Health Systems Midterm
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Health Canada definition for Canadian healthcare
universal coverage for medically necessary health care service, provided based on need, rather than ability to pay
First province wide universal health care plan? Second?
- Saskatchewan 1947-covered hospital visits
- BC was second (1948)
When did medicare take effect
July 1st, 1962; medicare election in 1960
In what year did all provinces have medicare?
Canada health act enacted in?
What are its 5 principles
- Public administration
What is the role of provincial/territorial governments in administering health care? (APRPN)
- Administer health insurance plans
- Planning and funding of care in hospitals and other health facilities
- Regulation of services provided by HCPs
- Planning and implementing health promotion+public health intiatives
- Negotiation of fee schedules with HCP
What is the breakdown of total healthcare expenditures?
- 65% provincial/territorial (but actually federal tax money due to fiscal transfer)
- 30% private sector
- 4% direct fiscal
What is the trend in health expenditure over time, until now?
- Hospital spending decreasing as a total %
- Drug spending increasing as a total %
Number of pharmacies in ontario? number of pharmacists in ontario?
Gender ratio of ontario pharmacists?
58 female- 42 male
Approximately how many pharmacies open every year?
Total additions to pharmacy register? How many from ontario? Total deletions from pharmacy register? Net gain?
- 750 additions
- 250 from ontario
- 250 deletions
- 500 net additions
% of ontario pharmacists that are internationall educated? most are educated where?
40% of ontario pharmacists are internationally educated, of these, 20% are educated in egypt.
Percentage of community to hospital pharmacy?
- 70% community
- 15% hospital
Next steps with pharmacy scope in Ontario
- prescribe for minor ailments
- order and interpret lab tests
- administer a drug by injection beyond flu/immunization
- initiate drug therapy beyond smoking cessation
- therapeutic substitution
Value proposition for pharmacists:
medication expert, who uses knowledge/sklls to make decisions that positively impact patient health
% increase in pharmacist workforce from 2006-2011? How does this rank with physicians/nurses
Workforce increased by 21%, higher than physicians/nurses
Average age of pharmacists in Ontario? How does this compare to Canada?
45 y.o.,highest in Canada
Density of pharmacists in ontario? comparison to rest of country
- 81/100,000; significantly less than other provinces
- 1228 patients/pharmacist; significantly higher than other provinces
Which province has highest percent of pharmacists working in urban areas? What is the percentage?
Where will pharmacists add value?
- Place to pick up prescriptions
- place to get advice
- medication expert
WHO definition of primary care
First level of contact with the health care system, bringing healthcare as close as possible to people, and constitutes first element of continuing care process. Addresses the main health problems in the community
Institute of medicine definition of primary health care
Integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health needs, developing a sustained partnership with patients, and practicing in the context of family and community
What are the 5 major aspects of primary care?
- First point of contact
- Continuity (relational, informational, management)
- Majority of health care needs
How many primary care physicians in ontario? how many are in family health models? how many in fee for service?
- 11500 primary care physicians,
- 8000 in primary health care models
- 3500 in regular fee for service
How many physician visits/capita/year in Canada? How does this rank worldwide
- Around the middle (japan is the highest-13.2)
Percentage of people that said they can get same day/next day appointments with their physician? Percentage of people who waited six days or more? How do these rank globally
- ranked very poor globally
Percentage of people who have difficulty getting after-hours care? Percentage of people who have been to the emergency room in past two years? How do these rank globally?
- rank very high, thus Canada is poor in this regard
What was the PHTCF? What were its 5 objectives?
800$milli to support jurisdictions in reforming primary health care from 2000-2006
- 5 objectives:
- -increase access to comprehensive PHC services
- -increase health promotion, disease and injury prevention and chronic disease management
- -expand 24/7 access
- -establish multi-disciplinary teams
- -faciitate co-ordination with other health serices
Generally to reform primary care to primary health
What are three ways that physicians get paid?
- Fee for Service
Explain capacitation payment model
- get paid monthly per registered patient
- adjusted only for age and sex (not for health status)
- independent of patient visits
What are some problems with each payment method?
- FFS: incentivises over provision of services, and is a barrier to interprofessional collaboration
- Capacitation: incentivizes underprovision of care, and "cream-skimming" (selecting healthy patients)
- Salary: incentivises low productivity (less patients, less patients seen)
List 3 reasons that supported the need for reforms before the current reforms took place
- Lack of care if physician goes on vacation
- Lack of access (24/7)
- Lack of incentive for physicians to work in family care (change payment models)
6 features of the ontario PHC reform
- -group/network practices
- -access (Telephone Health Advisory Service+ extended hours)
- -enrolment (voluntary; supports continuity)
- -monetary incentives
- -interdisciplinary teams
- -focus on prevention and comprehensiveness of care with monetary incentives
Number of people that work in the health care industry in Canada? What percentage of the workforce is this?
