Her Excellency, the Right Honourable Adrienne Clarkson,

Her Excellency, the Right Honourable Adrienne Clarkson,
Canada Health Act Annual Report 2003-2004
Minister of Health
Ministre de la Santé
The Honourable/L'honorable Ujjal Dosanjh
Ottawa, Canada K1A 0K9
December, 2004
Her Excellency, the Right Honourable Adrienne Clarkson,
Governor General and Commander-in-Chief of Canada
May it please Your Excellency:
The undersigned has the honour to present to Your Excellency the Annual Report
on the administration and operation of the Canada Health Act for the fiscal year
that ended March 31, 2004.
Ujjal Dosanjh
Canada Health Act Division, Health Canada
Chapter 3 – Nova Scotia
Preface
In presenting this year’s Annual Report on the Canada Health Act, I do so in the context of a year in
which great progress has been made in securing a strong and dynamic health care system for
Canadians.
On September 16, 2004, all First Ministers came together to reach an historic agreement – a Ten-Year
Plan to Strengthen Health Care. This Plan crosses party lines and transcends provincial boundaries. It
constitutes a truly national response to a national priority and puts us firmly on the road to sustainable
health care for many years to come.
The Action Plan reaffirms a commitment to the principles of the Canada Health Act: public
administration, comprehensiveness, universality, portability and accessibility. This commitment was more
than just a formality – it was a firm endorsement of the publicly funded health care system on which
Canadians rely and in which they strongly believe.
By reasserting that access to medically necessary insured services should be based on need, not on
one’s ability to pay, all First Ministers sent a very clear message that this country has no intention of
developing one health care system for the wealthy and another for everyone else.
The Action Plan also committed all parties to work together, across jurisdictions, across the country. By
emphasizing collaboration among all governments, the First Ministers made clear their intention to work
together for a common purpose; to fight for medicare, not over medicare.
With this Action Plan came new funding from the Government of Canada – some $41 billion over the
next 10 years to meet the funding recommendations of the Romanow Report and to make timely access
to quality care a reality for all Canadians.
Canada’s health care system is a reflection of the values we hold as a nation and of the commitment we
have made to one another as citizens.
By providing access to health services through a single-payer system, Canadians have made a
conscious and deliberate decision to make health care a basic right for all, not just a privilege for the
few. This collective choice is formally embodied in the Canada Health Act.
April 17, 2004, marked the 20th anniversary of the Canada Health Act. Since its unanimous passage by
Parliament in 1984, this Act has served as the Charter of Medicare, safeguarding key principles while
providing the provinces with the flexibility they need to innovate and pursue their own priorities. It has
served us well and remains an important touchstone of shared values.
While all governments have the responsibility to honour the principles of the Canada Health Act, it falls
to the federal government to ensure that those principles are respected. As Minister of Health, I have
an obligation to uphold the law and I will work to ensure that the benefits of medicare are available to
all Canadians.
Canada Health Act Annual Report, 2003-2004
iii
Chapter 3 – Nova Scotia
Any time individuals can pay for quicker access to medically necessary hospital or physician services, or
may be required to pay to access these services, represents a threat to the fundamental principles of
the Canada Health Act. Access to insured health services in our publicly financed health care system
must be based on need, not on the ability to pay.
As can be seen in Chapter 2 of this Report, there are some outstanding issues with respect to provincial
compliance. For example, full insurance coverage for all medically necessary services performed in
clinics in some jurisdictions is not available. While this and other issues remain of concern, I am
confident that resolution can be reached.
When such issues arise, my preferred approach is to try and work things out with the province or
territory involved in a spirit of goodwill and openness. Disputes may be addressed through the Canada
Health Act dispute avoidance and resolution process which was agreed to in 2002, and recently
formalized by First Ministers in September 2004. This process provides for either party to refer an issue
to an independent panel of experts to review the matter and make recommendations.
While it remains the responsibility of the Minister of Health to uphold and enforce the Act, I believe that
involving unbiased experts where there is disagreement over interpretation makes the application of the
Act much more transparent and impartial.
As Minister, I am satisfied that, for the most part, provincial and territorial health insurance plans meet
the criteria and conditions of the Canada Health Act. I look forward to working with all of my colleagues
to strengthen a health care system which defines us as a great nation.
Ujjal Dosanjh
Minister of Health
iv
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Nova Scotia
Acknowledgements
Health Canada would like to acknowledge the work and effort that went into producing this Annual
Report. It is through the dedication and timely commitment of the following departments of health and
their staff that we are able to bring you this report on the administration and operation of the Canada
Health Act:
Newfoundland and Labrador Department of Health and Community Services
Prince Edward Island Health and Social Services
Nova Scotia Department of Health
New Brunswick Department of Health and Wellness
Quebec Department of Health and Social Services
Ontario Ministry of Health and Long-Term Care
Manitoba Health
Saskatchewan Health
Alberta Health and Wellness
British Columbia Ministry of Health Services
Yukon Department of Health and Social Services
Northwest Territories Department of Health and Social Services
Nunavut Department of Health and Social Services
We also greatly appreciate the extensive work effort that was put into this report by our production
team: the desktop publishing unit, the translators, editors and concordance experts, and staff of Health
Canada at headquarters and in the regional offices.
Canada Health Act Annual Report, 2003-2004
v
Introduction
Introduction
The five principles of the Canada Health Act are
the cornerstone of the Canadian health care
system, and reflect the values that inspired
Canada’s single-payer, publicly-financed health
care system. This legislation, passed unanimously
by Parliament in 1984, affirms the federal
government’s commitment to a universal,
accessible, comprehensive, portable and publicly
administered health insurance system. The Act
aims to ensure that all residents of Canada have
access to necessary hospital and physician
services on a prepaid basis. The Canada Health
Act defines for the provinces and territories the
criteria and conditions that they must satisfy in
order to qualify for their full share of the federal
transfers under the Canada Health and Social
Transfer (CHST) cash contribution (effective
April 1, 2004, the cash contribution became
payable under the Canada Health Transfer).
This report is produced in accordance with the
requirement set out in section 23 of the Canada
Health Act:
“The Minister shall, as soon as possible after
the termination of each fiscal year and in any
event not later than December 31 of the next
fiscal year, make a report respecting the
administration and operation of this Act for
that fiscal year, including all relevant
information on the extent to which provincial
health care insurance plans have satisfied the
criteria , and the extent to which the provinces
have satisfied the conditions, for payment
under this Act and shall cause the report to be
laid before each House of Parliament on any of
the first fifteen days on which that House is
sitting after the report is completed.”
Canada Health Act Annual Report, 2003-2004
Under the Canada Health Act, the federal
Minister of Health is required to provide
information on the operation of provincial and
territorial health care plans as they relate to the
criteria and conditions of the Act. The approach to
this information gathering has been collaborative,
where provinces, territories and the federal
government have worked together to supply the
information needed by the Minister.
Chapter 1 provides an overview of the Canada
Health Act and the associated regulations and
policies that are used in the administration of the
Act. Chapter 2 reviews the administration of the
Canada Health Act during 2003-2004, and
includes a summary of compliance issues
addressed and deductions levied. It also describes
the evolution of federal transfers for health care in
Canada. Chapter 3 presents descriptions of the
provincial and territorial health insurance plans,
including statistical data on insured hospital,
physician and surgical-dental health care services.
The annexes to this report provide additional
information relevant to the administration of the
Act and its place in the Canadian health care
system.
Annex A is an office consolidation of the Canada
Health Act and its regulations (unofficial version
dated June 2001). Annex B presents the text of
two key policy statements that clarify the federal
interpretation of the criteria and conditions of the
Canada Health Act. Annex C provides a
description of the Canada Health Act Dispute
Avoidance and Resolution process which came
into effect in 2002. Annex D provides references
to documents that support information found in
provincial and territorial narratives. Annex E is a
glossary of terminology used in this report. Inside
the back cover you will find contact information
for provincial and territorial departments of health.
1
Chapter 1 – Canada Health Act Overview
reasonable access to health services without
financial or other barriers.”
Chapter 1 –
Canada Health Act
Overview
“The principles of the Canada Health Act
began as simple conditions attached to federal
funding for medicare. Over time, they became
much more than that. Today, they represent
both the values underlying the health care
system and the conditions that governments
attach to funding a national system of public
health care. The principles have stood the test
of time and continue to reflect the values of
Canadians.”
(Roy J. Romanow, Q.C., November, 2002)
In this chapter, the Canada Health Act, its
requirements and key definitions under the Act
are discussed. Also described are the regulations
and regulatory provisions of the Canada Health
Act and the interpretation letters by former
federal Ministers of Health Jake Epp and Diane
Marleau to their provincial and territorial
counterparts that are used in the interpretation
and application of the Act.
What is
the Canada Health Act?
The Canada Health Act (CHA or the Act) is
Canada’s federal legislation for publicly funded
health care insurance.
The Act sets out the primary objective of
Canadian health care policy, which is “to protect,
promote and restore the physical and mental wellbeing of residents of Canada and to facilitate
Canada Health Act Annual Report, 2003-2004
The CHA establishes criteria and conditions
related to insured health services and extended
health care services that the provinces and
territories must fulfill to receive the full federal
cash contribution under the Canada Health and
Social Transfer (CHST).
The aim of the CHA is to ensure that all eligible
residents of Canada have reasonable access to
insured health services on a prepaid basis, without
direct charges at the point of service for such
services.
Key Definitions under the CHA
Insured persons are eligible residents of a
province or territory. A resident of a province is
defined in the CHA as “a person lawfully entitled
to be or to remain in Canada who makes his home
and is ordinarily present in the province, but does
not include a tourist, a transient or a visitor to the
province.”
Persons excluded under the CHA include serving
members of the Canadian Forces or Royal
Canadian Mounted Police and inmates of federal
penitentiaries.
Insured health services are medically
necessary hospital, physician and surgical-dental
services provided to insured persons.
Insured hospital services are defined under
the CHA and include medically necessary in- and
out- patient services such as accommodation and
meals at the standard or public ward level and
preferred accommodation if medically required;
nursing service; laboratory, radiological and other
diagnostic procedures, together with the
necessary interpretations; drugs, biologicals and
related preparations when administered in the
hospital; use of operating room, case room and
anaesthetic facilities, including necessary
equipment and supplies; medical and surgical
equipment and supplies; use of radiotherapy
facilities; use of physiotherapy facilities; and
services provided by persons who receive
remuneration therefore from the hospital, but
3
Chapter 1 – Canada Health Act Overview
does not include services that are excluded by the
regulations.
Insured physician services are defined under
the Act as “medically required services rendered
by medical practitioners.” Medically required
physician services are generally determined by
physicians in conjunction with their provincial and
territorial health insurance plans.
Insured surgical-dental services are services
provided by a dentist in a hospital, where a
hospital setting is required to properly perform the
procedure.
Extended health care services as defined in
the CHA are certain aspects of long-term
residential care (nursing home intermediate care
and adult residential care services), and the
health aspects of home care and ambulatory care
services.
Requirements of
the Canada Health Act
The Canada Health Act (CHA or the Act) contains
the following nine requirements that the provinces
and territories must fulfill to qualify for the full
federal cash contributions:
† five program criteria that apply only to insured
health services;
† two conditions that apply to insured health
services and extended health care services;
and
† extra-billing and user charge provisions that
apply only to insured health services.
The Criteria
1. Public Administration (section 8 of CHA)
The public administration criterion, set out in
section 8 of the CHA, applies to provincial and
territorial health care insurance plans. The
intent of the public administration criterion is
that the provincial and territorial health care
insurance plans are administered and operated
on a non-profit basis by a public authority,
4
which is accountable to the provincial or
territorial government for decision making on
benefit levels and services, and whose records
and accounts are publicly audited.
2. Comprehensiveness (section 9)
The comprehensiveness criterion of the CHA
requires that the health care insurance plan of
a province or territory must cover all insured
health services provided by hospitals,
physicians or dentists (i.e., surgical-dental
services which require a hospital setting) and,
where the law of the province so permits,
similar or additional services rendered by other
health care practitioners.
3. Universality (section 10)
Under the universality criterion, all insured
residents of a province or territory must be
entitled to the insured health services provided
by the provincial or territorial health care
insurance plan on uniform terms and
conditions. Provinces and territories generally
require that residents register with the plans to
establish entitlement.
Newcomers to Canada, such as landed
immigrants or Canadians returning from other
countries to live in Canada, may be subject to
a waiting period by a province or territory, not
to exceed three months, before they are
entitled to receive insured health services.
4. Portability (section 11)
Residents moving from one province or
territory to another must continue to be
covered for insured health services by the
“home” jurisdiction during any waiting period
imposed by the new province or territory of
residence. The waiting period for eligibility to a
provincial or territorial health care insurance
plan must not exceed three months. After the
waiting period, the new province or territory of
residence assumes responsibility for health
care coverage.
Residents who are temporarily absent from
their home province or territory or from
Canada, must continue to be covered for
insured health services during their absence.
This allows individuals to travel or be absent
Canada Health Act Annual Report, 2003-2004
Chapter 1 – Canada Health Act Overview
from their home province or territory, within a
prescribed duration, while retaining their health
insurance coverage.
The portability criterion does not entitle a
person to seek services in another province,
territory or country, but is intended to permit a
person to receive necessary services in
relation to an urgent or emergent need when
absent on a temporary basis, such as on
business or vacation.
If insured persons are temporarily absent in
another province or territory, the portability
criterion requires that insured services be paid
at the host province’s rate. If insured persons
are temporarily out of the country, insured
services are to be paid at the home province’s
rate.
Prior approval by the health care insurance
plan in a person’s home province or territory
may also be required before coverage is
extended for elective (non-emergency)
services to a resident while temporarily absent
from their province or territory.
5. Accessibility (section 12)
The intent of the accessibility criterion is to
ensure insured persons in a province or
territory have reasonable access to insured
hospital, medical and surgical-dental services
on uniform terms and conditions, unprecluded
or unimpeded, either directly or indirectly, by
charges (user charges or extra-billing) or other
means (e.g., discrimination on the basis of age,
health status or financial circumstances). In
addition, the health care insurance plans of the
province or territory must provide:
† reasonable compensation to physicians and
dentists for all the insured health services
they provide; and
† payment to hospitals to cover the cost of
insured health services.
Reasonable access in terms of physical
availability of medically necessary services has
been interpreted under the Act using the
“where and as available” rule. Thus, residents
of a province or territory are entitled to have
access on uniform terms and conditions to
Canada Health Act Annual Report, 2003-2004
insured health services at the setting “where”
the services are provided and “as” the services
are available in that setting.
The Conditions
1. Information (section 13(a)) — the provincial
and territorial governments shall provide
information to the Minister of Health as may
be reasonably required, in relation to insured
health services and extended health care
services, for the purposes of the CHA.
2. Recognition (section 13(b)) — the provincial
and territorial governments shall recognize the
federal financial contributions toward both
insured and extended health care services.
Extra-billing and User Charges
The provisions of the CHA, that discourage extrabilling and user charges for insured health
services in a province or territory, are outlined in
sections 18 to 21. If it can be determined that
either extra-billing or user charges exist in a
province or territory, a mandatory deduction from
the federal cash transfer to that province or
territory is required under the Act. The amount of
such a deduction for a fiscal year is determined by
the federal Minister of Health based on
information provided by the province or territory
according to the Extra-billing and User Charges
Information Regulations described below.
Extra-billing (section 18)
Under the CHA, extra-billing is defined as the
billing for an insured health service rendered to an
insured person by a medical practitioner or a
dentist (i.e., a surgical-dentist providing insured
health services in a hospital setting) in an amount
in addition to any amount paid or to be paid for
that service by the health care insurance plan of a
province or territory. For example, if a physician
were to charge patients any amount for an office
visit that is insured by the provincial or territorial
health insurance plan, the amount charged would
constitute extra-billing. Extra-billing is seen as a
barrier or impediment for people seeking medical
5
Chapter 1 – Canada Health Act Overview
care and is therefore, contrary to the accessibility
criterion.
User Charges (section 19)
The CHA defines user charges as any charge for
an insured health service other than extra-billing
that is permitted by a provincial or territorial
health care insurance plan and is not payable by
the plan. For example, if patients were charged a
facility fee for receiving an insured service at a
hospital or clinic, the fee would be considered a
user charge. User charges are not permitted
under the Act because as is extra-billing, they
constitute a barrier or impediment to access.
Penalty Provisions of
the Canada Health Act
Mandatory Penalty Provisions
Under the CHA, provinces and territories that
allow extra-billing and user charges are subject to
mandatory dollar-for-dollar deductions from the
federal transfer payments under the CHST
(Canada Health Transfer effective April 1, 2004).
For example, if it has been determined that a
province has allowed $500,000 in extra-billing by
physicians, the federal transfer payments to that
province would be reduced by that amount.
Discretionary Penalty Provisions
Other Elements of the Act
Regulations (section 22)
Section 22 of the CHA enables the federal
government to make regulations for administering
the Act in the following areas:
† defining the services included in the CHA
definition of “extended health care services.”
† prescribing which services to exclude from
hospital services;
† prescribing the types of information that the
federal Minister of Health may reasonably
require from a province or territory to qualify
for a full federal transfer; and
† prescribing how provinces and territories are
required to recognize the CHST in their
documents, advertising or promotional
materials.
The only regulations in force under the Act are the
Extra-billing and User Charges Information
Regulations, which require the provinces and
territories to provide estimates of extra-billing and
user charges before the beginning of a fiscal year
so that appropriate penalties can be levied, as
well as financial statements showing the amounts
actually charged so that reconciliations with the
actual deductions can be made. (A copy of these
regulations is provided in Annex A).
6
Non-compliance with one of the five criteria or
two conditions of the CHA is subject to
discretionary penalties. The amount of any
deduction from federal transfer payments under
the CHST is based on the gravity of the default.
The CHA sets out a consultation process that
must be undertaken with the province or territory
before discretionary penalties can be levied. To
date, the discretionary penalty provisions of the
Act have not been applied.
Excluded Services
and Persons
Although the CHA requires that insured health
services are provided to insured persons in a
manner that is consistent with the criteria and
conditions set in the Act, not all Canadian
residents or health services fall under the scope
of the Act. There are two categories of exclusion
for insured services:
† services that fall outside the definition of
insured health services; and
† certain services and groups of persons are
excluded from the definitions for insured
services and insured persons.
These exclusions are discussed below.
Canada Health Act Annual Report, 2003-2004
Chapter 1 – Canada Health Act Overview
Non-insured Health Services
In addition to the medically necessary insured
hospital and physician services covered by the
CHA, provinces and territories also provide a
range of programs and services outside the scope
of the Act. These are provided at provincial and
territorial discretion, on their own terms and
conditions, and vary from one province or territory
to another. Additional services that may be
provided include pharmacare, ambulance services
and optometric services.
The additional services provided by provinces and
territories may be targeted to specific population
groups (e.g., children, seniors or social assistance
recipients), and may be partially or fully covered
by provincial and territorial health insurance plans.
A number of services provided by hospitals and
physicians are not considered medically necessary
and thus, are not insured under provincial and
territorial health insurance legislation. Uninsured
hospital services for which patients may be
charged include preferred hospital accommodation
unless prescribed by a physician, private duty
nursing services, and the provision of telephones
and televisions. Uninsured physician services for
which patients may be charged include telephone
advice, the provision of medical certificates
required for work, school, insurance purposes and
fitness clubs, testimony in court and cosmetic
services.
Excluded Persons
The CHA definition of “insured person” excludes
members of the Canadian Forces, persons
appointed to a position of rank within the Royal
Canadian Mounted Police, persons serving a
prison term in a federal penitentiary, and persons
who have not completed a minimum period of
residence in a province or territory (a period that
must not exceed three months). In addition, the
definition of “insured health services” excludes
services to persons provided under any other Act
of Parliament (e.g., foreign refugees) or under the
workers’ compensation legislation of a province or
territory.
