ANALYSIS
OF THE ROMANOW REPORT - BUILDING ON VALUES
THE
FUTURE OF HEALTH CARE IN CANADA
Prepared
by the Health Advisory Committee to
the
Executive of the Alberta and Northwest Conference of
The
United Church of Canada
The Advisory Committee reviewed and analysed
the Romanow Report and its recommendations. Where possible the Committee also
compared his recommendations and comments with those of the Senate Committee
(chaired by Senator Kirby) and the Premiers Advisory Council on Health
(chaired by Mr. Mazankowski). We
also compared them to the Values Statement on Health that we had developed.
Following is a brief summary of the results of our work. It follows the
chapter headings in the Romanow Report.
Mr. Romanow says the system is sustainable if Canadians want it to be, that our health care system is adequately meeting our needs, that outcomes compare favourably with other countries and that the resources that we allocate to health (as a % of GNP) also compare favourably. However he says that there is room to improve. He therefore makes recommendations to improve access, reduce waiting lists and to ensure that the Canada Health Act covers a comprehensive range of medically necessary care. The answer, he says, “is not to look to the private sector for solutions. Instead governments should seek the best solutions within the public system and ensure that adequate resources are available and services are accessible to all” and that “historically, single payer health systems have proven to be significantly more cost efficient than alternative approaches”. Both the Kirby and Mazankowski Reports express doubts about sustainability . Their recommended approach includes recommendations to reduce comprehensiveness and to raise additional money through premiums (a regressive tax) or private insurance.
Mr. Romanow feels that ‘what is needed is a truly national approach to medicare in the 21st century - an approach that sets aside the differences of provinces/territories and the federal government, and puts new and more effective governance approaches in place.’ He feels that ‘only by taking co-operative, deliberate, and decisive action on those issues, and setting aside differences of the past can we hope to restore Canadians’ confidence in the future of their health care system.’
He suggests that the following actions are required:
a renewed commitment, through the adoption of a new Canadian Health Covenant, to a universally accessible, publicly funded health care system
strengthening collaboration and leadership using a new Health Council of Canada
a
Canada Health Act for the 21st century
- expand
coverage to include ‘targeted’ home care and drugs
-
clarify coverage of diagnostic services
- add a new principle of
accountability
- update principles of portability and comprehensiveness
- include an effective dispute
resolution mechanism
adequate, stable and predictable funding arrangements - set the Federal cash contribution at 25% of the cost of insured services under CHA by 2005/06 ($6.5B above current level) and an escalator provision.
targeted
efforts to address immediate priorities
- rural
and remote access fund ($1.5B)- diagnostic services fund
($1.5B)
- primary health care transfer
($2.5B over 2 years)
- home care transfer
($2B over 2 years)
- catastrophic drug transfer
($1B annually starting in 2004)
Romanow says action is required on three fronts:
putting essential information management and technology systems in place
improving our ability to assess and manage the potential benefits of health care technologies
expand our applied research capacity across the country.
He recommends:
a personal health record for each Canadian that builds on work currently underway. CANADA HEALTH INFOWAY should continue to take leadership in this initiative
individual Canadians have ownership and access (with privacy protection) to their health records and better access to credible and trustworthy health information
explicit criminal code protection against abuse or misuse of personal health information
improved systems to assess technology and to ensure it is used appropriately
Mr. Romanow found that there is a malaise and frustration amongst health care workers related to cutbacks, poorly planned changes, real and perceived shortages of professionals, and overwork. Attempts at ‘quick fixes’ by increasing remuneration may have only served to create more disparities of distribution. There is a sense that reform is required in the way primary care is provided including methods of remuneration and developing team approaches to health care delivery. Dependence on overseas graduates is short sighted and raises concerns when these are recruited from developing countries. He assesses the situation as serious and requiring national solutions.
He recommends that funding be provided for improving the supply and distribution of practitioners and encouraging changes in patterns of practice. To enable and coordinate this he proposes that the new Health Council of Canada be responsible for broad human resource planning for health services in Canada.
Romanow defines primary health care as a “fundamental change” in our approach to health care that addresses the two major themes expressed in the presentations to the Commission i.e. “continuity and co-ordination of health care and health services; and action on individual and population health”. Primary health care would strike a “better balance between efforts to prevent illness and injury and those that cure people when they are sick” by:
Delivering appropriate, efficient, cost effective health care services to individuals and communities through processes that are based on interdisciplinary provider collaboration and/or communication.
