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Health Policy 3400A lecture notes (week 1, 3, and 9)

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Health Sciences
Health Sciences 3400A/B
Sharon Regan

Health Policy 3400A: Week 1 12/6/2013 8:25:00 AM *Entire text examinable unless told otherwise - not memorization (i.e. years) - rather: trends and major events 4 online discussions – 8 marks - respond to questions and each other - draw on course content, at least two posts, posts 24 hours apart Discussion #1: September 30 - October 2 Lecture 1: What is Policy Numerous definitions – policy, public policy, health policy Public policy: a course of action or inaction chosen by public authorities (government) to address a given problem or interrelated set of problems - governments make choices about whether they’re going to address something or not (when they make a choice to purposely not do something; that is still policy!) - i.e. too complex, just not on the agenda health policy*: is assumed to embrace courses of action (or inaction) that affect the set of institutions, organizations, service and funding arrangements of the health and health care system - it includes policy made by the public sector (government) as well as policies in the private sector - but because health is influenced by many determinants outside the health system, we are also interested in the actions and intended actions of organizations external to the health system that impact on health - i.e. advertising, education, media regulation’ definition 2: health policy (WHO): refers to decisions, plans and actions that are undertaken to achieve specific health care goals within a society - an explicit health policy can achieve several things: it defines a vision for the future which in turn helps to establish targets … Commonalities: Policy is about … - making decisions - crosses organizations - addresses issues/problems - action or inaction - principles/values - resource allocation (financial, and people!) o have to be willing to do this Health Policy Triangle Actors: - individuals, groups and organizations that participate in the policy process  formally and informally, directly and indirectly (i.e. voting, attending meetings, writing a letter) o government – federal, provincial, local o interest groups – outside of gov. o individuals – general public, influential people Context: - situational factors: conditions or events that may influence policy  i.e. SARS had transformative effect on health policy - structural factors: relatively unchanging elements of the society such as the political system, type of economy, and employment base - etc. (AUDIO) Policy Process: - the process of shaping policy initiatives, from agenda setting to implementation and evaluation Another way to think about policy… Ideas: how issues/policies are framed and presented Institutions (i.e. government; parties, structure, rules): rules, authority and values of an organization and the ways in which it makes decisions or acts Interests: actors … HS 3400A: Week 2 12/6/2013 8:25:00 AM (written out notes) HS 3400A: Week 3 12/6/2013 8:25:00 AM Review:  power: the ability to influence people, and in particular to control resources  dimensions of power (3): as decision-making, as non-decision making, as thought control (i.e. George bush reframing idea of taxes; i.e. instilling a preference before you even have an opinion)  theories of the distribution of power: pluralism (multiple interest groups all competing to influence gov’t), elitism (powerful group that holds the power to influence decision-making; i.e. pharmaceutical companies – CEOs of big companies, people holding high-power government positions), public choice (there are multiple interest groups, they believe that power is held predominantly by government/elected officials and civil servants – looking after own interests)  systems model of policy making o input  decision-making (black box because we don’t really know what’s happening; models to help us try to understand this process; i.e. punctuated equilibrium (sudden event = drastic change in policy; in between these is stability), rationalism (systematic step-by-step process of decision making), incrementalism (incremental changes from the status quo that can, over time, create big change; doesn’t allow for innovation), satisficing, nick-scanning? (taking rationalism and incremental)  output Learning Objectives: - Understand past historical events and trends that shape and influence current health policy - Explain how healthcare is financed - Describe the Canada Health Act and the 