Canada Health Act Annual Report, 2003-2004
The exclusion of these persons from insured
health service coverage predates the adoption of
the CHA and is not intended to constitute
differences in access to publicly insured health
care.
Policy Interpretation Letters
There are two key policy statements that clarify
the federal position on the CHA . These
statements have been made in the form of
ministerial letters from former federal health
Ministers to their provincial and territorial
counterparts. Both letters are reproduced in
Annex B of this report.
Epp Letter
In June 1985, approximately one year following
the passage of the CHA in Parliament, thenfederal Health minister Jake Epp wrote to his
provincial and territorial counterparts to set out
and confirm the federal position on the
interpretation and implementation of the CHA.
Minister Epp’s letter followed several months of
consultation with his provincial and territorial
counterparts. The letter sets forth statements on
the federal policy intent, which clarify the criteria,
conditions and regulatory provisions of the CHA.
These clarifications have been used by the federal
government in assessing and interpreting
compliance with the Act. The Epp letter continues
to be an important reference for interpreting the
Act.
Marleau Letter – Federal Policy on Private
Clinics
Between February 1994 and December 1994, a
series of seven federal-provincial-territorial
meetings dealing wholly or in part with private
clinics took place. At issue was the growth of
private clinics providing medically necessary
services funded partially by the public system and
partially by patients and its impact on Canada’s
universal, publicly funded health care system.
7
Chapter 1 – Canada Health Act Overview
At the Federal-Provincial-Territorial Health
Ministers Meeting of September 1994 in Halifax,
all ministers of health present, except for
Alberta’s health minister, agreed to “take
whatever steps are required to regulate the
development of private clinics in Canada.”
Diane Marleau, the federal Minister of Health at
the time, wrote to all provincial and territorial
ministers of health on January 6, 1995, to
announce the new Federal Policy on Private
Clinics. The Minister’s letter provided the federal
interpretation of the CHA as it relates to the issue
of facility fees charged directly to patients
receiving medically necessary services at private
clinics. The letter stated that the definition of
“hospital” contained in the CHA, includes any
public facility that provides acute, rehabilitative or
chronic care. Thus, when a provincial or territorial
health insurance plan pays the physician fee for a
medically necessary service delivered at a private
clinic, it must also pay the facility fee or face a
deduction from federal transfer payments.
Dispute Avoidance and
Resolution Process
In April 2002, the then-federal Health Minister
A. Anne McLellan outlined in a letter to her
provincial and territorial counterparts a Canada
Health Act Dispute Avoidance and Resolution
8
process, which was agreed to by provinces and
territories, except Quebec. The process meets
federal, provincial and territorial interests of
avoiding disputes related to the interpretation of
CHA principles, and when this is not possible,
resolving disputes in a fair, transparent and timely
manner.
The process includes the dispute avoidance
activities of government-to-government
information exchange; discussions and clarification
of issues, as they arise; active participation of
governments in ad hoc federal-provincial-territorial
committees on Canada Health Act issues; and
Canada Health Act advance assessments, upon
request.
Where dispute avoidance activities are
unsuccessful, dispute resolution activities may be
initiated, beginning with government-togovernment fact-finding and negotiations. If these
are unsuccessful, either Minister of Health
involved may refer the issues to a third-party
panel to undertake fact-finding and provide advice
and recommendations.
The federal Minister of Health has the final
authority to interpret and enforce the CHA. In
deciding whether to invoke the non-compliance
provisions of the Act, the Minister will take the
panel’s report into consideration.
Please refer to Annex C for a copy of Minister
McLellan’s letter.
Canada Health Act Annual Report, 2003-2004
Chapter 2 – Administration and Compliance
†
Chapter 2 –
Administration and
Compliance
†
†
†
Administration
In administering the Canada Health Act (CHA),
the federal Minister of Health is assisted by
Health Canada policy, communications and
information officers located in Ottawa and in the
six regional offices of the Department, and by
lawyers with the Department of Justice.
Health Canada takes its responsibilities under the
Canada Health Act seriously, working with the
provinces and territories to ensure that the
principles of the CHA are respected. Our
preference is always to work with provinces and
territories to resolve issues through consultation,
collaboration and cooperation.
The Canada Health Act Division
The Canada Health Act Division (the Division) is
part of the Intergovernmental Affairs Directorate
of the Health Policy Branch at Health Canada and
is responsible for administering the CHA. Officers
of the Division located in Ottawa and in regional
Health Canada offices fulfill the following ongoing
functions:
† monitoring and analysing provincial and
territorial health insurance plans for
compliance with the criteria, conditions and
extra-billing and user charge provisions of the
CHA;
† working in partnership with provinces and
territories to investigate and resolve CHA
Canada Health Act Annual Report, 2003-2004
†
†
†
†
compliance issues and pursue activities that
encourage compliance with the CHA;
informing the Minister of possible noncompliance and recommending appropriate
action to resolve the issue;
developing and producing the Canada Health
Act Annual Report on the administration and
operation of the CHA;
developing and maintaining formal and informal
contacts and partnerships with health officials
in provincial and territorial governments to
share information;
collecting, summarizing and analysing relevant
information on provincial and territorial health
care systems;
disseminating information on the CHA and on
publicly funded health care insurance programs
in Canada;
responding to information requests and
correspondence relating to the CHA through
the preparation of responses to inquiries about
the CHA and health insurance issues received
by telephone, mail and the Internet, from the
public, members of Parliament, government
departments, stakeholder organizations and
the media;
conducting issue analysis and policy research
in order to provide policy advice and
recommendations to the Minister concerning
the interpretation of the CHA; and
collaborating with provincial and territorial
health department representatives on the
Interprovincial Health Insurance Agreements
Coordinating Committee (see below).
Interprovincial Health Insurance
Agreements Coordinating
Committee
The Canada Health Act Division chairs the
Interprovincial Health Insurance Agreements
Coordinating Committee (formerly named the
Federal-Provincial/Territorial Coordinating
Committee on Reciprocal Billing), and acts as a
secretariat for the Committee. The Committee
was formed in 1991 to address issues affecting
the interprovincial billing of hospital and medical
9
Chapter 2 – Administration and Compliance
services as well as issues related to registration
and eligibility for health insurance coverage. It
oversees the application of interprovincial health
insurance agreements in accordance with the
Canada Health Act.
The within-Canada portability provisions of the
CHA are implemented through a series of bilateral
reciprocal billing agreements between provinces
and territories for hospital and physician services.
This generally means that a patient’s health card
will be accepted, in lieu of payment, when the
patient receives hospital or physician services in
another province or territory. The province or
territory providing the service will then directly bill
the patient’s home province. All provinces and
territories participate in reciprocal hospital
agreements and all, with the exception of Quebec,
participate in reciprocal medical agreements. The
intent of these agreements is to ensure that
Canadian residents do not face point-of-service
charges for medically required hospital and
physician services when they travel in Canada.
However, these agreements are interprovincial/
territorial and signing them is not a requirement of
the CHA.
In 2003-2004, the Committee updated hospital inpatient rates for all hospitals that bill for
interprovincial services in Canada and updated
the set of current national out-patient service
rates.
The Committee is currently reviewing its high cost
procedure (e.g. organ transplants) rates to reflect
current costs.
Compliance
As mentioned in Chapter 1, provinces and
territories must comply with the CHA criteria and
conditions in order to receive the full amount of
the Canada Health and Social Transfer (CHST)
cash contribution (effective April 1, 2004, the
cash contribution became payable under the
Canada Health Transfer). The following section
outlines how Health Canada determines
provincial/territorial compliance.
10
Health Canada’s approach to resolving possible
Canada Health Act compliance issues emphasizes
transparency, consultation and dialogue with
provincial and territorial health ministry officials.
In most instances, issues are successfully resolved
through consultation and discussion based on a
thorough examination of the facts. Deductions
have only been applied when all options to resolve
the issue have been exhausted. To date, most
disputes and issues related to the administration
and interpretation of the CHA have been
addressed and resolved without resorting to
deductions.
Health Canada officials routinely liaise with
provincial and territorial health ministry
representatives and health insurance plan
administrators to help resolve common problems
experienced by Canadians related to eligibility for
health insurance coverage and portability of
health services within and outside Canada.
Canada Health Act Division and regional office
staff monitor the operations of provincial and
territorial health care insurance plans in order to
provide advice to the Minister on possible noncompliance with the CHA. Sources for this
information include: officials representing
provincial and territorial governments; provincial
and territorial government publications; media
reports and correspondence received from the
public and other non-government organizations
and individuals. Staff in the Compliance and
Interpretation Unit, Canada Health Act Division,
assess issues of concern and complaints on a
case-by-case basis. The assessment process
involves compiling all facts and information related
to the issue and making recommendations to the
Minister for appropriate follow-up action.
Verification of the facts with provincial and
territorial health officials may reveal issues that
are not directly related to the CHA while others
may pertain to the CHA but are a result of
misunderstanding or miscommunication and are
resolved quickly with provincial assistance. In
instances where a CHA issue has been identified
and remains after initial enquiries, Division
officials then ask the jurisdiction in question to
investigate the matter and report back. Division
Canada Health Act Annual Report, 2003-2004
Chapter 2 – Administration and Compliance
staff then discuss the issue and its possible
resolution with provincial officials. Only if the
issue is not resolved to the satisfaction of the
Division after following the aforementioned steps,
do the penalty provisions of the Act come into
consideration.
Compliance Issues
During 2003-2004, the Canada Health Act
Division or the federal Minister of Health
discussed or otherwise communicated the CHA
concerns related to the following issues with the
respective provincial/territorial Health Ministries.
This information is factual as of March 31, 2004.
Unless otherwise indicated, bilateral
communications on these issues are on-going.
With respect to private payment for insured health
services, Health Canada is concerned that any
trend toward privatization that results in a twotiered system, where individuals can pay for
quicker access to medically necessary hospital or
physician services represents a threat to the
fundamental principles of the CHA, and therefore
to the overall health care system. Access to
insured services must be based on need, not the
ability to pay.
Some jurisdictions have recently questioned the
definition of the term “medically necessary” in the
Act. As noted by former federal Health Minister
Jake Epp in his 1985 interpretation letter to all
provincial and territorial health ministers,
provinces and territories, along with their medical
professionals, have the prerogative and
responsibility for interpreting what physician
services are medically necessary. As well,
provinces and territories determine which
hospitals and hospital services are required to
provide acute, rehabilitative or chronic care. In
practice, this means that provincial and territorial
health insurance plans, in consultation with their
respective medical professional colleges or
groups, are primarily responsible for determining
which services are medically necessary for health
insurance purposes. Once a service has been
Canada Health Act Annual Report, 2003-2004
determined by a province to be an insured service,
it must be covered by the provincial health
insurance plan, regardless of where it is delivered.
Patient charges for magnetic resonance
imaging (MRI) and computed tomography
(CT) scans
There are private MRI and CT clinics in British
Columbia, Alberta, Quebec and Nova Scotia, and
these provinces do not provide coverage for
medically necessary MRI and CT scans performed
at these private clinics. Under the Canada Health
Act, MRI and CT services are considered to be
insured health services when they are medically
necessary for the purpose of maintaining health,
preventing disease or diagnosing or treating an
injury, illness or disability, and are provided in a
hospital or a facility providing hospital care.
Health Canada originally communicated these
CHA concerns to all provinces in 2000, and a
multilateral examination of the issue was
subsequently conducted, however the issue of
charges to insured persons for MRI and CT
services was not resolved. In July 2003, former
federal health minister Anne McLellan wrote to
the four provincial health ministers concerned to
communicate her objection to the queue jumping
that results in provinces that allow private clinics
to sell quicker access to medically necessary
diagnostic services. Consultations with provincial
officials in all four provinces except Quebec
followed. Although multilateral discussions were
scheduled to begin in 2004, these discussions
were postponed at the request of the provinces,
pending the First Ministers’ discussions on
sustainability of the health care system.
In 2003, Health Canada learned that a
Newfoundland resident paid MRI Canada to
arrange an MRI service under the guise of a thirdparty payer arrangement at a Newfoundland
Hospital in July 2002. Health Canada relayed the
CHA concerns about this situation to the
Newfoundland and Labrador Department of
Health and Community Services. Newfoundland
responded that there are no plans to reimburse
the patient. A Canada Health Transfer (CHT)
11
Chapter 2 – Administration and Compliance
deduction in respect of this charge will be taken if
the issue is not resolved.
Patient charges by specialty referral
centres and for self-referrals to physician
specialists
Since 2002, two specialist referral clinics in
Vancouver have been offering expedited
consultations with physician specialists for a fee
for individuals who choose to bypass their family
physicians to seek specialized treatment. Charges
to insured persons for insured services contravene
the CHA. This practice is also a concern from a
CHA perspective because it encourages queue
jumping for insured health services. During a
meeting between British Columbia Ministry of
Health Services and Health Canada officials in
2003, the province indicated that Medical
Services Plan (MSP) policy allows specialists to
bill self-referred patients for the difference
between the fee paid by MSP and the fee charged
to self- referred patients. Health Canada officials
informed the province that this practice
constitutes extra-billing under the CHA and
further bilateral consultations are required on this
issue.
Patient charges for insured health services
in private surgical clinics
Health Canada has been engaged in bilateral
discussions with British Columbia on patient
charges for insured health services in private
surgical clinics since June 2000. Currently, the
British Columbia Medicare Protection Act
prohibits charges to insured provincial residents
for medically necessary services, but allows third
parties, e.g,. Workers’ Compensation Board, to
pay for these services. Some physicians working
in private clinics allow insured residents to
purchase health services under the guise of thirdparty payor arrangements. Health Canada has
continued to press British Columbia to improve its
capacity to audit and investigate charges at these
facilities so that insured persons are not charged
for insured health services. Following bilateral
discussions, British Columbia passed the
Medicare Protection Amendment Act (Bill 92) in
12
December 2003. This legislation would have
strengthened British Columbia’s ability to audit
and investigate those responsible for charging
beneficiaries for insured health services, but it
was not proclaimed. Health Canada officials had
not indicated that legislative amendments were
required, and left it to provincial officials to
determine how best to resolve the problem of
inappropriate patient charges. However, had this
legislation come into effect, it would have
addressed Health Canada’s concerns. CHST
deductions in respect of these charges were
applied against the March 2004 CHST cash
contribution, and future CHT deductions will be
levied unless this issue is resolved.
Patient charges for bone density scans
In April 2002, the press reported that a
Saskatchewan physician was providing preferred
access to bone density scans to patients in return
for a donation of $95 to a research foundation
incorporated by the physician in 1995. Charges to
insured persons for insured services contravene
the CHA. This practice is a concern from a CHA
perspective because it encourages queue-jumping
for insured health services, and Health Canada
subsequently communicated these concerns to
Saskatchewan Health. In 2003, Saskatchewan
Health informed Health Canada that they had
exchanged correspondence with the physician
about Saskatchewan’s concerns and
dissatisfaction with the practice. Health Canada
has asked Saskatchewan about next steps.
Patient Charges for medical/surgical
supplies
In September 2002, the press reported that
Manitoba physicians were charging for
medical/surgical supplies or “tray fees” to
patients. Health Canada communicated the CHA
concerns to Manitoba, namely, that charges to
insured persons for insured services contravene
the CHA. This issue was raised at a bilateral
meeting between Health Canada and Manitoba
Health officials in 2003, and Health Canada
requested further information on Manitoba’s
policy regarding tray fees. Later in 2003, Health
Canada Health Act Annual Report, 2003-2004
Chapter 2 – Administration and Compliance
Canada obtained evidence of tray fees having
been charged to a Manitoba resident at a nonhospital medical/surgical facility, and
subsequently wrote to Manitoba to request an
investigation. A response is still pending.
Canada Health and Social
Transfer (CHST) Deductions
in 2003-2004
Patient charges by a private surgical clinic
British Columbia did not report to Health Canada
the amounts of extra-billing and user charges
actually charged during 2001-2002, in accordance
with the requirements of the CHA Extra-Billing
and User Charges Information Regulations. As a
result of reports that British Columbia was
investigating cases of user charges, a $126,775
deduction was taken from British Columbia’s
March 2004 CHST cash contribution, based on
the Health Canada estimate for the amount of
these changes, for the 2001-2002 fiscal year
period.
Following media reports in March 2000, the Régie
de l’assurance maladie du Québec (RAMQ)
launched an investigation into claims that a
Quebec private clinic was charging patients up to
$400 for the use of operating rooms to perform
medical procedures for which physicians billed the
RAMQ. Health Canada originally communicated
the Canada Health Act concerns about insured
persons being charged for insured health services
to the Quebec Department of Health and Social
Services in 2000, requesting details about the
RAMQ investigation. In October 2002, press
reports continued to indicate that the clinic was
still charging patients. Health Canada has
continued to advise Quebec that the practice of
charging patients for the use of a facility during
the provision of an insured service is a
contravention of the CHA, and has made repeated
requests that Quebec inform Health Canada of
the results of its investigation into this practice.
Quebec health ministry officials have responded
that they are not at liberty to reveal the status of
the province’s investigation of the charges.
Drugs administered in hospitals
Health Canada is also concerned about patient
charges for drugs administered in out-patient
clinics of hospitals, and their appropriateness
under the CHA. Some provinces cover such drugs
e.g., Remicade, under provincial pharmacare
programs rather than under hospital insurance
programs. Health Canada officials have collected
and are reviewing information provided by
provinces during consultations on this issue.
Canada Health Act Annual Report, 2003-2004
With the closure of its abortion clinic in Halifax in
November 2003, wherein patients were charged
the facility fees in relation to the service, Nova
Scotia was deemed to be in compliance with the
Federal Policy on Private Clinics. Including
adjustments for prior years, a net deduction of
$7,119 was applied against Nova Scotia’s CHST
cash contribution during fiscal year 2003-2004.
History of Deductions and
Refunds under the Canada
Health Act
The Canada Health Act, which came into force
April 1, 1984, reaffirmed the national commitment
to the original principles of the Canadian health
care system, as embodied in the previous
legislation, the Medical Care Act and the Hospital
Insurance and Diagnostic Services Act. By putting
into place mandatory dollar-for-dollar penalties for
extra-billing and user charges, the federal
government took steps to eliminate the
proliferation of direct charges for hospital and
physician services, judged to be restricting the
access of many Canadians to health care services
due to financial considerations.
13
Chapter 2 – Administration and Compliance
During the period 1984 to 1987, subsection 20(5)
of the CHA provided for deductions in respect of
these charges to be refunded to the province if
the charges were eliminated before April 1, 1987.
By March 31, 1987, it was determined that all
provinces, which had extra-billing and user
charges, had taken appropriate steps to eliminate
them. Accordingly, by June 1987, a total of
$244.732 million in deductions were refunded to
New Brunswick ($6.886M), Quebec ($14.032M),
Ontario ($106.656M), Manitoba ($1.270M),
Saskatchewan ($2.107M), Alberta ($29.032M)
and British Columbia ($84.749M).
Following the CHA’s initial three-year transition
period, under which refunds to provinces and
territories for deductions were possible, penalties
under the CHA did not reoccur until fiscal year
1994-1995. As a result of a dispute between the
British Columbia Medical Association and the
British Columbia government over compensation,
several doctors opted out of the provincial health
insurance plan and began billing their patients
directly. Some of these doctors billed their
patients at a rate greater than the amount the
patients could recover from the provincial health
insurance plan. This higher amount constituted
extra-billing under the CHA. Including deduction
adjustments for prior years, dating back to fiscal
year 1992-1993, deductions began in May 1994
until extra-billing by physicians was banned when
changes to British Columbia’s Medicare
Protection Act came into effect in September
1995. In total, $2.025 million was deducted from
British Columbia’s cash contribution for extrabilling that occurred in the province between
1992-1993 and 1995-1996. These deductions and
all subsequent deductions are non-refundable.
