Week 7 - Provincial and Territorial Governments

Question 1

does canada have a national insurance plan?

Answer 1

• no
• canada has universal healthcare implemented by 13 single-payer insurance plans
• each is administered and operated by a province or territory
  –> a national plan would mean there would be one plan across the country administered by one organization
  –> universal healthcare means that all eligible citizens of a country have insured health coverage that can be achieve through health care plans in each province/territory

Question 2

what is the structure of provincial healthcare?

Answer 2

• each province/territory has their own ministry of health that is assigned to managing health care
• each ministry of health is headed by an elected member of parliament (currently Sylvia Jones)
• the ministry of health oversees a variety of subdivisions/branches/ agencies that assume responsibilities for various types of healthcare

Question 3

role of provincial ministry of health

Answer 3

• provide leadership and support to service delivery partners
• implement and regulate health insurance
• negotiate salaries and other policies with physicians’ professional associations

Question 4

4 categories of health care

Answer 4

1) primary
- services that the public has direct access to
- family physician, walk in clinic, hospital, physiotherapy, chiropractor, psychologist
2) secondary
- patient is seing a specialist for a consultation
- usually requires a referral from primary care doctor
3) tertiary
- highly specialized care (i.e cancer centre or cardiology centre)
- referred by a specialist in secondary care
- could be short or long term
4) quaternary
- an extension of tertiary care and even more specialized
- typically are hospitals associated with research provide this level of care

Question 5

what is an RHA?

Answer 5

• a regional health authority
• are autonomous health care organizations responsible for health care administration in a defined geographic region within a province/ territory
• through appointed or elected boards of governance, RHAs manage the funding and/or delivery of community and institutional health care services within their regions
• RHAs are sometimes referred to as Local Health Authorities.

Question 6

what is regionalization? and why did it occur?

Answer 6

• in the early 1990s, governments in Canada initiated public forums and reviews to enhance healthcare delivery
• the consensus was to decentralize decision-making, leading to regionalization
• regionalization = providing and delivering healthcare that is best suited to a population group within a given geographic area
• this approach aimed to engage communities in healthcare decisions, customize services to local needs, and improve public participation

Question 7

four goals of implementing regionalization

Answer 7

1) combine healthcare services over a broad continuum of care
2) emphasize health promotion and disease prevention to improve overall health
3) involve and engage the public
4) implement appropriate and effective governance

Question 8

explain Ontarios transition to implementing Ontario Health

Answer 8

• Ontario’s Ministry of Health and Ministry of Long-Term Care jointly oversee publicly funded healthcare in the province.
• until 2019, Local Health Integration Networks (LHINs) managed healthcare services in designated regions, focusing on population health and health promotion.
• LHINs operated under agreements with the Ministry, overseeing hospitals, community support services, mental health services, primary care, and community access centers.
• in 2019, under the Peoples Health Care Act 2019, Ontario Health, a single “super” agency, replaced LHINs to streamline healthcare administration
• Ontario Health is led by a CEO and board of directors
• the number of LHINs reduced from 14 to 5 and transitioned funding and responsibilities
• Ontario Health Teams (replacing LHINs) are made up of local providers like hospitals, primary care organizations, and mental health agencies.
• each Ontario health team is responsible for a smaller geographic area than the LHINs were. they are able to provide more focused and individualized health services to smaller communities

Question 9

who pays for healthcare?

Answer 9

• each province and territory has a method of financing health care services not covered by federal funding
• private and volunteer organizations provide significant revenue for specific services or hospitals
  –> for example, when a community hospital builds a new wing, a government grant covers part of the expense, and volunteer groups and the municipal government make up the balance

Question 9

what is a LHIN?

Answer 9

• local health integration networks
• there were 14 LHINs that worked with local health providers and community members to determine the health service priorities of the regions
• LHINs operated as not-for-profit organizations governed by a nine-member board of directors that is appointed by the province.
• prior to the formation of LHINs, health care services in Ontario were fragmented and many health care providers delivered care in isolation

Question 10

what do provincial/municipal governments pay for?

