The Canadian Health Care System Flashcards
How many systems are there in Canada?
one federal, three territorial, and ten provincial systems
What is the financing distribution of the system
Public 70%
Private 30%
What are major complexities in establishment of Canadian health policy?
include geographical diversity, socioeconomic divisions, and international pressures
What do provincial plans cover (mandatory and optional)?
each provincial plan must cover all medically necessary health services delivered in hospitals and by physicians
may choose to cover services such as home care and prescription drugs
How are non-insured health services and fees covered
private insurance or by the individual
What covers treatment for work-related injuries and diseases
Workers’ compensation funds
Responsibility of federal government in health care
Health care services for Aboriginal people, federal government employees (RCMP and armed forces), immigrants and civil aviation personnel
Marine hospitals and quarantine (Constitution Act 1867)
Invesstigations into public health
Regulation fo food and drugs
Inspection of medical devices
Administration of health care insurance
General information services related to health conditions and practices
Role in health derived from government’s constitutional powers over criminal law (basis for legislation such as Food and Drugs Act and Controlled Substances Act), spending and ‘pace, order and good government’
Responsibilities of provincial government in health care
establishment, maintenance and management of hospitals, asylums, charities and charitable institutions (Constitution Act 1867)
Licensing of physicians, nurses and other health professionals
Determining the standards for licensing all hospitals
Administering provincial medical insurance plans
Financing health care facilities
Delivery of certain public health services
What are the principles of the Canada Health Act
- Public Administration: provincial health insurance programs must be administered by public authorities
- Comprehensiveness: provincial health insurance programs must cover all necessary diagnostic, physician, and hospital services
- Universality: all eligible residents must be entitled to health care services
- Portability: emergency health services must be available to Canadians who are outside their home province, paid for by the home province
- Accessibility: user fees, charges, or other obstructions to insured health care services are not permitted
What is the legal foundation of the Canadian health system based on
• two constitutional documents:
1 Constitution Act (1867): deals primarily with the jurisdictional power between federal and provincial governments
- The Canadian Charter of Rights and Freedoms (1982): does not guarantee a right to health care but, given government’s decision to finance health care, they are constitutionally obliged to do so consistently with the rights and freedoms outlined in the Charter (including the right to equality, physicians’ mobility rights, etc.)
• two statutes: 1. Canada Health Act (1984) outlines the national terms and conditions that provincial health systems must meet in order to receive federal transfer payments
- Canada Health and Social Transfer Act (1996): federal government gives provinces a single grant for health care, social programs, and post-secondary education; division of resources at provinces’ discretion
When can the federal government reduce its contributions to provinces
Those that violate the key principles of the Canada Health Act
History of the Canadian Health Care System
1867 British North America Act (now Constitution Act) establishes Canada as a confederacy
• “establishment, maintenance, and management of hospitals” under provincial jurisdiction
1965 Royal Commission on Health Services (Hall Commission) recommends federal leadership and financial support with provincial government operation
1984 Canada Health Act passed by federal government
• replaces Medical Care Act (1966) and Hospital Insurance and Diagnostic Services Act (1957)
• provides federal funds to provinces with universal hospital insurance
• maintains federal government contribution at 50% on average, with poorer provinces receiving more funds
• medical insurance must be “comprehensive, portable, universal, and publicly administered”
• bans extra-billing by new fifth criterion: accessibility
1996 Canada Health and Social Transfer Act passed by federal government
• federal government gives provinces a single grant for health care, social programs, and post-secondary education; division of resources at provinces’ discretion
2001 Kirby and Romanow Commissions appointed Kirby Commission (final report, October 2002) • examines history of health care system in Canada, pressures and constraints of current health care system, role of federal government, and health care systems in foreign jurisdictions Romanow Commission (final report, November 2002) • dialogue with Canadians on the future of Canada’s public health care system
2004 First Ministers’ Meeting on the Future of Health Care produces a 10 year plan
• priorities include reductions in waiting times, development of a national pharmacare plan, and primary care reform
2005 Chaoulli v Québec, Supreme Court of Canada decision
• rules that Québec’s banning of private insurance is unconstitutional under the Québec Charter of Rights, given that patients do not have access to those services under the public system in a timely way