In January 1995, the federal Minister of Health,
Diane Marleau, expressed concerns to her
provincial and territorial colleagues about the
development of two-tiered health care and the
emergence of private clinics charging facility fees
for medically necessary services. As part of her
communication with the provinces and territories,
Minister Marleau announced that the provinces
and territories would be given more than nine
months to eliminate these user charges, but that
14
any province that did not, would face financial
penalties under the CHA. Accordingly, beginning
in November 1995, deductions were applied to the
cash contributions to Alberta, Manitoba, Nova
Scotia and Newfoundland and Labrador for noncompliance with the Federal Policy on Private
Clinics.
During the period from November 1995 to June
1996, total deductions of $3.585 million were
made to Alberta’s cash contribution in respect of
facility fees charged at clinics providing surgical,
ophthalmological and abortion services. On
October 1, 1996, Alberta prohibited private
surgical clinics from charging patients a facility fee
for medically necessary services for which the
physician fee was billed to the provincial health
insurance plan.
Similarly, due to facility fees allowed at an
abortion clinic, a total of $284,430 was deducted
from Newfoundland and Labrador’s cash
contribution before these fees were eliminated,
effective January 1, 1998.
For the period from November 1995 to December
1998, deductions from Manitoba’s CHST cash
contribution amounted to $2,055,000, ending with
the confirmed elimination of user charges at
surgical and ophthalmology clinics, effective
January 1, 1999. However, during fiscal year
2001-2002, a monthly deduction (from October
2001 to March 2002 inclusive) in the amount of
$50,033.50 was levied against Manitoba’s CHST
cash contribution on the basis of a financial
statement provided by the province showing that
actual amounts charged with respect to user
charges for insured services in fiscal years 19971998 and 1998-1999 were greater than the
deductions levied on the basis of estimates. This
brought total deductions levied against Manitoba
to $2,355,201.
With the closure of its abortion clinic in Halifax
effective November 27, 2003, Nova Scotia was
deemed to be in compliance with the Federal
Policy on Private Clinics. Prior to the closure, a
total deduction of $372,135 was made from Nova
Scotia’s CHST cash contribution for its failure to
Canada Health Act Annual Report, 2003-2004
Chapter 2 – Administration and Compliance
cover facility charges to patients while paying the
physician fee.
In January 2003, British Columbia provided a
financial statement in accordance with the CHA
Extra-Billing and User Charges Information
Regulations, indicating aggregate amounts
actually charged with respect to extra-billing and
user charges during fiscal year 2000-2001,
totalling $4,610. Accordingly, a deduction of
$4,610 was made to the March 2003 CHST cash
contribution.
In 2004, British Columbia did not report to Health
Canada the amounts of extra-billing and user
charges actually charged during fiscal year 20012002, in accordance with the requirements of the
CHA Extra-Billing and User Charges Information
Regulations. As a result of reports that British
Columbia was investigating cases of user charges,
a $126,775 deduction was taken from British
Columbia’s March 2004 CHST payment, based on
the amount Health Canada estimated to have
been charged during fiscal year 2001-2002.
Since the enactment of the Canada Health Act,
covering the period April 1984 to March 2004,
deductions totalling $8,753,151 have been applied
against provincial cash contributions in respect of
the extra-billing and user charges provisions of the
Canada Health Act. This amount excludes
deductions totalling $244,732,000 that were made
between 1984 and 1987 and subsequently
refunded to the provinces as per subsection 20(5)
of the CHA.
Evolution of Federal Health
Care Transfers
Grants to help establish programs
Federal support for provincial health care goes
back to the late 1940s when the National Health
Grants were created. These grants were
considered to be essential building blocks of a
national health care system. While the grants
were mainly used to build up the Canadian
Canada Health Act Annual Report, 2003-2004
hospital infrastructure, they also supported
initiatives in areas such as professional training,
public health research, tuberculosis control and
cancer treatment. By the mid 1960s, the grants
available to the provinces totalled more than
$60 million annually.
In the mid-1950s in response to public pressures,
the federal government agreed to provide financial
assistance to provinces to help them establish
health insurance programs. In January 1956, the
federal government placed concrete proposals
before the provinces to inaugurate a phased
health insurance program, with priority given to
hospital insurance and diagnostic services.
Discussions on these proposals led to the
adoption of the Hospital Insurance and Diagnostic
Services Act in 1957. The implementation of the
Hospital Insurance and Diagnostic Services
(HIDS) program started in July 1958, by which
time Newfoundland, Saskatchewan, Alberta,
British Columbia and Manitoba were operating
hospital insurance plans. By 1961, all provinces
and territories were participating in the program.
The second phase of the federal intervention
supporting provincial and territorial health
insurance programs resulted from the
recommendations of the Royal Commission on
Health Services (Hall Commission). In its final
report, tabled in 1964, the Hall Commission
recommended establishing a new program that
would ensure that all Canadians have access to
necessary medical care (physician services,
outside a hospital setting).
The Medical Care Act was introduced in
Parliament in early December 1966 and received
Royal Assent on December 21,1966. The
implementation of the Medical Care program
started on July 1, 1968. By 1972, all provinces
and territories were participating in the program.
Originally, the federal government’s method of
contributing to provincial and territorial hospital
insurance programs was based on the cost to
provinces and territories of providing insured
hospital services. Under the Hospital Insurance
and Diagnostic Services Act (1957), the federal
government reimbursed the provinces and
15
16
0
0
0
-1,982,000
MB
SK
AB
BC
0
-588,000
0
0
0
-72,000
0
-96,000
19961997
0
0
0
0
-1,982,000 -2,709,000 -2,022,000
0
0
0
-43,000
-2,319,000 -1,266,000
0
-269,000
0
0
0
-32,000
0
-46,000
19951996
-775,000
0
0
0
0
0
0
-586,000
0
0
0
-57,000
0
-132,000
19971998
-703,950
0
0
0
0
0
0
-612,000
0
0
0
-38,950
0
-53,000
19981999
-18,540
0
0
0
0
0
0
0
0
0
0
-61,110
0
42,570
19992000
-57,804
0
0
0
0
0
0
0
0
0
0
-57,804
0
0
20002001
-335,301
0
0
0
0
0
0
-300,201
0
0
0
-35,100
0
0
20012002
Note: Deductions are shown in the year they were applied to the cash contribution.
Deductions made in one fiscal year may include adjustments to previous fiscal year periods.
TOTAL
0
0
ON
YK
0
QC
0
0
NB
NU
0
NS
0
0
PE
NW
0
19941995
NF
Provinces/
Territories
(in dollars $)
-15,662
0
0
0
-4,610
0
0
0
0
0
0
-11,052
0
0
20022003
Deductions to Cash Contributions under the CHA: 1994-1995 through 2003-2004
-133,894
0
0
0
-126,775
0
0
0
0
0
0
-7,119
0
0
20032004
-8,753,151
0
0
0
-2,156,385
-3,585,000
0
-2,355,201
0
0
0
-372,135
0
-284,430
TOTAL
Chapter 2 – Administration and Compliance
Canada Health Act Annual Report, 2003-2004
Chapter 2 – Administration and Compliance
territories for approximately 50 percent of the
costs of hospital insurance. Under the Medical
Care Act (1966), the federal contribution was set
at 50 percent of the average national per capita
costs of the insured services, multiplied by the
number of insured persons in each province and
territory. Funding protocols based on conditional
grants continued until the move to block funding
was made in fiscal year 1977-1978.
Established Programs Financing (EPF)
On April 1, 1977, federal funding supporting
insured health care services was replaced by a
block fund transfer with only general requirements
related to maintaining a minimum standard of
health services through the passage of the
Federal-Provincial Fiscal Arrangements and
Established Programs Financing Act, 1977. Known
also as the EPF Act, the new legislation provided
federal contributions to the provinces and
territories for insured hospital and medical care
services (as well as for post-secondary education)
that were no longer tied to provincial
expenditures. Rather, federal contributions made
in fiscal year 1975-1976 under the existing costsharing programs were designated as the base
year for contributions, to be escalated by the rate
of growth of nominal Gross National Product
(GNP) and increases to the population.
Under the EPF Act, and subsequent funding
arrangements, the total amount of the provincial
and territorial health entitlement was now made
up of relatively equal cash and tax transfers. The
federal tax transfer involves the federal
government ceding some of its “tax room” to the
provincial and territorial governments, reducing its
tax rate to allow provinces to raise their tax rates
by an equivalent amount. With the EPF “health”
tax transfer, the changes in federal and provincial
tax rates offset one another, meaning there was
no net impact on taxpayers. The total amount of
the health care entitlement did not change.
The EPF Act also included a new transfer for the
Extended Health Care Services Program. This
group of health care services, defined as nursing
home intermediate care, adult residential care,
Canada Health Act Annual Report, 2003-2004
ambulatory health care and the health aspects of
home care, were block funded on the basis of $20
per capita for fiscal year 1977-1978, and subject
to the same escalator as insured health services.
This portion of the EPF transfer was made on a
virtually unconditional basis and, unlike the
insured services transfer, was not subject to
specified program delivery criteria.
The health care portion of the EPF cash transfer
was made on a semi-monthly basis to each
province and territory by Health Canada. While
this federal-provincial-territorial health care
insurance funding arrangement did include certain
program delivery criteria, Health Canada did not
have a viable mechanism to compel the provinces
and territories to fully comply with the conditions
set out in the existing hospital and medical care
legislation. Under the prevailing legislative
framework, the Government of Canada was
required to withhold all of the monthly health care
transfer to a province or territory for each month
if the conditions were not met.
It was not until the enactment of the Canada
Health Act in 1984 that special deduction
provisions came into force allowing for dollar-fordollar deductions for extra-billing and user
charges, and discretionary deductions when
provincial and territorial plans failed to fully
comply with other provisions set out in the Act.
These criteria and conditions remain in force to
the present day.
Canada Health and Social Transfer
(CHST)
In the 1995 Budget, the federal government
announced a restructuring of the EPF Act, now to
be called the Federal-Provincial Fiscal
Arrangements Act, with special provisions for a
Canada Health and Social Transfer (CHST). The
new omnibus or block transfer, to begin in fiscal
year 1996-1997, merged the health and postsecondary education funding of the EPF Act with
Canada Assistance Plan funding (the federalprovincial cost-sharing arrangement for social
services). When the CHST came into effect on
April 1, 1996, provinces and territories received
17
Chapter 2 – Administration and Compliance
CHST cash and tax transfer in lieu of entitlements
under the Canada Assistance Plan (CAP) and
Established Programs Financing. The combined
value of EPF and CAP cash was greater than the
CHST cash amount provided to provinces and
territories, reflecting the need for fiscal restraint
at the time the CHST was introduced.
Minor amendments to the CHA reflected a new
definition for “cash contribution”, and deletion of
definitions for “Act of 1977” and “contribution”.
Revised wording of section 5 made cash
contributions relating to all aspects of the CHA,
eliminating the requirement for section 6 (for
extended health care services). As well, the
wording of sections 5 and 13(b) were changed to
reference the CHST instead of the Act of 1977.
The new block fund was provided to support the
national criteria and conditions in the Canada
Health Act (public administration,
comprehensiveness, universality, portability and
accessibility) and the provisions relating to extrabilling and user charges, as well as maintaining
the CAP- related national standard that no period
of minimum residency be required or allowed with
respect to social assistance. Extended health care
services continued as part of the Canada Health
Act, subject only to the provision of information
and recognition of the federal transfer, as set out
in section 13 of the Canada Health Act. To this
day, these requirements remain unchanged since
1984.
The new legislation also transferred the cash
payment authority from Health Canada to the
Department of Finance. However, the Minister of
Health continued to be responsible for
determining the amounts of any deductions or
withholdings pursuant to the Canada Health Act,
including those for extra-billing and user charges,
and for communicating these amounts to the
Department of Finance before the payment dates.
The Department of Finance makes the actual
deductions, on behalf of the Department of
Health, from the twice-monthly CHST cash
contributions.
18
Health Accords: Increasing and
restructuring federal support for
health
In 2000 and 2003, First Ministers met to discuss
health care, focusing on reform, reporting and
funding requirements. In 2000, the federal
government announced $23.4 billion in new
spending over five years on health care renewal
and early childhood development. Between
2001-2002 and 2005-2006, the government
announced an additional $21.1 billion dollars for
increases to the CHST cash contributions, as well
as an additional $1.8 billion for targeted programs
(medical equipment and primary health care
reform), and $500 million for Canada Health
Infoway.
In 2003, the government committed $36.8 billion
over five years to support priority areas of reform
(primary care, home care and catastrophic drugs)
through increased CHST transfers ($14 billion)
and new, targeted transfers ($16 billion for the
Health Reform Transfer; $1.5 billion for medical
equipment), as well as support for federal direct
spending on health. This included $3.9 billion in
unrealized CHST increases committed under the
original timeframe of the 2000 Accord (up to and
including 2005-2006).
The federal government also agreed to restructure
the CHST to enhance the transparency and
accountability of federal support for health and
other social programs.
The Canada Health Transfer (CHT)
The CHST was restructured into two new
transfers, the Canada Health Transfer (CHT) and
Canada Social Transfer (CST), effective April 1,
2004. The CHT supports the Government of
Canada’s ongoing commitment to maintain the
national criteria and conditions of the Canada
Health Act. The CST, a block fund that support
post-secondary education and social assistance
and social services, continues to give provinces
and territories the flexibility to allocate funds
among social programs according to their
respective priorities.
Canada Health Act Annual Report, 2003-2004
Chapter 2 – Administration and Compliance
The existing CHST-legislated amounts have been
apportioned between the new transfers, with the
percentage of cash and tax points allocated to
each transfer reflecting provincial and territorial
spending patterns among the areas supported by
the transfers: 62 percent for the CHT and 38
percent for the CST.
The government’s 2003 budget set out a longterm predictable, sustainable and growing funding
framework for CHT and CST transfers, providing
legislated cash levels up to 2007-2008, while the
tax transfer component continues to grow in line
with the economy. CHT cash and tax transfers are
forecasted to be $25.1 billion in 2004-2005 ($14.3
billion in cash transfers, including CHST
supplements, and $10.8 billion in tax transfers).
CHT cash and tax transfers will reach $26.9 billion
in 2007-2008. In total, over the five-year period of
Canada Health Act Annual Report, 2003-2004
the Accord, cash support for health alone will
grow by an average annual rate of 10.2 percent.
Targeted federal transfers
supporting health
Health Reform: As part of the 2003 Accord on
Health Care Renewal, the Government of Canada
created a five-year, $16-billion Health Reform
Transfer (HRT) to help provinces and territories
accelerate reform in priority areas identified by
First Ministers: primary care, home care and
catastrophic drug coverage. First Ministers agreed
to prepare annual public reports to their citizens
on each of the reform areas using comparable
indicators, to inform Canadians on progress
achieved and key outcomes. Funding provided
under the HRT will be integrated into the CHT,
subject to a review by First Ministers by March
19
Chapter 2 – Administration and Compliance
31, 2008, of progress made in achieving reform
objectives.
In 2004-2005, provinces and territories will
receive $1.5 billion under the HRT, which is
allocated on an equal per capita basis. All cash
funding under the CHT, CST and HRT can be
withheld under the Canada Health Act.
Medical Equipment: Under the 2000 and 2003
Accords, the federal government provided
provinces and territories with $2.5 billion to
enhance the availability of publicly funded
diagnostic care and treatment services. The funds
were paid to third-party trusts, giving provinces
and territories the flexibility to draw down funds
as required over the lifespan of the trusts. These
funds were allocated on an equal per capita basis.
As they did for the HRT, provincial and territorial
governments were to report to Canadians on how
they invested the funding.
Additional information on federal-provincialterritorial funding arrangements is available on
request from the Department of Finance, or by
visiting its Web site at:
http://www.fin.gc.ca/FEDPROV/FTPTe.html
History of Federal Transfers Related
to Health Care
1957 The Hospital Insurance and Diagnostic
Services Act is passed unanimously in both
the House of Commons and the Senate,
establishing a cost-shared program
providing universal insurance coverage and
access to hospital services to all residents
of participating provinces. By 1961, all
provinces and territories have joined this
program.
1966 The Canada Assistance Plan (CAP) is
introduced, enabling the federal
government to pay for, among other things,
half the cost of certain services required by
persons deemed to be in need, but not
funded though other federal programs,
including the Hospital Insurance and
Diagnostic Insurance Act.
20
1968 The Medical Care Act is enacted,
establishing a cost-sharing program that
empowers the federal Health Minister to
make financial contributions to those
provinces and territories that operate
medical care insurance plans and meet
minimum delivery criteria. By 1972, all
provinces and territories are participating in
this program.
1977 The Federal-Provincial-Territorial Fiscal
Arrangements and Established Programs
Financing Act (EPF Act) is passed. The
Extended Health Care Services Program is
established providing virtually unconditional
per capita funding for certain types of longterm residential care services, home care
and adult day care services.
1984 The Canada Health Act (CHA) is passed,
amalgamating the provisions of the Hospital
Insurance and Diagnostic Services Act and
the Medical Care Act. The Act also includes
the extended health care services
provisions, which had previously been
included under the EPF. The Canada Health
Act now provides for dollar-for-dollar
deductions regarding extra-billing and user
charges, and discretionary deductions
relating to other elements of the criteria
and conditions set out in the Act.
The EPF Act is re-named Federal-Provincial
Fiscal Arrangements and Federal PostSecondary Education and Health
Contributions Act, 1977.
1995 It is announced in the federal budget that in
“established programs” funding under the
EPF Act and CAP cost sharing will be
replaced by Canada Health and Social
Transfer (CHST) block fund beginning April
1, 1996. CHST entitlements are set at
$26.9 billion for 1996-1997. CHST
entitlements for 1996-1997 are to be
allocated in the same proportion as
combined EPF and CAP entitlements for
1995-1996.
Section 6 of the CHA (amount payable for
extended health care services) was deleted
Canada Health Act Annual Report, 2003-2004
Chapter 2 – Administration and Compliance
in 1995 to reflect the new fiscal
arrangements adopted by the government
(i.e., Canada Health and Social Transfer)
that required one payment to provinces and
territories rather than multiple payments.
This change did not reduce the scope of
insured health services under the Act.
Extended health care services are not and
never were insured health services under
the CHA.
1996 A five-year CHST funding arrangement
(1998-1999 to 2002-2003) is announced in
the federal government budget. It provides
a cash floor transfer to provinces and
territories of $11 billion per year.
1998 The Federal-Provincial-Territorial Fiscal
Arrangements and Federal Post-Secondary
Education and Health Contributions Act is
amended to put in place a $12.5 billion
CHST cash floor, beginning in 1997-1998
and extending to 2002-2003.
1999 Increases in provincial and territorial CHST
cash entitlements of $11.5 billion over five
years are announced in the federal
government budget. The $11.5 billion is
provided to address fiscal pressures in the
health care sector.
2000 Increased CHST funding of $2.5 billion to
help provinces and territories fund health
care and post-secondary education is
announced in the February Budget. This
brings CHST cash to $15.5 billion for each
of the years from 2000-2001 to 2003-2004.
Following the First Ministers Meeting of
September 11, 2000, the Prime Minister
Canada Health Act Annual Report, 2003-2004
announces an increase in health funding
through the CHST of more than $21 billion
dollars in cash entitlements over five years.
