Medicare’s Unfinished Business : A Proposal for a Home and Continuing Care Program for Canada

By Sharon Sholzberg Gray

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Background:

For 20 years or more, the Canadian public has been asking for appropriate access to ongoing services that will maintain their health in the community and keep them well and outside of hospitals. So have numerous studies, reports and commissions as well as health organizations and health providers. These kinds of services have been a provincial priority. And they were an objective in the 2004 Health Accord agreed to by all provinces and territories. So why aren’t we there yet?

The reality is that despite best efforts, home and community care services are still inadequate to meet needs. In a new series on home care in the Globe and Mail, beginning Saturday, July 11, 2015, writers Kelly Grant and Elizabeth Church told the story of home care hours being cut back, massive underfunding, and a fraying patchwork of services in Ontario, while “other provinces grapple with similar dilemmas”. Yet transformative change from a hospital and physician-based medicare system is essential if our health system is to cope with an aging population and address the needs of underserved population groups in our country, for example, people with mental and physical health challenges, children with special needs, and those requiring palliative care services – whether seniors or not.

Most of the public discourse lately has been about our aging population, but any home and continuing care program must recognize the needs of all those who require services in the community or a non-hospital setting. The reality is that that our publicly funded health system was designed with hospitals and physician services as its focus and we live in a chronic care world, where episodic acute care services alone are not meeting our needs.

In the hospital, care is 100% funded and pharmaceuticals are provided. People know that if they have an acute care illness, they are entitled to care, although it may not always be provided in as timely a manner as they would prefer. Out of the hospital, they don’t know what services they are entitled to. Depending on where they live, they may or may not get access to home and continuing care and the supplies and drugs they need. They may not even know that medicare doesn’t cover these services until they need them.

The Challenge:

Monique Begin, the Health Minister who was the architect of the Canada Health Act, which set out the principles for universal access to hospital and physician services, has spoken very eloquently about the need to address the equally important issue of access to care in the community. One of the challenges to accomplishing this is that it is much easier to look at the walls around a hospital and to say everything within those walls and within that building is covered. It is much more difficult to define a home care program when we know that it would be impossible to support everyone at home on a 7/24 basis. What should be included in home care services and who should receive these services? What kind of pan-Canadian principles should apply to these services and is there is a federal/provincial consensus on common objectives?

Similarly, it is obvious that if someone needs to live in a long term care facility or a special care home, or a nursing home, or a home for the aged, or a continuing care centre, or a chronic care institution, or a hospice (there is a variety of terminology used across the country), it is appropriate to charge an affordable amount for room and board, but not for the health services and personal care provided. This has certainly not been the case across the country, when in some regions there have been excessive and unaffordable charges. What about supplies and necessaries of life? What about a spouse still living at home who needs money to live on?

What is required is an array of non-hospital services provided on an equitable basis throughout this country to meet the needs of individuals requiring care and their caregivers, especially with a growing frail elderly population, the high prevalence of dementia, the challenges faced by families who cannot take care of their children with special needs or their adult children who are differently abled, and the need for appropriate end-of-life services. (This paper will not address the various housing options which are required, although these are also part of the solution, nor will it address the need for Pharmacare, which is another key component of Medicare’s unfinished business.)

In their Globe and Mail article, Grant and Church raised the issue of Pharmacare “which “is often cited as the most egregious exclusion from Canada’s universal health-care system”. They concluded that at least individuals can find out which prescription drugs their provincial governments will pay for and there is some private insurance coverage. “Home care, on the other hand, is often a black hole of information, one many Canadians do not stumble into until they are old or sick or both.”

There is no excuse for not defining and achieving a Home and Continuing Care Program for Canada that is do-able, affordable, and equitable, and that provides comparable access throughout Canada to services, based-on pan-Canadian objectives that all levels of government can sign on to. Admittedly, finding the necessary intergovernmental consensus may be a challenge, but there are examples of past inter-governmental agreements that worked and they can be used as a model.

The Need for Federal Engagement:

Prior to the expiration of the 2004 Ten Year Health Accord, the provinces and territories asked for meetings with the federal government to discuss health system issues and future federal funding, but the Harper Government unilaterally announced the level of post Health Accord transfers without prior discussion. After 2016, the 6% annual escalator to the Canada Health Transfer (CHT) will be reduced to growth in GDP, but not less than 3% per year. At their meeting on January 30, 2015, the Council of the Federation, comprising Canada’s Premiers, again asked the federal government to be engaged in helping them in their efforts to innovate and to address the challenges of an aging society, but to no avail.

The Health Council of Canada Report released on September 19, 2013 asked the federal government to become engaged in ensuring that Canadians have access to the health services they deserve, stressing the need to “prevent and manage chronic disease as well as provide home care and long-term care services across this country on the principle of equity.” As Health Council Chair (and CEO of the Ottawa Hospital) Dr. Jack Kitts stated on launching the report: “Where you live and how much you earn shouldn’t matter when it comes to achieving good health”. All major health organizations in this country have been asking for federal engagement. And the opposition parties have committed themselves to meeting with the provinces and territories on health issues. It would be naive to think that meeting with the Premiers without putting more money on the table to help them move forward on their transformative agendas will be possible, whichever party forms the government after the election.

