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Instead of using scarce health-care dollars broadly, we should identify and support those Canadians falling through the cracks
By Bacchus Barua
Centre for Health Policy Studies
The Fraser Institute
However, recent calls for a national pharmacare program would have many believe that Canadians without private drug insurance - about one-third of the population - are out of luck.
Fortunately, this is far from the truth. There actually exists a vast network of provincial plans to help Canadians - particularly those who may be at higher risk of forgoing prescriptions due to financial considerations - pay for their prescription medications.
Perhaps most crucially, recipients of social assistance have drug coverage at very low or no cost in every province. And provincial governments across Canada also cover the severely disabled and those diagnosed with conditions such as multiple sclerosis and cystic fibrosis.
But most provinces go even further and ensure that most seniors and lower-income individuals and families with high drug costs don't face undue financial pressure.
For example, British Columbia helps cover the cost of prescription drugs for residents through a number of drug plans. The province's largest plan, Fair PharmaCare, covers 70 per cent of the cost of eligible prescription drugs for families with a net income less than $15,000. Once a family spends approximately two per cent of its net income on drugs or related costs, the province pays for 100 per cent of any subsequent costs for the rest of the year. The plan also covers families with higher incomes but requires them to first pay for their drug costs (up to two or three per cent of their income) before provincial coverage kicks in.
In addition, B.C. maintains specific plans for individuals with HIV, certain psychiatric conditions and palliative care patients, among others.
Ontario operates three principal drug programs: the Ontario Drug Benefit Plan (for seniors), the Trillium Drug Program (an income-based plan for all Ontarians) and OHIP+ (for children and youth). The plan for seniors covers residents over 65, plus those living in long-term care or special care homes, Ontarians on social assistance and those with disabilities. Those eligible for the plan pay very low amounts up front (ranging from zero to $100) before coverage begins, after which only small co-payments (ranging from $2 to $6.11) are required.
Like B.C., Ontario also covers the cost of some medications for people with specific medical conditions such as cystic fibrosis, HIV infection, anemia, age-related macular degeneration and inherited metabolic disease.
Quebec takes a unique approach by mandating all residents not covered by private group insurance to enrol in the government's drug insurance plan (RAMQ). Participating individuals pay premiums that range from zero to $616 per year, depending on family income. Individuals must pay the first $19.90 of drug costs out of pocket, then they only pay 34.9 per cent of the cost of eligible drugs up to a monthly maximum of $90.58 (after which all costs are covered).
However, the premiums along with the deductibles and co-pays are waived for a host of groups, including Quebecers on social assistance, children under 18, full-time students and persons with a functional impairment. In fact, 1.4 million Quebecers pay no annual premium (39 per cent of beneficiaries) - 900,000 of which are not required to make any direct contribution for their medication.
More generally across the provinces, lower-income Canadians have access to some form of provincial insurance that helps limit out-of-pocket costs to a small percentage of income for prescription drugs, if not more extensive coverage.
That being said, there's evidence that some Canadians may struggle to cover the costs of their prescription medications. One study recently estimated that one of every 12 Canadians (8.2 per cent) who required a prescription in 2016 had difficulty paying for it. If true, policy-makers should first identify these Canadians and help with the costs of their medications.
Somewhat bizarrely, however, the current prescription seems to be a national single-payer pharmacare program that would use scarce health-care dollars to subsidize everyone, including the majority of Canadians who likely don't need it.
Instead, we should help Canadians understand the coverage already available, and identify and support those Canadians falling through the cracks.
Provincial governments should remain able to tailor drug plans to address the needs and preferences of their populations.
A decentralized system also better fosters different experiences in each province, which makes it possible to better assess what works and what doesn't.
This dynamic may be lost with a national pharmacare program.Bacchus Barua is associate director of the Centre for Health Policy Studies at the Fraser Institute.
The status quo is no longer good enough to deliver equitable access to high quality care in a cost-efficient manner
By Karen Palmer
and Noah Ivers
If there's one thing provincial governments across Canada can agree on, it's that the status quo in health care is no longer good enough to deliver equitable access to high quality care in a cost-efficient manner.
Ontario's Ministry of Health under the previous government led the way by altering how hospitals are paid, in an effort to encourage implementation of best practices in patient care.
Yes and no.
And are there lessons learned for other provinces?
Some hospitals managed the change better than others. The 'secret sauce' has been open communication and strong collaboration between experts who best understand patient care - like doctors, nurses and patients, along with those who understand how hospitals work - like finance experts, hospital decision support teams and policy analysts.
In 2012, Ontario hospitals started replacing some of their global budgets - the annual amount hospitals traditionally receive to fund all patient care - with something called quality-based procedures or QBPs. These "patient-based payments" give hospitals a predetermined fee for each diagnosis (like pneumonia) or each procedure (like knee replacement) when patients are admitted.
The good thing about paying hospitals through global budgets is that they are predictable, stable and administratively very simple. The bad thing about global budgets, critics argue, is that they lack incentives to boost efficiency, are not always transparent or equitable, and funding isn't necessarily targeted at areas with the most impact on patients if government and hospital spending priorities don't align.
As part of this funding shift, hospitals were also given clinical handbooks - outlining evidence-based care pathways for each QBP diagnosis and procedure - to give doctors, nurses and other care providers better guidance on how to provide "the right care, in the right place, at the right time" and at the right cost.
