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Family Councils in Long Term Care
.Exploring the potential benefits and constraints of family councils in long-term care

BCCPA Newswire, Family Councilslong term careResidential CareSenior Care

Aug. 14, 2017 Our understanding of how care should be delivered to seniors depends greatly on applied research
Through research, we know that family plays an integral role in senior care. We also know how the involvement of individual family members can determine quality of life for residents in care.

What we need now is a greater understanding of how family councils function, and their impact on long-term residential care in B.C.

The role of family councils

Composed of family and friends of long-term care home residents, a family council meets regularly to identify and resolve issues affecting all residents, plan activities, and support each other. A family council must be organized, self-led, self-determining, and democratic.

Family councils typically work with a staff liaison appointed by the care home to assist the council.

Family councils aim to facilitate communication, and promote partnerships between staff, residents, as well as families of residents not actively involved in the council.

“Care providers work very closely each and every day with family councils and individual family members of residents in care facilities,” said Daniel Fontaine, CEO of the BC Care Providers Association.

“Family members play a very critical role in helping maintain and improve the quality of life of seniors living in a care setting. A fully functional and effective family council has proven to make a difference in the lives of many of B.C.’s senior population.”

Family councils in British Columbia

B.C.’s Residential Care Regulation supports family councils by stating that long-term care facilities must provide an opportunity for family members to form a council which promotes the individual and collective interests of residents in care, and involves them in decisions that affect their day-to-day.

Gerontological Education, Research and Outreach (GERO) at the UBC School of Nursing released a province-wide report on family councils in the province.

Out of the 222 long-term care sites surveyed across B.C., 151 had family councils. Most of these sites were privately-owned, and located in urban areas.

Facilities with successful family councils reported improved peer support, constructive attitudes, and learning opportunities at their sites.

The report also highlighted challenges to initiating and sustaining a family council, including a lack of interest, poor understanding of a family council’s purpose, and an inconsistency in family attendance.

Findings over the years

Previous research tackling the subject shows the benefits of family councils on long-term care significantly outweigh its drawbacks.

A 2007 study that set out to determine the presence, characteristics and impact of family councils on long-term care in U.S. found they “provide mutual support, empower its members, and advocate change to improve the residents’ quality of life.”

The study, published in the journal Geriatric Nursing, also mentioned family councils contribute to a culture of mutual respect within a long-term care facility.

One of the greatest challenges of maintaining an active council, researchers found, is the fluid nature of membership. Family members are busy with work and their personal lives. And when a resident in long-term care passes away, their family withdraws from the council in most cases.

The study called for increased efforts to identify the role of the facility in supporting family councils, and stated that the involvement of family councils has the potential to improve relationships between family, residents and staff, reduce and address complaints, and improve quality of life for seniors.




On the Sunshine Coast, an Effort to Reinvent Senior Care

We want to create a co-op model of long-term care, learning from COVID-19 tragedies.

By Paula Larrondo and John Richmond 29 Apr 2020 | TheTyee.ca

Paula Larrondo is a Chilean-Canadian activist and vice-president of Casa Salvador Allende. She has been a clinical social worker in medicine, oncology, palliative care and long-term care for more than 25 years. John Richmond grew up in B.C. He’s been a social worker in fields including harm reduction, supportive housing development, emergency medicine and complex continuing care.

Our proposition? Put the people who know best and have direct experience in seniors care, in charge of seniors care. Photo via Shutterstock.

[Excerpt] The for-profit nursing home business has been in trouble for years.

In February, B.C. Seniors Advocate Isobel Mackenzie tabled a reportdocumenting many of the shortcomings of the for-profit care sector, such as higher administration costs and 207,000 funded but undelivered care hours. This is in contrast to a non-profit sector that actually spent more per resident than it was funded for on delivering direct care and service delivery.

While the for-profit system has clearly failed, the non-profit system has its own problems. Residents of such facilities can have their own concerns with, for example, the dilapidated state of physical facilities, overcrowding and lack of cleanliness, and the challenge of raising complaints within a big bureaucracy.

As writer Nora Loreto has documented on her Twitter account, several facilities with a high number of deaths are non-profit or government-operated nursing homes.

There is an alternative to our current health care and seniors care delivery models however: the co-operative model. The co-op model, in particular a type used in Quebec called the “solidarity co-op” or multi-stakeholder co-operative, would empower seniors and workers by giving them a direct say in everything from design and organization of a facility to the day-to-day operations to the negotiations with funders to budgets.

As social entrepreneurs and activists in the local food movement, housing and energy co-ops and credit unions, we hope to work with the Sunshine Coast community to stop a proposed for-profit long-term care facility and replace it with a co-operative model. To be clear: we support any alternative to the private model.

The proposed Trellis Seniors Services Ltd. project on the Sunshine Coast originates with Mary and Dan McDougall of North Vancouver. Mary McDougall has been a player in B.C.’s for-profit senior care industry going back to the early 2000s.

During the Christy Clark BC Liberal government, Trellis signed a contract with Vancouver Coastal Health to build three facilities in Richmond, North Vancouver and the Sunshine Coast.

We share their concerns and are among those proposing an alternative approach. A new multi-stakeholder co-operative model of long-term care and assisted living on the Sunshine Coast would give what John Restakis called, in a groundbreaking 2008 report on co-operative seniors care, “control rights” — rights that would “offer some assurance that other interests will not override the interests of those receiving care.”

Read more at: On the Sunshine Coast, an Effort to Reinvent Senior Care


seniors help

Out-of-date for-profit long-term care homes had highest number of COVID-19 outbreaks

A new study of long-term care homes in Ontario shows that older facilities – most owned by corporations that have been paying out millions in profits to shareholders – were a significant factor in determining the likelihood of a COVID-19 outbreak.

These homes were most likely to have outdated design features, including shared bedrooms for up to four people and larger common areas where the virus could spread more easily among groups of people. While former Ontario governments passed newer building design requirements that removed shared and common rooms, there was no direction given to owners of the long-term care homes to implement them. Read more.

The COVID-19 pandemic has put a spotlight on the tragedy in long-term care homes that requires national attention and action. The Council of Canadians is calling on the federal government to work with provinces and territories on a national strategy that will make the homes safer for those who live and work there. To help build public pressure on governments, we are encouraging people to write letters to the editor of their local newspapers using the Council’s new easy-to-use tool.

Together, we can bring about the changes that are needed in long-term care homes across Canada.

Note: Based on your postal code, your letter will be automatically submitted to your 5 closest newspapers. You can use any of the talking points at the bottom of this page for your letter and be sure to add in your own, or send the form letter.


seniors help

Image by Chelsea Flook


The Council of Canadians is calling on governments across the country to do more to support and protect both the residents of long-term care and those who work to care for them.

Jan Malek July 2020
I recently had the opportunity to participate in a video conference where long-term care workers from across the country spoke about their experiences with the COVID-19 outbreak in Canada. Their stories echoed with sadness and frustration as they described the tragedy that has transpired in many homes across the country. 

To date, more than 8,800 people have died in seniors’ care homes across Canada from COVID-19, the majority of them in long-term care homes, according to numbers compiled by freelance journalist Nora Loreto. This number represents more than 80 per cent of all COVID-19 deaths in the country. 

Canada’s shameful record of COVID fatalities in long-term care is the highest of all developed country in the world. A report by the Canadian Institute of Health Information found that “the proportion of deaths occurring in long-term care (LTC) is double the OECD average.” It is a national tragedy that cannot be ignored, especially as the threat of another wave of COVID-19 infections looms. 

Workers in long-term care homes have unique insights on what is needed to avoid additional tragedies. Governments should be listening to their experiences closely – not to the managers or the corporate faces representing the homes – but the people who work and provide care in the homes (and whenever possible, the people who live in them too). 