The current federal government continues to take a hands off approach to working with the provinces and territories on health. While it is certainly true that health services are a provincial responsibility, it is also true that the use of the federal spending power in areas of provincial jurisdiction is constitutional, and historically has been used to ensure comparable and equitable access to health services throughout Canada. The planned reduction of the escalator will unfortunately have the effect of reducing the federal share of health spending and will make it more difficult to ensure comparable access to high quality services throughout Canada. This does not necessarily mean that a 6% escalator is the solution – there are other ways to transfer health funds that have been used in the past very successfully – eg. the targeted funds to the provinces for wait times and for the purchase of needed medical and diagnostic equipment. Experience shows that a targeted fund has the potential to achieve the desired outcome more than a block transfer does.

How to move forward:

The federal government must work together with the provinces and territories in a collaborative way to help ensure that Canadians have access to comparable and equitable health services that meet their needs wherever they live in this country. A federal government that refuses to even come to the F/P/T table is not an option.

As a start to addressing Medicare’s unfinished business, the federal government should provide financial support to the provinces and territories in the form of a targeted fund for a pan-Canadian Home and Continuing Care Program, in addition to the CHT with the 3% minimum escalator. The goals of this targeted fund should be defined in collaboration with the provinces and territories of Canada and should be based on common objectives and principles, innovative approaches and outcomes measurement, with provincial and territorial governments reporting to their respective populations on the basis of comparable data using agreed to indicators. Through a targeted fund, provinces and territories would then have increased financial resources to achieve progress in an area they are already committed to enhancing. Provinces and territories that already have programs in place that meet the objectives and standards applicable to the new targeted fund would still receive their funds. (Appendix A, attached to this proposal, contains some suggested objectives and principles for this fund and Appendix B presents some facts to consider when assessing the need for additional funding for health-care.)
There is a precedent for F/P/T agreement on targeted funds to achieve specific goals (the Wait Times Reduction Fund in the 2004 Health Accord, and the Diagnostic and Medical Equipment Fund in the 2003 Health Accord with additional funds provided in 2004). These were time-limited funds, but they helped move the agenda forward in these areas and have achieved some success. This proposed new targeted fund would not be time limited and would continue alongside the CHT funding. The targeted fund would need to be legislated at the federal level and of course agreed to by all provinces and territories, using the approach in the 2004 Health Accord, where the Province of Quebec signed on through a separate communiqué, or the approach taken in 2005 with child care agreements individually negotiated by the federal government with each province and territory, but based on common objectives. (The child care agreements were later cancelled by the Harper government.)
What should be the size of the new targeted fund? It is proposed that a $500 million dollar home and continuing care targeted fund be established. Over a 5 year period, it can gradually be increased until it reaches $1 billion per year, after which it should be subject to the same 3% escalator as the CHT. Depending on the economic climate, future “savings” to the federal government due to the reduction in the CHT escalator from 6% to 3% should be used to establish additional targeted funds to address other aspects of Medicare’s unfinished business such as Pharmacare as soon as possible.

 

Appendix A :

To be read with “Medicare’s Unfinished Business: A Proposal for a Home and Continuing Care Program for Canada

Some Suggested Objectives and Principles for a pan-Canadian Home and Continuing Care Program

1) Canadians will be entitled to an assessment of their home, community and long term-care needs upon discharge from a hospital bed or a hospital emergency stay, by a designated government agency.

2) Other access points to these services will also be in place, for example, referrals from Family Physicians, Nurse Practitioners, or Community Health Clinics. Additionally, persons requiring continuing care services and/or their families would be able to directly request an assessment of their needs by the designated government agency or body in their region that is well-publicized and known to the public.

3) Home and community services would include acute care
replacement services, preventative, rehabilitative and chronic care services, and palliative care services. For those requiring ongoing support in the home, the number of hours of service provided each week would be determined by assessing the health and social needs of the person requiring care and his or her family support available. Still, there would need to be a maximum number of hours provided each week, perhaps up to the level of the government payment per person in a facility-based continuing care setting.

4) A continuing care program would meet the needs of an aging population, people with physical and mental challenges, and children and young adults with special needs.

5) This program would strive for the implementation of best practices. (Note that the Working Group of the Council of the Federation is already committed to identifying and sharing best practices.)

6) This program would encourage innovation and the uptake of processes and design based on best evidence of what works well.

7) This program would include caregiver support, both financial and in terms of services, like respite.

8) This program would recognize and value the important role of a variety of care providers, including physicians, registered and practical nurses, rehabilitation professionals, social workers, mental health workers, and personal support workers.

