Chapter 3 The Role of Provincial and Territorial Governments in Healthcare PDF

Chapter 3 The Role of Provincial and Territorial Governments in Health Care Learning Outcomes 1. Discuss the common elements of healthcare delivery among provinces and territories 2. Outline the differences and similarities between regional and single health authorities. 3....

Chapter 3 The Role of Provincial and Territorial Governments in Health Care Learning Outcomes 1. Discuss the common elements of healthcare delivery among provinces and territories 2. Outline the differences and similarities between regional and single health authorities. 3. Explain how provinces and territories finance healthcare services. 4. Discuss the particulars of public and private health insurance in Canada 5. Describe what hospital and healthcare services are insured under public health plans 6. Explain the prevalence of drug and dental plans in Canada Division of Powers Canada has universal health care but no national, single-payer health insurance plan. Canada has 13 separate insurance programs run by 10 provinces and 3 territories, loosely bound by federal agreements and the Canada Health Act Provincial and territorial governments oversee the health of their populations To receive federal funding, provinces and territories must abide by the Canada Health Act Structure of Provincial/Territorial Healthcare: An Overview Each ministry is headed by an elected member of Parliament appointed to the position of minister of health (MOH) The ministries Provide leadership and support to service delivery partners Implement and regulate health insurance Negotiate salaries and other policies with physicians’ professional associations All provinces and territories provide three general categories of health care Levels of Care Regionalization Initiatives Across Canada In the early 1990s, governments conducted public forums, reviews, and other studies to improve health care delivery and decided to decentralize decisions about health care issues through regionalization Subsequently all provinces/territories adopted regionalization Four desired goals: Amalgamate health care services Stress health promotion and disease prevention Involve the public Implement appropriate and effective governance Single Health Authority Several jurisdictions have moved back to a single health authority (SHA) where the MOH is responsible for overall delivery of healthcare Various reasons for SHA Desire to distance from bureaucracy & layered services Hoped to make services more cohesive and easier to access No evidence to determine which model works best Rationalization/Centralization of Health Services Most jurisdictions have adopted a centralized approach to delivering healthcare services Way to reduce costs and improve the quality and continuity of patient care Led to rationalization (or centralizing) of health services within communities—particularly in large hospitals Larger hospitals merged under one administrative body offering specialized services at different sites Resulted in the closure or allocation of services to smaller hospitals in rural areas to justify keeping them open Health Care: Who Pays for It? Each province and territory has a method (e.g. premiums, payroll tax) of financing health care services not covered by federal funding Private and volunteer organizations provide significant revenue for specific services or hospitals Ex: 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. Other Sources of Funds Provincial, territorial, and municipal governments Provide some funds for services such as Preventive health measures Medical- and hospital-based services (both inpatient and outpatient) Treatment of chronic diseases Community-based rehabilitation care Long-term care Fund and regulate hospitals Contribute financially to Community health organizations Services delivered by certain health care professionals (other than physicians) Teaching and research institutions 10 Private and Public Health Insurance Third-party health insurance offsets the costs of noncovered services Approximately 60% of Canadians carry private health insurance Employee plans provide benefits such as Vision and dental care Private nursing services Assistive devices Enhanced medical services Provincial Insurance Plans The following criteria must all be met for a person to be eligible for provincial or territorial health insurance: Canadian citizenship or permanent resident status Resident of the province or territory in which they are seeking health coverage Physical residence in that jurisdiction for at least five months of the year Health Cards Once an application is approved, the ministry issues the applicant a health card Health care fraud has been a costly problem. As a result: Health care facilities require individuals to present their health cards at the point of service for validation. Most jurisdictions now have photo identification health cards and increased security measures to protect the information on the cards. It is a serious offence to knowingly facilitate the illegal use of a health card. Health care providers are encouraged to watch for and to report anything suspicious. Lost cards must be reported immediately, as must changes of address or name. Private Health Care Numerous private clinics and services exist across the country Some circumvent the legal principles of the Canada Health Act by offering services not technically considered medically necessary. For example, preventive screening tests such as colonoscopies, 3-D imaging of fetuses for pregnant women, or MRIs that are not medically necessary Other services often paid for privately include Counselling Physiotherapy Sports medicine Travel health assessments Genetic testing Pharmacogenomics testing Insured and Uninsured Services Provincial and territorial All provinces and territories provide specific services (e.g., eye care, governments must decide dental care, drug benefits) to certain on population groups, such as The need for different Those receiving income types of hospital beds assistance or guaranteed income supplements The mix of Older adults (i.e., those over 65) professional health care staff Disabled persons The structure of the Children of low-income families (in many jurisdictions) system Hospital budgets The Federal Government provides health insurance to Inuit and First Physicians’ fees Nations Peoples living on reserves 15 Hospital Services In the hospital setting, insured services for inpatients include Standard hospital accommodation Meals Certain medications Operating room and delivery room services and anesthetic facilities Diagnostic and laboratory services Routine medical and surgical supplies Routine nursing care Certain rehabilitative services (e.g., physiotherapy) Private nursing care is not covered unless a doctor orders it (then it is considered medically necessary). The cost of a private room may be covered under some circumstances. 16 Ambulance Services Ambulance services are not addressed in the Canada Health Act; therefore, the provinces and territories can establish their own guidelines and fee schedules. People using an ambulance, even for medically necessary reasons, may be responsible for a copayment. Fees are not usually charged for medically necessary transportation between hospitals. Interfacility transfers (e.g., from one nursing home to another) usually require a copayment. Most jurisdictions either reduce or eliminate the copayment for low-income individuals and families. If used as a mode of transportation (misuse), the ‘user’ is charged the full amount of the ambulance transfer Insured Health Care Providers Other Than Physicians Public insurance plans pay for very few supplemental services (often referred to as paramedical services). For example: Physiotherapy Chiropractic Podiatry Massage therapy Naturopathy Osteopathy services Extended Health Care Services (1 of 2) Long-term care homes offer 24/7 accommodation, meals, and nursing care and support to individuals no longer able to live on their own. In most provinces and territories, these facilities are overseen by legislation that sets standards of care and performs regular inspections. Long-term care facilities are encouraged to seek accreditation through Accreditation Canada. Provincial and territorial governments design their own funding formulas for long-term care facilities. Extended Health Care Services (2 of 2) Most provinces and territories offer a variety of other services, such as Home care Adult day care programs Respite care Assisted living accommodation Group homes Hospice care Palliative care Medical Assistance in dying Drug Plans 60%-70% of Canadians have private or employer- sponsored insurance plans with drug benefits. Private insurance plans require beneficiaries to pay dispensing fees. Some plans will cover only drugs prescribed from a formulary list. Many private insurance plans offer an “open access” plan, insuring all prescription medications approved by Health Canada prescribed on an outpatient basis.