 implications for health policy decisions - Understand the provisions of healthcare services in Canada - Identify which level of government is responsible for specific healthcare services Constitution Act: - in terms of who has responsibility for what in terms of health care - shapes the provincial gov’t in particular in terms of delivering health services  main responsibility stays at provincial level (hospitals, home health, clinics, etc.)  federal gov’t: funding, sets the vision in terms of what we want to achieve, some responsibility for particular groups of people, set out legislation that gives criteria for funding for provincial gov’t, o fairly limited in terms of health care delivery Before 1962: - before WWII (1939), health care delivered primarely privately and funded  - physicians working out of home  did not have the structured health care  did not have provincial/federal input in terms of funding - charity hospitals (churches mostly), reliance on family as primary caregivers, doctors paid by individuals - 1940s: shifting  Tommy Douglas introduced provincial health insurance in 1947  believes that everyone should have equitable access to health care  ―humanity first‖; common good supersedes private or corporate interest  universal health care should be available regardless to ability to pay 1962: implementation of medical insurance plan for physician services in Saskatchewan  prior to implementation physicians campaigned against Tommy Douglas (then premier)  23 day strike by physicians - bill the government for the services they provide: fee for service  ―fee schedule‖ dictated billing (and therefore the reciprocation from provincial government) Tommy Douglas: father of Medicare 1962-1968: - substantial change - Emmett Hall chairs first royal commission on health services in 1964  one of founding fathers of medicare  ―ability to pay should not be a precursor‖: justice, equity, fairness, universality began to shape medical care  ―Health services must not be denied to certain individuals simply because the latter make no contribution to the economic development of Canada or because he cannot pay for such services. Important as economics is we must also take into account the human and spiritual aspects involved‖ - 1968: Medical Care Act: federal legislation for 50/50 cost sharing for provincial/territorial medical insurance plans 1968-1984: - what started in Saskatchewan rolls across the country - provinces/territories develop medical insurance plans  physician remunerated on a fee-for-services basis - 1979: government decides 50/50 wasn’t working – block funding  started unequal funding (federal funding less, provincial more!) - 1980: Health Services Review (Emmett Hall Report)  must address (and end) user fees and extra billing; created inequity between those who can pay and those who can’t; a preferential health service; believes this needs to end in order to restore national balance  and must set national standards (each government’s responsibility in terms of funding) * RECOMMEND: reference at bottom of slide to table in book * Canada Health Act (1984) - The act sets out the primary objective of Canadian health care policy: ―to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers‖ - fails to define what reasonable access is and doesn’t define or describe other barriers to access (vague legislation in terms of big picture issue but specific on what’s provided as medically necessary: hospital, physician and surgical dental services) * broad language left for the provinces to determine - Medically necessary hospital, physician, and surgical dental services  Reasonable access  Provision of insured health services - The CHA sets out health insurance program criteria and conditions – 5 principles – for provinces to receive full federal cash contribution – Canada Health Transfer - ―Medicare‖ refers to Canada’s health insurance program - auditing to make sure that services billed by physicians were viable - Services not included under the CHA:  Home care  Residential care  Dental care outside hospital  Pharmaceutical outside hospital  Extended health services – physiotherapy, massage
 therapy, etc. -
 Groups of people not covered the CHA  First Nations people living on reserves  Inuit people  Canadian Forces  Royal Canadian Mounted Police  Veterans  Inmates  Refugee claimants Other funding arrangements: - directly through the federal gov’t or programs in between fed. and prov. - not covered under CHA in terms of medically necessary, but can have other arrangements (audio) (review audio for the following) Comprehensive Universal Portability (hospital and physician services are comparable across the country, up to 3 months) Accessibility Public Administration  they can’t make any profit off of administration/operation of health care insurance plan Late 1980s and 1990s: (cracks in the healthcare system) - economic downturn; as a result, federal government decreases payment to provincial governments (now on the hook for even more! The imbalance is evident) - Reduction in federal transfer payments - Adoption of business models in healthcare  Restructuring and regionalization (decreases in services across the board, wards closing = surgery backlog, long waiting lists for heart, hip, knee surgeries; people start expressing concerns; etc.)  