2011 First progress report by the Health Council reviews progress (2004 First Ministers’ 10 year plan) • significant reductions in wait times for specific areas (such as cancer, joint replacement and sight restoration), but may have inadvertently caused increases in wait times of other services • despite large investments into EMRs, Canada continues to have very low uptake, ranking last in the Commonwealth Fund International Health Policy survey, with only 37% use among primary care physicians • little progress in creating a national strategy for equitable access to pharmaceuticals; however, there has been some success in increasing pharmacists’ scope of practice, reducing generic drug costs, and implementing drug information systems • increases in funding to provinces at 6% per annum until the 2016 2017 fiscal year; from then onwards, increases tied to nominal GDP at a minimum of 3% per annum
2012 Second progress report by the Health Council reviews progress towards 2004 First Ministers’ 10 year plan
• funding is sufficient; however, more innovation is needed including incentivizing through models of remuneration
• 46 recommendations made to address the lack of progress
2014 Expiry of current 10 Year Health Care Funding Agreement between federal and provincial governments
2015 Negotiations underway for a new Health Accord with a $3 billion investment over four years to homecare and mental health services by the elected Liberal government
2017 New 10 year Canada Health Accord reached with a $11.5 billion federal investment over 10 years to homecare and mental health services and a 3% annual rise in the Canada Health Transfer (down from 6% in the previous agreement) by the elected Liberal government
What is the protected total health care expenditure
in 2016 is expected to reach $228 billion, 11% of the GDP, approximately $6,299 CDN per person
What are the sources of health care funding
• 70% of total health expenditure in 2016 came from public-sector funding with 65% coming from the provincial and territorial governments and another 5% from other parts of the public sector: federal direct government, municipal, and social security funds. 30% is from private sources including out of pocket (15%), private insurance (12%) and other (3%)
What do public sector funds cover
- public sector covers services offered on either a fee for service, capitation, or alternate payment plan in physicians’ offices and in hospitals
- public sector does not cover services provided by privately practicing health professionals (e.g. dentists, chiropractors, optometrists, massage therapists, osteopaths, physiotherapists, podiatrists, psychologists, private duty nurses, and naturopaths), prescription drugs, OTC drugs, personal health supplies, and use of residential care facilities
What is the health care delivery system in Canada
- hospital services in Canada are publicly funded but delivered through private, not-for-profit institutions owned and operated by communities, religious organizations, and regional health authorities
- other countries, such as the United States (a mix of public and private funding, as well as private for-profit and private not-for-profit delivery) and the United Kingdom (primarily public funding and delivery) have different systems of deliver
What is the MCC
Certifies physicians with the LMCC LMCC acquired by passing the MCC Qualifying Examination Parts I and II
What is the RCPSC
Certifies specialists who complete an accredited residency program and pass the appropriate exam Voluntary membership of the RCPSC is designated FRCPC or FRCSC
What is the CFPC
Certifies family physicians who complete an accredited residency program and pass the Certification Examination in Family Medicine
What is a licensing body
13 provincial medical regulatory (licensing) authorities
All postgraduate residents and all practicing physicians must hold an educational or practice license from the licensing body in the province in which they study or practice
What is the CPSO
Membership to the provincial licensing authority is mandatory
Licensing authority functions include:
Provide non-transferable licensure to physicians
Maintaining ethical, legal, and competency standards and developing policies to guide doctors
Investigating complaints against doctors
Disciplining doctors guilty of professional misconduct or incompetence
At times of license investiture and renewal, physicans must disclose if they have a condition (such as HIV positivity, drug addiction, or other illnesses that may impact their ability to practice safely)
What is the minimum requirement for licensure by most provincial licensing authorities
certification by the LMCC plus either the RCPSC or CFPC is a minimum requirement for licensure by most provincial licensing authorities
Who is responsible for monitoring ongoing CME and professional development
RCPSC and CFPC
What is the premise of self-regulation
self-regulation is based on the premise that the licensing authority must act first and foremost in the interest of the public
Who governs physician certification
physician certification is governed nationally, while the medical profession in Canada self-regulates under the authority of provincial legislation
Role of CMA
Provides leadership to doctors and advocates for access to high quality care in Canada
Represents physician and population concerns at the national level
Membership is voluntary
Role of OMA and Other PTMAs
Negotiates fee and benefit schedules with provincial governments
Represents the economic and professional interests of doctors
Membership is voluntary
Role of CMPA
