The Medicare and Private Baskets of Health Services in Canada: Two Silos and No Dialogue - PowerPoint PPT Presentation

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The Medicare and Private Baskets of Health Services in Canada: Two Silos and No Dialogue

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Title: The Medicare and Private Baskets of Health Services in Canada: Two Silos and No Dialogue


1
The Medicare and Private Baskets of Health
Services in Canada Two Silos and No Dialogue
  • Lawrence Nestman, Professor
  • Christine Joffres, Ed. D.
  • School of Health Services Administration,
    Dalhousie University, Nova Scotia, Canada
  • 5th International Conference on Priorities in
    Health Care, November 3-5, 2004, Wellington, New
    Zealand
  • Do not use any of the slides without prior
    authorization from the authors

2
Acknowledgements
  • Three year study funded by Canadian Health
    Services Research Foundation and the Canadian
    Institute of Health Research, with matching funds
    from the Nova Scotia Health Research Foundation,
    Newfoundland and Labrador Centre for Applied
    Health Research and Ontario Ministry of Health
    and Long Term Care.
  • Project Team includes Thomas Rathwell, Lawrence
    Nestman, Nuala Kenny, Christine Joffres, and
    Steve Jreige from Dalhousie University Raisa
    Deber, Patricia Conrad, and Heather Chappell from
    the University of Toronto Doreen Neville and
    Roger Chafe from Memorial University of
    Newfoundland.

3
Objectives of the study
  • To identify prioritization processes used by
    public and private insurers in Canada when
    purchasing health care services
  • To explore the impacts of purchasing mechanisms
    on equity
  • To identify ways to improve the interface of the
    Medicare and Private Baskets
  • Public insurers 10 provinces, 3 territories,
    the federal government
  • Private insurers employers unions (group
    health plans)

4
Methods
  • Interviews with 15 senior civil servants from
    7/10 of the Canadian provinces.
  • Interviews with 19 senior benefits consultants
    from international and national consulting firms.
  • Interviews and focus groups with 7/8 of the
    largest insurance organizations in Canada.
  • Two focus groups with 12 employers.
  • Preliminary data analyses grounded theory
    principles (open and axial coding, constant
    comparisons, theoretical memos).

5
Canada
  • 31 million inhabitants
  • 10 Provinces, 3 territories and federal
    government 13 different health systems
  • Health is a provincial responsibility
  • Health care expenditure
  • - 10 of GPD
  • -70 publicly funded
  • -30 are privately funded (40 PI)

6
Canada Health Act - 1984
  • Comprehensiveness
  • Universality
  • Portability
  • Public administration
  • Accessibility

Universal Access to Public Care
7
Current Situation
  • Hospital care and physician care publicly
    funded.
  • Considerable province-to-province variation
    exists for public coverage of home care, long
    term care, and services provided by health
    professionals other than physicians.
  • Drugs, dental care, and vision care mostly
    privately funded.
  • Privately funded health plans 2 options
  • Self-insured (the majority) by private employers
    and some unions
  • Fully insured (small organizations)
  • Health services funded by the provincial plan
    under the Act cannot be also funded by private
    insurance companies.

8
Self-insured plans-Privately fundedEmployers -
Unions
  • Decision Making Criteria
  • Legal sieve (2 levels)
  • Provincial delisting
  • Affordability (cost of services, service
    utilization, number of people affected, financial
    impact on private package)
  • Economic welfare of people affected (unions
    mostly)
  • Effectiveness (varies)
  • Demand (varies)
  • Comparisons with similar others (private
    employers mostly)
  • Organizational characteristics (type of industry,
    organizational size, leadership, workforce
    make-up, location, presence of a union, etc.)

  • Process.
  • Employees/Unions feedback on desired/needed
    services
  • Benefits consultants or insurance feedback on
    cost and product utilization, similar others, and
    financial impact on package.
  • Benefits committees or human resource personnel
    evaluate data and make recommendations to CEO or
    the Board of Trustees re. Addition of new
    services
  • Unions if financial surplus available and makes
    decision re. inclusion of new service. For
    individual demands, have some discretionary funds
    (then economic welfare of people affected becomes
    important). No surplus funds balanced against
    other priorities and may go to labour
    negotiations.

9
Private Insurance - Adding a New Product to
Private Baskets
10
Provincial Department of Health
Decision-Making Criteria and Processes for New
Services
11
Results continued
  • Two silos and no dialogue due to
  • -Disparities in value systems
  • -Minimal understanding of the other
  • -Mutual distrust
  • Inter- and intra-provincial erosion of equity
  • -Comprehensiveness
  • Reduction or elimination of publicly covered
    services, including rehabilitative
    chiropractic services, assistive devices, eye
    dental care, home support, mental services,
    out-of-province coverage, out-patient
    pharmaceuticals
  • -Access
  • Waiting lists (mushrooming of private clinics
    for diagnostic services eye care)
  • Queue jumping
  • -Increased burden of healthcare expenditures on
    employers and employees
  • Flex plans, caps on reimbursements
  • Increased co-payment of premiums, increased
    deductibles
  • -Decreased choice
  • Pre-authorization of specific interventions,
    restricted formularies

12
CONCLUSIONS
  • Priority setting myopia?
  • A reactive, fragmented system focusing mostly on
    cost containment rather than improving population
    and individual health
  • A system focused on biomedical individualism
    rather than the broader determinants of health
  • Need for an integrated public-private approach
  • Citizen engagement via citizens forums for
    health care
  • Moving beyond health care or medicine to health
  • Horizontal and vertical coherency
  • Stewardship from the Public sector
  • Political expediency is not acceptable

13
Conclusion
  • A man, walking along the shore, hears a plea for
    help from someone drowning in the river he races
    over and pull him from safety, only to hear
    another cry for aid, and another cry for help,
    and yet another cry for help. After helping the
    fourth victim, he goes further downstream to
    another and still another victim, ushering them
    all to safety only to find someone else in
    distress. Though he can still save one person
    after another, he will soon be overwhelmed. And
    because he is so busy saving people from
    drowning, he doesnt have the time to turn
    upstream to see who keeps pushing them in the
    water in the first place. (A. Weston, 1991, J.
    Social Philos., 22, 109-118)

14
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