The new money addresses concerns raised
by provincial and territorial governments
that additional funds are needed to deal
with immediate fiscal pressures in the
health, post-secondary education and social
services/social assistance sectors.
A $1billion Medical Equipment Fund is
established to enable provinces and
territories to immediately purchase and
install medical equipment for diagnostic
services and treatment. The Fund was
allocated on an equal per capita basis in
fiscal years 2000-2001 and 2001-2002.
2003 Federal transfers supporting provincial and
territorial health care are restructured
following the February 2003 Health Care
Renewal Accord and the subsequent 2003
Budget. The CHST is augmented by the
five-year $16 billion Health Reform Fund
beginning in 2003- 2004. Two new
transfers, the Canada Health Transfer
(CHT) and Canada Social Transfer (CST),
are to be established by April 1, 2004, from
a split in the CHST.
As part of the 2003 Accord, the federal
government also provided provinces and
territories with a three-year, $1.5 billion
Diagnostic/Medical Equipment Fund to
support specialized staff training and
equipment that improves access to publicly
funded diagnostic services.
21
Chapter 3 – Provincial and Territorial Health Care Insurance Plans in 2003-2004
requirements of the CHA, while statistics identify
current and future trends in the Canadian health
care system.
Chapter 3 –
Provincial and
Territorial Health
Care Insurance
Plans in 2003-2004
The following chapter presents the 13 provincial
and territorial health insurance plans that make up
the Canadian publicly funded health insurance
system. The purpose of this chapter is to
demonstrate clearly and consistently the extent to
which provincial and territorial plans fulfilled the
requirements of the Canada Health Act (CHA)
program criteria and conditions in 2003-2004.
Officials in the provincial, territorial and federal
governments have worked together to provide and
review the information. The information submitted
to Health Canada for this report by each
provincial and territorial department of health
consists of two components:
† a narrative description of the provincial or
territorial health care system relating to the
five criteria and the first condition (that of
providing the Minister of Health with
information in relation to insured health
services and extended health care services) of
the CHA, which can be found following this
chapter; and
† statistics identifying trends in the provincial
and territorial health care systems, which are
included at the end of each narrative
description.
To help prepare their submissions to the report,
Health Canada has provided provinces and
territories with the document Canada Health Act
Annual Report – 2003-2004: A Guide for Updating
Submissions. This guide is designed to help
provinces and territories meet the reporting
requirements of Health Canada and was
developed through discussion with provincial and
territorial officials. Annual revisions to the guide
are based on Health Canad’s analysis of health
plan descriptions from previous annual reports and
its assessment of emerging issues relating to
insured health services.
The process for reporting to Health Canada for
the current annual report was launched in a
federal- provincial-territorial conference call held
in April 2004, where a timetable was established
for providing information to Health Canada and
for producing the report.
Insurance Plan Descriptions
For the following chapter, provincial and territorial
officials were asked to provide a narrative
description of their health insurance plan
according to the program criteria areas of the
CHA in order to illustrate how the plans satisfy
these criteria. This narrative description also
includes information on how each jurisdiction met
the CHA requirement for recognition of federal
contributions that support insured and extended
health care services and a section outlining the
range of extended health care services in their
jurisdiction; where extended health care includes
nursing home intermediate care services, adult
residential care services, home care services and
ambulatory health care services.
The first component is used to help with the
monitoring and compliance of provincial and
territorial health care plans with respect to the
Canada Health Act Annual Report, 2003-2004
23
Chapter 3 – Provincial and Territorial Health Care Insurance Plans in 2003-2004
Improvements to Accessing Health
Care Services
During 2003-2004, provinces and territories
continued to implement initiatives to ensure and
enhance access by residents to insured health
services. Examples of this include:
† the October 2003 opening of the Sir Thomas
Ruddick hospital in Stephenville,
Newfoundland, which provides hospital
services to many rural communities;
† the opening of the Prince Edward Island
Cancer Treatment Centre in November 2003,
which allows most cancer patients to remain
on the Island for their treatment;
† the announcement of funding to open 25
surgical beds and an additional operating room
in the QEII Health Sciences Centre in Halifax,
Nova Scotia, to improve access to hospital
services and address emergency overcrowding;
† an announcement by New Brunswick in
February 2004, of a two-year, five-site
collaborative practice project to improve
access to primary health services;
† during 2003-2004, Quebec increased the
number of Family Medicine Groups to provide
access to physician services 24 hours a day;
† the investment by Ontario of $385 million in
funding to put hospitals on a sustainable
footing, reduce wait times for surgeries and
increase full-time nursing positions;
† the launch by Manitoba of the Health Services
Wait Time Information Web site to help
patients and physicians know how and where
to find the timeliest care. In February 2004,
Health Links-Info Santé was implemented to
provide Manitobans with health care
information 24 hours a day;
† the launch of the Target Time Frames for
Surgery system by Saskatchewan, which will
help patients receive surgical care according to
their need. Funding of $15.3 million was
announced to purchase medical equipment
identified on a priority basis by the Regional
Health Authorities;
† the launch of HealthLink Alberta and
InformAlberta, two new Web sites to help
24
†
†
†
†
Albertans access reliable health information
and locate health services in their own health
regions. In October 2003, Alberta implemented
an Electronic Health Record that links
physicians, pharmacists, hospitals, home care
and other providers across the province, while
maintaining the privacy and security of the
information;
an increase in funding of $6.7 million,
announced in September 2003 to strengthen
recruitment, retention and education of nurses
across British Columbia; in May 2003, it was
announced that 30 new spaces for nurse
practitioners would be added to the University
of British Columbia and the University of
Victoria;
in January 2004, an announcement was made
of a pilot project at the Whitehorse General
Hospital in Yukon to determine if the addition
of knee replacement surgery would improve
access to hospital services. In November 2003,
it was announced that the Yukon Telehealth
Project would expand to three additional sites;
the completion in 2003 of Phase I and II of the
new Inuvik Regional Hospital in the Northwest
Territories. The last phase of the hospital will
be completed in 2006; and
the launch of the Ikajuruti Inungnik
Ungasiktumi (IIU) telehealth network in
Nunavut. The IIU network improves
accessibility to health care services by
increasing the frequency a patient will be seen
by a specialist or their community physician
and increasing the services from outside
specialists at the community level.
Provincial and Territorial Health Care
Insurance Plan Statistics
For 2003-2004, the statistical section of the
annual report has been simplified and streamlined
in response to feedback received from provincial
and territorial officials and based on a review of
data quality and availability. The statistical
information is now located at the end of each
provincial or territorial narrative.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Provincial and Territorial Health Care Insurance Plans in 2003-2004
The purpose of the statistical tables is to place
the administration and operation of the CHA in
context and to provide a national perspective on
trends in the delivery and funding of insured
health services in Canada that are within the
scope of the Act.
The statistical tables contain resource and cost
data for insured hospital, physician and surgicaldental by province and territory for five
consecutive years ending on March 31.
All information has been provided by provincial
and territorial officials. In order to ensure
consistency in reporting, Health Canada provided
provincial and territorial governments with a
user’s guide (Canada Health Act Annual Report
2003-2004: A Guide for Updating Submissions)
that outlines what information to provide and how
to present it. The guide was prepared in
consultation with representatives in each
provincial and territorial government.
Private-for-Profit Facilities
Measures four through six capture statistics on
private-for-profit health care facilities that provide
insured hospital services. These measures have
been broken down into two sub-categories based
on the services provided under the definition of
insured hospital services in the CHA.
Insured Physician Services within Own
Province or Territory
Statistics in this sub-section relate to the
provision of insured physician services to
residents in each province or territory, as well as
to visitors from other regions of Canada.
Insured Services Provided to Residents in
Another Province or Territory – Hospitals
This sub-section presents out-of-province or outof-territory insured hospital services that are paid
for by a person’s home jurisdiction when they
travel to other parts of Canada.
Although efforts are made to capture data on a
consistent basis, differences exist in the reporting
on health care programs and services between
provincial and territorial governments. Therefore,
comparisons between jurisdictions are not made.
Insured Services Provided to Residents in
Another Province or Territory – Physicians
Provincial and territorial governments are
responsible for the quality and completeness of
the data they provide.
Insured Services Provided Outside Canada –
Hospitals
Organization of the
Information
Information in the tables is grouped according to
the nine subcategories described below.
Registered Persons
Registered persons are the number of residents
registered with the health care insurance plans of
each province or territory.
Public Facilities
Statistics on facilities providing insured hospital
services, excluding psychiatric hospitals and
nursing homes (which are not covered under the
CHA), are provided in fields two and three.
Canada Health Act Annual Report, 2003-2004
This sub-section reports on physician services
that are paid by a jurisdiction to other provinces
or territories for their visiting residents.
Hospital services provided out-of-country
represent a person’s hospital costs incurred while
travelling outside of Canada that are paid for by
their home province or territory.
Insured Services Provided Outside Canada –
Physicians
Physician services provided out-of-country
represent a person’s medical costs incurred while
travelling outside of Canada that are paid by their
home province or territory.
Insured Surgical-Dental Services Within Own
Province or Territory
The information in this subsection describes
insured surgical-dental services provided in each
province or territory.
25
Chapter 3 – Newfoundland and Labrador
Newfoundland and
Labrador
significant investments were made in delivering
health and community services. Medical and
diagnostic equipment including a new Magnetic
Resonance Imaging (MRI) unit and dialysis
services were announced. Also, the Department
continued to move forward with the Early
Childhood Development initiative and the
Provincial Primary Health Care Renewal
Framework.
1.0 Public Administration
Introduction
Fourteen regional boards deliver the majority of
the publicly funded health services in
Newfoundland and Labrador. Of these, eight are
institutional health boards, four are health and
community services boards and two are integrated
boards, delivering both institutional and
community services. Included in the eight
institutional boards are a provincial board for
cancer services and a regional board for nursing
homes, both located in St. John’s.
The provincial government appoints health boards,
whose members serve as volunteers. These
boards are responsible for delivering health
services to their regions and, in some cases, to
the province as a whole, interacting with the
public to determine health needs. The boards
receive their funding from the provincial
government, to which they are accountable. The
Department of Health and Community Services
provides the boards with policy direction and
monitors programs and services.
In Newfoundland and Labrador almost 19,000
health care providers and administrators provide
health services to the 519,000 residents.
In 2003-2004 improving community-based
services was a major focus for the Department.
The Department engaged in intensive, provincewide consultations on mental health. Over 800
individuals took part in the three-month process
and the findings have provided the basis for
developing a mental health strategy. In addition,
Canada Health Act Annual Report, 2003-2004
1.1 Health Care Insurance Plan and
Public Authority
Health care insurance plans managed by the
Department include the Hospital Insurance Plan
and the Medical Care Plan (MCP). Both plans are
non-profit and are audited by the Auditor General
of the Province.
The Hospital Insurance Agreement Act, amended
in 1994, is the legislation that enables the
Hospital Insurance Plan. The Act gives the
Minister of Health and Community Services the
authority to make Regulations for providing
insured services on uniform terms and conditions
to residents of the province under the conditions
specified in the Canada Health Act and
Regulations.
The Medical Care Insurance Act (1999) was
assented to on December 14, 1999, and came
into force on April 1, 2000. This Act empowers the
Minister to administer a plan of medical care
insurance for residents of the province. It allows
for developing Regulations to ensure that the
provisions of the statute meet the requirements of
the Canada Health Act as it relates to
administering of the medical care insurance plan.
There have been no legislative amendments to the
Medical Care Insurance Act (1999) or the
Hospital Insurance Agreement Act in 2003-2004.
The MCP facilitates the delivery of comprehensive
medical care to all residents of the province by
implementing policies, procedures and systems
27
Chapter 3 – Newfoundland and Labrador
that permit appropriate compensation to providers
for rendering insured professional services.
service billed and that the service is insured under
the Medical Care Plan.
The MCP operates in accordance with the
provisions of the Medical Care Insurance Act
(1999) and Regulations, and in compliance with
the criteria of the Canada Health Act.
Beneficiary audits are performed by personnel
from the Department under the Medical Care
Insurance Act (1999). Individuals are randomly
selected on a bi-weekly basis.
1.2 Reporting Relationship
The Department is mandated with administering
the Hospital Insurance and Medical Care Plans.
The Department reports on these plans through
the regular legislative processes; e.g., Public
Accounts.
The Department will be tabling its 2003-2004
Annual Report in the House of Assembly in fall
2004 under the Provincial Accountability
Framework. All health boards and some health
agencies will also table their reports.
The Department’s Annual Report highlights the
accomplishments of 2003-2004 and provides an
overview of initiatives and programs that will
continue to be developed in 2004-2005. The
Report is a public document and is circulated to
stakeholders. It will be posted on the
Department’s Web site.
1.3 Audit of Accounts
Each year the Province’s Auditor General
independently examines provincial public
accounts. MCP expenditures are now considered
a part of the public accounts. The Auditor General
has full and unrestricted access to MCP records.
Hospital boards are subject to Financial
Statement Audits, Reviews and Compliance
Audits. Financial Statement Audits are performed
by independent auditing firms that are selected by
the boards under the terms of the Public
Tendering Act. Review engagements, compliance
audits and physician audits are carried out by
personnel from the Department under the
authority of the Newfoundland Medical Care
Insurance Act (1999). Physician records and
professional medical corporation records are
reviewed to ensure that the record supports the
28
2.0 Comprehensiveness
2.1 Insured Hospital Services
The Hospital Insurance Agreement Act (1990) and
the Hospital Insurance Regulations 742/96 (1996)
provide for insured hospital services in
Newfoundland and Labrador.
Insured hospital services are provided for in- and
out-patients in 33 facilities (15 hospitals and 18
community health centres) and 14 nursing
stations. Insured in-patient services include:
† accommodation and meals at the standard
ward level;
† nursing services;
† laboratory, radiological and other diagnostic
procedures;
† drugs, biologicals and related preparations;
† medical and surgical supplies, operating room,
case room and anaesthetic facilities;
† rehabilitative services (e.g., physiotherapy,
occupational therapy, speech language
pathology and audiology);
† out-patient and emergency visits; and
† day surgery.
Coverage policy for insured hospital services is
linked to the coverage policy for insured physician
services, although there is no formalized process.
Ministerial direction is required to add to or to deinsure a hospital service from the list of insured
services. The Department of Health and
Community Services manages the process.
2.2 Insured Physician Services
The enabling legislation for insured physician
services is the Medical Care Insurance Act
(1999).
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Newfoundland and Labrador
Other governing legislation under the Medical
Care Insurance Act include:
† the Medical Care Insurance Insured Services
Regulations;
† the Medical Care Insurance Beneficiaries and
Inquiries Regulations; and
† the Medical Care Insurance Physician and Fees
Regulations.
Licensed medical practitioners are allowed to
provide insured physician services under the
insurance plan. A physician must be licensed by
the Newfoundland Medical Board to practise in
the province.
Physicians can choose not to participate in the
health care insurance plan as outlined in
subsection 12(1) of the Medical Care Insurance
Act (1999), namely:
“(1)
Where a physician providing insured
services is not a participating physician1, and
the physician provides an insured service to a
beneficiary, the physician is not subject to this
Act or the regulations relating to the provision
of insured services to beneficiaries or the
payment to be made for the services except
that he or she shall:
(a) before providing the insured service, if he
or she wishes to reserve the right to charge
the beneficiary for the service an amount in
excess of that payable by the Minister
under this Act, inform the beneficiary that
he or she is not a participating physician
and that the physician may so charge the
beneficiary; and
(b) provide the beneficiary to whom the
physician has provided the insured service
with the information required by the
minister to enable payment to be made
under this Act to the beneficiary in respect
of the insured service.
(2) Where a physician who is not a participating
physician provides insured services through a
professional medical corporation, the
1
professional medical corporation is not, in
relation to those services, subject to this Act
or the regulations relating to the provision of
insured services to beneficiaries or the
payment to be made for the services and the
professional medical corporation and the
physician providing the insured services shall
comply with subsection (1).”
For purposes of the Act, the following services are
covered:
† all services properly and adequately provided
by physicians to beneficiaries suffering from an
illness requiring medical treatment or advice;
† group immunizations or inoculations carried out
by physicians at the request of the appropriate
authority; and
† diagnostic and therapeutic x-ray and laboratory
services in facilities approved by the
appropriate authority that are not provided
under the Hospital Insurance Agreement Act
and Regulations made under the Act.
There are no limitations on the services covered,
provided they qualify under one or more of the
conditions listed above.
Ministerial direction is required to add to or to deinsure a physician service from the list of insured
services. This process is initiated following
consultation by the Department with various
stakeholders, including the provincial medical
association. The Department manages the
process and public consultation is involved.
2.3 Insured Surgical-Dental
Services
The provincial Surgical-Dental Program is a
component of the MCP. Surgical-dental
treatments properly and adequately provided to a
beneficiary and carried out in a hospital by a
dentist are covered by the MCP if the treatment
is of a type specified in the Surgical-Dental
Services Schedule.
The Medical Care Insurance Act (1999) defines “participating physician” as a physician who has not made an election, under
subsection 7(3), to collect payments in respect of insured services rendered by him or her to residents, otherwise than from
the Minister.
Canada Health Act Annual Report, 2003-2004
29
Chapter 3 – Newfoundland and Labrador
All dentists licensed to practise in Newfoundland
and Labrador and who have hospital privileges are
allowed to provide surgical-dental services. The
dentist’s licence is issued by the Newfoundland
Dental Licensing Board.
Dentists may opt out of the Plan. These dentists
must advise the patient of their opted-out status,
stating the fees expected, and providing the
patient with a written record of services and fees
charged. One dentist is currently in an opted-out
category.
Because the Surgical-Dental Program is a
component of the MCP, management of the
Program is linked to the MCP regarding changes
to the list of insured services. The Department
manages the process.
Addition of a surgical-dental service to the list of
insured services must be approved by the
Department.
2.4 Uninsured Hospital, Physician
and Surgical-Dental Services
Hospital services not covered by the Plan include:
† preferred accommodation at the patient’s
request;
† cosmetic surgery and other services deemed
to be medically unnecessary;
† ambulance or other patient transportation
before admission or upon discharge;
† private duty nursing arranged by the patient;
† non-medically required x-rays or other services
for employment or insurance purposes;
† drugs (except anti-rejection and AZT drugs)
and appliances issued for use after discharge
from hospital;
† bedside telephones, radios or television sets
for personal, non-teaching use;
† fibreglass splints;
† services covered by Workers’ Compensation
legislation or by other federal or provincial
legislation; and
† services relating to therapeutic abortions
performed in non-accredited facilities or
facilities not approved by the Newfoundland
Medical Board.
30
The use of the hospital setting for any services
deemed not insured by the Medicare Plan would
also be uninsured under the Hospital Insurance
Plan.