Physician-run organization that protects the integrity of member physicians
Provides legal defence against allegations of malpractice or negligence
Provides risk management and educational programs
Membership is voluntary
Role of RDoC and PHO
Upholds economic and professional interests of residents across Canada
Facilitates discussion amongst PHOs regarding policy and advocacy items
Role of CMFS and FMEQ
Medcal students are represented at their universities by student bodies, which collectively form the CFMS or FMÉQ
FMÉQ membership includes that of francophone medical schools
What is a fiduciary duty
- the doctor-patient relationship is formed on trust, which is recognized in the concept of fiduciary duty/ responsibility of physician towards patient
- a fiduciary duty is a legal duty to act solely in another party’s interest; one may not profit from the relationship with principals unless he/she has the principal’s express consent
What are ethics addresses
• ethics addresses:
- principles and values that help define what is morally right and wrong
- rights, duties and obligations of individuals and groups
What is the definition of autonomy
Recognizes an individual’s right and ability to decide for himself/herself according to his/her beliefs and values Not applicable in situations where informed consent and choice are not possible or may not be appropriate
What is the definition of beneficence
Patient-based ‘best interests’ standard that combines doing good, avoiding harm, taking into account the patient’s values, beliefs, and preferences, so far as these are known Autonomy should be integrated with the physician’s conception of a patient’s medically-defined best interests Aim is to minimize harmful outcomes and maximize beneficial ones Paramount in situations where consent/choice is not possible or may not be appropriate
What is the definition of non-maleficence
Obligation to avoid causing harm; primum non nocere (“First, do no harm”) Limit condition of the Beneficence principle
What is the definition of justice
Fair distribution of benefits and harms within a community, regardless of geography or privilege Concept of fairness: Is the patient receiving what he/she deserves – his/her fair share? Is he/she treated the same as equally situated patients? How does one set of treatment decisions impact others? Basic human rights, such as freedom from persecution and the right to have one’s interests considered and respected
What is the difference between autonomy and competence
Autonomy: the right that patients have to make decisions according to their beliefs and preferences
Competence: the ability or capacity to make a specific decision for oneself
What is the CMA Code of ethics
• the Code of Ethics is:
■ prepared by physicians for physicians and applies to physicians, residents, and medical students
■ based on the fundamental ethical principles of medicine
■ sources include the Hippocratic Oath, developments in human rights, recent bioethical discussion
■ CMA policy statements address specific ethical issues not mentioned by the code (e.g. abortion, transplantation, and euthanasia)
The CMA Code of Ethics is a quasi-legal standard for physicians; if the law sets a minimal moral standard for doctors, the Code augments these standards
Based on autonomy the patients have the right to what
■ control of their own information
■ the expectation that information concerning them will receive proper protection from unauthorized access by others
Process for disclosing HIV status of a patient to someone else
• physicians should seek advice from their local health authority or the CMPA before disclosing HIV status of a patient to someone else
■ many jurisdictions make mandatory not only the reporting of serious communicable diseases (e.g. HIV), but also the reporting of those who harbour the agent of the communicable disease
■ physicians failing to abide by such regulations could be subject to professional or civil actions
What is physician patient privilege and can it happen
• unlike the solicitor-client privilege, there is no ‘physician-patient privilege’ by which a physician, even a psychiatrist, can promise the patient absolute confidentiality
Who imposes confidentiality laws
• legal duty to maintain patient confidentiality is imposed by provincial health information legislation and precedent-setting cases in the common law
What is the CMA Code of Ethics stance on disclosing health information to a third party
“Disclose your patients’ personal health information to third parties only with their consent, or as provided for by law, such as when the maintenance of confidentiality would result in a significant risk of substantial harm to others or, in the case of incompetent patients, to the patients themselves. In such cases take all reasonable steps to inform the patients that the usual requirements for confidentiality will be breached”
- Protect the health information of your patients
- Provide information reasonable in the circumstances to patients about the reasons for the collection, use, and disclosure of their health information
- Be aware of your patients’ rights with respect to the collection, use, disclosure, and access to their health information; ensure that such information is recorded accurately
Reasons to breach confidentialty
- suspected child abuse or neglect – report to local child welfare authorities (e.g. Children’s Aid Society)
- fitness to drive a vehicle or fly an airplane – report to provincial Ministry of Transportation (see Geriatric Medicine, GM11)
