way to get cost savings. Without a significant price
differential, we will not realize any gain at all.
When you look at the price of various molecules - let's take the statins as an
example. There are six, seven or eight different statins to treat cholesterol.
The price differential of those molecules is plus or minus 5 per cent, with one
exception, that exception being - I will not disclose which product it is, but
there is one product on the market that is nearly half the cost. One might ask:
Why do not we reference it to that particular product? Well, the particular
product also happens to be half as effective, clinically. Hence, market dynamics
work in that kind of system.
We know that if we come to market with a product that is half as effective as
the rest of the products, there is no possible way we can come out with an equal
parity price and expect to get anything on the market. Hence, market dynamics, I
think, do work.
It is also important to reflect on two other things.
First, I firmly believe that partnership is important. I believe that we each
have specific interests. I also believe that we are each committed to a
sustainable quality health care system. The challenge becomes how to make it
work. Reference pricing forces the hand - the interests of one stakeholder
forces the hand of many others.
Reference pricing was tried in Norway. The outcome was that patients were
dissatisfied because they had to pay more, and physicians were dissatisfied
because they were spending more of their office time consulting on costs than
care. There was significant stakeholder dissatisfaction.
Patient health management brings different partners together to look at the
evidence and to look at affordability. Collectively, they implement a system
that they can measure and move collectively towards a common goal. It works
because all of the stakeholders are aligned towards a common goal.
The Chairman: Dr. Tamblyn, Quebec is the only jurisdiction with a
universal drug plan. As such, are other studies being done on the plan - for
example, who has been helped, who has been hurt - other than the one you
referenced it in your handouts? You also gave us an article from the Journal
of the American Medical Association.
If there are other studies, can you point us to them?
Dr. Tamblyn: A lot of money is being spent on pharmacare - there are
policies across the country for formula exclusion, inclusion, cost sharing of
various components - but there is really very little information about the
The Chairman: Are you saying that the policy evaluation process -
Dr. Tamblyn: I am saying that it is scant across the ground. It is
frightening. This is virgin territory.
The Chairman: Hence, in spite of the fact that Saskatchewan, British
Columbia and Quebec have programs - the Atlantic provinces do not have any. I
would assume that in excess of $1 billion of public funds is being spent on
those programs, right?
Dr. Tamblyn: I just talked to Ontario yesterday, and they are spending $2
billion a year on their program.
The Chairman: I am amazed, and depressed, by the scarcity of management
information in the health care industry, an industry that is so information
intensive. There was a time when I could ask the president of a hospital,
"What does a hip replacement cost?" Today, nobody has the foggiest
If everyone ran their businesses that way, we would be in a lot of trouble.
Dr. Montague: I think what Dr. Tamblyn says is correct, that there is
little in terms of evidence-based policy application across the country for
health care. There could be a lot more. There is a lot of data in the health
system, but very, very little information.
It is very difficult to undo a policy; implementation is much easier. Hence, we
should learn from research projects, like the one we have talked about here,
that find unintended adverse policy outcomes. It is important for policy makers
to think about these things. In the long term, it is important to have the data
before a policy is put in place.
Having said all of this, of course, Canada is no different than any other
country. Other countries have the same problem. It is what Minister Boudreault
at the time complained about when we started ICONS - they wanted to manage by
outcomes, but they were forced to manage by cost because they did not have the
outcomes. However, one of the spin-offs of a measurement-oriented
disease-management program is that it starts to fill in the information gap; it
is not just a collection of other data.
The Chairman: Right.
So, Dr. Tamblyn, keep doing projects like that, because at some point the system
will acquire enough information.
Senator Robertson: Mr. Skilton, we have heard for some time about the
lengthy approval process in trying to get a new drug to market. How does our
Department of Health compare to the length of time required to get approval in
Mr. Skilton: In your package, you will see a reference to a study by Dr.