For purposes of the Medical Care Insurance Act
(1999), the following is a list of non-insured
physician services:
† any advice given by a physician to a
beneficiary by telephone;
† the dispensing by a physician of medicines,
drugs or medical appliances and the giving or
writing of medical prescriptions;
† the preparation by a physician of records,
reports or certificates for, or on behalf of, or
any communication to, or relating to, a
beneficiary;
† any services rendered by a physician to the
spouse and children of the physician;
† any service to which a beneficiary is entitled
under an Act of the Parliament of Canada, an
Act of the Province of Newfoundland and
Labrador, an Act of the legislature of any
province of Canada, or any law of a country or
part of a country;
† the time taken or expenses incurred in
travelling to consult a beneficiary;
† ambulance service and other forms of patient
transportation;
† acupuncture and all procedures and services
related to acupuncture, excluding an initial
assessment specifically related to diagnosing
the illness proposed to be treated by
acupuncture;
† examinations not necessitated by illness or at
the request of a third party except as specified
by the appropriate authority;
† plastic or other surgery for purely cosmetic
purposes, unless medically indicated;
† testimony in a court;
† visits to optometrists, general practitioners
and ophthalmologists solely for determining
whether new or replacement glasses or
contact lenses are required;
† the fees of a dentist, oral surgeon or general
practitioner for routine dental extractions
performed in hospital;
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Newfoundland and Labrador
† fluoride dental treatment for children under
four years of age;
† excision of xanthelasma;
† circumcision of newborns;
† hypnotherapy;
† medical examination for drivers;
† alcohol/drug treatment outside Canada;
† consultation required by hospital regulation;
† therapeutic abortions performed in the
province at a facility not approved by the
Newfoundland Medical Board;
† sex reassignment surgery, when not
recommended by the Clarke Institute of
Psychiatry;
† in-vitro fertilization and OSST (ovarian
stimulation and sperm transfer);
† reversal of previous sterilization procedure;
† surgical, diagnostic or therapeutic procedures
not provided in facilities other than those listed
in the Schedule to the Hospitals Act or
approved by the appropriate authority under
paragraph 3(d); and
† other services not within the ambit of section 3
of the Act.
All diagnostic services (e.g., laboratory services
and x-ray) are performed within public facilities in
the province. Hospital policy on access ensures
that third parties are not given priority access.
Medical goods and services that are implanted
and associated with an insured service are
provided free of charge to the patient and are
consistent with national standards of practice.
Patients retain the right to financially upgrade the
standard medical goods or services. Standards for
medical goods are developed by the hospitals
providing those services in consultation with
service providers.
Surgical-dental and other services not covered by
the Surgical-Dental Program are the dentist’s, oral
surgeon’s or general practitioner’s fees for routine
dental extractions in hospital.
3.0 Universality
3.1 Eligibility
Residents of Newfoundland and Labrador are
eligible for coverage under the provincial health
care program.
The Medical Care Insurance Act (1999) defines a
“resident” as a person lawfully entitled to be or to
remain in Canada, who makes his or her home and
is ordinarily present in the province, but does not
include tourists, transients or visitors to the
province.
The Medical Care Insurance Beneficiaries and
Inquiries Regulations (Regulation 20/96) identify
those residents eligible to receive coverage under
the plans. As the administrator of the Regulations,
the MCP has established rules to ensure that the
Regulations are applied consistently and fairly in
processing applications.
Persons not eligible for coverage under the plans
include:
† students and their dependants already covered
by another province or territory;
† dependants of residents if covered by another
province or territory;
† certified refugees and refugee claimants and
their dependants;
† foreign workers with Employment
Authorizations and their dependants who do
not meet the established criteria;
† foreign students and their dependants;
† tourists, transients, visitors and their
dependants;
† Canadian Forces and Royal Canadian Mounted
Police (RCMP) personnel;
† inmates of federal prisons; and
† armed forces personnel from other countries
who are stationed in the province.
3.2 Registration Requirements.
Registration under the Medical Care Plan (MCP)
and possession of a valid MCP card are required
in order to access insured services. New residents
are advised to apply for coverage as soon as
Canada Health Act Annual Report, 2003-2004
31
Chapter 3 – Newfoundland and Labrador
possible on arriving in Newfoundland and
Labrador.
It is the parent’s responsibility to register a
newborn or adopted child. The parents of a
newborn child will be given a registration
application upon discharge from hospital.
Applications for newborn coverage will require, in
most instances, a parent’s valid MCP number. A
birth or baptismal certificate will be required
where the child’s surname differs from the
parents’ surname.
Applications for coverage of an adopted child will
require a copy of the official adoption documents,
the birth certificate of the child, or a Notice of
Adoption Placement from the Department.
Applications for coverage of a child adopted
outside Canada will require Permanent Resident
documents for the child.
3.3 Other Categories of Individual
Foreign workers, clergy and dependants of North
Atlantic Treaty Organization (NATO) personnel are
eligible for benefits. Holders of Minister’s Permits
are also eligible, subject to MCP approval.
4.0 Portability
4.1 Minimum Waiting Period
Insured persons moving to Newfoundland and
Labrador from other provinces or territories are
entitled to coverage on the first day of the third
month following the month of arrival.
Persons arriving from outside Canada to establish
residence are entitled to coverage on the day of
arrival. The same applies to discharged members
of the Canadian Forces, the RCMP and released
inmates of federal penitentiaries. For coverage to
be effective, however, registration is required
under the MCP. Immediate coverage is provided
to persons from outside Canada who are
authorized to work in the province for one year or
more.
32
4.2 Coverage During Temporary
Absences in Canada
Newfoundland and Labrador is a party to the
Agreement on Eligibility and Portability regarding
matters pertaining to portability of insured
services in Canada.
Sections 12 and 13 of the Hospital Insurance
Regulations (1996) define portability of hospital
coverage during temporary absences both within
and outside Canada. Portability of medical
coverage during temporary absences both within
and outside Canada is defined in Department of
Health and Community Services policy.
Eligibility policy for insured hospital services is
linked to the eligibility policy for insured physician
services, although there is no formalized process.
Coverage is provided to residents during
temporary absences within Canada. The Province
has entered into formal agreements (i.e., the
Hospital Reciprocal Agreement) with other
provinces and territories for the reciprocal billing
of insured hospital services. In-patient costs are
paid at standard rates approved by the host
province or territory. In- patient, high-cost
procedures and out-patient services are payable
based on national rates agreed to by provincial
and territorial health plans.
Except for Quebec, medical services incurred in all
provinces or territories are paid through the
Medical Reciprocal Agreement at host province or
territory rates. Claims for medical services
received in Quebec are submitted by the patient
to the MCP for payment at host province rates.
In order to qualify for out-of-province coverage, a
beneficiary must comply with the legislation and
MCP rules regarding residency in Newfoundland
and Labrador. A resident must reside in the
province at least four consecutive months in each
12 month period to qualify as a beneficiary.
Generally, the rules regarding medical and hospital
care coverage during absences include:
† before leaving the province for extended
periods, a resident must contact the MCP to
obtain an out-of-province coverage certificate;
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Newfoundland and Labrador
† beneficiaries leaving for vacation purposes may
receive an initial out-of-province coverage
certificate of up to 12 months’ duration. Upon
return, beneficiaries are required to reside in
the province for a minimum four consecutive
months. Thereafter, certificates will only be
issued for up to eight months’ coverage;
† students leaving the province may receive a
certificate, renewable each year, provided they
submit proof of full-time enrolment in a
recognized school located outside the province;
† persons leaving the province for employment
purposes may receive a certificate of up to 12
months’ coverage. Verification of employment
may be required;
† persons must not establish residence in
another province, territory or country while
maintaining coverage under the Newfoundland
Medical Care Plan;
† for out-of-province trips of 30 days or less, an
out-of-province coverage certificate is not
required, but will be issued upon request;
† for out-of-province trips lasting more than 30
days, a certificate is required as proof of a
resident’s ability to pay for services while
outside the province; and
† failure to request out-of-province coverage or
failure to abide by the residency rules may
result in the resident having to pay the entire
cost of any medical or hospital bills incurred
outside the province.
Insured residents moving permanently to other
parts of Canada are covered up to and including
the last day of the second month following the
month of departure. Coverage is immediately
discontinued when residents move permanently to
other countries.
4.3 Coverage During Temporary
Absences Outside Canada
The Province provides coverage to residents
during temporary absences outside Canada. Outof-country insured hospital in- and out-patient
services are covered for emergency, sudden
illness and elective procedures at established
rates. Hospital services will be considered under
Canada Health Act Annual Report, 2003-2004
the Plan when the insured services are provided
by a recognized facility (licensed or approved by
the appropriate authority within the state or
country in which the facility is located) outside
Canada. The maximum amount payable by the
Government’s hospitalization plan for out-ofcountry in- patient hospital care is $350 per day, if
the insured services are provided by a community
or regional hospital. Where insured services are
provided by a tertiary care hospital (a highly
specialized facility), the approved rate is $465 per
day. The approved rate for out-patient services is
$62 per visit and hæmodialysis is $220 per
treatment. The approved rates are paid in
Canadian funds.
Physician services are covered for emergencies or
sudden illness and are also insured for elective
services not available in the province or within
Canada. Physician services are paid at the same
rate as would be paid in Newfoundland and
Labrador for the same service. If the services are
not available in Newfoundland and Labrador, they
are usually paid at Ontario rates, or at rates that
apply in the province where they are available.
4.4 Prior Approval Requirement
Prior approval is not required for medically
necessary insured services provided by accredited
hospitals or licensed physicians in the other
provinces and territories.
If a resident of the province has to seek
specialized hospital care outside the country
because the insured service is not available in
Canada, the provincial health insurance plan will
pay the costs of services necessary for the
patient’s care. However, it is necessary in these
circumstances for such referrals to receive prior
approval from the Department. The referring
physicians must contact the Department or the
MCP for prior approval.
Prior approval is not required for physician
services; however, it is suggested that physicians
obtain prior approval from the Plan so that
patients may be made aware of any financial
implications. General practitioners and specialists
may request prior approval on behalf of their
33
Chapter 3 – Newfoundland and Labrador
patients. Prior approval is not granted for out-ofcountry treatment of elective services if the
service is available in the province or elsewhere
within Canada.
5.0 Accessibility
5.1 Access to Insured Health
Services
Access to insured health services in
Newfoundland and Labrador is provided on
uniform terms and conditions. There are no coinsurance charges for insured hospital services
and no extra-billing by physicians in the province.
5.2 Access to Insured Hospital
Services
In Newfoundland and Labrador there is a health
care workforce of nearly 19,000 individuals. Half
of this workforce belongs to regulated
professional groups.
The supply of health professionals is a highpriority issue in this province, especially in rural
areas.
The Provincial Health and Community Services
Human Resource Planning Steering Committee
completed its final report on human resource
planning in fall 2003. The report summarized the
committee’s findings and provided key
recommendations. Workforce forecasts were
produced for 13 health occupations. In addition,
the Department reported on employer-based
indicator trends, completed a workforce supply
analysis for registered nurses and licensed
practical nurses, completed overall workforce
retirement projections, and participated on an
Early Retirement Committee, jointly chaired
between Treasury Board Secretariat and the
Newfoundland and Labrador Nurses’ Union. The
Department is also involved in an Atlantic Health
Education/Training Planning study expected to
conclude in March 2005. This project will allow the
consolidation of human resource projections at the
34
Atlantic level, permitting the four provinces to
engage in joint training and education activities
where opportunities exist.
The forecasts of the Health Human Resources
Planning report showed potential shortages for
some health occupations, mostly the younger,
mobile, allied health groups where turnover is the
highest. Generally the study found that while
there are health human resource issues needing
attention, stability in the system is expected in the
next three to five years.
Continuing with the Department’s commitment to
encourage graduating health professionals to
remain in this province, the Department offered a
number of bursaries in exchange for return in
service commitments. A total of approximately
$1 million was spent in 2003-2004 on the
awarding of thirty-seven physician and resident
bursaries. In the allied health professions, 17
bursaries were awarded to students graduating
from disciplines such as physiotherapy,
occupational therapy, speech language pathology,
audiology, clinical psychology and pharmacy. There
were also 10 nurse practitioner bursaries
awarded. Approximately 50 nursing students
availed themselves of the Rural Student Nursing
Incentive Program. As well, three scholarships
were awarded by the Department through the
Scholarships for Graduate Program in Health
Administration program.
A new hospital was opened in Stephenville and
operations were transferred from the old site. The
new hospital, which cost $34.5 million to
construct, contains 46 beds, a four-station
haemodialysis unit, and offers services in general
surgery, internal medicine, obstetrics/
gynaecology, ophthalmology and mental health.
A new wing of the regional hospital in Gander was
opened, which includes state-of-the-art operating
rooms, intensive/coronary care units, emergency
and out-patient departments and ancillary
equipment and technology.
Best practices and operational reviews were
carried out at some health boards to improve
service delivery and curtail deficits.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Newfoundland and Labrador
Government invested $25.4 million in medical and
diagnostic equipment in 2003-2004; $24.9 million
from the federal government as part of the 2003
First Ministers’ Accord on Health Care Renewal
and $0.5 million from provincial sources. The
funding was allocated to purchase equipment such
as X-ray units, ultrasound units, nuclear medicine
equipment and a second MRI machine.
Preparations are now underway to establish the
new MRI machine in Corner Brook.
A Provincial Kidney Program was established to
set strategic directions for renal care in
Newfoundland and Labrador. Two new satellite
dialysis units were announced, bringing the
number of dialysis sites to seven in the next one
to two years.
Regarding the availability of selected diagnostic,
medical, surgical and treatment equipment and
services in facilities providing insured hospital
services:
† an MRI unit is located in St. John’s;
† Computed Tomography (CT) scanners are
available in St. John’s, Carbonear, Clarenville,
Gander, Grand Falls/Windsor, Corner Brook,
St. Anthony and Happy Valley/Goose Bay;
† renal dialysis is provided in St. John’s,
Clarenville, Grand Falls/Windsor, Corner Brook
and Stephenville;
† cancer treatment is provided at the Dr. H. Bliss
Murphy Cancer Centre, St. John’s, and
satellite clinics in Gander, Grand
Falls/Windsor, Corner Brook and St. Anthony;
and
† specialized surgical services are available at six
regional hospitals.
Basic surgery is also offered at these locations
and in seven district hospitals. Tertiary surgery,
e.g. trauma, cardiac, neonatal and neurosurgery,
are offered in St. John’s. Quantenary care is not
available. Provincial residents access this level of
care at out-of-province facilities.
In October 2003, the Department established a
provincial Task Force on Infection Control related
to Communicable Diseases in Health Institutions
and Ambulance Services. The Task Force’s
mandate was to assess the current state of
Canada Health Act Annual Report, 2003-2004
infection control practices, procedures and
resources in the institutional health sector and
provide recommendations on improvements as
indicated. The Task Force presented its findings in
winter 2003. They are being reviewed by
Government.
Following an extensive public consultation, the
Department approved a provincial primary health
care renewal framework, Moving Forward
Together: Mobilizing Primary Health Care. The
Framework outlines the structure for remodelling
primary health care in Newfoundland and
Labrador through an incremental approach.
The Framework supports four goals: (1) enhanced
access to, and sustainability of, primary health
care; (2) an emphasis on self reliant and healthy
citizens and communities; (3) promotion of a
team-based, interdisciplinary and evidenced-based
approach to services provision; and (4) enhanced
accountability and satisfaction of health
professionals. Provincial supports included
establishing of the Office of Primary Care, the
Primary Health Care Advisory Council, linkages
with local college and university programs and
professional associations, and developing
provincial working groups to support
learning/problem-solving and provider capacitybuilding.
Seven proposals for interdisciplinary, team-based,
primary health care projects across the province
were approved.
Primary health care working groups were initiated
to develop partnerships, processes and tools for
scope of practice shifts, physician payment
models and information management. The initial
focus was on the electronic health record.
Agreements on two Atlantic projects were
reached: Building a Better Tomorrow Initiative
(BBTI) and Self-care Telecare. The BBTI will
support team and inter-professional development
and change management in project areas. A
needs assessment for 24/7 telephone advice
service was also initiated through the Self-care
Telecare project.
A discussion document, Working Together for
Mental Health: A Proposed Mental Health
35
Chapter 3 – Newfoundland and Labrador
Services Strategy for Newfoundland and
Labrador, was released and was followed by a
three month consultation process including over
800 individuals.
The report Investing in Health - A Report on
Public Health Capacity in Newfoundland and
Labrador summarized the findings on public health
capacity and made recommendations for future
actions to ensure health protection, injury
prevention and protection of the population from
existing and emerging communicable and chronic
diseases.
The integrated Public Health Information System
(iPHIS) developed by Health Canada was piloted
in the Eastern Region of the province as a tool to
optimize disease surveillance and case
management.
5.3 Access to Insured Physician and
Surgical-Dental Services
The number of physicians practising in the
province has been relatively stable, with an
upward trend since 2003. The Department is
committed to working with regional health boards
to develop a provincial human resource plan for
physicians based on the principle of access to
services.
During 2003-2004, four new physicians began
practice in the province who had previously
received financial assistance from one of the
Department’s bursary programs. A total of 37
new awards were issued to students and residents
in different years of training in 2003-2004, a
significant increase over previous years.
5.4 Physician Compensation
The legislation governing payments to physicians
and dentists for insured services is the Medical
Care Insurance Act (1999).
The current methods of remuneration to
compensate physicians for providing insured
health services include fee-for-service, salary,
contract and sessional block funding.
36
Compensation agreements are negotiated
between the provincial government and the
Newfoundland and Labrador Medical Association
(NLMA), with involvement of the Newfoundland
and Labrador Health Boards Association, using
traditional and formalized negotiation methods.
Arising from the most recent agreement, the
Physician Services Liaison Committee was formed
in October 2002, to provide a mechanism whereby
medical issues of mutual concern can be
addressed cooperatively between the Government
and the NLMA.
In 2003, an arbitrated award was reached with the
provincial medical association which resulted in a
three year agreement being implemented in May
2003. The total value of the award was $54 million
dollars over three years. The award was unique in
that it included varying increases to different feefor-service physician groups based upon fee rate
comparisons with their Maritime peers, dedicated
dollars to increase Emergency Department rates,
a universal on-call payment policy and salary
increases of 18 percent.
The dispute resolution in the agreement to
determine deficits or surplus for fee-for-service
funding is Arbitration under the Arbitration Act.
5.5 Payments to Hospitals
The Department is responsible for funding
regional boards for ongoing operations and capital
purchases. Funding for insured services is
provided to the boards as an annual global budget
and is distributed in 12 monthly advance
payments. Payments are made to regional boards
in accordance with the Hospital Insurance
Agreement Act (1990) and the Hospitals Act. As
part of their accountability to the Government,
boards are required to meet the Department’s
annual reporting requirements, which include
audited financial statements and other financial
and statistical information. The global budgeting
process devolves the budget allocation authority,
responsibility and accountability to all appointed
boards in the discharge of their mandates.
Throughout the fiscal year, the health boards may
forward additional funding requests to the
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Newfoundland and Labrador
Department for changes in program areas or
increased workload volume. These requests will be
reviewed and, if approved by the Department,
funded at the end of each fiscal year. Any
adjustments to the annual funding level, such as
for negotiated salary increases, additional
approved positions or program changes, are
funded based on the implementation date of such
increases and the cash flow requirement in a given
fiscal year.
Boards are continually facing challenges in
addressing increased demands when costs are
rising, staff workloads are increasing, patient
expectations are higher and new technology
introduces new demands for time, resources and
funding. Boards are continuing to work with the
Department to address these issues and provide
effective, efficient and quality health services.
6.0 Recognition Given to
Federal Transfers
Funding provided by the federal government
through the Canada Health and Social Transfer
(CHST) has been recognized and reported by the
Government of Newfoundland and Labrador
through press releases, government Web sites,
and various other documents. For fiscal year
2003-2004, these documents included:
† the 2003-2004 Public Accounts Volume I;
† the Estimates 2004-2005; and
† the Budget Speech 2004.
These reports, tabled by the Government to the
House of Assembly, are publicly available to
Newfoundland and Labrador residents and have
been shared with Health Canada for information
purposes.
7.0 Extended Health Care
Services
Newfoundland and Labrador has established longterm residential and community-based programs
Canada Health Act Annual Report, 2003-2004
as alternatives to hospital services. These
programs are provided by seven regional boards.
Services include the following:
† Long-term residential accommodations are
provided for clients requiring high levels of
nursing care in 18 community health centres
and 22 nursing homes. There are approximately
2,800 beds located in these 40 facilities.