How did this all pan out?
We recently published a study showing that, as with most complex system change, some hospitals managed better than others at rolling out QBPs. As one senior hospital executive put it, "I think the hospitals are pushing back and saying: slow down, because this is tougher to manage than we thought and it's got all kinds of complication in the implementation."
Hospitals struggled to adapt if they were less ready for change, especially when it was more complex in nature or they didn't have the management capacity to support it.
Conversely, hospitals that were able to adapt showed a high degree of readiness for change and had good capacity to manage it, especially when new requirements were less complex.
Change never goes as planned and large-scale change in complex health care systems is no exception.
Old patterns can be difficult to break. The first time you try, failure may seem inevitable. But as every entrepreneur knows, it should be viewed as an opportunity to learn and try again. Similarly, the ability to take stock along the way - through embedded evaluations - allows health system leaders to honestly look at what is working and what isn't.
Whether as individuals or in complex systems, knowing when to admit that it's time to change course is critical to any improvement.
We suggest that a structured process be put in place to help identify and choose the right tools for the job, so that adoption of new initiatives is enabled and desired outcomes are achieved. To that end, we propose that those seeking change - regardless of the setting - ask three questions:
Big change takes big courage, a shared vision and clear communication. Ontario's efforts to explore how to implement change are valuable and instructive, and Ontario's Ministry of Health, hospitals, provincial health care agencies and care providers should be lauded for their efforts.
Scaling up Ontario's successes to other provinces, and continuing to experiment, would help ensure that high quality affordable health care is available to all Canadians.Karen S. Palmer is a health-care systems and policy research at Women's College Research Institute in Toronto, an adjunct professor at Simon Fraser University and a contributor to EvidenceNetwork.ca, which is based at the University of Winnipeg. Noah Ivers is a family physician at Women's College Hospital, scientist at Women's College Research Institute, and assistant professor at the University of Toronto.
Astronauts and seniors with frailty have much in common and innovative research may help solve problems for both
By John Muscedere
It turns out that understanding the effects of space travel on the body may be important to understanding what happens to us on Earth as we get older. And the reverse is also true: studying frailty in aging seniors has much to offer space travel.
A novel partnership between the Canadian Space Agency, the Canadian Institutes of Health Research and the Canadian Frailty Network is examining the health impact of inactivity both on older adults and astronauts. It's a world first.
On space missions, astronauts, like Canada's Chris Hadfield, may spend months in a zero-gravity, weightless environment. One cosmonaut, Russia's Valery Polyakov, spent 438 days in space, but even brief journeys into space may have significant health consequences. Surprisingly, research on these effects is often conducted using prolonged bed rest in humans on Earth.
Floating in space looks innocuous, even peaceful. But the health impacts of weightlessness are similar to those found in people who are inactive here on the ground, which results in rapid muscle and bone weakening. Other consequences of weightlessness mimic what we see in older adults living with frailty: hardening of the arteries, retention of fluid, loss of bone density or osteoporosis, among others.
In Canada, the most rapidly increasing segment of the population is individuals over 80 years old - of whom over half are frail. As a result, a large and growing proportion of our health and social care spending goes toward older Canadians living with frailty.
Frailty can occur at any age, though it most often occurs in seniors, and describes those with precarious health who are at heightened risk of dying. For those with frailty, illnesses - like minor infections or injuries - may result in rapid deterioration in health.
The goal of the research partnership is to help identify ways to better detect frailty to improve outcomes or reduce the severity of frailty in older adults.
The new partnership builds on previous inactivity studies and will also help highlight the hazards of inactivity and bedrest. Bedrest or inactivity continues to be common in acutely ill patients and those in long-term care, whether by prescription, by health-care professionals, by institutional design or lack of understanding regarding the need for activity by the human body.
There are some notable differences in the space-frailty comparison, however. Although the effects of bedrest are reversible in younger volunteers and astronauts with intensive therapy, they may not be in older individuals, where short periods of bedrest may convert someone who is independent to functionally dependent.
Other research has included looking at how low-gravity environments affect the onset of osteoarthritis, a common condition among Canadian seniors. Osteoarthritis also happens to be a common condition for astronauts once they return to Earth. There has also been research studying cardiovascular health and an aging population by looking at the lifestyle of astronauts. Research has shown that increased carotid artery stiffness occurs in astronauts in a span of months, which is equivalent to changes seen in 20 years of aging.
Importantly, results yielded by this partnership will be shared internationally with other researchers and space organizations to enable the collaborative efforts necessary to solve the complex problems posed by aging and space flight.
Although we don't usually associate aging and space travel, the space exposure of astronauts is informative and offers accelerated models for studying the effects of aging on the ground. With nearly six decades of human spaceflight history, space agencies have a wealth of data to inform life sciences research on frailty.
Pooling knowledge and resources may help us develop innovative approaches to the problems posed by both aging and prolonged space flights.Dr. John Muscedere is the scientific director and CEO of the Canadian Frailty Network. He is professor of Critical Care Medicine at Queen's University and an intensivist at Kingston General Hospital, and a contributor with EvidenceNetwork.ca, which is based at the University of Winnipeg.