- communicable diseases – report to local public health authority (see Population Health and Epidemiology, PH24)
- improper conduct of other physicians or health professionals – report to College or regulatory body of the health professional (sexual impropriety by physicians is required reporting in some provinces)
- vital statistics must be reported; reporting varies by province (e.g. in Ontario, births are required to be reported within 30 days to Office of Registrar General or local municipality; death certificates must be completed by a MD then forwarded to municipal authorities)
- reporting to coroners (see Physician Responsibilities Regarding Death, ELOM14)
- Duty to Protect/Warn
• physicians who fail to report in these situations are subject to prosecution and penalty, and may be liable if a third party has been harmed
What is duty to protect/warn and when does it apply
- the physician has a duty to protect the public from a known dangerous patient; this may involve taking appropriate clinical action (e.g. involuntary detainment of violent patients for clinical assessment), informing the police, or warning the potential victim(s) if a patient expresses an intent to harm first established by a Supreme Court of California decision in 1976 (Tarasoff v. Regents of the University of California); supported by Canadian courts
- obliged by the CMA Code of Ethics and recognized by some provincial/territorial regulatory authorities
- concerns of breaching confidentiality should not prevent the MD from exercising the duty to protect; however, the disclosed information should not exceed that required to protect others
- applies in a situation where:
- there is a clear risk to identifiable person(s);
- there is a risk of serious bodily harm or death; and
- the danger is imminent (i.e. more likely to occur than not)
- there should be a duty to inform when a patient reveals that he/she intends to do serious harm to another person(s) and it is more likely than not that the threat will be carried out.
- where a threat is directed at a person or group and there is a specific plan that is concrete and capable of commission and the method for carrying it out is available to the threatener the physician should immediately notify the police and, in appropriate circumstances, the potential victim The report should include the threat, the situation, the physician’s opinion, and the information upon which it is based.
In what situations can disclosure of health records for legal proceedings occur
disclosure of health records can be compelled by a court order, warrant, or sub poena
Privacy of health information is protected by what
privacy of health information is protected by professional codes of ethics, provincial and federal legislation, the Canadian Charter of Rights and Freedoms, and the physician’s fiduciary duty
What is PIPEDA
the feder l government created the PIPEDA in 2000 which established principles for the collection, use, and disclosure of information that is part of commercial activity (e.g. physician practices, pharmacies, private labs)
• PIPEDA has been superseded by provincial legislation in many provinces, such as the Ontario Personal Health Information Protection Act, which applies more specifically to health information
Duties of physicians with regard to the privacy of health information
• inform patients of information-handling practices through various means (e.g. posting notices, brochures and pamphlets, and/or through discussions with patients)
• obtain the patient’s expressed consent to disclose information to third parties
■ under Ontario privacy legislation, the patient’s expressed consent need not be obtained to share information between health care team members involved in the “circle of care.” However, the patient may withdraw consent for this sharing of information and may put parts of the chart in a “lock box”
- provide the patient with access to their entire medical record; exceptions include instances where there is potential for serious harm to the patient or a third party
- provide secure storage of information and implement measures to limit access to patient records
- ensure proper destruction of information that is no longer necessary
- regarding taking pictures or videos of patients, findings, or procedures, in addition to patient consent and privacy laws, trespassing laws apply in some provinces
- CPSO published policy is designed to help Ontario physicians understand legal and professional obligations set out under the Regulated Health Professions Act, 1991, the Medicine Act, 1991, and the Personal Health Information Protection Act, 2004. This includes regulations regarding express or implied consent, incapacity, lock boxes, disclosure under exceptional circumstances, mandatory reporting, ministry audits, subpoenas, court orders and police, as well as electronic records and voice messaging communications: http://www.cpso.on.ca/Policies-Publications/Policy/Confidentiality-of-PersonalHealth-Information
- it is the physician’s responsibility to ensure appropriate security provisions with respect to electronic records and communications
What are “lock boxes”
The term “lock boxes” applies to situations where the patient has expressly restricted his or her physician from disclosing specific aspects of their health information to others, even those involved in the patient’s circle of care. Note that PHIPA provisions denote that patients may not prevent physicians from disclosing personal health information permitted/required by the law.