Residents pay a maximum of $2,800 per month
based on each client’s assessed ability to pay,
using provincial financial assessment criteria.
The balance of funding required to operate
these facilities is provided by the Department.
† Persons requiring protective oversight or
minimal assistance with activities of daily living
can avail themselves of residential services in
personal care homes. There are approximately
2,400 beds located in 110 homes across the
province. These homes are operated by the
private for-profit sector. Residents pay a
maximum of $1,110 per month, based on an
individual client assessment using standardized
financial criteria.
Home Care Services
Home care services include professional and nonprofessional supportive care to enable people to
remain in their own homes for as long as possible
without risk. Professional services include nursing
and some rehabilitative programs. These services
are publicly funded and delivered by staff
employed with six regional boards. Nonprofessional services include personal care,
household management, respite and behavioural
management. These services are delivered by
home support workers through agency or selfmanaged care arrangements. Eligibility for nonprofessional services is determined through a
client financial assessment using provincial
criteria. The current ceiling for home support
services is $2,707 for seniors and $3,875 for
persons with disabilities.
Special Assistance Program
The Special Assistance Program is a provincial
program that provides basic supportive services
to assist financially eligible clients in the
37
Chapter 3 – Newfoundland and Labrador
community with activities of daily living. The
benefits include access to health supplies, oxygen,
orthotics and equipment.
Drug Programs
The Senior Citizens’ Drug Subsidy Program is
provided to residents over 65 years of age who
receive the Guaranteed Income Supplement and
who are registered for Old Age Security benefits.
Eligible individuals are given coverage for the
ingredient portion of benefit prescription items.
Any additional cost, such as dispensing fees, are
the client’s responsibility. Income support
recipients are eligible for the Social Services Drug
Plan, which covers the full cost of benefit
prescription items, including a set markup amount
and dispensing fee.
Other Programs
The Department administers the Emergency Air
and Road Ambulance Programs through the
Emergency Health Services Division.
The Road Ambulance Program provides quality
pre-hospital emergency and routine treatment,
care and transportation. It also includes the
transfer of patients between facilities and return
of patients to their place of residence. Road
ambulances are operated by 59 organizations – 30
private companies, 22 community or volunteer
groups, and seven regional health boards
throughout the province.
The Air Ambulance Program provides air transport
to patients requiring emergency care who could
not be transported by a commercial airline or by
road ambulance because of urgency or time, or
remoteness of location. This program uses two
fixed-wing aircraft and five chartered helicopters.
These helicopters are also used for routine
transportation of doctors and nurses to remote
communities for clinics. A third fixed wing aircraft
is used in Labrador for regional medical services
38
transports, including routine appointments by
coastal residents in Happy Valley/Goose Bay.
Residents who travel by commercial air to access
medically necessary insured services that are not
available within their area of residence or within
the province, may qualify for financial assistance
under the Medical Transportation Assistance
Program. This program is administered by the
Department. Kidney donors and bone
marrow/stem-cell donors are eligible for financial
assistance, as administered by the Health Care
Corporation of St. John’s, when the recipient is a
Newfoundland and Labrador resident eligible for
coverage under the Newfoundland Hospital
Insurance and Medical Care Plans.
The Dental Health Plan incorporates a children’s
dental component and a social assistance
component. The children’s program covers the
following dental services for all children up to and
including the age of 12: examinations at six-month
intervals; cleanings at 12-month intervals; fluoride
applications at 12-month intervals for children
aged 6 to 12; x-rays (some limitations); fillings
and extractions; and some other specific
procedures that require approval before
treatment. Services are available under the social
assistance component to recipients of social
assistance who are 13 to 17 years of age:
examinations (every 24 months); x-rays (with
some limitations); routine fillings and extractions;
emergency extractions, when the patient is seen
for pain, infection, or trauma. Adults receiving
social assistance are eligible for emergency care
and extractions. Beneficiaries covered under the
Dental Health Plan must pay a co-payment
amount directly to the dentist for each service
provided (e.g., fillings, extractions, etc.), except
for examinations, dental cleanings, fluoride
applications, radiographs and retention pins for
fillings. In circumstances where the beneficiary is
receiving income support, the co-payment is paid
by the Dental Health Plan.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Newfoundland and Labrador
Registered Persons
1999-2000
1. Number as of March 31st (#).
618,118
2000-2001
1
616,944
2001-2002
2
565,000
2002-2003
3
560,644
2003-2004
4
599,907 5
Insured Hospital Services Within Own Province or Territory
Public Facilities
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
2. Number (#):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
33
0
0
0
33
32
0
0
0
32
32
0
0
0
32
32
0
0
0
32
33
0
0
0
33
3. Payments ($):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
509,018,766
0
0
0
509,018,766
537,428,824
0
0
0
537,428,824
619,884,087
0
0
0
619,884,087
672,874,609 6
0
0
0
672,874,609 6
681,953,170 6
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
1
0
1
1
0
1
1
0
1
1
0
1
1
0
1
not available
0
not available
not available
0
not available
not available
0
not available
not available
0
not available
not available
0
not available
387,030
0
387,030
270,750
0
270,750
338,200
0
338,200
286,425
0
286,425
280,250
0
280,250
Private For-Profit Facilities
4. Number (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
5. Number of insured hospital services
provided (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
6. Payments ($):
a. surgical facilities
b. diagnostic imaging facilities
c. total
Canada Health Act Annual Report, 2003-2004
681,953,170 6
39
Chapter 3 – Newfoundland and Labrador
Insured Physician Services Within Own Province or Territory
1999-2000
7. Number of participating physicians (#):
a. general practitioners
b. specialists
c. other
d. total
2000-2001
2001-2002
2002-2003
2003-2004
7
432 8
437 8
448 8
478 8
414 8
480 8
485 8
504 8
500 8
545 8
not applicable not applicable not applicable not applicable not applicable
912 8
922 8
952 8
978 8
959 8
8. Number of opted-out physicians (#):
a. general practitioners
b. specialists
c. other
d. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
9. Number of not participating
physicians (#):
a. general practitioners
b. specialists
c. other
d. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2,489,000
2,443,000
not applicable
4,932,000
2,340,000
2,318,000
not applicable
4,657,000
2,263,000
2,218,000
not applicable
4,481,000
2,147,000
2,206,000
not applicable
4,353,000
2,109,987
1,843,902
not applicable
3,953,889
11. Total payments to physicians paid through fee
for service ($):
a. general practitioners
42,429,000
b. specialists
72,780,000
c. other
not applicable
d. total
115,209,000
43,251,000
73,239,000
not applicable
116,490,000
42,751,000
75,177,000
not applicable
117,928,000
50,961,000
78,157,000
not applicable
129,118,000
62,613,000
90,739,000
not applicable
153,352,000
12. Average payment per fee for service service
($):
a. general practitioners
b. specialists
c. other
d. all services
17.05
29.79
not applicable
23.36
18.49
31.60
not applicable
25.01
18.89
33.90
not applicable
26.32
23.74
35.43
not applicable
29.66
23.97
38.79
not applicable
31.38
13. Number of services provided through all
payment methods (#): 9
a. medical
b. surgical
c. diagnostic
d. other
e. total
3,104,000
468,000
1,361,000
not applicable
4,932,000
2,878,000
433,000
1,346,000
not applicable
4,657,000
2,728,000
398,000
1,345,000
not applicable
4,481,000
2,607,000
379,000
1,367,000
not applicable
4,353,000
not available
not available
not available
not applicable
3,953,889
14. Total payments to physicians paid through all
payment methods ($): 9
a. medical
72,500
b. surgical
10,923
c. diagnostic
31,786
d. other
not applicable
e. total
115,209,000
71,987
10,834
33,670
not applicable
116,490,000
not available
not available
not available
not applicable
117,928,000
not available
not available
not available
not available
129,118,000
not available
not available
not available
not available
153,352,000
15. Average payment per service, all payment
methods ($): 9
a. medical
b. surgical
c. diagnostic
d. other
e. all services
not available
not available
not available
not applicable
25.01
not available
not available
not available
not available
26.30
not available
not available
not available
not available
29.66
not available
not available
not available
not available
31.38
10. Number of services provided through fee for
service (#):
a. general practitioners
b. specialists
c. other
d. total
40
not available
not available
not available
not applicable
23.36
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Newfoundland and Labrador
Insured Services Provided to Residents in Another Province or Territory
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
1,549
1,699
1,681
1,588
1,640
25,546
24,929
26,155
26,464
26,305
10,144,354
10,608,368
10,312,515
10,817,595
12,397,072
19. Total payments, out-patient ($).
3,138,582
3,047,375
3.213,978
3,488,186
3,303,844
20. Average payment, in-patient ($).
6,549.00
6,244.00
6,135.00
6,812.00
7,559.00
123.00
122.00
123.00
132.00
126.00
Physicians
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
22. Number of services (#).
161,000
173,000
143,000
143,000
121,072
4,327,000
4,562,000
4,082,000
4,231,000
4,222,118
28.41
26.35
28.56
29.57
34.87
16. Total number of claims, in-patient (#).
17. Total number of claims,
out-patient (#).
18. Total payments, in-patient ($).
21. Average payment, out-patient ($).
23. Total payments ($).
24. Average payment per service ($).
Insured Services Provided Outside Canada
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
73
111
62
61
62
260
287
258
278
283
198,072
1,102,540
123,692
269,963
363,153
15,626
36,260
22,567
18,432
167,588
2,713.00
9,933.00
1,995.00
4,426.00
5,857.00
60.00
126.00
87.00
66.00
592.00
Physicians
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
31. Number of services (#).
4,000
6,000
4,000
3,000
5,342
107,000
424,000
67,000
172,000
473,460
19.61
70.16
16.37
54.30
88.63
25. Total number of claims, in-patient (#).
26. Total number of claims,
out-patient (#).
27. Total payments, in-patient ($).
28. Total payments, out-patient ($).
29. Average payment, in-patient ($).
30. Average payment, out-patient ($).
32. Total payments ($).
33. Average payment per service ($).
Insured Surgical-Dental Services Within Own Province or Territory
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
35
35
26
33
not available
9,000
11,000
10,000
11,000
not available
354,000
389,000
409,000
419,000
not available
38.73
35.06
39.82
37.76
not available
34. Number of particpating dentists (#).
35. Number of services provided (#).
36. Total payments ($).
37. Average payment per service ($).
Canada Health Act Annual Report, 2003-2004
41
Chapter 3 – Newfoundland and Labrador
Endnotes
1.
2.
3.
4.
5.
6.
Data are as of March 1, 2000.
Data are as of April 11, 2001.
Data as of April 30, 2002.
Data as of April 15, 2003.
Data as of May 17, 2004.
New Methodology for 2002-2003. Operating costs only: does not include capital, deficit or non-government funding. Payments
represent the final provincial plan funding provided to regional health care boards for the purposes of delivering insured acute
care services.
7. Excludes inactive physicians.
8. Total Salaried and Fee-for-service.
9. Fee-for-Service only.
42
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Prince Edward Island
personal health practices and safe, positive
workplaces.
Prince Edward
Island
Introduction
The Ministry of Health and Social Services is a
very large and complex system of integrated
services that protect, maintain and improve the
health and well-being of Prince Edward Islanders.
The continued sustainability of the system is a
primary concern. Spending on health and social
services has grown rapidly in recent years to 42
percent of the total provincial government
program expenditures. The availability of health
professionals is also affecting our ability to
sustain services.
We are concerned about the high rate of chronic
conditions in our province: conditions such as
cardiovascular disease, cancer, diabetes and
mental illness. Wellness initiatives will help
Islanders increase their acceptance of
responsibility for their health and to reach their
full health potential. This will be achieved through
community partnerships to promote healthy
lifestyles and to reduce risk factors for chronic
disease, and through increased access to primary
health services that support disease prevention
and management.
Recruitment, retention and human resource
planning will remain a priority to ensure an
adequate supply and appropriate mix of health
and social service professionals to meet changing
needs. Retention initiatives are supported by
comprehensive workplace wellness programs that
promote organizational excellence, positive
Canada Health Act Annual Report, 2003-2004
Overview of the Health and Social
Services System
Prince Edward Island has a publicly administered
and funded health system that guarantees
universal access to medically necessary hospital
and physician services as required by the Canada
Health Act. Many other health and social services
are funded in whole, or in part, by the provincial
government. The system includes a wide range of
integrated health and social services such as
acute care, addictions, mental health, social
assistance and housing services. In addition, some
specialty services such as cardiac surgery and
neurotrauma services are offered in two referral
hospitals within the purview of the Provincial
Health Services Authority.
In December 2002, the Prince Edward Island
health system underwent restructuring. The
Provincial Health Services Agency was created to
administer all acute care hospital services
including cancer treatment, mental health and
addictions within two referral hospitals. The
Eastern Kings and Southern Kings Regional
Health Authorities were merged to form the Kings
Regional Health Authority.
Facilities
Prince Edward Island has two referral hospitals
and five community hospitals, with a combined
total of 474 beds. Along with seven government
manors that house 558 (+ 10 respite) long-term
care nursing beds, Islanders have access to an
additional 389 (+11 temporary beds) in private
nursing homes. The system also operates several
addictions and mental health facilities, 1,167
seniors’ housing units and 461 family housing
units.
Construction of a new $50 million health facility
was completed and opened in April 2004 in
Summerside. Computed Tomography (CT)
scanning and a wide range of diagnostic imaging
services are available at the referral hospitals. A
43
Chapter 3 – Prince Edward Island
new linear accelerator and Magnetic Resonance
Imaging (MRI) services are now operating.
Human Resources
The public sector health and social services
workforce has approximately 4,000 employees.
Prince Edward Island has 200 health care
professionals per 10,000 residents, compared with
the national average of 182 per 10,0001.
Structure
The system includes the Department of Health
and Social Services, the Provincial Health
Services Authority (PHSA) and four Regional
Health Authorities, which are governed by the
Regional Health Boards. The Department works
with the Regional Health Authorities and the
PHSA to establish system goals and objectives,
develop policy and outcome standards and
allocate resources. The Regional Health
Authorities plan and deliver primary health care
and social services. The PHSA is responsible for
delivering of acute care services across Prince
Edward Island.
Financial Resources
During the past 10 years, provincial spending on
health and social services increased from $270
million to more than $410 million in 2003-2004, an
average increase of about five percent per year.
Increased costs are due to inflation, population
growth, new technologies and the increasing use
of services by all age groups.
Major health and social services expenditures are
allocated to: Hospital Services, 31 percent; Social
Services, 21 percent; Long Term Care, 10 percent;
Physician Services, 12 percent; and other services
such as Provincial Drug Programs, Public Health
Nursing and Addiction Services, 26 percent.
1
44
Critical Issues
Supply of health professionals
Maintaining an adequate supply of workers is one
of the most critical issues facing the system.
Recruitment and retention of skilled employees
are expected to be a challenge throughout the
labour market in coming years due to a major
demographic shift. The effect of this trend is
being felt first in the health sector, which is
labour-intensive and depends on a specialized
workforce, and particularly in less-populated areas
such as Prince Edward Island. The supply of
health professionals is now decreasing as the
workforce ages, the number of people retiring
increases and the supply of available health care
graduates declines. To address this issue, the
system must increase its focus on workplace
wellness and human resource planning to ensure
an adequate supply and the right mix of health
professionals to meet changing needs.
Public expectation and demand
The demand for services is increasing in almost
every area for a variety of reasons, including
population growth, the availability of new drugs
and technology and increasing public
expectations. Residents are asking for more
doctors, nurses, drugs, technology and family
services. They want access to care in their own
communities. They are also concerned about
waitlists for services. While rising expectations
are creating pressure to increase spending on
acute care, they are severely limiting the ability of
the system to innovate and shift resources to
other areas of need.
Increasing public expectation is a very critical
issue. Demand alone cannot drive the system. The
public must become more informed about
reasonable access and the need for real changes
in the way services are delivered, particularly in
primary health services.
Canadian Institute for Health Information, 1997.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Prince Edward Island
Appropriate access to primary health
services
There is growing evidence that investments in
primary health services have a great impact on
health and sustainability. Primary health services
are those that people access first and most often,
such as family physician services, public health
nursing, screening programs, addiction services
and community mental health services.
Personal health practices
People’s capacity to accept responsibility for their
health is influenced by social and economic
conditions. Comprehensive strategies are needed
to address these conditions. It is critical that the
health system increase its capacity to work with
others to help individuals, families and
communities accept responsibility for, and
achieve, good health.
Aging population
As baby boomers age, we will experience the
biggest demographic shift in history. It is expected
that the proportion of the population aged 65 and
over in Prince Edward Island will increase from 13
percent today to 15 percent in 2011 and to 27
percent in 2036. This will affect the health system
in several ways. The incidence of diseases such as
cancer, heart disease, diabetes and dementia is
expected to increase. Demand is expected to rise
for acute care, long-term care, home care, mental
health and other services. This issue becomes
more critical when we consider that the health
care workforce will be aging at the same time,
there will be fewer family members to support
their aging parents, and the amount of resources
required to sustain services for seniors could
negatively affect other government services that
support health. It is critical that the health system
be prepared to meet these changing needs.
Disease prevention and management
Many diseases are preventable. For example,
meningitis can be prevented through vaccination.
The spread of sexually transmitted diseases can
be prevented through responsible sexual
Canada Health Act Annual Report, 2003-2004
behaviour. Many chronic conditions are also
preventable. Risk factors for cardiovascular
disease and cancer can be reduced or eliminated
through education and supports that result in a
change in lifestyle.
The World Health Organization suggests that
diabetes is rising in epidemic proportions
worldwide. Prince Edward Island had 17 new
cases of diabetes diagnosed each month in the
mid- 1970s, compared with 45 cases per month in
the mid-1990s. It is projected that this number will
grow to 65 cases per month in 2006. There is
clear and undisputable evidence that effective
blood sugar control can prevent or delay the onset
of serious complications from diabetes, such as
heart disease, blindness and kidney disease,
which have enormous human and financial costs.
The prevalence of cancer and diabetes in this
province is expected to increase significantly as
the population ages. It is imperative that our
system step up its efforts to help Islanders
prevent, delay and manage these conditions.
The Department in partnership with other sectors,
released a comprehensive and integrated
Provincial Strategy for Healthy Living in June
2003 in order to improve the health of Islanders.
Focusing on tobacco reduction, healthy eating and
physical activity, promising strategies for
promoting population health in Prince Edward
Island include building healthy public policy,
creating supportive environments, strengthening
community action, developing personal skills and
reorienting health services. Goals of the Strategy
are: to reduce the growth in the prevalence of
preventable chronic disease in Prince Edward
Island; to reduce tobacco use and the harm it
causes to the population of Prince Edward Island;
to increase the number of Islanders who
participate in regular physical activity in sufficient
quantity to promote optimal health; to improve
healthy eating habits that support good nutritional
health; and to increase capacity for health
promotion and chronic disease prevention. The
current focus of the Strategy includes developing
regional networks, internal and external
communication strategies, and an evaluation
framework. Healthy Living Coordinators were
45
Chapter 3 – Prince Edward Island
hired in two of the four Regional Authorities in
2003-2004. The Coordinators will help move the
strategy forward at the community level.
1.0 Public Administration
1.1 Health Care Insurance Plan and
Public Authority
The Hospital Care Insurance Plan, under the
authority of the Minister of Health and Social
Services, is the vehicle for delivering hospital care
insurance in Prince Edward Island. The enabling
legislation is the Hospital and Diagnostic Services
Insurance Act (1988), which insures services as
defined under section 2 of the Canada Health Act.