Rossen, who studied Canada, Australia, Sweden, and the United States in terms of
the approval process. They looked at the review process for 87 molecules common
to all countries. They found the process in terms of time to be similar in
Canada and Australia, both of which are significantly longer than Sweden and the
United States. They also did a subanalysis on priority drugs, and found that
Canada and Australia lag significantly behind Sweden and the United States in
getting approvals of these products, so that patients can have access to them.
I would like to illustrate with one example. It is sad and telling, at the same
time. An asthma drug by the name of Singulair was discovered here in Canada;
nevertheless, Canada was the 29th country to approve Singulair in the world.
That is mind-boggling.
Senator Morin: Was it a Canadian discovery?
Mr. Skilton: It was a Canadian discovery.
Senator Robertson: If anyone has any recommendations about how we can
improve that process, we would love to hear them. I know this topic has been
kicked around for years, but the same complaints keep coming up. Surely, there
has to be a better process. If any of you, perhaps with help from your friends
in the industry, can design a better process, it might be rather fun to look at
Mr. Skilton: Let me just respond to that. The TPP has conducted several
internal assessments over the last 10 years. I think it is time for a public
review of that organization. I know many other countries have headed in a
different direction, and it might be time for that to happen.
Senator Yves Morin (Acting Chairman) in the Chair.
The Acting Chairman: I wish to thank all the witnesses for their
attendance here today. We appreciate it.
Senators, our next witness is the director general of the Association
québécoise de défense des droits des personnes retraitées et
préretraitées. Monsieur Smereka.
Mr. Myroslaw Smereka, Director General, Association québécoise de défense
des droits des personnes retraitées et préretraitées: On behalf of the
Association québécoise de défense des droits des personnes retraitées et
préretraitées, I wish to thank the Senate committee for giving us this
opportunity to speak and to put forward our arguments and recommendations in
Our association was established in 1979 and now has 40 sections throughout the
province of Quebec. Our mandate is to safeguard the economic, cultural and
social rights of retired and semi-retired persons.
What the AQDR is asking for is an adequate income above the poverty line, decent
housing at an affordable price, home care that allows people to go on living
independent lives, equality - both under law and in fact - between men and
women, and free and universal access to health care and social services.
The three points we would like to raise today go beyond the goal of safeguarding
the interests of seniors, that is to say the interests of one sector of the
population. What we wish to address goes to the very logic of the Committee's
Our first point is to suggest we adopt the concept of patient as opposed to that
of consumer of health services.
Our second point turns upon the role of private for-profit suppliers of health
services as opposed to that of private non-profit agencies.
And third, the issue of the types of health care provided under the Canada
Health Act as compared to the types of health care that will be dispensed as
more and more of these medical services are delivered outside a hospital
setting, which is to say within the community and at home.
To conclude, we will briefly comment on health promotion and preventive care for
seniors, regarding more specifically the interests of retired and semi-retired
On the first point: We should begin by saying we agree with Dr. Noralou Roos,
professor in the Department of Community Health Sciences of the University of
Manitoba, and with what she stated before the Senate committee in Winnipeg, this
past mid-October. Let me quote the Winnipeg Free Press of October 16:
It (the Senate report) plays into the ideological debate that the private sector
is the saviour to the public sector, that is failing. Your view of private
versus public health care is very unbalanced. In summary, you are not delivering
a factual non-ideological report.
We begin by saying that we are of the same opinion.
The Acting Chairman: I should specify at this point that we are not
really drawing up a report, but simply outlining options. You are therefore
perfectly free not to opt for the private system. The committee has itself never
expressed a preference in that regard. I do not believe Dr. Roos did either. She
is opposed to the public system, is that also your position? That choice is
entirely up to you.
Mr. Smereka: We will come back to that when addressing our second point.
Private means private for-profit as opposed to private non-profit.
The Acting Chairman: I see.
Mr. Smereka: We are not, therefore, necessarily opposed to the private
sector on this issue.
The Acting Chairman: No, I understand what you were saying.