What is consent
autonomous authorization of a medical intervention by a patient
Who makes a decision if a patient can’t
where a patient cannot make an autonomous decision (i.e. incapable), it is the duty of the SDM (or the physician in an emergency) to act on the patient’s known prior wishes or, failing that, to act in the patient’s best interests
there is a duty to discover, if possible, what the patient would have wanted when capable
central to determining best interests is understanding the patient’s values, beliefs, and cultural or religious background
- more recently expressed wishes take priority over remote ones
- patient wishes may be verbal o written
- patients found incapable to make a specific decision should still be involved in that decision as much as possible
What ethical principle has the most weight when making consent decisions
usually the principle of respect for patient autonomy overrides the principle of beneficence
How do you determine incapacity
agreement or disagreement with medical advice does not determine findings of capacity/incapacity
• however, patients opting for care that puts them at risk of serious harm that most people would want to avoid should have their capacity carefully assessed
What are the four basic requirements of valid consent
- Voluntary
■ consent must be given free of coercion or pressure (eg. from parents or other family members who might exert ‘undue influence’)
■ the physician must not deliberately mislead the patient about the proposed treatment
2 Capable
■ the patient must be able to understand and appreciate the nature and effect of the proposed treatment
- Specific
■ the consent provided is specific to the procedure being proposed and to the provider who will carry out the procedure (e.g. the patient must be informed if students will be involved in providing the treatment) - Informed
■ sufficient information and time must be provided to allow the patient to make choices in accordance with his/her wishes, including:
◆ the nature of the treatment or investigation proposed and its expected effects
◆ all significant risks and special or unusual risks
◆ alternative treatments or investigations and their anticipated effects and significant risks
◆ the consequences of declining treatment
◆ risks that are common sense need not be disclosed (i.e. bruising after venipuncture)
◆ answers to any questions the patient may have
■ the reasonable person test – the physician must provide all information that would be needed “by a reasonable person in the patient’s position” to be able to make a decision
■ disclose common adverse events (>1/200 chance of occurrence) and serious risks (e.g. death), even if remote
■ it is the physician’s responsibility to make reasonable attempts to ensure that the patient understands the information
■ physicians should not withhold information about a legitimate therapeutic option based on personal conscience (e.g. not discussing the option of emergency contraception)
Criteria for administration of treatment for an incapable patient in emergency situations
- Patient is experiencing extreme suffering
* Patient is at risk of sustaining serious bodily harm if treatment is not administered promptly
Ontario Consent flowchart
ELOM 8
What risks do you need to disclose
The Supreme Court of Canada expects physicians to disclose the risks that a “reasonable” person would want to know. In practice, this means disclosing minor risks that are common as well as serious risks that happen infrequently, especially those risks that are particularly relevant to a particular patient (e.g. hearing loss for a musician)
Forms of legal consent
• consent of the patient must be obtained before any medical intervention is provided; consent can be verbal or written, although written is usually preferred
■ a signed consent form is only evidence of consent – it does not replace the process for obtaining valid consent
■ most important component is what the patient understands and appreciates, not what the signed consent form states
■ implied (e.g. a patient holding out their arm for an immunization) or expressed
- consent is an ongoing process and can be withdrawn or changed after it is given, unless stopping a procedure would put the patient at risk of serious harm
- HCCA of Ontario (1996) covers consent to treatment, admission to a facility, and personal assistance services (e.g. home care)
Exceptions to consent
- Emergencies
■ treatment can be provided without consent where a patient is experiencing severe suffering, or where a delay in treatment would lead to serious harm or death and consent cannot be obtained from the patient or their SDM
■ emergency treatment should not violate a prior expressed wish of the patient (e.g. a signed Jehovah’s Witness card)
■ if patient is incapable, MD must document reasons for incapacity and why situation is emergent
■ patients have a right to challenge a finding of incapacity as it removes their decision-making ability
■ if a SDM is not available, MD can treat without consent until the SDM is available or the situation is no longer emergent - Legislation
■ Mental Health legislation allows for:
◆ the detention of patients without their consent
◆ psychiatric outpatients may be required to adhere to a care plan in accordance with Community Treatment Orders (see Psychiatry, PS51)
◆ Public Health legislation allows medical officers of health to detain, examine, and treat patients without their consent (e.g. a patient with TB refusing to take medication) to prevent transmission of communicable diseases - Special Situations
■ public health emergencies (e.g. an epidemic or communicable disease treatment)
■ warrant for information by police
