Canadian Health Care Part 2

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Warm-Up
• What is one food you never get tired of eating?
Look at Quiz #4
• Take 5-10 minutes
Learning Objectives
• Understand Primary, Secondary and Tertiary Health Care
• Understand what medical services fall under Primary, Secondary and
• Tertiary Care
• Distinguish who pays for certain medical services
• Identify problems challenges and solutions with the Canadian health
care system
Terms
• Primary
• Secondary
• Tertiary
• Gatekeeper model
• Fee-For-Service Payments
Slide adapted by Ruth Lavergne
Levels of Health Care
• Primary
• Secondary
• Tertiary
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 Primary Care
What is it?
•Routine care
•Care for urgent but minor or common health problems

Providers:
•General Health practitioners (family doctors)
•Nurse practitioners

Types of care:
• Check-ups
• Prevention services
• Ongoing treatment of common ailments
• Mental health care
• Maternity and childcare
• Psychosocial services

(3,11)
Where Canadians can access primary care
Doctors Offices
Gatekeeper model - A gatekeeper is a healthcare provider who is the
first point of contact for patients, and who decides what level of care
the patient will get next
• Patient choice of physician . . . up to a point
• May involve waitlists
• Usually (but not always) a family doctor
• Nurse practitioners, physician assistants much more involved in many
places, just not yet in BC
Who pays?
• Provinces (e.g. MSP, OHIP), mostly fee-for service in BC

(2,3)
 Walk-in Clinics
• Definition: clinics that accept
patients on a walk-in basis
• What they provide: low
barrier, first contact access
• What they don’t provide:
coordination or continuity

Who pays: Provinces

(2,3, 7)
Emergency Care
• Emergency Department (ED)
• Staffed by physicians and surgeons
• ED also serves as primary care (especially after hours) for many patients
Who pays?
• Provinces
• Emergency medical care (and patient transfer services)
• Transportation (road or air ambulance)
Who pays?
• Province subsidizes
• Some out-of-pocket payment (in BC $80 if you have MSP, $500 if you do not)

(2,3, 11)
Background Stats
• Family physicians provide comprehensive care for the
community and are an integral part of the healthcare system.
• Among the provinces, Ontario, Manitoba, Saskatchewan and
British Columbia have the fewest family physicians per 100,000
persons in the population.
• according to the Canadian Medical Association, Canada’s
physician-to-population ratio ranks 29th out of 36 high-income
nations.
• Nine hundred thousand British Columbians don’t have a family
doctor.

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Why is this doctor shortage happening?

• Health care system structure

• Provincial government policy decisions in the 1990s
• Reduced # of family physicians
• Reduced # of medical school seats
• Reduced # of family medicine residency positions
• Barriers to access for international medical students aiming to practice in Canada
• Decrease in government investment in primary care
• Family medicine is not a high-income field
• The average salary of a family doctor in BC per year = between $85,000 on the low
end (for part time roles) to $216,000-$250,000 per year on the higher end.
• The average salary of a general surgeon in BC per year – $412,000

(4)
Lack of Medical Schools in Canada
• British Columbia and Ontario have the fewest medical school
seats per population, while Quebec has the most.
• British Columbia has the smallest medical class size and the
least number of family medicine residency spots
• BC also has one of the highest percentages of provincial
residents without family doctors.
• There are 17 medical schools in all of Canada

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Barriers for Internationally Trained Doctors
• Residency is post-graduate training required for licensing.
• Canadian Resident Matching Service, the organization responsible for
matching applicants with residency programs, separates positions
into two streams: Canadian medical graduates, and international
medical graduates.
• When applying, international medical graduates are permitted to
compete for just 10 per cent of positions and are restricted to a
handful of under-serviced specialties, like family medicine.

(5,6)
How Physicians are paid
Most physicians are independent contractors
• Fee for Service
• Based on actual item of care provided
• What it is, how complex
• Most common method of paying physicians
Other models
• Capitation
• Paid based on the number of patients cared for
• Sessional
• Paid per hour of service
• New Model in BC – Longitudinal Family Practice Payment Model

(7,8)
Why Fee-For- Service is a Problem
• "The problem with this type of payment is that it requires the family
doctor to do everything related to the patient's care — the medical
care, the nursing care and the administrative work," said Dr. Goldis
Mitra, a family physician and assistant professor .
• There’s pressure to get through patients, and with some speed and
volume, at a time when an aging population means more people have
not one, but multiple chronic conditions.
• Family doctors can’t take breaks or vacations – leading to burn out

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Trickle down impact of Canada’s Doctor
Shortage: Long wait times
Long wait times:
• A recent Ontario-based study found that that the median wait time
between a patient being referred to a specialist and attending an
appointment was 11.3 weeks for nonurgent referrals and 7 weeks for
urgent referrals.
Without timely access to community care, patients often resort to more
costly forms of care:
• emergency departments
• This type of care strains medical resources further, which leads to an
overwhelmed healthcare system that increases physician burn-out and
encourages early exit from the workforce.

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Hospital Emergency Wait Times

Why do you think emergency rooms have such long wait

times?