Here are some things I learned from long-term care workers: 

* There was a lack of communication in the first wave of COVID-19. Many workers reported
difficulty getting information on infection rates and weren’t always made aware of who was
sick with the virus. This lack of information made it difficult to limit the spread. In some
provinces the health directives were unclear and poorly communicated within the homes.
One worker said they knew they should wear a face mask, but the management of the home
they worked in discouraged it because it would “scare the residents.”   

* Many workers said they had to “beg” for proper personal protective equipment (PPE). Homes
are required to have a three-month supply in case of outbreaks or pandemics but many
workers found the supplies were old and degraded, or not substantial enough in quantity to
last longer than a few weeks. 

* By far, the most repeated concern workers expressed was staffing shortages. Workers have
been sounding the alarm of staffing shortages in long-term care homes for years and they say
the pandemic made this crisis even worse. 



COVID-19 Has Exposed the Perils of ‘Financialized’ Seniors’ Care

The pandemic has highlighted worse outcomes and more deaths in for-profit care homes.

In May, Orchard Villa, a long-term care home in Pickering, Ont., made headlines for a bad COVID-19 outbreak. Just two months into Ontario’s lockdown, 77 patients in the 233-bed home had died. A report by Canada’s military revealed horrifying conditions, short staffing and neglect.

Some family members blamed for-profit ownership, arguing that COVID-19 had simply exposed, in tragic fashion, the impact of prioritizing profits in the operation of seniors housing.

Notably, Orchard Villa had been purchased in 2015 by private equity firm Southbridge Capital, adding it to Canada’s growing stock of “financialized” seniors’ housing — bought by financial firms as an investment product.

To access the article, please click on: COVID-19 Has Exposed the Perils of ‘Financialized’ Seniors’ Care


The COVID-19 pandemic has exposed the “place blindness” that causes policy-makers to overlook the specific needs and potential of rural Canada.

S. Ashleigh Weeden
July 8, 2020

“To realize the radical potential of the rural, we must leave behind outdated assumptions  
that both rural decline and unchallenged urbanization are the twin edges of some inevitable  

The first six months of this new decade have forced us to reconsider nearly everything: how we work, how we connect with each other and, with increasing urgency, the purposes, functions and futures of the structures and institutions at the core of our social and economic systems. The COVID-19 pandemic and the widespread reckoning with racism brought about by the latest resurgence of the Black Lives Matter movement are both happening in the shadow of a global climate emergency. The confluence of crises has forced our collective hand. These are not polite invitations to consider incremental change, they are radical disruptions that are shaking us by our collective shoulders and asking: What will you do now?

“……..we need to overcome the laziness of viewing the application of public policy  
interventions through the lens of “urban versus everywhere else” and develop place-based 
approaches that recognize the value of a diversity of both rural and urban communities and 
the critical linkages between them.”

If we have learned anything in the first half of 2020, it’s that our public institutions and policy machinery can be far more nimble than we sometimes give them credit for. We’re doing things we didn’t think we could do before — from the universal income support of the Canada Emergency Response Benefit to a massive shift in public consciousness and engagement with anti-racism movements. Many of our assumptions about the way we do government can and should be re-examined. It’s not so much that the convergence of multiple crises has broken our socio-economic systems, it’s that they have exacerbated the cracks and crevices that were already there, with the kind of acute clarity that means they can no longer be ignored.

One such increasingly volatile fault line is the rural-urban divide. The tendency toward conflict between rural and urban communities, despite their many interconnections, long predates this unexpectedly chaotic year. Contributors to Policy Options noted the growing disconnect between rural and urban Canada in 2017. In 2018, the economic geographer Andrés Rodríguez-Pose drew direct links between such divides and their socio-economic and political consequences by calling the geographic distribution of growing populism “the revenge of the places that don’t matter.” Whether it’s the glaring ineffectiveness of the way we approach investments in rural broadband, the social and economic pressures linked to “disaster gentrification” or renewed awareness of the centrality of rural places in providing critical resources like energy or food (and the racialized dynamics of the labour of some parts of Canada’s agri-food system) — 2020 has surfaced serious sinkholes in Canadian rural policy.

Curious about the following questions? 
– Do we value rural places?
– Is there a “right to be rural”?
– Who gets to decide what happens next?
– Realizing the radical potential of rurality
Read more by clicking on:  The COVID-19 pandemic has exposed the “place blindness” that causes policy-makers to overlook the specific needs and potential of rural Canada.


Amit Arya July 16, 2020 

Palliative Care has been lacking for decades in long-term care

Our overhaul of nursing homes needs to integrate a proper model for palliative care, which, shockingly, very few residents ever receive.

When the Canadian Armed Forces were called in to help Ontario’s nursing homes during the COVID-19 pandemic, they were shocked by the care and treatment of our nation’s seniors. Their report shared details that Ontario Premier Doug Ford referred to as gut-wrenching. Findings included:

“Poor palliative care standards, including no mouth or eye care supplies for dying residents.”

“Palliative care orders are not charted, are unknown to staff and therefore not often observed and residents’ documents are out of date.”

“Lack of pain treatment, including a patient with a fractured hip and inadequate palliation.”

What may also be shocking is that these findings are not unique to the pandemic. Even on a good day, palliative care is often utterly inadequate in nursing homes, and this needs to change.

In Ontario, the average resident of a nursing home dies within 18 months. For many of us, these are the places we will go to die, yet palliative care is not something people in these homes predictably receive. In fact, only six percent of residents in a nursing home have a record of receiving palliative care in the last year of life, according to a 2018 study by the Canadian Institute for Health Information (CIHI).

As Canada discusses reforming our nursing homes in the wake of COVID-19, it is important that we recognize the need for early, integrated palliative care. What this means is that suffering is monitored and then addressed in a timely fashion when required, not just in the last days or weeks. It means that we attend to the physical and emotional well-being of patients and their families while continuing to learn about what quality of life means for them. This care happens while patients are being treated for their underlying illnesses and continues after they or their doctors decide that treatment is no longer helpful, desirable or necessary.

Palliative care does not hasten death, as some people believe. It improves the quality of life that remains. And it should not be reserved for the last desperate hours or days, because suffering usually starts much earlier. Importantly, it can be provided alongside other treatments to sustain life, if appropriate.

Palliative care is built on frequent, deep conversations between health workers, patients and their family members. The goals of these conversations are twofold: to ensure that patients and families understand the medical situation and the healthcare team understands what is important to the patient in the time that is left. These essential discussions take time and trained health workers – something in short supply in the nursing home system.

There is a huge staffing discrepancy that exists between institutions. In my experience as a palliative care physician, those dying in hospice have a nurse who cares for four other patients. But those approaching end-of-life in nursing homes may have a nurse who cares for about 30 other patients in the day, or even 60 other patients at night. Imagine.

For decades, our nursing home system has not been meeting the needs of our seniors. Even worse, as the population has aged, resources havent grown to meet the demand. People in nursing homes are now much sicker and more medically “complex.”  Often they have diseases with no cure, such as dementia or heart failure, lung disease or kidney problems.

Nurses and doctors in these homes are not always trained to recognize when a patient could benefit from palliative care to ease symptoms such as breathlessness, pain or agitation. Even if they are, they do not necessarily have the resources, time or knowledge to help. Too frequently, when a patient’s underlying condition predictably worsens, they are sent to the emergency department – putting them at risk for more confusion (called “delirium”) due to the change in environment and caregivers, and quicker loss of muscle mass because no one gets them out of bed. Improving nursing home care may allow more seniors to receive the care in the place they actually consider their home.

