The Senate Standing Senate Committee on Social Affairs, Science and Technology The Health of Canadians – The Federal Role Final Report on the state of the health care system in Canada Chair: The Honourable Michael J. L. Kirby Volume Six: Deputy Chair: The Honourable Marjory LeBreton Recommendations October 2002 for Reform Ce document est disponible en français. v v v Available on the Parliamentary Internet: www.parl.gc.ca (Committee Business – Senate – Recent Reports) 37th Parliament – 2nd Session The Standing Senate Committee on Social Affairs, Science and Technology Final Report on the state of the health care system in Canada The Health of Canadians - The Federal Role Volume Six: Recommendations for Reform Chair The Honourable Michael J. L. Kirby Deputy Chair The Honourable Marjory LeBreton OCTOBER 2002 TABLE OF CONTENTS TABLE OF CONTENTS........................................................................................................ i ORDER OF REFERENCE..................................................................................................vii SENATORS.......................................................................................................................... viii LIST OF ABBREVIATIONS................................................................................................ ix ACKNOWLEDGEMENTS................................................................................................... xi FOREWORD........................................................................................................................xiii INTRODUCTION..................................................................................................................1 PART I:: ACCOUNTABILITY........................................................................................................................................................3 CHAPTER ONE..................................................................................................................... 5 THE NEED FOR AN ANNUAL REPORT ON THE STATE OF THE HEALTH CARE SYSTEM AND THE HEALTH STATUS OF CANADIANS............................................................................................. 5 1.1 Summary of Some Key Points from Volumes One through Five.......................................................5 1.1.1 The role of the federal government ...............................................................................................................5 1.1.2 Objectives of federal health care policy ..........................................................................................................6 1.1.3 The current system is not fiscally sustainable ..............................................................................................8 1.1.4 A national health care guarantee is critical to successful reform...............................................................10 1.2 Improving Governance – The Need for a National Health Care Commissioner .........................11 1.2.1 Canadian Medical Association (CMA) ...................................................................................................13 1.2.2 Colleen Flood and Sujit Choudry.............................................................................................................14 1.2.3 Tom Kent ..................................................................................................................................................15 1.2.4 Duane Adams ..........................................................................................................................................15 1.2.5 Lawrence Nestman.....................................................................................................................................16 1.3 The Committee’s Proposal............................................................................................................................17 PART II:: EFFICIENCY MEASURES..............................................................................................................................23 CHAPTER TWO .................................................................................................................. 25 HOSPITAL RESTRUCTURING AND FUNDING IN CANADA ....................................................... 25 2.1 Funding Methods for Hospitals in Canada: Advantages and Disadvantages..................................27 2.1.1 Line-by-line.................................................................................................................................................28 2.1.2 Ministerial discretion ..................................................................................................................................29 2.1.3 Population-based.........................................................................................................................................29 2.1.4 Global budget..............................................................................................................................................30 2.1.5 Policy-based.................................................................................................................................................31 2.1.6 Facility-based..............................................................................................................................................32 i 2.1.7 Project-based ...............................................................................................................................................32 2.1.8 Service-based ...............................................................................................................................................32 2.2 Service-Based Funding: Review of International Experience..............................................................33 2.2.1 United States..............................................................................................................................................33 2.2.2 United Kingdom .........................................................................................................................................34 2.2.3 France.........................................................................................................................................................34 2.2.4 Denmark....................................................................................................................................................35 2.2.5 Norway.......................................................................................................................................................35 2.2.6 Review of international experience by the Comité Bédard.........................................................................36 2.3 The Rationale for Service-Based Funding in Canada.............................................................................36 2.3.1 Appropriateness of service mix ...................................................................................................................40 2.3.2 Over-servicing and up-coding ......................................................................................................................40 2.3.3 Rates, information and data.......................................................................................................................41 2.3.4 Innovation ...................................................................................................................................................42 2.3.5 Comprehensive health care..........................................................................................................................43 2.3.6 Escalation of costs.......................................................................................................................................43 2.3.7 Lack of simplicity.......................................................................................................................................43 2.3.8 Committee commentary...............................................................................................................................44 2.4 Academic Health Sciences Centres and the Complexity of Teaching Hospitals............................46 2.5 Small and Rural Community Hospitals......................................................................................................48 2.6 Financing the Capital Needs of Canadian Hospitals..............................................................................50 2.7 Public Versus Private Health Care Institutions .......................................................................................53 Appendix 2.1 Academic Health Sciences Centres in Canada and their Affiliated Hospitals and Regional Health Authorities ........................................................................................................................59 CHAPTER THREE ............................................................................................................. 63 DEVOLVING FURTHER RESPONSIBILITY TO REGIONAL HEALTH AUTHORITIES.................... 63 3.1 RHAs Across Canada: A Portrait................................................................................................................64 3.2 RHAs: Goals and Achievements .................................................................................................................66 3.3 Barriers that Prevent RHAs from Functioning