Mr. Smereka: I would now like to speak of the distinction to be made
between patient and consumer of health services.
From the economic standpoint, the provision of health services includes a series
of transactions whereby a consumer, known as the patient, requests services from
a supplier who in turn will be paid for the services thus provided.
To illustrate the conceptual difference between a patient and a consumer of
health services, let us compare two possible scenarios: on the one hand, you
have a consumer of whatever and, on the other, two possible scenarios for the
consumer of health care services.
First example: You are dealing with any type of service. You call a taxi and ask
the driver to take you to the other end of town. You do not have enough money to
pay the fare. Should you still get taken to your destination?
Let us now go to the health care scenarios. You arrive at a hospital emergency
department with a ruptured appendix. You do not have enough money to pay for the
operation. Should you receive treatment nonetheless?
Second series of scenarios: You have won an all-expenses paid trip to a
destination of your choice, subject to only one condition. You must embark on
your trip within the next twelve months. Should you accept the prize?
Health care: You have won an open-heart operation in the hospital of your choice
subject to only one condition: the operation must take place within the next
twelve months. Should you accept?
We see, from this comparison, that health care is not a product like any other
product, but rather a merit good provided on the basis both of need and of
Market models are not designed to allocate resources on the basis of need but on
the basis of demand, that is to say on the basis of what I want and what I can
I may be able to say what I want, but society allows health professionals to
determine what it is that I need. Consumers buy what they want, what they ask
for and what they can afford. Patients receive what they need. This is all the
more true inasmuch as our society considers it a breach of ethics to supply
medical services we do not need.
The problem of finding the resources necessary to pay for something that we need
is fundamentally different from that of paying for things that we simply want or
that we insist upon.
Second point: The issue of the proper role of a private for-profit health care
provider as opposed to the role of the private non-profit health care provider.
As Ms Raisa B. Deber of the Department of Health Administration of the
University of Toronto stated in one of her articles, health care systems are
three dimensional: there is the financing aspect, the provision aspect and the
allotment aspect. Financing includes the ways in which money will be gotten from
the various consumers, including from potential consumers of health care
Provision includes the ways these health care services are organized and
delivered. Allotment includes the various ways in which financing and provision
come together, for example in the way suppliers will be paid for what they do.
There are several models of how we can arrange for the money to flow between the
patient and the health care provider. The difference between these various
models stems from the number of intermediaries involved.
We have included, in the appendix, three examples of the way money can flow to
and fro when you buy directly, as used to be the case previously under our
health insurance system. Table 2 outlines our health insurance system and lists,
what is even more complex, various regional or private entities, and so the
money in fact flows in four directions. That is what the tables show.
But the last model, the fourth one, opens the door to private for-profit health
care providers. The health care providers here take on the responsibility of
making sure that a preestablished range of services are deliver to a
preestablished patient population.
In Canada the health care system is mainly funded by the state, with services
being provided by the private sector. But this private sector is mostly
non-profit since more than 95 per cent of Canadian hospitals are administered by
non-profit corporations acting under a community-based board of directors,
volunteer agencies or municipalities.
The choice comes in at the allotment level. The allotment of tax moneys, either
towards private for-profit health care providers or towards salaries and
benefits for health care workers in private non-profit facilities.
It is easy to confuse the financial aspect and the health care provision aspect.
Under the Canadian system, though health care services are not supplied by the
state they are funded by the state.
Third point: This point concerns health services that are currently being
provided, as opposed to those which might be provided further on.
A Health Canada pamphlet entitled "The Canadian Health Care System"
clearly outlines the fundamental issue. The debate has gone beyond the health
care system to address the issue of health itself, recognizing that health
implies more than just health care. The new policy directions taken by the
provinces follow this paradigm shift. The focus is now on a more comprehensive
and integrated health concept and no longer simply on health care.
In other words, governments have responded to the need to adapt the health care
system to present day realities by encompassing a number of health factors,
recognizing that although health care contributes greatly to health, these must
be seen as only one element among a larger number of health factors.