Effective and timely palliative care can help to recognize and treat pain in someone with dementia, which can decrease agitation and improve quality of life. For example, for a person with advanced lung disease, physicians can prescribe steroids and low-dose opioids to relieve shortness of breath, and antibiotics to treat predictable infections in the nursing home. For someone in the last hours or days, treatments may focus on ensuring comfort for the patient, and emotional support for their grieving loved ones.

And palliative care doesn’t just involve medication. It can include companionship for a person who is isolated, to give them hope and purpose in life. It can mean a receptive ear or spiritual counsel for family members, to address any feelings of guilt, anxiety or anger that they might have.

Palliative care allows people to live the best life possible until the end.

But all of this requires qualified staff who have sufficient time to evaluate the health of patients, meet with their families regularly, and adjust treatments as a disease progresses. It means knowing when to intervene and just as importantly, knowing when to stop.

So what needs to be done?

  • Culture change. In many nursing homes, palliative care is equated with end-of-life care. But effective 21st century” palliative care means treating symptoms in a timely way, maintaining function and wellbeing for as long as possible, and ensuring treatments flow from ongoing discussions to understand what matters most for the patient.
  • More staff. Staffing ratios need to improve in nursing homes for all front-line health workers. This will help them monitor symptoms closely, deliver appropriate treatment and allow the residents to personalize their daily routines and avoid monotony. Workers in nursing homes deserve the same pay as their counterparts in hospitals.  Having more staff also permits a team approach including physicians, nurse practitioners, nurses, personal support workers, physiotherapists, occupational therapists, social workers, activation therapists (professionals who plan recreational activities such as movies and bingo), and spiritual care.
  • Education and training standards. The care in nursing homes is highly specialized. We wouldn’t allow health workers to work on the labour and delivery ward without training in obstetrics, nor would we allow someone unable to perform CPR to work in an emergency room. How is it acceptable that nursing home staff are not required to have training and skill in the basics of palliative care?  You may be surprised to hear that many medical students and residents – even those moving into careers in family medicine or geriatrics – do not have any required rotations in palliative care.
  • Access to palliative care specialists. Although there will not be enough palliative care specialists in the near future to directly see all nursing home residents, specialists need to be more available to provide advice when a patient or family has concerns that are not resolved with initial attempts by the nursing home staff.
  • Virtual care. Due to COVID-19, some nursing homes are now using virtual care to provide additional support from hospital-based specialists. This improves access and needs to continue beyond the pandemic.
  • Accurate prognosis. When predicting life expectancy, even the best doctors and nurses can often be wrong. Very soon, cutting edge tools developed from “big data” could help health workers, nursing home residents and their families make better decisions and avoid overtreatment.
  • Frequent conversations about current and future treatment. It is important for nursing home residents – along with their loved ones – to understand their condition well in order to choose the right treatments for them. Nursing home staff should offer treatments that relieve suffering, and if appropriate, treatments that prolong life without greatly sacrificing quality of life. But having these discussions, often centred around meeting with family members, requires skill, training and time.

Long-term care needs to fall under the Canada Health Act. To ensure equitable access and high-quality care, our federal government must implement a national long-term care strategy.  This will ensure standards don’t vary based on where one lives, and include measurements to assess the quality of care in nursing homes. Important metrics include monitoring of pain and symptoms, advance care planning and goals of care discussions, psychological and emotional well-being of patients and their families, hospital transfers and place of death.

And if we get the model of palliative care right in nursing homes, we can learn to improve care for patients in other settings, too, such as homes and retirement facilities. As our population ages, more people will develop incurable diseases like dementia and require skilled care, including palliative care.

Our death-denying culture tends to push people who are aging and dying out of sight and out of mind. COVID-19 has had a devastating impact on long-term care residents and their families, and we’re seeing the tragic effects of this indifference. We must make sure those in the final phase of their lives have the best palliative care we know how to deliver. Reform and redesign of Canada’s long-term care homes need to include early, integrated palliative care so we can live the best lives we can – with the least suffering – until the end.

This article is part of the Facing up to Canada’s long-term care policy crisis special feature.

For related content, check out the IRPP’s Faces of Aging research program.

Do you have something to say about the article you just read? Be part of the Policy Options discussion, and send in your own submission. Here is a link on how to do it. 


Click on the bold text to access

Andrew Longhurst: B.C. needs to significantly boost supply of public assisted living for seniors

Too many seniors in our province struggle to find publicly subsidized assisted living where they can be supported as they age. Amidst an affordable housing crisis felt across generations, the need to significantly boost the supply of subsidized assisted living is more urgent than ever before.

Assisted living is a type of supportive housing for people with moderate levels of disability who need daily personal assistance to live independently (meals, help with bathing, or taking medications, etc.). Publicly subsidized assisted living is part of B.C.’s larger home and community care system. There is also a large private-pay assisted living sector, where seniors pay entirely out-of-pocket and fees are completely unregulated. For-profit corporations provide the vast majority of private-pay units, while non-profits provide the majority of publicly subsidized units

Access to publicly subsidized assisted living units in B.C. dropped significantly — by 17 per cent — between 2008 and 2017. (Access is measured as the number of units for every 1,000 seniors age 75 and older).

Perhaps not surprisingly, the private-pay assisted living market has benefited as a result, as seniors and their families look for other options when subsidized care is unavailable. Between 2010 and 2017, 1,130 private-pay units were added throughout the province, while a mere 105 publicly subsidized units were added.

Private-pay care may be an option for some, but it is beyond the means of most low- and moderate-income seniors. Senior couples at the median (middle) income of $61,900 can scarcely afford a one-bedroom assisted living unit, which would eat up 58 per cent of their income. For seniors living alone, even a bachelor suite would require over 80 per cent of their income.

B.C. currently relies on private-sector financing of assisted living, which is more expensive than the provincial government financing new construction. This approach is a relic of the early 2000s when government refused to take on debt in order to build critical social infrastructure.

To read the full article, click on the bold text above.


Dr. Eric Cadesky: B.C. doctors working to improve care for residential-care patients


The Fix – New Program for Ontario Nursing Home


Every Voice Counts: Provincial Residential Care Survey Results


PRIVATE For PROFIT/Corporations

Private virtual health services are booming in a ‘policy vacuum’

By Theresa Boyle Staff Reporter

Jan. 17, 2021
[Excerpts] When over-the-counter medication failed to quell a sudden and intense allergic reaction, the Toronto senior turned to her computer in search of a remedy.

A quick Google search brought her to the website of Maple Corp., one of the country’s largest providers of virtual health care.

In no time at all, she was communicating, via secure text messaging, with a family doctor who gave her a prescription for a nasal spray. The doctor also recommended that she try to get out of a dog-sitting arrangement, which appeared to bring on the allergic reaction.

The virtual visit cost the patient $49.

Such transactions are occurring at record rates during the pandemic, which has seen a surge in the use of virtual health-care services.

While it’s widely accepted that growth in virtual care is long overdue, defenders of public medicare question the expanding role of private providers in a publicly funded health system.

Critics charge that private providers don’t always act in the best interests of patients and taxpayers, or operate within the provisions of the Canada Health Act.

The Canada Health Act requires that medically necessary services provided by doctors be covered by provincial health insurance plans.

“Charging patients out of pocket for it would mean that the Canada Health Act would be meaningless if that were allowed to continue,” Mehra [executive director of the Ontario Health Coalition] argued.

A recent article in the CMAJ — “Private virtual care thriving in a legal grey zone” — said confusion and convenience may explain why Canadians are still paying privately for virtual-care services even though the public system covers variations of the same service.

There is much concern among family doctors that virtual care could interrupt the “continuity of care” for patients. For example, it’s possible that a patient’s family doctor would never be informed of services provided through virtual care.