- 1,000,000 people
- 6% of the workforce.
What makes a profession? What is the hallmark?
- Autonomy/control over their own work [use social closure status to ensure this, such as restricting who can practice](hallmark)
- Formal, specialized body of knowledge
- Altruism: putting others in society before yourself
- Often socially Sanctioned by legislation
What is Self-regulation? What is one problem with self Regulation?
power to set and enforce standards given to the group, but implicit agreement to act in the public's best interest
Public has no say (no democratic process)
When was the RHPA legislated? What are some of the goals of the RHPA?
- -fair and even playing field
- -give public access and choice
- -eliminate expectation of exclusive rights to specific practices
What are the five major themes of the RHPA
- Accountable public interest
- Public Access: transparency to public
- Patient choice: controlled acts aren't exclusive
- Eradication of abuse
- Equity: if somebody is qualified, they must be allowed to join
What is the most important reason a profession may be regulated?
If lack of regulation of the profession will cause more public harm than regulation of the profession.
Controlled acts model
- nobody can perform controlled acts except for licensed health care professionals
- 14 in total
- No member of public can perform any of the acts
- No single profession can perform every act (no exclusive scopes of practice)
The title doctor is restricted to
physicians, dentists, chiropractors, psychologists, optometrists, naturopaths (pending)
Explain some aspects of the Drug and Pharmacies Regulation ACT (DAPRA)
- 139-only operate pharmacies if accredited
- 142- no corporation can own without majority pharmacist ownership
- 144-nobody other than pharmacist or 142 can own a pharmacy
What are the different types of community pharmacies?
- Banner (IDA-pharmasave): purchase product through banner
- Franchise: they own lease and everything, you only own inventory
- Chain: no ownership by the pharmacist
- Mass merchandisers
- Independents: if more than 5 independents owned by one owner, then it's a chain
Community pharmacy workflow model
Reception-> Data entry-> product dispensing-> verification -> release to patient
What are the 3 main sources of revenue in community pharmacy?
- 1.Prescription medication dispensing
- 2. Consumer goods (including schedule 2/3 drugs)
- 3. Cognitive services
Capitation model of reimbursement in community pharmacy
Reimbursed per patient, seen in chronic care facilities (especially in scotland and new zealand)
What is the Resource Based Relative Value Scale model of reimbursement
- based on a physician software program
- fee is prorated to reflect number of drugs and conditions
Usual and Customary Dispensing Fee was intended to cover the following serices
- 1) establishment of new/existing patient medication profiles
- 2) professional consultation
- 3) health care services information
- 4) after hours emergency, prescription service
- 5) delivery service
- in addition to just dispensing
What are the three components of the Evolving Pharmacy Economic Model
- Funding for core dispensing services (cost of medication, dispensing services fee, processing charge/commercial terms, health systems access allowance)
- Expanded medication related services (fee for service)
- Expanded patient care services (fee for service + RBRVS)
What is the purpose of "Collaborative Drug Therapy Management"
- Evolution of pharmacists from safeguarding the distribution of drugs to securing the success of drug therapy
- Has helped promote positive health outcomes in a number of diseases
What services are reimbursed in Ontario for pharmacists?
- Basic medication review
- pharmaceutical opinion
- smoking cessation
What is the Healthy Living Pharmacy Concept ?
What is the New Medicines Service? Where are both of these implemented?
- focuses on public health services delivered in community pharmacy
- pharmacy must have certain attributes to qualify (a "type of accreditation")
- -requires local engagement, and a trained "health champion"
- New medicines Service addresses non-adherence for chronic disease patients (helps to decrease non-adherence)
What are some current issues that are limiting progression of community pharmacy?
- Slow uptake (from corporations, MDs, pharmacists; as well as overregulation)
- Lack of IT support (ex. E-health)
- Lack of education and training (pharmacists resistant to expanded scope)
- Lack of process
What were three things implemented in the reform to primary care?
- Patient enrolment
- Alternate payment structures
- multi-disciplinary teams
Community Health Centres
- -started based on Tommy Douglas' principles (medicare guy)
- -created in 1970s, expansion up till 2012
- over 100 sites in Ontario
- -physicians are employees and paid a salary
- -focus is on social determinants of health and health promotion, as well as reducing barriers to health care
- -patients are registered to CHC and not the physician
Aboriginal Health Access Centres
- modelled after CHCs
- 10 exist- created in 1995
- include traditional healing and cultural programs
- NFP governance with aboriginal community representatives
Why were Health Services Organization and Primary Care Networks phased out?