Putting a major emphasis on prevention and promotion activities
He recommends a Primary Health Care Transfer ($2.5B annually) to be used to 'fast track' implementation based on four essential building blocks - continuity of care, early detection and action, better information on needs and outcomes and new and stronger incentives to achieve transformation. Both the Senate Committee and the Mazankowski Reports have recommendations supporting the implementation of primary health care approaches.
Canadians’ first concern is with access. Long waiting times are the main, and in many cases, the only reason some Canadians say they would be willing to pay for treatments outside of the public health care system. The Commission rejects the two polarized positions that the problem of wait lists is perception and not reality, and at the other end of the spectrum that the problems are so severe that only allowing parallel private facilities can solve the matter.
The Report recommends improving timely access to health care services through special initiatives to improve waitlist management, by removing obstacles to primary care reform, and by increasing the supply of advanced diagnostic services. The Commission recommends using the new Diagnostic Services Fund to shorten waiting times for diagnostic services.
“Care guarantees”, which provide patients with a guarantee to treatment within a certain period of time, were recommended in both the Senate Committee Report (Kirby) and the Premier’s Advisory Council on Health Report (Mazankowski). The Commission examined the concept, but did not embrace it because there are no reliable methods available to determine the appropriate guaranteed time and the likelihood of the system being able to meet the time lines.
Waitlist management must be a joint effort by provinces and territories, working with regional health authorities, hospitals, physicians and other health organizations. Standardized and objective criteria should be implemented for assessing patients to ensure that the time they wait between diagnosis and treatment is only dependent upon the seriousness of their condition.
The recommended actions to manage wait lists should achieve three broad goals - fairness, appropriateness, and certainty.
Mazankowski recommended central booking services and putting waiting lists on a website
Improving Quality
Canada lacks the basic and critical information needed to measure the results, assess performance, and judge the quality of the health care system. Moreover, current responsibilities for ensuring quality and safety are widely distributed among different players in the health care system, including professional and regulatory bodies. These various players in the system do not share a common understanding of the challenges in improving quality and safety. Nor do they share a common vision for the future.
Romanow recommends that ‘Working with the provinces and territories, the Health Council of Canada should establish a national framework for measuring and assessing the quality and safety of Canada’s health care system’
He sees the work of the Health Council of Canada as essential to replace today’s patchy picture of Canada’s health care system with a clear, comprehensive and consistent analysis of the outcomes the system achieves and the progress that is being made in improving quality.
Mr. Mazankowski recommended a new Outcomes Commission to monitor and measure results and report publicly. The Senate Committee recommended ‘more research be undertaken in order to enhance quality in health services and in health care delivery’.
As Romanow addresses the problem of shortages of health care providers in rural and remote communities, his focus is predominantly on their recruitment and retainment. He recommends a Rural and Remote Access Fund to support new approaches for delivering health care services and improving the health of people in rural and remote communities including “the expansion of training opportunities for a range of health professionals in rural or remote settings”. He also recommends expanding ‘telehealth’ to improve access for rural and remote communities.
All provinces/territories offer some kind of Home Care but that varies as to the amount of services, what types of home care services are covered and how much individuals pay to cover a portion of the costs. It is, however, one of the fastest growing components of the health care system. Home care services are a less costly substitute for services previously provided in hospitals.
He recommends that the proposed new Home Care Transfer Fund ($2B over 2 years) be used to support the expansion of the Canada Health Act to include medically necessary home care services in the following areas (initially at least):
Home mental health case management and intervention services
Home care services for post-acute patients including medication management and rehabilitation services
Palliative home care services to support people in their last 6 months of life
Romanow also recommends that Human Resources Development Canada, in conjunction with Health Canada, be directed to develop proposals to provide direct support to informal care givers to allow them to spend time away from work to provide necessary home care assistance at critical times. Some suggestions for such support are direct remuneration (under EI), tax breaks, job protection, caregiver leave and respite. The Senate Committee also recommended that the Government examine the feasibility of allowing EI benefits for up to six weeks for an employed person that takes leave to care for a relative receiving palliative care. They estimated the cost of EI benefits for caregivers for 6 weeks at $240M annually.