To read more, visit https://www.thestar.com/news/canada/2021/01/17/as-pandemic-rages-virtual-health-services-are-booming-in-a-policy-vacuum.html


A series of articles by the Tyee [Excerpts]
Click on the bold to access the articles.

Profits Before Patients? The Corporate Push into BC’s Primary Care System
Big business sees opportunity in replacing the family doctor with corporate clinics or virtual care. Advocates see peril. First in a series.

Andrew MacLeod 7 Sep 2020 | TheTyee.ca
Andrew MacLeod is The Tyee’s Legislative Bureau Chief in Victoria and the author of All Together Healthy (Douglas & McIntyre, 2018). Find him on Twitter or reach him at amacleod@thetyee.ca

Telus, a publicly traded Vancouver-based company worth $29 billion, was making inroads into health care before the COVID-19 pandemic began. It’s moving more heavily into primary care, traditionally provided by generalist family doctors who are patients’ first point of contact with the health-care system. They look after day-to-day concerns and also provide a co-ordinating role when people need ongoing care or to see a specialist.

Besides Babylon, which is available in B.C., Alberta, Saskatchewan and Ontario, Telus offers a similar service nationally called Akira that it promotes through employers.

Telus has bought clinics operating under the Copeman and Medisys brands, both of which operate in a “legal grey area,” charging patients annual fees in the thousands of dollars while still billing provincial health plans. 


Why Are Corporations Moving into Health Care? Doctors Say It’s the System’s Fault
But MDs are regulated and governed by an ethical code. Big Business isn’t, advocates warn.

Andrew MacLeod is The Tyee’s Legislative Bureau Chief in Victoria and the author of All Together Healthy (Douglas & McIntyre, 2018). Find him on Twitter or reach him at amacleod@thetyee.ca

McCracken [medical director of the large urban clinic]: “Corporate values are very different from physician values, let’s be honest, and it can really be a detriment for patient care,” she said. “I think the public really needs to know what’s going on.” Allowing a shift to corporate care doesn’t even make financial sense for the government, 

McCracken added. “We have a good body of evidence that shows us that if we don’t get in front of health-care problems… ultimately it costs the health system more by longer hospitalizations, more frequent hospitalizations, and more significant interventions that are required.” 

A lack of access to continuing care for vulnerable groups would bring those kinds of increased costs, she said.


Corporations Want Your Health Records. Who’s Keeping Them Safe?
Big Business has moved into managing patients’ health files, but privacy laws haven’t kept pace, advocates say. Part of a series.

Andrew MacLeod 10 Sep 2020 | TheTyee.ca
Andrew MacLeod is The Tyee’s Legislative Bureau Chief in Victoria and the author of All Together Healthy (Douglas & McIntyre, 2018). Find him on Twitter or reach him at amacleod@thetyee.ca

For corporations like Telus and Well Health moving into providing primary health care, the real opportunity may be in using their new relationship with patients to build other parts of their businesses, particularly as providers of digital health records.

That’s the assessment of Rita McCracken, a family doctor who practises in East Vancouver, who provides care in a nursing home and teaches at the University of British Columbia. She sees a longer-term strategy playing out.

“Do you think Telus thinks it’s going to get rich on the fee-for-service fees, or do you think they’re much more interested in the incredibly rich health data that they’re able to acquire through acquisition of primary care?” she asked.


What Happens When Health Care Becomes a Stock Market Play?
Even before the COVID-19 pandemic, Vancouver company Well Health Technologies Corp. was growing rapidly and had ambitious expansion plans.

Some investors saw an opportunity. But other people saw a threat to public health care.

Andrew MacLeod 9 Sep 2020 | TheTyee.ca
Andrew MacLeod is The Tyee’s Legislative Bureau Chief in Victoria and the author of All Together Healthy (Douglas & McIntyre, 2018). Find him on Twitter or reach him at amacleod@thetyee.ca

Well [Health Technologies Corp.] had, over a couple of years, acquired 21 primary care clinics in B.C., become the electronic medical record provider to another 1,446 clinics across Canada and dedicated a significant marketing budget to promoting its services. Well is something new, a Canadian company focused on providing direct health-care services and traded on the stock market. Investors have been enthusiastic, bidding up Well’s stock price. Shares that were worth 25 cents a little more than two years ago had risen to about $2 by early this year. The COVID-19 pandemic brought more interest, and shares topped $6 by Sept. 1.

By September, Well was worth about $790 million and looked set to keep growing.
But what may be good for investors is likely going to be bad for patients, said Marcy Cohen, a community researcher who has worked on issues around primary care and community care for two decades. “They’re obviously trying different strategies about how and where the profit possibilities are,” Cohen said. “Because they’re a corporation, their responsibility is to their shareholders. They are looking at health care as a revenue generating opportunity, so they’re looking and experimenting with all the different ways they might be able to make a profit out of health care.”)


How BC Can Fix Primary Health Care, With or Without Corporations

Health Minister Adrian Dix says business can play a role in delivering health services. Not everyone agrees. Part of a series.

Andrew MacLeod 11 Sep 2020 | TheTyee.ca
Andrew MacLeod is The Tyee’s Legislative Bureau Chief in Victoria and the author of All Together Healthy (Douglas & McIntyre, 2018). Find him on Twitter or reach him at amacleod@thetyee.ca

To describe the way he practises medicine, Baldev Sanghera gives the example of a teenager who comes into his Burnaby clinic seeking help with acne.

Sanghera would treat the skin problem. But he says he’d also be attentive to the patient’s anxiety that goes along with it. He would take the opportunity to talk with them about mental health, self-esteem and confidence.

If more is going on, he might talk about linking the teen with a school counsellor or teachers to help with educational supports or discuss sexual health.

The kinds of topics a doctor can raise when they have built a relationship with a patient over time. It’s entirely different from the kind of care the patient would have gotten from a walk-in clinic or a virtual service focused on one-off appointments, he said. “You wouldn’t do that if you were just providing the single episodic care visit, which is, ‘Oh you’ve got acne, here’s your antibiotic. OK, thanks, bye.’” 

Walk-in clinics are needed to relieve pressures in the system, he said, but they should be closely co-ordinated with physicians who are providing long-term care for patients, he said. “Episodic care sometimes misses the big picture, and you’re focused on the immediate need of that person at that point.”


A Family Doctor Prescription Fixing Primary Care

The rise of corporate health-care providers in British Columbia is worrying, says Jeanette Boyd, president of the BC College of Family Physicians. But she says it really needs to be recognized as a symptom of a deeper disease.

Andrew MacLeod 14 Sep 2020 | TheTyee.ca
Andrew MacLeod is The Tyee’s Legislative Bureau Chief in Victoria and the author of All Together Healthy (Douglas & McIntyre, 2018). Find him on Twitter or reach him at amacleod@thetyee.ca

“Absolutely they are filling a vacuum, but it’s a vacuum I feel is artificial and can be addressed in other ways,” she said. “If we all work together, we can potentially find solutions that don’t bring in the same inherent risk that bringing in a big corporate agency does.”

The problem is not a shortage of doctors. The province is producing more family physicians than ever, she said, but the system encourages them to move into other areas of practice.

Doctors get into family medicine because they want to make a difference and value the long-term relationships involved in providing direct patient care, she said. But they find the fee-for-service system, where each visit or treatment is assigned a dollar value, doesn’t allow them to spend as much time with patients as they may need.

“There is that need for the immediate gratification, and we know those investments in primary and preventative care, looking at dealing with the social determinants of health and access to housing, access to important food security, preventative health care, we don’t see the benefits of that until three or four or 10 election cycles,” she said.

So governments tend to focus on areas where they can have an immediate impact, like improving access to surgeries or urgent care, Boyd said.