Under Part I of the Hospital and Diagnostic
Services Insurance Act, it is the function of the
Minister, and the Minister has the power, to:
† ensure the development and maintenance
throughout the province of a balanced and
integrated system of hospitals and schools of
nursing and related health facilities;
† approve or disapprove the establishment of
new hospitals and the establishment of, or
additions to, related health facilities;
† approve or disapprove all grants to hospitals
for construction and maintenance;
† establish and operate, alone or in cooperation
with one or more organizations, institutes for
training hospital and related personnel;
† conduct surveys and research programs and to
obtain statistics for its purposes;
† approve or disapprove hospitals and other
facilities for the purposes of the Act in
accordance with the Regulations; and
† subject to the approval of the Lieutenant
Governor in Council, to do all other Acts and
things that the Minister considers necessary or
advisable for carrying out effectively the intent
and purposes of the Act.
In addition to the duties and powers enumerated
in Part I of the Act, it is the function of the
Minister, and the Minister has power, to:
46
† administer the plan of hospital care insurance
established by this Act and the Regulations;
† determine the amounts to be paid to hospitals
and to pay hospitals for insured services
provided to insured persons under the plan of
hospital care insurance and to make retroactive
adjustments with hospitals for under-payment
or over-payment for insured services according
to the cost as determined in accordance with
the Act and the Regulations;
† receive and disburse all monies pertaining to
the plan of hospital care insurance;
† approve or disapprove charges made to all
patients by hospitals in Prince Edward Island
to which payments are made under the plan of
hospital care insurance;
† enter into agreements with hospitals outside
Prince Edward Island and with other
governments and hospital care insurance
authorities established by other governments
for providing insured services to insured
persons;
† prescribe forms necessary or desirable to carry
out the intent and purposes of the Act;
† appoint inspectors and other officers with the
duty and power to examine and obtain
information from hospital accounting records,
books, returns, reports and audited financial
statements and reports thereon;
† appoint medical practitioners with the duty and
power to examine and obtain information from
medical and other hospital records, including
patients’ charts with medical records and
nurses’ notes, reports and accounts of patients
who are receiving or have received insured
services;
† appoint inspectors with the duty and power to
inspect and examine books, accounts and
records of employers and collectors to obtain
information related to the hospital and
insurance plan;
† withhold payment for insured services for any
insured person who does not, in the opinion of
the Minister, medically require such services;
† act as a central purchasing agent to purchase
drugs, biologicals or related preparations for all
hospitals in the province; to supervise, check
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Prince Edward Island
and inspect the use of drugs, biologicals or
related preparations by hospitals in the
province and to withhold or reduce payments
under the Act to a hospital that does not
comply with Regulations relating to purchasing
drugs, biologicals or related preparations; and
† supervise and ensure the efficient and
economical use of all diagnostic or therapeutic
aids and procedures used by or in hospitals
and to withhold or reduce payments under the
Act to a hospital that does not comply with the
Regulations relating to using such aids and
procedures.
The Health Ministry, through the Department, has
the responsibility for the overall efficiency and
effectiveness of the provincial health system.
Specifically, the Department is responsible for:
† setting overall directions and priorities;
† developing policies and strategies, legislation,
provincial standards and measures;
† monitoring provincial health status;
† monitoring and ensuring that the Provincial
Health Services Authority (PHSA) and the four
Regional Health Authorities comply with
Regulations and standards;
† evaluating the performance of the health
system;
† allocating funds to the PHSA and the four
Regional Health Authorities;
† improving the quality and management of a
comprehensive province-wide health
information system;
† ensuring access to high-quality health services;
† addressing emerging health issues and
examining new technology before
implementation; and
† directly administering certain services and
programs.
The PHSA and four Regional Health Authorities
are responsible for service delivery as allowed
under the Health and Community Services Act
(1993). The Authorities operate hospitals, health
centres, manors and mental health facilities, and
hire physicians, nurses and other health-related
workers.
Their responsibilities include:
Canada Health Act Annual Report, 2003-2004
† assessing the health needs of residents in their
regions;
† providing for the input and advice of their
residents;
† allocating and managing resources, setting
priorities, hiring staff and making the best use
of available resources;
† consulting with other organizations involved in
the health field;
† developing policies, standards and measures;
† planning and coordinating, with the
Department and other Authorities, the delivery
of the full range of health services;
† promoting health and wellness in their
communities;
† making information available to residents on
choices about health and health services;
† ensuring reasonable access to health services;
and
† monitoring, evaluating and reporting on
performance to residents and to the Ministry.
In December 2001, Prince Edward Island’s health
regions were awarded accredited status by the
Canadian Council on Health Services
Accreditation. The results of the accreditation
process were announced following a
comprehensive self-assessment process and
surveys conducted in June 2001, by a team of 11
physicians and senior health administrators from
across the country.
1.2 Reporting Relationship
An annual report is submitted by the Department
to the Minister responsible and is tabled by the
Minister in the Legislative Assembly. The Annual
Report provides information on the operating
principles of the Department and its legislative
responsibilities, as well as an overview and
description of the operations of the departmental
divisions and statistical highlights for the year.
The PHSA and four Regional Health Authorities
are required under section 24 of the Health and
Community Services Act to submit an annual
report in the fall to the Minister of Health and
Social Services. The Minister has the authority to
request other information, as deemed necessary,
47
Chapter 3 – Prince Edward Island
on the operations of the Regional Health
Authorities and their delivery of health services in
their areas of jurisdiction. Regional Health
Authorities are required to hold annual public
meetings at which information about their
operations and the provision of health services is
presented.
1.3 Audit of Accounts
The provincial Auditor General conducts annual
audits of the Public Accounts of the Province of
Prince Edward Island. The Public Accounts of the
Province include the financial activities, revenues
and expenditures of the Department.
Each Regional Health Authority has the
responsibility to engage its own public accounting
firm to conduct annual financial statement audits.
The audited financial statements are provided to
the Ministry and the Department of the Provincial
Treasury. The reports are presented at public
meetings held annually within each region.
Audited statements are also presented to the
Legislative Assembly and included within the
published Public Accounts of the Province of
Prince Edward Island.
The provincial auditor general, through the Audit
Act, has the discretionary authority to conduct
further audit reviews on a comprehensive or
program-specific basis with respect to the
operations of the Department, as well as the
PHSA and each of the four Regional Health
Authorities.
2.0 Comprehensiveness
2.1 Insured Hospital Services
Insured hospital services are provided under the
Hospital and Diagnostic Services Insurance Act
(1988). The accompanying Regulations (1996)
define the insured in- and out-patient hospital
services available at no charge to a person who is
eligible. Insured hospital services include:
† necessary nursing services;
† laboratory;
48
† radiological and other diagnostic procedures;
† accommodations and meals at a standard ward
rate;
† formulary drugs, biologicals and related
preparations prescribed by an attending
physician and administered in hospital;
† operating room, case room and anaesthetic
facilities;
† routine surgical supplies; and
† radiotherapy and physiotherapy services
performed in hospital.
As of March 2004, there were seven acute care
facilities participating in the Province’s insurance
plan. In addition to 454 acute care beds, these
facilities house 20 rehabilitative beds, 19 daysurgery beds, as defined under the Hospitals Act
(1988), and seven insured chronic care beds.
2.2 Insured Physician Services
The enabling legislation that provides for insured
physician services is the Health Services Payment
Act (1988). Amendments were passed in 1996.
Changes were made to include thephysician
resource planning process.
Insured physician services are provided by medical
practitioners licensed by the College of Physicians
and Surgeons. The number of practitioners who
billed the Insurance Plan as of March 31, 2004,
was 202.
Under section 10 of the Health Services Payment
Act, a physician or practitioner who is not a
participant in the Insurance Plan is not eligible to
bill the Plan for services rendered. When a nonparticipating physician provides a medically
required service, section 10(2) requires that
physicians advise patients that they are not
participating physicians or practitioners and
provide the patient with sufficient information to
enable recovery of the cost of services from the
Minister of Health.
Under section 10.1 of the Health Services
Payment Act, a participating physician or
practitioner may determine, subject to and in
accordance with the Regulations and in respect of
a particular patient or a particular basic health
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Prince Edward Island
service, to collect fees outside of the Plan or
selectively opt out of the Plan. Before the service
is rendered, patients must be informed that they
will be billed directly for the service. Where
practitioners have made that determination, they
are required to inform the Minister thereof and
the total charge is made to the patient for the
service rendered.
As of March 31, 2004, no physicians had opted
out of the Health Care Insurance Plan.
Any basic health services rendered by physicians
that are medically required are covered by the
Health Care Insurance Plan. These include:
† most physicians’ services in the office, at the
hospital or in the patient’s home;
† medically necessary surgical services, including
the services of anaesthetists and surgical
assistants where necessary;
† obstetrical services, including pre- and postnatal care, newborn care or any complications
of pregnancy such as miscarriage or
Caesarean section;
† certain oral surgery procedures performed by
an oral surgeon when it is medically required,
with prior approval that they be performed in a
hospital;
† sterilization procedures, both female and male;
† treatment of fractures and dislocations; and
† certain insured specialist services, when
properly referred by an attending physician.
New codes for MRI services, and several other
codes, were developed through the negotiation
process between the Department and the Medical
Society of Prince Edward Island.
The process to add a physician service to the list
of insured services involves negotiation between
the Department and the Medical Society.
2.3 Insured Surgical-Dental
Services
Dental services are not insured in the Health Care
Insurance Plan. Only oral maxillofacial surgeons
are paid through the Plan. There are currently two
surgeons in that category. Surgical- dental
procedures included as basic health services in
Canada Health Act Annual Report, 2003-2004
the Tariff of Fees are covered only when the
patient’s medical condition requires that they be
done in hospital or in an office with prior approval
as confirmed by the attending physician.
A surgical-dental service (post operative removal
of mandibular wires in an office setting) has been
added as a result of negotiations between the
Dental Association and the Department.
2.4 Uninsured Hospital, Physician
and Surgical-Dental Services
Provincial hospital services not covered by the
Hospital Services Plan include:
† services that persons are eligible for under
other provincial or federal legislation;
† mileage or travel, unless approved by the
Department;
† advice or prescriptions by telephone, except
anticoagulant therapy supervision;
† examinations required in connection with
employment, insurance, education, etc.;
† group examinations, immunizations or
inoculations, unless prior approval is received
from the Department;
† preparation of records, reports, certificates or
communications, except a certificate of
committal to a psychiatric, drug or alcoholism
facility;
† testimony in court;
† surgery for cosmetic purposes unless medically
required;
† dental services other than those procedures
included as basic health services;
† dressings, drugs, vaccines, biologicals and
related materials;
† eyeglasses and special appliances;
† physiotherapy, chiropractic, podiatry,
optometry, chiropody, osteopathy, psychology,
naturopathy, audiology, acupuncture and
similar treatments;
† reversal of sterilization procedures;
† in vitro fertilization;
† services performed by another person when
the supervising physician is not present or not
available;
49
Chapter 3 – Prince Edward Island
† services rendered by a physician to members
of the physician’s own household, unless
approval is obtained from the Department; and
† any other services that the Department may,
upon the recommendation of the negotiation
process between the Department and the
Medical Society, declare non-insured.
Provincial hospital services not covered by the
Hospital Services Plan include private or special
duty nursing at the patient’s or family’s request;
preferred accommodation at the patient’s request;
hospital services rendered in connection with
surgery purely for cosmetic reasons; personal
conveniences, such as telephones and televisions;
drugs, biologicals, and prosthetic and orthotic
appliances for use after discharge from hospital;
and dental extractions, except in cases where the
patient must be admitted to hospital for medical
reasons with prior approval of the Department.
The process to de-insure services by the Health
Care Insurance Plan is done in collaboration with
the Medical Society and the Department.
All Island residents have equal access to services.
Third parties such as private insurers or the
Workers’ Compensation Board of Prince Edward
Island do not receive priority access to services
through additional payment.
PEI has no formal process to monitor compliance;
however, feedback from physicians, hospital
administrators, medical professionals and staff
allows the Department to monitor usage and
service concerns.
3.0 Universality
3.1 Eligibility
The Health Services Payment Act and
Regulations, section 3, define eligibility for the
health care insurance plans. The plans are
designed to provide coverage for eligible Prince
Edward Island residents. A resident is anyone
legally entitled to remain in Canada and who
makes his or her home and is ordinarily present on
50
an annual basis for at least six months plus a day
in Prince Edward Island.
All new residents must register with the
Department in order to become eligible. Persons
who establish permanent residence in Prince
Edward Island from elsewhere in Canada will
become eligible for insured hospital and medical
services on the first day of the third month
following the month of arrival.
Residents who are ineligible for coverage under
the health care insurance plan in Prince Edward
Island are members of the Canadian Forces, Royal
Canadian Mounted Police (RCMP), inmates of
federal penitentiaries and those eligible for certain
services under other government programs, such
as Workers’ Compensation or the Department of
Veterans Affairs’ programs.
Ineligible residents may become eligible in the
following cases: members of the Canadian Forces,
RCMP and penitentiary prisoners on discharge,
release or release following the termination of
rehabilitation leave. Where such is granted by the
Canadian Forces, the province, where
incarcerated or stationed at time of release or
discharge, or the province where resident on
completing rehabilitation leave as may be
appropriate, will provide initial coverage for the
customary waiting period of up to three months.
Parolees from penitentiaries will be treated in the
same manner as discharged parolees.
Foreign students, tourists, transients or visitors to
Prince Edward Island do not qualify as residents
of the province and are, therefore, not eligible for
hospital and medical insurance benefits.
3.2 Registration Requirements
New or returning residents must apply for health
coverage by completing a registration application
from the Department. The application is reviewed
to ensure that all necessary information is
provided. A health card is issued and sent to the
resident within two weeks. Renewal of coverage
takes place every five years and residents are
notified by mail six weeks before renewal.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Prince Edward Island
The number of residents registered for the Health
Care Insurance Plan in Prince Edward Island as of
March 31, 2004, was 142,022.
3.3 Other Categories of Individual
Foreign students, temporary workers, refugees
and Minister’s Permit holders are not eligible for
health and medical coverage. Kosovar refugees
are an exception to this category and are eligible
for both health and medical coverage in Prince
Edward Island. There were 50 Kosovar refugees
registered for Medicare as of March 31, 2004.
4.0 Portability
4.1 Minimum Waiting Period
Insured persons who move to Prince Edward
Island are eligible for health insurance on the first
day of the third month following the month of
arrival in the province.
4.2 Coverage During Temporary
Absences in Canada
Persons absent each year for winter vacations and
similar situations involving regular absences must
reside in Prince Edward Island for at least six
months plus a day each year in order to be eligible
for sudden illness and emergency services while
absent from the province, as allowed under
section 5.(1)(e) of the Health Services Payment
Act.
The term “temporarily absent” is defined as a
period of absence from the province for up to 182
days in a 12-month period, where the absence is
for the purpose of a vacation, a visit or a business
engagement. Persons leaving the province under
the above circumstances must notify the
Registration Department before leaving.
Prince Edward Island participates in the Hospital
Reciprocal Billing Agreement and the Medical
Reciprocal Billing Agreement.
Canada Health Act Annual Report, 2003-2004
The payment rate is $887 per day for hospital
stays. The standard inter-provincial out-patient
rate is $153. The methodology used to derive
these rates is as if the patient had the services
provided in Prince Edward Island.
4.3 Coverage During Temporary
Absences Outside Canada
The Health Services Payment Act is the enabling
legislation that defines portability of health
insurance during temporary absences outside
Canada, as allowed under section 5.(1)(e) of the
Health Services Payment Act.
Insured residents may be temporarily out of the
country for a 12-month period one time only.
Students attending a recognized learning
institution in another country must provide proof
of enrolment from the educational institution on
an annual basis. Students must notify the
Registration Department upon returning from
outside the country.
For Prince Edward Island residents leaving the
country for work purposes for longer than one
year, coverage ends the day the person leaves.
For Island residents traveling outside Canada,
coverage for emergency or sudden illness will be
provided at Prince Edward Island rates only, in
Canadian currency. Residents are responsible for
paying the difference between the full amount
charged and the amount paid by the Department.
The amount paid for insured emergency services
outside Canada in 2003-2004 was $180,288.
4.4 Prior Approval Requirement
Prior approval is required from the Department
before receiving non-emergency out-of-province
medical or hospital services. Island residents
seeking such required services may apply for prior
approval through a Prince Edward Island
physician. Full coverage may be provided for
(Prince Edward Island-insured) non-emergency or
elective services, provided the physician
completes an application to the Department. Prior
approval is required from the Medical Director of
51
Chapter 3 – Prince Edward Island
the Department to receive out-of-country hospital
or medical services not available in Canada.
5.0 Accessibility
5.1 Access to Insured Health
Services
Both of Prince Edward Island’s hospital and
medical services insurance plans provide services
on uniform terms and conditions on a basis that
does not impede or preclude reasonable access to
those services by insured persons.
5.2 Access to Insured Hospital
Services
The construction of the new Prince County
Hospital in Summerside continued in 2003-2004.
The new facility was completed and occupied in
April 2004.
Ambulance Services
The Department has renewed Agreements with
each of the five private ambulance operators in
the province to ensure the provision of emergency
and non-emergency ground ambulance services on
a 24-hour, seven day per week basis. The
Department provides operating subsidies to
operators who deliver service as per the
requirements and standards contained within
these agreements.
The Out of Province Medical Transport Support
Program subsidizes the user fee for patients who
require ground ambulance services to access
specialized medical care outside the province.
Accessibility – New Initiatives
The Nurse Recruitment Strategy, announced in
the 2000 Prince Edward Island Budget, has been
revised and a number of new initiatives have been
implemented. In addition to focusing on
Registered Nurse recruitment, the strategy also
looks at retention initiatives in Prince Edward
Island. While the Nurse Recruitment Strategy
52
addresses all sectors of health care, priority is
given to the institutional sector, which covers
acute and long-term care services. The
Department is monitoring the results of the
strategies.
Activity in the fourth year of the four-year Nursing
Recruitment and Retention Strategy included:
† Summer Student Employment Program – 77
nursing students who completed their second
or third year of a four-year Bachelor in Nursing
Program gained additional clinical exposure to
acute care and long-term care through this
12-week employment program.
† Student Sponsorships – 116 students, who at
the beginning of the school year are entering
their third or fourth year of a Bachelor in
Nursing Program, received $2,400 in financial
assistance.
† Refresher Program Cost Assistance – Tuition
costs were reimbursed to two candidates who
successfully completed a Nursing Refresher
Course.
† Clinical Education Resources – Three new
clinical educator positions were created.
† Enhanced Recruitment Resources – Relocation
assistance was provided to 22 nurses who
moved to Prince Edward Island.
† Work Force Development – Development of a
planning strategy to manage emerging issues
and to ensure current and future nurses
develop competencies that match workplace
requirements.
† In an effort to encourage more youth to
consider careers in the health sector, the
Health Care Futures – Public Sector program
provided employment for 120 students in 2003
in a variety of settings including hospitals,
government long-term care facilities and
community care. In addition, the Health Care
Futures – Private Sector program provided a
50 percent cost-sharing on the salary costs of
students hired by the owners of private nursing
homes and community care facilities.
There is also activity underway with Health
Infostructure Atlantic to further develop an
Electronic Health Record within Atlantic Canada.
The major focuses of these activities include the
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Prince Edward Island
overall Electronic Health Record, Health
Surveillance and Telehealth activities.
5.3 Access to Insured Physician and
Surgical-Dental Services
Physician services are accessible throughout the
province except for specialties where there are
vacancies.
Recruitment processes were undertaken for family
physicians, anaesthetists, radiologists, radiation
and medical oncologists, psychiatrists, and a
pathologist and plastic surgeon.