According to the quote from the Health Canada pamphlet, the health care system
has been given a new direction and it now relies less on a clinical care model,
that is to say on the services of doctors working in a hospital setting, and
more on a community health care model focusing to a greater degree on promoting
health and preventing disease.
The question then is the following: Do we wish to extend what is presently
provided for under the Canada Health Act and the five principles outlines in it?
The present plan provides for all medically necessary services dispensed by
hospitals and doctors.
As a society, do we wish to extend this to care provided within the community or
at home? Or do we want home care to be synonymous with fee for service. The AQDR
recommends the first of these two options.
In closing, I would like to say that it is all well and good to speak in favor
of health promotion and disease prevention, as governments seem to be doing, but
the words must be backed by a financial commitment.
Public funds should not be going to one-shot pilot projects. The issues we
should be focusing on as far as seniors are concerned are: diabetes, obesity,
malnutrition and violence towards the elderly. The AQDR recommends that the
federal government extend the application of the Canada Health Act to these
three medical issues.
The Acting Chairman: Thank you, Mr. Smereka. Ms Gagnon or Ms Richer, do
you have any comments concerning this paper?
Ms Anne Gagnon, health advisor, Association québécoise de défense des
droits des personnes retraitées et préretraitées: Yes. There are a few
comments I would like to make.
The Acting Chairman: I would rather you did not read them. If you would
just proceed with your comments, then we will have enough time left for
Ms Gagnon: All right. For fun, I spoke of "spontaneous
generation". I mean by this that the day I turned 65, I did not wake up and
say: Am I rich and healthy or am I poor and sick? That is the health system's
cartoon version of what it means to become a senior.
As a great-grandmother, I know that health is not something you can divide up.
If you look at the factors of health and try to isolate birth, early childhood,
adolescence and so on, you know that you want health to go from the womb to the
tomb; it is as simple as that, otherwise there will not be any healthy seniors.
That is just a comment.
The Acting Chairman: Thank you very much. And you,Ms Richer, do you have
Ms Yollande Richer, vice-president, Association québécoise de défense des
droits des personnes retraitées et préretraitées: On the three points
made concerning privatization, we know that England will have to invest 32 per
cent more because privatization is not working at all.
The United States has the most expensive system in the world. As far as HMOs are
concerned, there are people who never get to go to the hospital, who are, as it
were, black listed.
So in Canada we are really wondering which model to follow. In any case, almost
50 per cent of health care has already been privatized.
The Acting Chairman: So you would be in favor of maintaining the present
system. But I would like to hear a bit more about the issues more particular to
I see that you have identified the problems more particular to elderly people:
diabetes, obesity, violence towards seniors. Are there any recommendations you
would like to make concerning the issue of violence towards elderly people?
Ms Gagnon: Yes. My recommendations, first of all, stem from one thing
that we have noticed. For ten years, now, we have had CLSCs. You know how these
work specifically on the problem of violence towards the elderly.
The research is there. The data is there. The legislation is also there. What we
are asking then is this: when are we going to see the connection between what we
know, which is violence towards the elderly, and the legislation? How are we
going to enforce those legislative provisions? How are we going to manage to
support seniors who cannot speak up concerning the verbal or psychological
violence they are subjected to? These are the questions that concern us.
The Acting Chairman: You are right, it is a most important issue.
Senator Maheu: I am in full agreement. Several years ago I took part in
some conferences on seniors settling in Arizona, in my own city at the time, and
I am still surprised that you often see elected officials who do not realize the
psychological, financial or medical impact of the abuse experienced by seniors.
I would like to address the issue of pharmaceutical abuse among the elderly.
When I was a member of the House, there were, in my county, 27 golden age clubs.
I therefore often heard about the problem. Often, you have doctors who feel they
are on the leading edge of medical practices and who would rather administer
drugs to seniors than have them stay in hospital and, often, the patients are
sent home prematurely.