“We’re seeing this disproportionate emphasis on things that are absolutely important, but perhaps aren’t leading to the longer term, high-quality impacts that we’re really needing to see for the broader sustainability of the health-care system overall.”

Corporations like Telus and Well Health Technologies Corp. have stepped into that fractured system.

They offer services that many patients find convenient, and it is understandable why doctors might choose to work for them, Boyd said. It’s a model where they can show up at work and earn a salary without the headaches or long-term responsibilities of running the business themselves.

Boyd said use of corporate services often leads to extra costs for the system. Patients may consult the online service and then go to their doctor for the same issues. Duplicate tests may be ordered.

The provincial government could do much to improve primary care, Boyd said.


Judge rules against private care for patients as four-year B.C. trial challenging universal health system ends

Dr. Brian Day, CEO of Cambie Surgeries Corp., argued wait times in the public system are too long.PHOTO BY DARRYL DYCK/THE CANADIAN PRESS/FILE

Sep 11, 2020 [Excerpts]
Dr. Brian Day had argued patients have a constitutional right to pay for private care when wait times in the public system are too long

Justice John Steeves of the Supreme Court of British Columbia said in a written ruling after a four-year trial that Day and other plaintiffs failed to show patients’ rights are being infringed by the [Medicare Protection] act, adding its focus is on equitable access, not ability to pay.

“Equal or identical care between patients is not part of the purpose of the (Medicare Protection Act) and nor is it achievable,” Steeves said, adding those who are healthier and wealthier would benefit most from a parallel health-care system.
Lawyers also failed to provide enough evidence that patients’ constitutional rights are being violated, he said.

Duplicative private health care “would not decrease wait times in the public system and there is expert evidence that wait times would actually increase,” he said. “This would cause further inequitable access to timely care.”

British Columbia Health Minister Adrian Dix. PHOTO BY CHAD HIPOLITO/THE CANADIAN PRESS/FILE

In April 2018, Dix announced that starting in October of that year, doctors who bill patients extra for services covered by the Medical Services Plan could face initial fines of $10,000 as part of amendments to the Medicare Protection Act that had not been enforced for 15 years.

The new punishments were necessary because Ottawa had withheld $16 million in health transfer payments over extra billing by private clinics, Dix said.

Private clinics are not illegal, but billing for medically necessary services is a violation of the Canada Health Act.

Dix said private clinics have played a small role when they are contracted to do day surgeries and last year performed about 12,000 procedures out of 300,000 done in the public system.
“The issue here is extra billing and undermining the basis of public health care,” he said.

Dr. Rupinder Brar, spokeswoman for Doctors for Medicare, an interveners at trial, said Day’s position involved having doctors bill for care in both the public and private systems where they could charge more and therefore prioritize those patients.

“It sets up perverse incentives for doctors,” she said, noting physicians are free to opt out of the public system if they choose to practise in private clinics, but not do both.

“This court case was about me being a doctor and charging patients whatever I want, so those people who can afford it will see me and I’ll see them first,” Brar said.

To read the full article, click on: Judge rules against private care for patients as four-year B.C. trial challenging universal health system ends


Judge’s decision expected in constitutional challenge of B.C.’s Medicare Protection Act

VANCOUVER September 9, 2020

A decision is expected Thursday in a marathon legal battle that could change the future of Canada’s health care system.

B.C. Supreme Court Justice John Steeves is expected to release his judgment in a constitutional challenge of key provisions of B.C.’s Medicare Protection Act, four years after the matter landed in the court.

The plaintiffs, led by Brian Day, a private-medicine advocate and chief executive officer of the for-profit Cambie Surgeries Corporation, have argued that patients have a right to pay out of pocket for swifter access to necessary medical care when wait times in the public system are too long. They seek to overturn provisions of the act that prohibit physicians from accepting pay from both public and private purses, limit extra billing and ban health insurance for services that are already covered under the public plan.

Critics counter that the case is not about health care delivery but money, and that opening the door to a two-tier system would prioritize treatment based on a person’s ability to pay over need, upending the very foundation of Canada’s public health care system.

“It’s a really important case, in the context of Canadian medicare as we know it,” said Steve Morgan, a professor of health policy at the University of B.C.

The breadth of grievances brought forward by the plaintiffs make the case bigger than what is commonly referred to as the Chaoulli case, he said. In that landmark 2005 decision, the Supreme Court of Canada struck down prohibitions on private insurance, finding the ban violated the Quebec Charter of Human Rights and Freedoms.

“There is a lot in this case; it’s like Chaoulli for non-Quebec Canada, amplified because it’s got that and a few other things that are arguably bigger than the Chaoulli case,” Dr. Morgan said.

“I think the health policy research community, the health policy scholarship community in Canada, are probably holding their collective breath right now wondering what will happen. I do remember when the Chaoulli decision came down, I remember the gasps. People thought, ‘How could the court have ruled in that way?’”

The Chaoulli decision did not open the floodgates to private insurance in Canada, as some had predicted. This is because it only applied to Quebec, and the court said a prohibition on private insurance could be justified if wait times were not unreasonable. The province allowed private insurance for certain treatments, and the decision prompted provinces to set wait-time benchmarks.

Rupinder Brar, a Vancouver addictions-medicine physician and member of the board of Canadian Doctors for Medicare, an intervening party in the B.C. case, said she was anxiously awaiting the verdict.

“A lot of the time you hear the plaintiffs talking about this court case being about wait times, and the public, when it has nothing to do with health care delivery at all,” Dr. Brar said Wednesday. “We know from evidence around the world that if the plaintiffs were to win, our wait times would actually get longer, because the same physicians and nurses would be working in a dual practice. People would have less access to care, and not more.

“What this court case is about is physicians’ billing, and the money physicians can make.”

Final arguments for the case concluded in February.

“I’m looking forward to completing my judgment and signing my name on it,” Justice Steeves told lawyers at the end of the trial on Feb. 28. “Once I’ve done that, I’ll join the rest of the world in watching the progress of this case with great interest.”


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US doctor in Canada: Medicare for All would have made America’s COVID response much better

America needs a health care system that puts public health ahead of profits. I know we can do better. I see it everyday in Canada amid the coronavirus.
Dr. Khati Hendry Opinion contributor Published August 5, 2020

I’m a family physician who moved to Canada from California 14 years ago, largely because of Canadian Medicare, the country’s national health insurance program. I’ve been much happier practicing medicine where my patients have universal coverage. It frees up doctors like me to focus on patient care and frees patients to focus on their health, instead of worrying about how to pay for it.

But I have never felt more grateful to work in a universal health care system than during the COVID-19 pandemic. My heart aches for the millions of Americans who have fallen ill and then have had to worry about how they will pay for tests and treatment, who have gone to work while sick for fear of losing their health coverage or who have lost not only their jobs but their insurance, leaving them at risk for financial ruin.

While no country is immune from COVID-19, Canada has been able to mount a much more effective response. Canada’s infection rate is a tiny fraction of that of the United States, and trending downwards. Its health system has two big advantages when fighting the pandemic: universal health coverage and an administratively simpler system.

Canadian Medicare is good for patients

Canada’s publicly financed single-payer system covers everybody, regardless of age, health or job status. No one loses coverage due to COVID-19. Canadian Medicare covers services like hospital and emergency care, doctor appointments and lab tests—without copays, deductibles or medical bills. Everyone is in a single “network,” so there are no artificial limits on which hospital or health provider a patient can see. As a result, Canadians are much less likely to delay testing or treatment for COVID-19, or for the chronic medical conditions that increase the risk of severe illness and death from the virus.

Canada’s universal system also has made it easier for medical and public health professionals to respond quickly — and together — without the administrative headache of multiple insurance companies.