The Report says that we have ‘only seen the tip of the iceberg when it comes to potential for new prescription drugs.’ However the ‘benefits of current and potential new drugs will only be fully realized if prescription drugs are integrated into the system.’ “The Commission’s view is that we need to begin the process of integrating coverage for prescription drugs within medicare as part of a longer term strategy to ensure all Canadians benefit from comprehensive prescription drug coverage”.
Romanow recommends A Catastrophic Drug Transfer ($1B annually). The Federal government would reimburse the Provinces and Territories for 50% of the costs of their drug plans above $1,500 per person per year (for those persons whose costs exceed $1,500). The plans would need to ensure that no one would pay more than $1,500 per year for prescription drugs. This is designed to encourage all provinces to provide minimum coverage at least for all their residents and thus reduce disparities in coverage across the country.
The Senate Committee proposed a plan that would have the Federal government pay 90% of all prescription drug expenditures over $5,000 a year for an individual. The remaining 10% would be paid by the provincial/territorial plan or the individual’s private plan. To be eligible provinces/territories would have to put in place a plan that ensured that no family would have to pay more, out of pocket, than 3% of its family income. Private plans would have to guarantee that no individual plan member would have to pay out of pocket more that $1,500 per year or 3% of family income whichever is less. The estimated cost is about $500M or about ½ of the one proposed by Romanow.
Romanow also recommends the establishment of a New National Drug Agency to :
develop (collaboratively with provinces/territories) a national formulary for prescription drugs
evaluate and approve new prescription drugs
provide ongoing evaluation of existing drugs
negotiate and contain (through analysis and monitoring) drug prices
provide comprehensive, objective and accurate information to health care providers and the public
He recommended that aspects of Canada’s patent laws be reviewed in order to improve access to generic drugs and contain costs. Specifically he points to notice of compliance regulations and the practice of ‘evergreening’.(making variations to existing drugs to extend patent coverage). Mr. Romanow points out that the 20 year patent protection has become the international norm and says that there is ‘no empirical evidence to suggest that Canada’s patent protection laws are responsible for increasing drug prices’.
“The poor health status of Canada’s Aboriginal peoples is a well known fact and a serious concern not only to aboriginal peoples but also to all Canadians......There are deep and continuing disparities between Aboriginal and non-Aboriginal Canadians both in their overall health and in their ability to access health care services.” “In fundamental terms, there is a ‘disconnect’ between Aboriginal peoples and the rest of Canadian society, particularly when it comes to sharing many of the benefits of Canada’s health care system.
There are five underlying reasons for this disconnect:
competing constitutional assumptions
fragmented funding for health services
inadequate access to health care services
poorer health outcomes
different cultural and political influences
Mr. Romanow recommends that funding from federal and provincial sources for Aboriginal health care be pooled and services integrated. The consolidated funding would be used to create new Aboriginal health partnerships that would be responsible for develping policies, providing services and improving the health of Aboriginal peoples.
The report clearly recognizes that international trade agreements are a potential threat to the power of governments to make policy choices with respect to health care - and other social services and recommends that the Federal and Provincial governments take steps to prevent potential challenges to Canada’s health care system. He also:
encourages alliances with other
countries to ensure that trade agreements support rather than
diminish the power of governments to establish and maintain public health
care systems.
calls on the federal government to
be a leader in assisting poor countries in strengthening their health care
systems through foreign aid and development programs.
urges provincial, territorial and federal governments to stop
recruiting health professionals from poor countries.
Over
all, we believe that acting on these recommendations would result in policies
and practices which maintain and extend the common good, allow citizens of
Canada and other countries to decide the ways and means of funding and
delivering health services and stop the pirating of health professionals from
poor countries where the need for trained personnel is staggering.
Conclusion
The title of the Romanow Report “Building on Values” is clearly reflected in his recommendations. He proposes a new Canadian Health Covenant that would be a ‘common declaration of Canadians and their governments’ commitment to a universally accessible, publicly funded health care system’. Those values are closely aligned to the ones adopted by this Committee some time ago. It follows, therefore, that we find favor with his basic approach and recommendations. We think Mr. Romanow has proposed a framework for reforming and updating Canada’s health system that would achieve the results clearly desired by Canadians.
The next step is to persuade governments to move cooperatively to implement these changes.
January 30, 2003