- HSOs phased out in 90s
- PCN phased out in 2001 (turned to Family health network)
- relied on Capitation model of reimbursement
Family Health Network
- Replaced Family health networks
- capitation+ limited FFS= blended capitation
- patients enrolled to physicians
- oncall 24/7 with nurse support
- physicians work in groups
- 32 in Ontario
Comprehensive Care Model
- Recent (July 2005)
- Only 333 physicians (thus not very popular)
Family Health Groups
- FFS+bonus/premium payments= blended FFS
- basically a move to FFS in group practice
- eligible for EMR funding
- 236 groups (pretty popular)
Family Health Organizations
- Introduced in 2005
- Predominantly capitation + ffs+ bonuspremium payments= blended capitation
- Has a lead physician+ 3 other physicians
- Only difference between FHO and FHN is scope of include codes and capitation rate
- most popular primary care model
Family Health Teams
- not actually a payment model (groups already in FHO/FHN/RNPGA)
- funding for a director, allied health professionals, and implementation of EMR
- about 200 FHTs in Ontario
- Blended capitation
- similar to CHC but CHC focus on reducing barriers and FHT focus on interprofessional expertise.
How many physicians (%) are in reformed primary care models? How many patients (%)
- 65% physicians
- 75% patients
What are some benefits of primary care reform?
- Continuity of patient-provider relationship
- Increased accountability of physicians for their patients
- increased access associated with les emergency admissions
- group practices associated with increased productivity
- interdisciplinary care associated with quality of care
CHC (salary model) had higher scores for what compared to FFS and capitation models?
- Comprehensive care
- chronic disease management
- health promotion
- addressing lifestyle modifications
What is Alternate level of care
Patients who no longer require an acute care bed but for whom no long-term care bed is available
What is home care?
- An array of services in the home and community setting that encompass health promotion and teaching, curative intervention, end-of-life care, rehabilitation, support and maintenance, social adaptation and integration, and support for the informal (family) caregiver
- Often integrate delivery of
- very broad definition
What is the difference between formal and informal home care? What percentage of home care is delivered by family members?
- Formal: care that is paid for, either publically or privately
- Informal: family, friends, volunteers providing care
- 80% of all home care delivered by family members
- 15% of Canadians provided care to a family/friend with a chronic condition
How many Canadians use home care? How much spending does home care recieve compared to LTC and hospitals?
Almost 1,000,000 at any given time (50% increase from 1998-> 2008)
Home care funding is lower than LTC and wayyy lower than Hospitals
Two types of services provided by home care, and what percentage of people use each?
- Home Health (68% of clients)-nursing/PT/OT
- Home Support (38% of clients)- home making and personal care (provided by PSW)
How are home care services capped?
some provinces cap number of hours/spending to the equivalent cost of a LTC facility
in Ontario, the average is around 14 hours of home care / week
What is a Community Care Access Centre? How many are there in Ontario?
- Single point of entry for all gov't funded LTC services
- Receive referrals for home care from anyone
- Assess eligibility, authorize, case manage
- No co-pays
- provide info for other community support agencies
- CCACs do not provide care but contract and manage third parties to provide care
Acute Care and CCACs. What is the "home first" initiative?
- some CCAC case managers present in every hospital in their LIHN
- majority of home care referrals are from hospitals
- Home first initiative: investment in home care to reduce alc until LTCF beds are available
How many people use home care in Ontario?
Avg. age, impairments, medications?
What is the mean and median of home care use in Ontario? What does this tell you?
- 500,000 clients, avg age is 78, 68% have cognitive impairments, 25% on antidepressents
- Mean 164
- Median 51
Thus minority of people people using home care for an extended period of time
What is a pharmacists role with CCAC, and when did it start?
- Provide Medication Management Support Service (MMSS).
- Began as a pilot project in Scarborough in 2004
How are pharmacists reimbursed when working with CCACs?
- pharmacists salaried employees of CCAC
- pharmacists paid on fee/visit basis
- CCACs contracts community pharmacy
What are community supportservices
- Various services that assist people to live independently, delivered in homes or in community centres
- -usually charitable/NFP
- -usually requires a copay
- -up to client to make arrangements (CCAC will only provide info)
What are three types of residential care options available to the elderly?
- Nursing care
- Supportive housing
Long term care facilities/Nursing homes
- nursing homes(privately owned) but the care is provided for by the MoHLTC
- for people who need high assistance (nursing support available 24 hours a day)
- nurses administer medication
- nursing home must have a contracted pharmacy provider (24/7), usually given in multidose packaging
- pharmacists reimbursed for medchecks in nursing homes
- Funded by the government
- For clients in Supportive housing or retirement homes who need more care than home care.
- privately owned; on site support
- dont need a pharmacy contract
- not gov't subsidized/funded
- moderate support
- privately owned buildings, but assisted living services (thus paid for by MoHLTC)
- 24/7 support, but no nursing services
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