Layoffs of healthcare workers, hospital closures, and unit closures (tens of thousands of nurses created shortage that we are still dealing with today!) - Concerns about sustainability of healthcare funding - Issues in healthcare include increased wait times for physicians, surgeries, emergency care - Numerous provincial commissions  Attempts to address economic impact on healthcare; looking for solutions  ―Innovation‖ to address ―crisis‖ 2000s: - Romanow Commission (2002):  to examine the long-term sustainability of a universally accessible and publicly funded healthcare system  Canadians value Medicare; aligns with values  what needs to be done to modernize health care; making it more responsive  passionately believes medicare is sustainable and shouldn’t be looking to privatize - Kirby Commission (2002; same time!)  what should the federal role in health care be?  traditionally: portion of funding, criteria, sets a vision of what health policy should be, some responsibility of services, etc. o should this change? More involvement? Less?  Believes that there might be some efficiency in privatizing services o starts the discussion on how this might be implemented - First Minister’s Accord on Health Care Renewal (2003):  recommit to medicare  agreement on health care renewal - First Minister’s Plan (2004)  ten year plan to strengthen health care  figuring out how health care will be sustainable going into the future Key Features/Commitments of the 2003 Accord and 2004 10-year plan:  Commitment to Medicare and Canada Health Act  Wait times reduction  Health human resources planning – address shortage of healthcare providers  Home care – compassionate care benefit (fed); expanded home care (prov.)  Primary health care – multidisciplinary teams; 24/7 access; electronic health  eHealth/telehealth  Pharmaceutical policy – catastrophic drug coverage (very ill and drugs are extremely expensive? , national strategy  Aboriginal health – consultation; clarify roles and responsibilities; funding  Other – public health, rural health,  Funding - Annual increase of 6% Institutes to monitor health care better… 2000s: - Health Council of Canada  monitor and report on Accord and health care - Canadian Patient Safety Institute:  response to research regarding adverse events - Public Health Agency of Canada:  post SARS and pandemic concerns - Patient Wait Times Guarantees Initiative  significant media focus on wait times 2010-2013: audio - provinces will only see a 1-2% increase in funding from fed. - leave it to the provinces to make majority of decisions Federal-Provincial Health Care Financing: AUDIO  Primarily generated through tax revenue – provincial and federal  Federal government - Canada Health Transfer ~ $40 billion disbursed to provinces and territories (~ $10 billion goes to Ontario)  Health care accounts for ~ 46% of provincial spending  Ontario – 2013-14 - $48 billion Ministry of Health and Long-term Care o Federal portion about 20-25%  Federal portion of funding may decrease after 2016.  Ontario Health Insurance Plan (OHIP) – entitles Ontario residents to provincially funded health coverage o Falls under MOH and long term care; comes out of approx. $48 B budget Ontario: 20% federal, 80% provincial (they have the power; through tax dollars predominantly) Total Expenditures: 70.5% taxation 14.7% out of pocket 12.8% private insurance 2% other Private Health Insurance & Out-Of-Pocket: - prescription drugs; dental care; vision care; rehabilitative services; complementary and alternative services - private health insurance – majority employment-based policies  partly by employer, partly by employee  partial to complete coverage of extended services such as prescription drugs, dental, vision, etc. - out of pocket: additional expense not covered but provincial insurance plans and private health insurance Trends in Expenditures: - hospital spending has been decreasing fairly steadily (due to restructuring, increased funding for home care, increase in technological advances – shorter hospital stays, etc.) - spending more money on drugs/pharmaceuticals every decade!  big change between 90s and 2000s  trying to reign in here  big business! - physicians have leveled off, or decreased slightly Total Health Expenditure per Capita across Countries: - in relation to other countries  Canada around 4,000 per person  in the middle of developed countries  can't equate spending to outcomes though!!  i.e. US has some very negative outcomes Exercises: - review the historical events and trends discussed - identify key events and trends that shape or influence Canadian health care today  how do they shape/influence healthcare?  