Do you have a comment on that? In the AQDR's view is there a big problem in that
Ms Richer: Yes. It is said that pharmaceutical companies make larger
profits than banks. That is cause for concern. It is also said that each year
939 new drugs are marketed, of which only 61 are effective.
We know that seniors are easily influenced by advertising and we know of the
lobbying efforts of pharmaceutical companies. I think there is an enormous
problem there and this is one of the issues that the AQDR has been promoting
since the drug insurance plan was set up in Quebec.
The Canadian government is going to have to decide upon the various criteria the
pharmaceutical companies and cartels will have to abide by; in that area of
activity, nothing really surprises me. I also think that regulations will have
to be put into place to make sure seniors are not treated like a type of
commodity. And then there is the misleading advertisement. Seniors are really
Senator Maheu: Perhaps you yourself should lobby the Canadian government.
Ms Richer: We did lobby the government concerning patents when Bill C-91
was being considered. We went to Ottawa. We testified before the committees and
promoted a list of generic drugs. Very often, neither the doctor nor the
pharmacist will tell seniors that they have the right to obtain a generic drug,
or even tell them that such a drug exists. There is a lot to be done in that
Senator Maheu: Bearing in mind, however, that if generic drugs exist it
is because of the previous research, development and investments made by
Ms Richer: Yes. On that point, I should answer that as tax payers we paid
for at least part of that research. Pharmaceutical companies do a lot of their
research in universities. We are funding those research efforts. And I believe
that, there too, the system is being abused. People are always saying that all
this costs money, but the population is often not aware of the true costs.
Consider the case of our neighbors to the south. See the enormous amounts of
money they spend on advertising. It makes no sense: they spend billions of
dollars. And I think that in Canada there is a tendency to do the same.
Often, in Quebec, we are told that the blame lies with senior women since,
unfortunately, men die at an earlier age.
The Acting Chairman: I am sure that senator Pépin will come to the
defence of men.
Senator Pépin: Demographically, the senior category is the fastest
growing one. We will have to consider both needs and access. Then, after access
to medical services, to doctors, we will have to consider the issue of access to
The age category of 65 and over is getting larger all the time. You have to take
that into account. You spoke of drugs. Yesterday, Mr. Castonguay and Mr. Forget
spoke of drugs and of how these should be prescribed, what is the appropriate
way to prescribe them and the appropriate way to use them. They consider there
is a problem here that needs to be addressed.
You mentioned the equality, under the law and in fact, between senior men and
senior women. Does that mean that in access to health care unfair distinctions
are made in that regard? What does it mean? I am looking, on page 2 of your
brief, at the principal demands put forward by your association.
Ms Gagnon: Senator, allow me to answer. I am very pleased by your
question. Twenty years ago, the National Council of Welfare published a report
entitled "Women and poverty; twenty years later." This report shocked
and offended a number of reporters who said: it is just not possible to believe
that of all the women in Canada the most badly off would be those of Quebec;
surely that must be the case in Newfoundland, as always.
We said: we are sorry you are disturbed by our figures, but poverty is worst
among seniors, and even more among senior women in Quebec. About twenty years
ago, we brought out another publication and I regret I did not keep one. This
was entitled "Montreal, two realities in one."
We were saying that Montreal was cut in two by Papineau Street. East of
Papineau, believe it or not, people lived ten years less than they did west of
Papineau. So there were two realities in one. This study showed the gap. The
International Women's Year made people aware of the fact there was a very
serious problem there.
As far as retired people or people over 60 are concerned, you have to get
involved with prevention. I stress the word "prevention" since you
cannot be concerned about health if you are not concerned about prevention.
Another is that you cannot really address the issue of health if you do not
address the issue of poverty. What to you do to alleviate poverty in order to
make sure the children are healthy and that these children later turn into
healthy adults? I do not see how you can have one without the other.