Answer 10

• fund and regulate hospitals
• preventive health measures
• medical- and hospital-based services (both inpatient and outpatient)
• treatment of chronic diseases
• community-based rehabilitation care
• care for nursing home residents
• contribute financially to community health organizations, services delivered by certain health care professionals (other than physicians), and teaching and research institutions.

Question 11

private health insurance in canada

Answer 11

• approximately 60% of Canadians carry private health insurance, many through their employers
• third-party health insurance offsets the costs of non-covered services
• they provide benefits such as: vision and dental care, private nursing services, assistive devices and enhanced medical services
• 40% of Canadians who do not have private health insurance include those who are unemployed, underemployed, or self-employed
• all provinces and territories provide specific services (e.g., eye care, dental care, drug benefits) to certain population groups who are considered vulnerable

Question 12

what populations do provincial governments cover healthcare for?

Answer 12

• those receiving income assistance or guaranteed income supplements
• adults over the age of 65
• persons with disabilities
• children of low-income families

Question 13

eligibility for provincial health coverage

Answer 13

• canadian citizenship or permanent resident status
• resident of the province or territory in which they are seeking health coverage
• physically residing in that jurisdiction for at least 5months of the year (aries slightly among jurisdictions)

Question 14

insured and uninsured services in Canada

Answer 14

• under the Canada Health Act, medically necessary hospital and medical services are insured everywhere in Canada, in addition to in-hospital care
• the Canada Health Act does not include long-term care, residential and rehabilitation facilities, or home and community care services
• ambulance services are not addressed in the Canada Health Act so provinces and territories can establish their own guidelines and fees
  –> these services are under provincial/territorial legislation so it varies province to province

Question 15

supplementary benefits outside of the CHA

Answer 15

• all jurisdictions (provinces) provide supplementary benefits and services outside of the Canada Health Act. - the governments determine eligibility guidelines for specific services, funding formulas, and the length of time these services will be insured
• supplementary benefits include health care services such as: optometric, dental, physiotherapy, or chiropractic care
• in all provinces and territories dental surgery is covered if it must be done in a hospital (e.g.,facial or dental fractures, tumours, reconstructive surgery, and other medically necessary reasons)

Question 16

insured hospital services

Answer 16

in the hospital setting insured services for inpatients include:
- standard hospital accommodation
- meals
- certain medications
- operating room and delivery room services
- anaesthetic facilities
- diagnostic and laboratory services
- routine medical and surgical supplies used for hospitalized patients
- routine nursing care
- certain rehabilitative services (i.ephysiotherapy received in the hospital)
- emergency treatment
day surgery
diagnostic and radiological procedures at a hospital or at private diagnostic centres
–> provincial plans do not cover private nursing care unless ordered by a doctor, at which point the care becomes medically necessary and is covered

Question 17

insured medical services

Answer 17

• medically necessary care provided by a medical doctor
• services provided by a specialist (referred by a primary care doctor)
  –> Since “medically necessary” is subjective, services vary from one jurisdiction to anothe

Question 18

are medications covered by the CHA?

Answer 18

Canada’s Medicare system is unique among developed countries insofar as it is the only universal public healthcare system that does not include universal coverage of prescription drugs

Question 19

drug plans in canada

Answer 19

• all provinces and territories across Canada offer publicly funded prescription medication programs (often called pharmacare).
  –> most Canadians have private or employer-sponsored insurance plans with drug benefits
  –> however, these plans vary widely, resulting in unequal coverage among Canadians as many Canadians don’t have access to private supplementary insurance

Question 20

what is OHIP?

Answer 20

• stands for the Ontario Health Insurance Plan
• Ontario adopted its provincial plan in 1966 as part of health care reform across the country
• OHIP is funded by taxes paid by residents (a health premium), by employers (payroll tax) and by transfer payments from the federal government
• OHIP covers “medically necessary” services, including hospital and doctor services.