what do you think are the most significant issues impacting healthcare? - baby boomers = punctuated equilibrium - chronic disease levels - mental health more prominent Health Care Services: - *** look at diagram Public Health: - primarily targets populations, not individuals  generally speaking! (programs meant to change populations; i.e. smoking cessation, sexual health in high school)  addresses individual care, but not primarily - 6 essential functions:  pop. Health assessment  health promotion  disease and injury control and prevention (i.e. preventing falls, etc.)  disease*** (typo) prevention  surveillance (contact tracing, structured reporting from local to international level)  emergency preparedness (i.e. pandemic) - post SARS – commissions identified significant challenges in the capacity of public health to rapidly respond to challenges  early 2000s: 2% provincial budget (do a lot with a little!)  post SARS: 4-6% - Ontario Chief Medical Officer of Health – Dr. Arlene King - Ontario – 36 public health units Primary Care: - considered foundation of Canadian health care system - first point of contact primarily with physician or nurse practitioner for acute episodic care & coordination of other services - Historically, physicians paid fee-for-service but new models of remuneration (payment) - Shift from acute episodic care to chronic disease management - Introduction of new models of primary care (and a blend!)  Interdisciplinary care  Nurse practitioner led clinics  24/7 access - In Ontario – Family Health Teams, Family Health Organizations, Family Health Groups, as well as some solo physician practices. - Primary care funded directly through the provincial governments Acute Hospital/Inpatient Care: - covered by CHA Hospitals - generally private, but not for profit - regionalization (geographic level where decision is made; they know their population’s needs best); given provided requirements are met! - governments have significant authority through funding LHINS: - hospitals, community care access centres, community support services, long-term care, mental health and addictions services, community health centres - regionalized also – decision making at a local level Emergency Care: - primarily in hospitals - 24/7 access to emergency services  covered by CHA in hospitals - linked to ―first responders‖ paramedic and ambulance services  not CHA - concerns raised about wait times  1 in 10 is longer than 8 hours … audio thru all the services, sorry nat… PHARMACEUTICAL CARE - Medications covered in hospital (under Medicare) - Provincial drug plans cover low income and seniors (Ontario Public Drug Programs) - A National Pharmaceuticals Strategy was requested – including addressing inconsistent coverage among provinces; catastrophic coverage; sharing of evidence; purchasing power - little action on the strategy to date - ―Of the $21 billion spent on prescribed drugs in Canada in 2006, 46% was financed by the public sector, and 36% was funded by private insurers. The remaining $3.9 billion was paid directly out-of-pocket by Canadian households.‖ REHABILITATIVE/INTERMEDIATE CARE - Inpatient rehabilitative services in hospital (and deemed medically necessary) covered by provincial health plans - Most rehabilitative services not covered or only partially covered - Most individuals pay out-of-pocket or have private health insurance (employer-based) - Ontario – covers most seniors under a new initiative - ―Helping Ontario's Seniors Stay Healthy, Active and Independent‖  Physiotherapy, exercise and falls prevention classes help seniors stay healthy, and recover from surgery or injury. Residents in long- term care homes, seniors in retirement homes, and those living in their homes in the community, who need these publicly funded services, will continue to get them. LONG-TERM CARE (RESIDENTIAL CARE) - Institutional or home care – typically older adults or others with significant disabilities - Long-term care homes– typically individuals require 24 hour nursing care or supervision - Not covered explicitly under the Canada Health Act so coverage varies across the county  Combination of private and public (provincial government) funding - Ownership varies – some privately owned; others mix of private and public ownership - In Ontario, LTC homes licensed by the MOHLTC and governed by legislation HOME CARE - Seniors were 14% of population in 2009 expected to rise to 24% in 2036 - Seniors wish to ―age in place‖ - Seniors - 14% of population but consume ~ 44% of provincial healthcare dollars - Home and community support services are funded by various sources, including:  the government (provincial and/or municipal)  donations to voluntary organizations (who often deliver these  private insurance or benefit plans (e.g. private health insurance)  the individual (e.g. by purchasing services privately) - Ontario – home care can include:  Visiting Health
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