Senator Pépin: I fully agree with you on the matter of prevention. In
fact we do broach the topic in our report. One of the witnesses was saying
prevention is all well and good but you also have to ensure treatment. Our aim,
in this study, is to determine what should be done to give everyone access to
What comes out of this is that the two most serious issues are an insufficient
access to doctors and the long wait before you get treatment. We also speak of
This could mean the type of team they have in the CLSCs, but including doctors,
nurses, laboratory technicians, ophthalmologists and optometrists.
Ms Gagnon: And dietitians as well.
Senator Pépin: If we found that you also have to work with people who
are a little bit better off, how would you see that? Are you completely opposed
to a greater financial contribution from seniors?
Ms Richer: We, the senior citizens, have paid our whole lives. Federally,
you had, in 1970, billions of dollars in a dedicated fund for seniors, for
workers, and this sum just dissolved into the general administration of the
country. The same thing happened in Quebec.
I believe it is the government that owes us money. We, the seniors, claim that
we have already paid. If the baby boomers want to obtain a supplementary
insurance for their retirement, let them. As far as we are concerned, the answer
The dangerous thing about this new formula is that the government wants to do
the same thing it did with drug insurance. We were told: this will not cost
much, just a small annual tax of a hundred odd dollars. It has doubled after
just two or three years.
So we will be told: Oh well, this year it will be just a hundred dollars. And
then the following year, they will say: oh, we have no more money. The system is
not working anymore. We will have to double premiums. Then there will be fee for
service and that means privatization. You have to tell it like it is.
We are going to have to think about the type of health system that we want as a
society. The American system is not working. People are beginning to talk about
unnecessary surgical procedures. Doctors are beginning to speak out and to say
that the system is not working. We have to find a way that works.
Ralph Nader came here to tell us that, Ted Kennedy came here to tell us that: do
not change your system, you are headed for a disaster.
Senator Pépin: Maybe there is another solution.
Ms Richer: Our governments have the money, the billions of dollars to
build those super hospitals they want to see set up in Montreal. The latest
technology is nice, but do you need to have MRIs in every hospital. Equipment is
nice, concrete as well, but what we want is health care for the population and
that simply does not seem to be a priority.
In their public pronouncements, governments never address the issue of care
except for a brief mention here and there. There has to be controls on spending.
It used to be health care; today there is also education, health and social
welfare. Governments just reach into the till for as much as they need, anyway
they want and then they shore up whatever aspect of the system seems to be in
direst need. We cannot go on like this. Its unbelievable! We of the AQDR say
that we cannot go on like this.
Senator Pépin: So you need teams of home care specialists.I do not know
if that is really the way they are called, but we are also speaking of
palliative care, in particular for people who are gravely ill.
Ms Richer: As you know, home care does not presently cost the government
anything. People are released from hospital too quickly and some will have to go
back in. You still have women working on a volunteer basis.
So I think that, as you were saying earlier on, we'll have to consider
interdisciplinary teams of care givers. I think the time has come and the
willingness to proceed is there. But there is a problem with doctors. They
themselves are saying: we do not want to go work in a CLSC, we do not want to
work in emergency departments and we do not want to go into home care either. So
you do have a problem there.
In Ontario, there are a number of pilot projects that are working well. We in
Quebec have only one and there is no follow-up to let us to know whether it is
working out or not. Many doctors simply do not want to get into this.
It is going to be very difficult. The knowledge is there, the documents have
been drafted, the action plan is there, but it is going to be difficult to put
all this into effect.
Senator Léger: Thank you for being here. I have not been in the Senate
very long, but from what I've heard up to now, the baby boomers are very
concerned; they do not know what to do. So please do not stop seeking and making
suggestions, because you are the ones who will come up with a solution. It must
be said that this is not the end of anything, but only the beginning. So please
Ms Gagnon: Senator Léger, you spoke of the baby boomers and God knows we
have tried to interest them in all this. What is happening is that the seniors
like us are running out of breath. When we get an invitation such as this one
here, I can assure you that we are up very early that morning to prepare our
testimony and to make sure we can appear before the Committee. Our budgets are
very limited, and our volunteers are tired. I am very glad that you mentioned
baby boomers. How can we reach them?