Video

• Check Wait Times

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Short-Term Solutions to the Family Doctor
Shortage
Infrastructure changes
• Reducing barriers to practice for international doctors to bridge critical gaps
• applying financial incentives to attract new graduates to family medicine
• providing much-needed administrative support to current physicians.

Increasing Residency spots

• The B.C. Practice Ready Assessment program will also increase from 32 to 96
seats to provide internationally educated family doctors with post-graduate
training.

Video by CBC National Library of Medicine

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Long-Term Solutions to the family doctor
shortage
• Increasing the number of medical graduate slots in Canada
• Establishing family doctor specific entry streams in medical schools or family
doctor specific medical schools
• Team-Based Care: create bigger clinics with different health- care providers that
meet the community’s needs,” and that allows everyone to take a break
occasionally.
• Get rid of the Fee-for service model
• Creation of a national data collection framework is needed to quantify the need
for, and facilitate the distribution and mobility of, FPs across the country.

(4)
Secondary Care
What is it?
• Specialist care
• Must be referred from a GP to receive care
Providers:
• Specialists such as surgeons, Gynecologists, cardiologist
Example: Primary care providers seeing a patient with
vision problems will refer them to an ophthalmologists

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 Specialist physician
services
Generally provided in
outpatient departments of
hospitals, some provided in
private doctors' offices
Who pays?
• Most specialists paid fee-for-
service, by province, though
some paid salaries or under
other arrangements (often
via health authorities)

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Rehabilitation Inpatient vs. Outpatient
Rehabilitation Inpatient
• joint replacement surgery, amputation, stroke, brain dysfunction spinal cord replacement
Who Pays?
• Provinces
Rehabilitation Outpatient
• Physiotherapists, Occupational Therapists, etc.
Who Pays?
• Public coverage varies by province
• Private health insurance
• Out of pocket

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Problems Secondary Care- Case Study
• Meera has suffered from headaches since she was a child. Sometimes, the frequency is as high as one a
day. Recently, the headaches have been getting worse and she has trouble getting out of bed.
• Meera saw her family doctor, who referred her to a neurologist headache specialist. After three
months, she had heard nothing, and the headaches were getting worse. She checked back in with her
family doctor, who said that a fax had been sent to the neurologist; he showed her a copy of it in her
chart. The doctor said it can take a long time to see a specialist, and that she should go home and wait.
• Three months later, still waiting to see a specialist, Meera had a headache so terrible she had to go to
the emergency room. After a long wait, the doctor told her she had a migraine, and that she should
definitely see a neurologist. Meera was so upset, she called the neurologist’s office herself, only to be
told they hadn’t received a fax about her case. She called her family doctor and was told by reception
that the office had a record of the fax on file, but that they would resend it to the neurologist anyway.
• Six months after that – about a year after the first fax – Meera finally saw the neurologist. She
confirmed the headaches were migraines and started her on some pills that have improved the
situation.
• Meera was still frustrated though – she had to wait a year to see the specialist, first because of a lost
fax, and then a long wait list. What if she had had a brain tumour? And why are we still using fax
machines, anyway?
What are some problems Meera is experiencing with the health care system??
Solution: Secondary Care
• The Fix: Canada must increase the use of digital referrals by
doctors.
• Electronic consultation and referral services are promising
innovations to help address inequitable access occurring in a
fragmented, inefficient system.
• Further development of these services is needed, including
improved integration with clinical workflows, electronic
medical records and health information systems.
 Tertiary Care
What is it?:
• Specialized hospital care.
• Requires specialized equipment and treatment
Providers:
• Sub-specialized staff caring for patients over an
extended period
Hospitals services
• Mostly organized by regional health authorities
Who pays?:
• Provinces.

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Problems with Tertiary Care
• problem with the idea of “tertiary medical care” is that it is focused
on the disease rather than the people being treated
• We should encompass the whole person in treating them, not just their complex disease
• The second problem is that the term implies that we generally care
for a patient by working up through the three levels of medical care
(primary through tertiary).
• Since we only have tertiary care in specialized hospitals it becomes
exclusionary
• This isn’t the case for someone coming in from severe trauma from a car
accident
• tertiary care should come first

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Solution: Tertiary Care
•Implement continuous tertiary care across
all settings and types of providers.
The Role of the Patient
Patient-Centred Care – Providing care that is respectful of and
responsive to individual patient preferences, needs, and values, and
ensuring that patient values guide all clinical decisions.

The medical systems structure creates a large power imbalance

between patient and physician that can sometimes cause harm.

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Challenges to the System
The Aging Population
• Fewer family doctors to care for our growing and ageing
population and with increased patient care complexity and a
higher prevalence of chronic health issues, will result in
reduced patient access to care, worse patient outcomes and
further stressors on our healthcare system.
• If Canada doesn’t provide solutions, the problem will only
get worse as the population ages.
Frontline Documentary
• https://www.youtube.com/watch?v=UVvEkeH4O8o

• DOC: COVID has put a spotlight on disparities in American

healthcare and the large urban hospitals hit hard by the
pandemic. But many of these “safety net” hospitals, whose
primary mission is to serve low-income, working-class
communities, have been in crisis for years.
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