Question 21

eligibility for OHIP

Answer 21

• are a Canadian citizen or permanent resident or a holder of a work permit
• make Ontario their permanent and principal home
• are physically present in Ontario for at least five months of the year

Question 22

examples of uninsured services under OHIP

Answer 22

–> people pay directly for uninsured services, or they may be covered by private insurance.

• services that are not medically necessary or are experimental
• prescription drugs and those provided in non-hospital settings
• eyeglasses, contact lenses, refractive surgery
• routine dentistry
• cosmetic surgery that is not medically necessary

Question 23

insured services under OHIP

Answer 23

• medically necessary physician services
• hospital Services
• routine eye exams (for specified patients in specified age groups)
• medically necessary eye care services for patients of all ages
• dental services that require hospitalization
• limited physiotherapy services provided by designated clinics
• limited podiatry services
• insured services provided in other provinces of Canada
• services provided outside of Canada with prior ministry approval and limited emergency services

Question 24

what is the Ontario Drug Benefit program?

Answer 24

Ontario provides drug coverage to particular populations, including those who are 65 years old and over.

In addition, others who qualify include people:
- living in a long-term care home, home for special care or Community Home for Opportunity
- are 24 years of age or younger and not covered by a private insurance plan
- receiving professional home and community care services
- receiving benefits from Ontario Works or Ontario Disability Support Program
- enrolled in the Trillium Drug Program

Question 25

what is the trillium drug program?

Answer 25

• known as a drug plan of “last resort” for those without any or inadequate coverage
• helps people who have high prescription drug costs relative to their household income and covers all drugs approved under the Ontario Drug Benefit Program

Question 26

what is the exceptional access program?

Answer 26

• a program patients can apply for a patient drugs are not funded under the Ontario Drug Benefit program
• patients are expected to pay a deductible expense of 4% of their household net income towards the cost of medications as well as a co-payment of up to $2 for each prescription

Question 27

what did the CFMA say?

Answer 27

• in 2004, the Commitment to the Future of Medicare Act was introduced under the provincial government
  1) physicians cannot charge more (extra-billing) than the amount payable under OHIP for insured service to an insured person.
  2) charging patients for an insured service is prohibited under OHIP
  3) prohibits queue jumping and accepting payment for giving patients preferred access to insured services
  4) prescribed health care providers must report queue jumping and can lead to a fine
  5) possible violations ofCFMA with respect to charging for insured services and preferential access will lead to investigations and penalties
  6) The Canada Health Act prohibits using block or annual fees to bypass the universality of medicare. Physicians, hospitals, or clinics cannot deny access to insured services if a patient opts out of paying block or annual fees, as per the Act.

Question 28

what did Ontario’s Action Plan for Healthcare

Answer 28

• in 2012, the Ontario government announced its Action Plan for Health Care in an attempt to improve services for residents while making health care more cost effective and efficient. The priorities of the Action Plan included:
  1) keep Ontarians healthier by focusing on childhood obesity, a smoke-free Ontario, and cancer screening.
  2) to provide patients with faster access to services and increased access to family health care, including faster and more flexible services.
  3) providing the right care, at the right time, and the right place. This incorporates improved quality, more efficient access to care closer to home, a senior strategy, and local integration reform.

Question 29

what did the Patients First Act say?

Answer 29

in December 2016, the Ontario government announced its Patients First Act, with the following goals:
- improve access to primary care for people in Ontario, including a single number to call when they need health information or advice on where to find a new family doctor or nurse practitioner.
- improve local connections between primary care providers, inter-professional health care teams, hospitals, public health and home and community care to ensure a smoother patient experience and transitions.
- streamline and reduce administration of the health care system and direct savings into patient care.
- enhance accountability to better ensure people in Ontario have access to care when they need it.
- formally connect Local Health Integration Networks (LHINs) and local boards of health to leverage their community expertise and ensure local public health units are involved in community health planning.
- strengthen the voices of patients and families in their own health care planning.
- increase the focus on cultural sensitivity and the delivery of health care services to Indigenous peoples and French speaking people in Ontario.