We try to include them since, today, they are retiring at an increasingly early
age, and they are not very worried yet because they almost all have retirement
funds and expect that their old age will be golden. They are going to have to
understand, however, that we need them and that they should get involved in
volunteer activities right away.
Senator Léger: Today, people have fewer children. What is going to
happen, then? We should conserve our energy in order to be able to go on. But
you are right, you must sometimes be a little out of breath. But, this is a
Senator Pépin: I would like to get back to what I call home care. Thirty
or forty years ago, the family doctor would make house calls. There was also a
nurse who would come by to give shots. Now we know that doctors no longer make
house calls, and I am thinking that the interdisciplinary health care team might
be a solution.
As far as home care is concerned, you are right to say that we are releasing
people from the hospital much too quickly. Sometimes we release people who are
still seriously ill and there should be someone there to take care of them.
Oftentimes, these are women who leave their job and volunteer.
There is an issue there that must be addressed. We absolutely have to do
something for people who are seriously ill. There will have to be home visits
and services for these patients.
Ms Gagnon: To answer your question, I would have to say that we currently
have palliative services for about 14 per cent of the population, which is
really an aberration. Let me yield the floor to Mr. Smereka.
Mr. Smereka: I do not really know how to say this, but the federal
government is going to have to make a decision because the current system is the
result of a historic process of integration of all the previous bits and pieces
As we say in our brief, for all practical purposes, you have, with regards to
health care, stuck to five principles based on the idea that people who are sick
will be treated by a doctor in a hospital setting.
Later, you extended this by saying: Well, the doctor could be in a clinic. But
the very way we view health has changed. Health factors have become concerns.
Poverty, the environment, rich neighborhoods versus poor neighborhoods, the
Papineau Street divide and so on.
And yet, as a government, you decided, in 1977, to no longer share health care
costs with the provinces but, instead, to transfer tax points, saying: "We
will give you money and tax points and, provinces, it is up to you to decide on
what you want." And you included all that in the Canadian transfer system.
You put all the welfare programs and the Canada system plan together. But you
are still saying to the provinces: "Do as you as you please within those
And so, in 1977, a financial decision was made. Since then, you stand accused of
no longer paying your half of the 50-50 sharing agreement. What people forget is
that in 1977, you turned that50 per cent into 25 per cent in cash and 25 per
cent in tax points.
It is nonetheless true that as you were working towards a financial solution to
the health care issue, you did not adapt the Canada Health Act to the way health
factors were evolving. And that is why we ask whether the Canada Health Act
should not be reviewed in order to consider how it might be extended in its
application. But what should we be extending? Well, extending the insurance
coverage by enforcing the five basic principles, including access.
Were you to decide that doctors should also serve outside a hospital setting,
the Act contains provisions that allow you to extend coverage to home care. But
you haven't passed the necessary regulations. Sure, the Act was passed, but this
should have been followed-up by regulations. Regulations are required for
complementary care. As for extending the scope of the Act, that is up to you.
Senator Pépin: We have to accommodate provincial governments. Provinces
have the lead in this matter. We cannot just tell them where they should be
spending the available funds. We cannot do that anymore.
Mr. Smereka: I am simply saying that the means are already there in the
existing legislation. It is true that, historically, you did not take the
necessary measures. You did not go on to phase two which was to pass the
regulations that normally accompany an act.
Senator Maheu: We will have to check on that.
Senator Pépin: Yes.
The Acting Chairman: Are there any other questions?
Senator Maheu: I could say much more concerning the current situation of
seniors, but I do not really have any question.
The Acting Chairman: Well then, all that remains for me is to thank Ms
Gagnon, Ms Richer and Mr. Smereka. On behalf of the Committee, thank you. Your
comments will certainly receive serious consideration and should we have further
questions, we will be sure to contact you.
The committee adjourned.