9) ) High quality care will be a hallmark of a national continuing care program, with special attention paid to required staffing levels, the skill mix of caregivers, and working conditions.

10) There would be equitable and affordable room and board payments for those needing residential, institutional, continuing, long term facility-based care and services, including hospice care. In no case should these payments prevent access to the appropriate setting.

11) This program would be recognized as a combination of health and social services and not be part of the Canada Health Act, something strongly recommended by the late Evelyn Shapiro, chief architect of the Manitoba Home Care Program and a person honoured by the Canadian Federation of Nurses Unions as one of their champions of Medicare. This would create the flexibility to do social assessments and not to over-medicalize services that people may require on an ongoing basis. There would be separate federal legislation implementing the new targeted transfer.

12) This program would be based on appropriateness of care, providing a seamless continuum of services as well as one-stop shopping.

13) Canadians would know what kind of services they can access and how to access them.

14) This program will need leadership throughout the health system at all levels to create a focus on maintaining good health and accessing appropriate care at all stages of the life cycle, thus obviating the need for more and more medical interventions and procedures, and would help create the high quality equitable health system that Canadians need and deserve, wherever they live in this country.

15) A definitive list of principles and standards for this program would be determined by collaboration and discussion among all levels of government, with input from health organizations, health providers and the public through an agreed-to consultative process.

16) The amount of federal money in the targeted fund would be agreed to by all levels of government.

17) This new program is do-able and affordable and would benefit Canadians from coast to coast to coast.

 

Appendix B

To be read with “Medicare’s Unfinished Business: A Proposal for a Home and Continuing Care Program for Canada”

Some facts to consider when assessing the need for additional funding for health care:

1)The rate of growth of health spending in Canada hasn’t kept pace with inflation and population growth for the last 4 years according to the Canadian Institute for Health Information.

2) Contrary to the prevailing wisdom, or at least the wisdom of those who argue for more private health insurance and private spending on health services as a magic solution to meeting health needs, total government spending in Canada on health care is not one of the highest amongst OECD countries. It is true that the latest OECD figures show that Canada was in the top quartile when considering both public and private expenditures together. However, Canada was in the middle of the pack when looking at government expenditures only, since Canada has higher private spending levels than the OECD countries to which it is usually compared – 70% public spending and 30% private, and this has been the same for many years. Public spending in Canada for health is less than the European countries to which it is usually compared.

3) Canadians provide billions of dollars of caregiving to family members, friends and neighbours. In 2012, 28% of Canadians aged 15 years or older provided care to a family member or friend with a long term health condition, disability, or aging needs. These caregivers have stressed the need for assistance and support , both financial and through government health and social services. (Statistics Canada Report, September 2013). Programs like the federal government’s EI compassionate leave program for end-of-life care and caregiver tax credits are insufficient, although helpful.

4) It is a growing challenge for Canadians to pay for non-Canada Health Act services (e.g. home and continuing care services, prescription drugs) when they are not available or insufficiently available in their province or territory or region.

5) One of the ways to achieve success in reducing wait times for acute care procedures (an ongoing concern of Canadians) is to ensure that alternate level of care patients in hospitals (ALC patients) who don’t require acute care are moved out of acute care hospital beds as soon as possible to services that more appropriately meet their needs, such as home care and continuing care. Moreover, hospital beds are more expensive than community alternatives. The problem is that there are not enough resources available in the community to take care of these patients, many of them having complex conditions. The need for more out-of-hospital services is particularly urgent since Canada has a very low number of hospital beds per capita compared to the OECD average.

6) Those who talk about the need to have an honest conversation about the sustainability of our health system usually use this as a code for more privatization of either spending or delivery. What is really needed is an evidence-based approach. The evidence shows that individual Canadians cannot afford to carry the burden of needed health services that are not available to them or insufficiently available. The evidence, based on numerous studies, also shows that there are no magic savings to be derived from private for-profit delivery of publicly funded services. The honest conversation needs to be about taxation and the need for a tax system that is fair, reduces income disparities, and can pay for the infrastructure and services that Canadians say they need and want. To quote Alex Himmelfarb, a former Clerk of the Privy Council and Alex Himmelfarb, “the Canadian tax conversation has become dangerously distorted. Any reasonable discussion of taxes must take into account the highly valued services they buy.”

7) Over the long run, the best way to sustain our health system and to ensure a healthy population is to invest in the determinants of health (housing, alleviation of poverty, social services, education, etc,), to focus on wellness and disease prevention, and to provide a broad continuum of health services that meets needs in the most effective, efficient, evidence-based, and innovative manner. Talking and writing about transformative change isn’t enough. We need to do it.

 

 

Sharon Sholzberg-Gray is a lawyer by profession who has spent her entire career working in the non-profit sector as CEO of various national health and social policy organizations, including the Canadian Healthcare Association (CHA). She has served on numerous Boards and Advisory Committees and speaks and writes extensively about legal, health and social issues.

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