In my province of British Columbia, our ongoing history of collaboration between physicians and the provincial health system made it easier to coordinate responses from hospitals, primary care clinics and long-term care facilities. From the start, emergency response committees held daily meetings to address challenges of hospital capacity, distribution of supplies and protective equipment, testing procedures, staffing policies, telemedicine, COVID-19 protocols and the safety of health care workers. The British Columbia public health officer gives regular updates and guidance as we move through pandemic phases.

Instead of primary care practices shutting down and forcing patients to go without care, as reported in many parts of the United States, we have been able to work together through our province’s longstanding “Divisions of Family Practice.” Most of us work in private practice, but we get help to coordinate with other family doctors to make sure that on-call shifts are covered, our practices are safe and our patients get the care they need during the pandemic. I have not had to care for a patient with COVID directly yet, but I have been part of the extensive planning process. 

America should follow
As health care shifted from in-person to virtual practically overnight, Canadian health authorities put systems in place for more provincial phone triage, patient self-assessment protocols, virtual care software and better internet access to remote areas. The province made investments to support the needs of vulnerable populations, such as aboriginal communities, and those who are homeless, live in rural areas, travel for agricultural work or struggle with mental illness or addiction — groups that have suffered disproportionately from COVID-19 in the United States.


Surgical backlog must not be fixed at the expense of the healthcare system

August 4, 2020 Authors: Lesley BarronThara Kumar

As we breathe a tentative sigh of relief that COVID-19 numbers are stabilizing, the ripple effects of the pandemic are becoming more apparent.

Thousands of surgical procedures were cancelled when hospitals adjusted operations to brace for the wave of COVID-19 patients. Now, as governments grapple with this backlog, some have announced their intention to contract out care to private for-profit investor-owned facilities.

British Columbia is using all available beds to address its backlog. This now includes contracting out publicly funded care to for-profit surgical centres such as False Creek Surgical Centre, owned by Kensington Capital Advisers, a private equity firm. Manitoba recently announced that it, too, is considering contracting with for-profit facilities to address its backlog, as has Alberta with its recently announced Bill 30.

There is no doubt that COVID-19 has demanded healthcare systems adapt quickly, without the benefit of the long-term planning usually required for systems change. In the case of surgical backlogs, we should treat an acute wait list problem differently than we treat a chronic one. We must, however, ensure that short-term fixes don’t cause long-term harms – and that they ideally benefit the system.

Investor-owned, for-profit facilities may seem like an obvious solution to COVID-19 surgical backlogs. But what does previous experience tell us about these facilities?

Care delivered in for-profit facilities costs more than not-for-profit care and mortality and morbidity are worse. Past contracts in Alberta have paid higher prices to for-profit facilities than to public hospitals for the same services. Death rates from COVID-19 have been dramatically higher in for-profit long-term care facilities than in publicly owned or not-for-profit homes; in eastern Ontario, 83% of long-term care deaths occurred in for-profit homes. Why this discrepancy? Because investor-owned facilities owe a fiduciary responsibility to earn money for their shareholders, meaning less money is available for patient care. This must not be the way forward for our healthcare system.

So how do we create lasting capacity within the public system beyond the current crisis? Our response must be rooted in the solid evidence about system reform.

To clear the surgical backlog, we must scale-up hospital capacity by extending operating hours to include evenings and weekends. We should immediately implement team-based single-entry centralized wait-lists for the first available surgeon so patients can access care as quickly as possible. This approach has dramatically improved surgery wait times. “Surgical smoothing” would separate planned and unplanned surgeries into different operating room streams, eliminating the problem of emergencies bumping other surgeries. We must scale-up cost-effective, not-for-profit, publicly funded ambulatory surgical centres, such as rural and satellite sites, managed by hospitals.

In the short-term, if governments insist on using private investor-owned facilities in addition to, or instead of, exploring not-for-profit and public solutions, what are some critical elements that must be in place to minimize undermining the rest of our healthcare system?

First, provinces should only be turning to for-profit facilities after exhausting all efforts to increase capacity in the existing not-for-profit infrastructure. Where such for-profit facilities exist, government should consider purchasing them and bringing them under public ownership as B.C. did when it recently bought two private MRI facilities.

Second, any contracting out to investor-owned facilities must not delay or undermine initiatives to expand access to care within the public or private not-for-profit system (such as B.C.’s surgical strategy announced in 2018). Nor should new investor-owned facilities be built to address this pandemic-induced short-term backlog. This is the time to invest in our public health care system, not in a profit-driven industry.

Third, we must have full public oversight of investor-owned facilities. Governments must ensure they are transparent, operate within the law, and are subject to the same standards of inspection and certification as not-for-profit hospitals. This means not charging patients extra fees or selectively “cream skimming” healthier patients whose treatments cost less as a way to increase corporate profits. It means ensuring that proper personal protective equipment and infection control practices are in place.

We have a once-in-a-generation opportunity to learn from this pandemic and improve our healthcare system. We need to come out of this crisis with a stronger, more equitable public healthcare system, not a more fractured one.

As we recover from this crisis, we should be working toward a future that always puts patients above profits. If this crisis is instead used as an opportunity to expand and entrench for-profit investor-owned delivery of health services, it will be at our peril.


COVID-19 Has Exposed the Perils of ‘Financialized’ Seniors’ Care

The pandemic has highlighted worse outcomes and more deaths in for-profit care homes.

Martine August 29 Jul 2020 | The Conversation Canada
Martine August is an assistant professor in the school of planning at the University of Waterloo in Kitchener, Ont. This article originally appeared in the Conversation Canada.

A report by Canada’s military revealed horrifying conditions, short staffing and neglect.

Some family members blamed for-profit ownership, arguing that COVID-19 had simply exposed, in tragic fashion, the impact of prioritizing profits in the operation of seniors housing.

Researchers have found that for-profit facilities have lower staffing levels, lower quality of care and poorer resident outcomes in both the US and Canada.
Notably, Orchard Villa had been purchased in 2015 by private equity firm Southbridge Capital, adding it to Canada’s growing stock of “financialized” seniors’ housing — bought by financial firms as an investment product.


Careful, Canada: What Ireland has learned about two-tier health care

This column is an opinion by Steve Thomas, director of the Centre for Health Policy and Management at Trinity College in Dublin, Ireland. He has been studying the issue of privatization in Canada, is the author of a chapter on Canadian health care in the book ‘Is Two-Tier Health Care the Future?,’ and has collaborated with the University of Toronto and University of Ottawa. For more information about CBC’s Opinion section, please see the FAQ.

Steve Thomas – for CBC News Opinion
December 14, 2019
The introduction of private health insurance in Ireland allowed a two-tier system to develop with long waiting lists in the public system and limited financial protection for households, says Steve Thomas. 

It is striking that as Canada seems on the cusp of embracing two-tier health care, Ireland is struggling to limit it.

In 1957, the Irish Republic decided to set up a voluntary health insurer owned by the state to take the pressure off the public system, allowing health care to be bought by those who had the means.

It sounded reasonable, and 60 years later, private health insurance has taken off with almost half the population covered and plans offered by private companies. This allows faster access to public care subsidized by the state, and queue-jumping of the very long waiting lists by those who are better off financially.


Thirteen things you need to know about the people trying to end Canadian health care as we know it.

PressProgress September 7, 2016

Meet the right-wing interests who have launched a constitutional challenge against Canada’s health care system.


Although Day claims his court challenge is all about his constitutional rights, it’s hard to overlook the influence of an audit that found “significant evidence” Day had been “extra billing” patients on a “frequent and recurring basis.”

Day originally filed his lawsuit in 2009. But the BC Medical Services Commission first raised concerns about “extra billing” practices at Day’s company as far back as May 2007. His company was formally notified it would be audited in September 2008. Lo and behold, Day filed a lawsuit several months later.

The audit, completed in 2012, found evidence Day’s clinics extra billed patients for “publicly-insured medical services” to the tune of half-a-million dollars during just one 30-day time span.
Canadian Doctors for Medicare explains “extra billing” is “against federal and provincial law” and can include “extra fees for medical consultations, examinations, diagnostic testing and other manners of ‘upgraded services’.”

Day recently told the National Post that he thinks “a wealthy person” deserves a higher standard of care than everybody else:
“We in Canada will give the same level of services to a wealthy person as to person who isn’t wealthy, and that doesn’t make sense.”


Private health-care is all about doctor profits, federal lawyer tells B.C. court

Camille Bains · The Canadian Press · Posted: Nov 25, 2019
Plaintiffs ‘want to make steady money in the public system and then make more money [in the private system]’

Profit for doctors providing surgery in private clinics is at the heart of a trial that threatens to undermine Canada’s universal health-care system and its principles of equity and fairness for everyone, a federal lawyer says.

B.J. Wray, representing the attorney general of Canada, told the B.C. Supreme Court that a legal challenge by Dr. Brian Day  aiming to strike down provisions of the province’s Medicare Protection Act is based on increasing income because doctors enrolled in the public system are prohibited from charging patients for medically necessary services in private clinics.
“The corporate plaintiffs want to make steady money in the public system and then make more money in the privately funded system,” she told Justice John Steeves.


The secret moves to increase private health care

By Bob Hepburn Star ColumnistWed., Jan. 9, 2019

……..major financial interests in Toronto are quietly supporting a controversial lawsuit by Dr. Brian Day of Vancouver, founder of the private Cambie Surgery Centre, who has brought a constitution challenge to B.C.’s restriction to private health care. The case is now before the B.C. Supreme Court and is expected to land eventually before the Supreme Court of Canada. These interests are reportedly ramping up an $8-million war chest to help fund Day’s court cases. 


China Caring for our Seniors

CASTANET Colin Dacre – May 26, 2018

The Summerland Seniors Village is one of 21 B.C. facilities owned by Retirement Concepts, a company purchased by China’s Anbang Insurance for $1B last year. In February, the Chinese government seized control of the company and jailed its CEO for fraud.

Central Okanagan MP Dan Albas says he’s heard from family members of residents at the Summerland Seniors Village that care has degraded since the takeover.
He said he’s been told of instances where the facility has been staffed so short, a single nurse is supervising 20 residents overnight.


Charter challenge issue strike at the heart of the priniciples of medicare


Universal health care on trial: What you need to know about a historic Charter challenge in B.C.
For a decade, surgeon Brian Day has been fighting to undo laws barring patients from paying for medical care at private clinics like his. Here’s a primer on how the case came to be, and how its outcome could affect you.

The B.C. law doesn’t explicitly prohibit well-off patients from buying their way to the front of the queue. Rather, it dampens the market for private care by prohibiting physicians from “enrolling” to work in the public and private systems at the same time; by forbidding enrolled doctors from charging patients for publicly covered services; and by barring the sale of private insurance for medically necessary hospital and doctor care. (Private insurance is, of course, widely available for care not covered by Canada’s “universal” system, which does not include prescription drugs, most dental care, home care and other services provided outside hospitals and physicians’ offices.)

For more than two decades, the B.C. government looked the other way while Dr. Day’s Cambie Surgery Centre, which opened in 1996, and other private surgical clinics bucked the law. 

The BC Health Coalition, Canadian Doctors for Medicare and the patients and doctors who intervened with them, described in their written closing arguments how they believe shortages of anesthesiologists, nurses and doctors contributed to waiting lists in the public system. One doctor who testified in the case made $965,826 in 2016-17 working for Cambie and the Specialist Referral Clinic, another plaintiff in the case – about four times as much as what he usually earned in public billings.


Advocates demand end to extra billing, upset over 15.9 million federal claw back


A Welcome Second Chance for BC Medicare Protection

This article points out a few aspects that are not often talked about.

For every dollar of extra billing by a private for profit clinic, the federal government claws back an equal amount from its cash transfers.

In 2015-16, that amount was $15.9 million, enough for 53,000 MRIs. So effectively, we all pay for the extra billing.

B.C. is the only province that Ottawa has repeatedly fined for unlawful extra billing.


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Why isn’t there a single medical licence for all doctors in Canada?


Dr. Mike Benusic, medical resident, ER doc and spokesperson for Medical Residents of Canada poses for photos in a Roncesvalles clinic in Toronto, Ont. on Thursday, Dec. 20, 2018.

Monika Dutt has worked as a doctor in Nova Scotia, Saskatchewan, the Northwest Territories and Ontario.

Although she has been practising medicine since 2005, a combination of family medicine and public health, each move has required Dr. Dutt to go through the “frustrating and expensive” process of getting a new medical licence.

That’s because, while there is a standard set of requirements physicians need to meet to apply for a full licence to practise medicine in Canada, all 13 provinces and territories have separate licensing requirements and fees.

“The Ontario application required 42 documents, right back to my medical-school transcripts,” said Dr. Dutt, who is now the CEO of the Timiskaming Health Unit in northeastern Ontario. There were also thousands of dollars in fees.

For example, the Nova Scotia College of Physicians and Surgeons has an annual fee of $1,950, plus an additional $975 if the fee is paid after July 1. A temporary licence costs an additional $850. There are also fees to review qualifications, $550, and a documentation fee of $450. A copy of a diploma costs $75 and a letter confirming a physician is a member is $40. Physicians who do locums (temporary postings) pay $250 more a month. Other provinces have similar fees. Universities and hospitals also charge fees for documentation.

“It really adds up,” Dr. Dutt said.

She said she understands why rigorous licensing is necessary – “to weed out the small number of physicians who have done awful things” – but it is not clear why the provinces and territories don’t recognize each other’s licences.

Dr. Dutt is not alone in asking that question. A growing chorus of medical groups – including the Canadian Medical Association, Resident Doctors of Canada and the Canadian Federation of Medical Students – are pushing for some form of national licensing.

After all, training is similar in Canada’s 17 medical schools and in residency programs across the country, and patients are not appreciably different.

The physician groups pushing for change argue requiring separate licences in every jurisdiction makes it difficult, and sometimes impossible, for physicians, particularly in rural and remote parts of the country, to find doctors to fill in for them while they’re on holidays or when they wish to reduce their hours as they grow older.

The onerous licensing rules also discourage interprovincial co-operation – for example, a Vancouver orthopedic surgeon can’t easily go to St. John’s to do hip replacements, even if there is a desperate need.

“The current fragmented system doesn’t just create annoyance for physicians, it creates real barriers to patient care,” Mike Benusic, the lead on national licensing for Resident Doctors of Canada, said in an interview. He said RDC believes the onerous relicensing provision is an unfair restriction on labour mobility and, as such, violates the Canadian Free Trade Agreeement.

He splits his time between working as a public-health resident in Toronto and lending a hand in family practice in rural Alberta – which means having two licences.

Like many young physicians, he does locums in clinics or hospitals, often on weekends and holidays.

“Locums allow you to check out places, to see if you would like to practise there. They also pay well, so you can pay off some student debt,” he said.

Locums are also an important recruitment tool, especially for rural and remote communities, who use them to woo doctors.

According to a survey by Resident Doctors of Canada, 18.5 per cent of medical residents say, once they are in practice, they are planning to do locums in another province or territory. But 52 per cent said they would do so if it did not require the hassle and expense of getting additional licences.

Dr. Benusic understands the hesitancy. He was asked to help out temporarily in a family practice in rural British Columbia, but realized the licensing process would take months and bring additional costs. A B.C. licence costs $1,700, requires a criminal record check and a plethora of other documents.

“Meanwhile, there were 800 patients waiting for care,” he said. “So who are these rules serving?”

Linda Inkpen, president of the Federation of Medical Regulatory Authorities of Canada (FMRAC), which shares best practices among jurisdictions, said regulation is a provincial/territorial responsibility in medicine, just as it is in law, engineering and other fields, and that’s not going to change.

“Constitutional issues put up major barriers to the idea of a national licence,” she said in an interview. Dr. Inkpen added, “it’s also not clear how much it’s really needed either.”

While there are surveys showing what physicians might do in theory, there’s very little data on how many actually practise in more than one jurisdiction.

The CMA, in a small survey, found 10 per cent of physicians were licensed in more than one province or territory. But only 1,300 of the country’s 80,000 physicians were surveyed, and those who responded are likely those most interested in the issue of national licensing.

Some physicians feel the colleges are merely protecting their turf and their income by maintaining separate regimes in each jurisdiction, but Dr. Inkpen said that is unfair. “We are there to uphold standards and we take that role seriously,” she said. (However, the standards are more or less the same in every province and territory.)

She added provinces and territories “hold regulatory bodies very close to their chest,” as demonstrated by the lengthy federal-provincial battle over a national securities regulator.

Dr. Inkpen said FMRAC has spent considerable time and effort breaking down provincial barriers, spurred by the Canadian Free Trade Agreement that come into force in 2017. For example, the application process is now similar in each province and territory.

FMRAC, in conjunction with the provincial and territorial regulators, is looking at some sort of “trusted physician licence” (similar to a Nexus card for frequent flyers), which would provide expedited clearance for physicians to work temporarily in other jurisdictions.

But that falls short of the “portable locum licence” that the residents’ group is looking for.

“The mandate of regulatory authorities is to protect the public – and we support that fully,” Dr. Benusic said. “But we think a single licence would do that as effectively – maybe even more effectively – than separate licences in every jurisdiction.”



Canada has the key to lowering drug prices. Here’s why it won’t be used any time soon

By Kelly Crowe
November 24, 2018

There’s a battle being fought in the backrooms of Ottawa and the outcome could determine how much Canadians will pay for new drugs.

The federal government has developed a series of regulations that would lower Canada’s patented drug prices, which are among the highest in the world. Canada is second only to the U.S. in per capita drug costs.

But the new rules were like a gauntlet thrown down in the path of the pharmaceutical industry which has been lobbying federal government officials ever since.

“Drug companies understand very well what’s at stake and they’re massively mobilizing to make sure nothing happens,” said Marc-André Gagnon, a pharmaceutical policy researcher at Carleton University.

The dispute is over a policy document called “Protecting Canadians from Excessive Drug Prices” — a series of amendments to the Patent Medicine Regulations that former Health Minister Jane Philpott announced on May 16, 2017.

“Canadians are paying too much for prescription drugs,” Philpott said at the time. “These measures will go a long way towards helping Canadians afford the medicines they need to live healthy, productive lives.”

Bringing Canada’s drug prices down sounded like a reasonable idea. And the plan would work according to the industry’s own calculations.

The president of Janssen Canada, Chris Halyk, estimated “an average reduction in prices of approximately 20%,” in a submission letter sent to the Health Minister in February.

But if drug prices go down, so do industry revenues, falling by up to $26 billion over ten years according to one industry report.

That’s one reason why the industry’s resistance has been so intense. And it’s wielding a big stick, threatening that companies could hold back the launch of new drugs in Canada if the amendments are approved.

In Janssen Canada’s letter to the Health Minister, Halyk wrote “…the level of price reductions that are being proposed could result in it being not financially viable to launch some medicines in Canada.”

The pharmaceutical industry is also warning that it might reduce research and development in Canada, putting jobs at stake.

“[The regulations] will have negative economic implications, leading to reduced research and development (R&D) investments, less innovation in Canada and fewer jobs in our life sciences sector,” wrote AstraZeneca Canada’s president Jamie Freedman in a letter to Health Canada.

(A recent analysis found that the pharmaceutical industry has not been keeping up with previous R&D commitments.)

Because of the industry uproar, the staff at the Patented Medicine Prices Review Board (PMPRB) decided to start detailed consultations with stakeholders last June, inviting several industry representatives to sit on the steering committee to assist in developing an implementation roadmap.

But so far those discussions are not going well — a fact revealed by the frustrated bureaucrat who’s leading the group.

In a newsletter last month, Douglas Clark, executive director of the PMPRB, reported that “progress on the issues under discussion has been slower than anticipated owing to the complexity of the subject matter and conflicting views of participants on the merits of the underlying policy.”

In other words, the industry representatives are reluctant to talk about ways to implement the very rules that they are fighting against.

“It’s been a frustrating process,” said Clark who is trying to get industry input on the nuts and bolts of putting the new rules into effect.

“It’s a bit like pulling teeth to engage the industry on these changes where their position is they’re opposed to the underlying policy.”

Innovative Medicines Canada represents more than 45 pharmaceutical companies. It has two seats at the steering committee table, but can’t comment on the discussions.

“The PMPRB’s terms of reference for the committee impose strict confidentiality on its members and deliberations,” said Innovative Medicines Canada’s spokesperson Sarah Dion-Marquis in an email.

There are several other industry representatives at the table, along with representatives from provincial agencies and the private insurance industry. There are also two patient organizations — the Canadian Organization for Rare Disorders (CORD) and Myeloma Canada.

After several meetings Clark said the steering committee has split into two factions.

“You’ve got public and private payers on one side and industry and patient groups on the other and views can be quite polarized,” he said, adding that the patient groups are aligned with industry on most of the issues.

“There’s not a lot of daylight between their two positions,” said Clark.

Both patient groups have made submissions to Health Canada calling for the entire process to be halted.

Health Canada officials are also in the room, taking notes on the industry objections. And industry lobbyists are also speaking directly to federal officials on Parliament Hill.

Since last March, Innovative Medicines Canada and several other pharmaceutical companies have registered more than 50 communications with officials in the Prime Minister’s Office (PMO) and the office of the Minister of Health.

“Our government engages regularly with health sector stakeholders, including the pharmaceutical industry, to discuss issues of [importance] to Canadians, including the price of prescriptions, national pharmacare, innovation, and drug shortages,” said Matt Pascuzzo, PMO press secretary, in an email.

In June, Innovative Medicines Canada’s president, Pamela Fralick, also met face-to-face with Health Minister Ginette Petitpas Taylor. BIOTECanada, a biotechnology trade association, was also there.

“The PMPRB was raised at this meeting, along with several other topics,” said Dion-Marquis.

What are the proposed new rules that have sparked so much controversy?

Right now when deciding how much a new drug should cost in Canada, the PMPRB compares the Canadian price to the average of seven countries including the U.S. which has the highest drug prices in the world.

The amendments would change those comparator countries by dropping the U.S. and adding other countries with lower drug prices including Australia.

The new regulations would also force companies to reveal to the PMPRB the true price they’re charging, after confidential price negotiations with provinces.

And there would be a new formula to assess the value of new drugs, using a pharmacoeconomic measurement called a “quality-adjusted life year” (QALY).

The industry has issues with each of those changes, insisting that there will be severe consequences to both drug access and to industry jobs.

“As our industry, and many other stakeholders, have stated publicly on many occasions, we are deeply concerned the proposed PMPRB regulatory changes will delay and potentially limit patients’ access to new, life-saving medicines and vaccines, and will further put at risk thousands of jobs in Canada’s vital life science sector,” said Dion-Marquis in an email.

So who’s winning the back room drug price war?

The new rules were supposed to come into effect on January 1st — just over 5 weeks from today.

But the federal government has quietly abandoned that plan. And so far it has not announced a new implementation date.