The Primary Health Care Redesign project
encourages physicians, nurses and other
appropriate health care providers to work in
collaborative group practices with shared
responsibilities for client outcomes. In 2003-2004,
five Family Health Centres operated in
Charlottetown, Summerside, O’Leary, Hunter
River/Rustico and Souris. These centres
expanded family physician services to include
primary health care nurses and other health
professionals.
5.4 Physician Compensation
A collective bargaining process is used to
negotiate physician compensation. Bargaining
teams are appointed by both physicians and
government to represent their interests in the
process.
The legislation governing payments to physicians
and dentists for insured services is the Health
Services Payment Act.
Most physicians work on a fee-for-service basis.
However, alternate payment plans have been
developed and some physicians receive salary,
contract and sessional payments. Alternate
payment modalities are growing and seem to be
the preference for new graduates.
the province under the Health and Community
Services Act. The financial (budgetary)
requirements are established annually through
consultation with the Department and are subject
to approval by the Legislative Assembly through
the annual budget process.
Payments (advances) to PHSA and the Regional
Health Authorities for hospital services are
approved for disbursement by the Department in
line with cash requirements and are subject to
approved budget levels.
The usual funding method includes using a global
budget adjusted annually to take into
consideration increased costs related to such
items as labour agreements, drugs, medical
supplies and facility operations.
6.0 Recognition Given to
Federal Transfers
The Government of Prince Edward Island
acknowledged the federal contributions provided
through the Canada Health and Social Transfer in
its 2003-2004 Annual Budget and related budget
documents and its 2002-2003 Public Accounts,
which were tabled in the Legislative Assembly and
are publicly available to Prince Edward Island
residents.
7.0 Extended Health Care
Services
Extended health care services are not an insured
service, except for the insured chronic care beds
noted in section 2.1. Extended care services are
provided through the four Regional Health
Authorities of the Health and Social Services
system.
5.5 Payments to Hospitals
The PHSA and four Regional Health Authorities
are responsible for delivering hospital services in
Canada Health Act Annual Report, 2003-2004
53
Chapter 3 – Prince Edward Island
7.1 Nursing Home Intermediate
Care and Adult Residential Care
Services
Nursing home services are available on approval
from regional admission and placement
committees for placement into public manors and
licensed private nursing homes. There are
currently 18 long term care facilities in the
province, nine public manors and nine licensed
private nursing homes, with a total of 968 beds,
including respite and temporary beds. Nursing
home admission is for individuals who require
24-hour registered nurse (nursing care)
supervision and care management. The
standardized Seniors Assessment Screening Tool
is used to determine service needs of residents
for all admissions to nursing homes. Payment for
long term care is the responsibility of the
individual. When a resident of a facility or
someone coming into a facility does not have the
financial resources to pay for their own care, they
can apply for financial assistance under the Social
Assistance Act Regulations, Part II. The Province
subsidizes 73 percent of residents in nursing
homes. The federal government subsidizes
approximately 7.5 percent of nursing home
residents through Veterans Affairs Canada. The
remaining 19.5 percent finance their own care.
In addition to nursing home facilities, there are 36
licensed community care facilities in Prince
Edward Island. As of March 31, 2004, the total
number of licensed community care facility beds
was 951. A Community Care Facility is a privately
operated licensed establishment with five or more
residents. These facilities provide semi-dependent
seniors and semi-dependent physically and
mentally challenged adults with accommodation,
housekeeping, supervision of daily living activities,
meals and personal care assistance for grooming
and hygiene. Care needs are assessed using the
Seniors Assessment Screening Tool and are at
Level 1, 2 or 3. Residents are eligible to apply for
financial assistance under the Social Assistance
Act Regulations, Part I. It should be noted that
payment to community care is the responsibility of
the individual. Clients lacking adequate financial
54
resources may apply for financial assistance under
the Prince Edward Island Social Assistance Act.
7.2 Home Care Services
Home Care and Support provides assessment and
care planning to medically stable individuals, and
defined groups of individuals with specialized
needs, who without the support of the formal
system, are at risk of being unable to stay in their
own home, or are unable to return to their own
home from a hospital or other care setting.
Services provided through Home Care and
Support include nursing, personal care, respite,
occupational and physical therapies, adult
protection, palliative care, home and communitybased dialysis, assessment for nursing home
placement and community support. The Senior’s
Assessment Screening Tool is used to determine
the nature and type of service needed.
Professional services in home care are currently
provided at no cost to the client. Visiting
homemaker services are subject to a sliding fee
scale based on an individual’s income assessment,
which is generally waived for palliative care
clients.
7.3 Ambulatory Health Care
Services
Prince Edward Island has public Adult Day
Programs that provide services such as
recreation, education and socialization for
dependent elders. Individuals who require this
service are assessed by regional Home Care staff.
The overall purpose of adult day programs, is to
allow clients to remain in their homes as long as
possible, provide respite for care givers, monitor
client’s health and provide social interaction.
There are Adult Day Programs in all four health
regions.
The Prince Edward Island Dialysis Program is a
community-based service that operates under the
medical direction and supervision of the
Nephrology team at the QEII Health Sciences
Centre in Halifax.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Prince Edward Island
There are five hemodialysis clinics in the province.
This is a publically funded service. Prince Edward
Island also offers a hemodialysis service to out-ofprovince/country visitors from the existing clinic
locations. The provision of this service is based on
the capacity within the clinics and the availability
Canada Health Act Annual Report, 2003-2004
of human resources to provide this treatment at
the time of the request. Cost of the service is
covered through reciprocal billing if from another
Canadian jurisdiction and by the visitor if from out
of Canada.
55
Chapter 3 – Prince Edward Island
Registered Persons
1. Number as of March 31st (#).
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
134,006
138,205
140,001
141,031
142,022
Insured Hospital Services Within Own Province or Territory
Public Facilities
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
2. Number (#):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
7
not applicable
not applicable
not applicable
7
7
not applicable
not applicable
not applicable
7
7
not applicable
not applicable
not applicable
7
7
not applicable
not applicable
not applicable
7
7
not applicable
not applicable
not applicable
7
3. Payments ($):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
104,000,000
not applicable
not applicable
not applicable
104,000,000
106,774,200
not applicable
not applicable
not applicable
106,774,200
109,128,000
900
not applicable
not applicable
109,128,900
115,697,000
not applicable
not applicable
not applicable
115,697,000
121,944,000
not applicable
not applicable
not applicable
121,944,000
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
4. Number (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
5. Number of insured hospital services
provided (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
6. Payments ($):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
Private For-Profit Facilities
56
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Prince Edward Island
Insured Physician Services Within Own Province or Territory
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
7. Number of participating physicians (#):
a. general practitioners
99
b. specialists
74
c. other
not applicable
d. total
173
101
75
not applicable
176
101
75
not applicable
176
97
92
not applicable
189
96
94
not applicable
190
8. Number of opted-out physicians (#):
a. general practitioners
b. specialists
c. other
d. total
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
9. Number of not participating
physicians (#):
a. general practitioners
b. specialists
c. other
d. total
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
10. Number of services provided through
fee for service (#):
a. general practitioners
b. specialists
c. other
d. total
848,816
415,130
not applicable
1,263,946
861,112
409,917
not applicable
1,271,029
816,197
358,600
not applicable
1,174,797
716,597
362,619
not applicable
1,079,216
783,632
397,916
not applicable
1,181,548
11. Total payments to physicians paid
through fee for service ($):
a. general practitioners
b. specialists
c. other
d. total
15,700,000
17,100,000
not applicable
32,800,000
15,800,000
17,200,000
not applicable
33,000,000
16,588,900
15,559,600
not applicable
32,148,500
16,537,250
16,446,970
not applicable
32,984,220
16,234,598
17,054,737
not applicable
33,289,335
12. Average payment per fee for service
service ($):
a. general practitioners
b. specialists
c. other
d. all services
18.00
41.00
not applicable
26.00
18.00
42.00
not applicable
26.00
20.00
43.00
not applicable
27.00
23.00
45.00
not applicable
31.00
21.00
43.00
not applicable
28.00
13. Number of services provided through
all payment methods (#):
a. medical
b. surgical
c. diagnostic
d. other
e. total
154,930
144,947
115,253
848,816
1,263,946
152,796
143,940
113,181
861,112
1,271,029
107,683
140,020
110,897
816,197 1
1,174,797
96,152
150,036
116,431
716,597
1,079,216
14. Total payments to physicians paid
through all payment methods ($):
a. medical
b. surgical
c. diagnostic
d. other
e. total
6,600,000
8,800,000
1,700,000
not applicable
32,800,000
6,500,000
8,900,000
1,800,000
15,800,000
33,000,000
5,061,000
8,703,600
1,795,000
16,588,900 1
32,148,500
4,892,997
9,509,720
2,044,253
16,537,250
32,984,220
15. Average payment per service, all
payment methods ($):
a. medical
b. surgical
c. diagnostic
d. other
e. all services
43.00
61.00
15.00
not applicable
26.00
43.00
62.00
15.00
not applicable
26.00
Canada Health Act Annual Report, 2003-2004
47.00
62.00
16.00
20.00
27.00
51.00
63.00
18.00
23.00
31.00
1
1
111,896
162,577
123,443
783,632 1
1,181,548
4,845,230
9,880,089
2,329,418
16,234,598 1
33,289,335
43.00
61.00
19.00
21.00
28.00
57
Chapter 3 – Prince Edward Island
Insured Services Provided to Residents in Another Province or Territory
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
1,812
1,903
2,220
2,059
2,006
14,428
14,839
17,572
16,790
15,638
10,600,000
10,127,380
9,417,000
11,713,751
14,208,471
19. Total payments, out-patient ($).
2,300,000
2,380,567
2,930,100
2,879,064
2,578,895
20. Average payment, in-patient ($).
5,850.00
5,322.00
4,242.00
5,689.00
7,083.00
160.00
160.00
167.00
171.00
165.00
Physicians
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
22. Number of services (#).
56,084
46,832
67,435
48,369
45,255
3,080,000
3,370,102
3,871,900
3,778,171
3,795,244
55.00
72.00
57.00
78.00
84.00
16. Total number of claims, in-patient (#).
17. Total number of claims,
out-patient (#).
18. Total payments, in-patient ($).
21. Average payment, out-patient ($).
23. Total payments ($).
24. Average payment per service ($).
2003-2004
2
Insured Services Provided Outside Canada
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
21
30
26
23
37
106
112
85
152
130
27. Total payments, in-patient ($).
53,800
54,180
123,127
79,577
155,922
28. Total payments, out-patient ($).
21,700
43,494
13,702
25,954
24,366
2,561.00
1,806.00
4,736.00
3,459.00
4,214.00
205.00
388.00
161.00
171.00
187.00
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
25. Total number of claims, in-patient (#).
26. Total number of claims,
out-patient (#).
29. Average payment, in-patient ($).
30. Average payment, out-patient ($).
Physicians
31. Number of services (#).
32. Total payments ($).
33. Average payment per service ($).
2003-2004
666
728
677
521
706
38,274
57,365
33,995
30,076
37,100
57.00
79.00
50.00
58.00
53.00
2
Insured Surgical-Dental Services Within Own Province or Territory
1999-2000
34. Number of particpating dentists (#).
2000-2001
2001-2002
2002-2003
2003-2004
2
2
2
2
2
176
145
176
312
393
36. Total payments ($).
37,600
53,100
60,989
88,443
90,851
37. Average payment per service ($).
214.00
366.00
347.00
283.00
231.00
35. Number of services provided (#).
Endnotes
1. Includes general practitioners.
2. Figures may be subject to change for 03/04 as reciprocal billing arrangements allow a one year period for submissions of
claims.
58
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Nova Scotia
Nova Scotia
Introduction
The management of day-to-day health services
delivery in Nova Scotia is the responsibility of the
Province’s nine District Health Authorities
(DHAs). These DHAs were created under the
Health Authorities Act, which came into effect on
January 1, 2001. The passage of this Act brought
Nova Scotia closer to its goal of developing an
affordable, high-quality, sustainable health care
system.
Under the Health Authorities Act, the DHAs are
required to provide the Minister of Health with
monthly and quarterly financial statements and
audited year-end financial statements. They are
also required to submit annual reports, which
provide updates on implementing DHA business
plans. These provisions ensure greater financial
accountability. The sections of the Health
Authorities Act related to financial reporting and
business planning came into effect on April 1,
2001.
Pursuant to the Provincial Finance Act (2000) and
government policies and guidelines, the
Department of Health is required to release
annual accountability reports outlining outcomes
against its business plan for that fiscal year. The
2003-2004 accountability report will be available
in late 2004.
Nova Scotia continues to be committed to the
delivery of medically necessary services that are
consistent with the principles of the Canada
Health Act.
In March 2003, the Department of Health
released a plan for better health care entitled,
Canada Health Act Annual Report, 2003-2004
“Your Health Matters”. This plan focuses on
health promotion, more doctors and nurses,
shorter wait lists, seniors’ care and health
services within communities. This report can be
viewed at:
www.gov.ns.ca/health/your_health_matter
s.htm
In March 2004, and as a follow-up to this report,
the Department of Health released the report
entitled “Ministers’ Report to Nova Scotians:
Confident Change for Quality Care”. This report
can be viewed at:
www.gov.ns.ca/health/report/default.htm
Additional information related to health care in
Nova Scotia may be obtained from the
Department of Health Web site at:
www.gov.ns.ca/health
1.0 Public Administration
1.1 Health Care Insurance Plan and
Public Authority
Two plans cover insured health services in Nova
Scotia: the Hospital Insurance Plan (HSI) and the
Medical Services Insurance Plan (MSI). The
Department of Health administers the HSI Plan,
which operates under the Health Services and
Insurance Act, Chapter 197, Revised Statutes of
Nova Scotia, 1989: sections 3(1), 5, 6, 10, 15, 16,
17(1), 18 and 35, passed by the Legislature in
1958.
The MSI is administered and operated on a nonprofit basis by an authority consisting of the
Department of Health and Atlantic Blue Cross
Care, under the legislation previously mentioned
(sections 8, 13, 17(2), 23, 27, 28, 29, 30, 31, 32
and 35).
Section 3 of the Health Services and Insurance
Act states that subject to this Act and the
Regulations, all residents of the province are
entitled to receive insured hospital services from
hospitals on uniform terms and conditions, and
that all residents of the province are insured upon
uniform terms and conditions in respect of the
59
Chapter 3 – Nova Scotia
payment of insured professional services to the
extent of the established tariff. Section 8 of the
Act gives the Minister of Health, with approval of
the Governor in Council, the power to, from time
to time, enter into agreements and vary, amend or
terminate the same with such person or persons
as the Minister deems necessary to establish,
implement and carry out the MSI Plan.
Atlantic Blue Cross Care, by virtue of the 1992
Memorandum of Agreement, is mandated to:
† determine the eligibility of providers
participating in the Plan;
† plan and conduct information and education
programs necessary to ensure that all persons
and providers are informed of their
entitlements and responsibilities under the
Plan;
† make payments under the Plan for any claim or
class of claims for insured health services for
which the Province is liable; and
† develop an audit and assessment system of
claims and payments, to maintain a continuous
audit process and to establish any other
administrative structures required to fulfill its
mandate.
1.2 Reporting Relationship
Atlantic Blue Cross Care is required to submit to
the Province, no later than the 20th day of each
month, monthly expenditure reports, including
such detail as determined by the Province. Within
30 days of the end of the fiscal quarter, Atlantic
Blue Cross Care is required to provide a report
that includes expenditures to the end of the
quarter and a forecast of expenditures to the end
of the year. Atlantic Blue Cross Care is required
to provide minutes and any information necessary
to keep the Province informed of all meetings,
conferences, etc. that are charged to the MSI
Plan. Reports prepared by Atlantic Blue Cross
Care are forwarded to the respective Insured
Program areas of the Department of Health for
review and follow-up.
Section 17(1)(i) of the Health Services and
Insurance Act, and sections 11(1) and 12(1) of
the Hospital Insurance Regulations, which relate
60
to this Act, set out the terms for reporting by
hospitals and hospital boards to the Minister of
Health, their annual budget estimates and their
monthly reports of actual revenues and
expenditures.
1.3 Audit of Accounts
The Auditor General’s office audits all
expenditures of the Department of Health,
including Pharmacare, the provincial drug
program. The Department of Health’s internal
auditors perform a financial audit of the
administration contract at Atlantic Blue Cross
Care. An external audit is also conducted for
Atlantic Blue Cross Care, which includes the
administrative contract. No official audit is
performed on Medicare payments; however, this is
being recommended by the Auditor General’s
office.
All Long-term Care facilities, Home Care and
Home Support agencies are now required to
provide the Department with annual audited
financial statements.
Under section 34(5) of the Health Authorities Act,
every hospital board is required to submit to the
Minister of Health by July 1st each year, an
audited financial statement for the preceding
fiscal year.
The Report of the Auditor General of Nova Scotia,
tabled on November 28, 2003, contained audits
that are relevant to the Canada Health Act:
† IWK Health Centre;
† Long-term care; and
† Payments to physicians.
1.4 Designated Agency
Atlantic Blue Cross Care administers and has the
authority to receive monies to pay physician
accounts under a Memorandum of Agreement
with the Department of Health. Atlantic Blue
Cross Care receives written authorization from
the Department for the physicians to whom it may
make payments. The rates of pay and specific
amounts depend on the physician contract
negotiated between Doctors Nova Scotia and the
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Nova Scotia
Department of Health.
There is no legislation governing the role of
Atlantic Blue Cross Care. Atlantic Blue Cross
Care abides by the terms and conditions of the
1992 contract and its payment mechanism. Under
this contract, Atlantic Blue Cross Care is required
to submit to the Province:
† annual audited financial statements;
† detailed line-by-line Full-Time Equivalent counts
on budget requests for which the Department
actually approves staffing levels;
† line-by-line budgets showing salary, benefits,
travel, postage, etc.; and
† a copy of the annual report.
All Atlantic Blue Cross Care system development
for MSI and Pharmacare is controlled through a
joint committee. All MSI and Pharmacare
transactions are subject to a review by the Office
of the Auditor General.
2.0 Comprehensiveness
2.1 Insured Hospital Services
Nine District Health Authorities (DHAs) and the
IWK Health Centre (Women and Children’s
Tertiary Care Hospital) deliver insured hospital
services to both in- and out-patients in Nova
Scotia in a total of 35 facilities1.
Accreditation is not mandatory, but all facilities
are accredited at a facility or district level. The
enabling legislation that provides for insured
hospital services in Nova Scotia is the Health
Services and Insurance Act, Chapter 197, Revised
Statutes of Nova Scotia, 1989: sections 3(1), 5,
6, 10, 15, 16, 17(1), 18 and 35, passed by the
Legislature in 1958. Hospital Insurance
Regulations were made pursuant to the Health
Services and Insurance Act.
† necessary nursing services;
† laboratory, radiological and other diagnostic
procedures;
† drugs, biologicals and related preparations,
when administered in a hospital;
† routine surgical supplies;
† use of operating room, case room and
anaesthetic facilities;
† use of radiotherapy and physiotherapy
services, where available; and
† blood or therapeutic blood fractions.
Out-patient services include:
† laboratory and radiological examinations;
† diagnostic procedures involving the use of
radio-pharmaceuticals;
† electroencephalographic examinations;
† use of occupational and physiotherapy
facilities, where available;
† necessary nursing services;
† drugs, biologicals and related preparations;
† blood or therapeutic blood fractions;
† hospital services in connection with most minor
medical and surgical procedures;
† day-patient diabetic care;
† services other than medical services provided
by and within the Nova Scotia Hearing and
Speech Clinic;
† ultrasonic diagnostic procedures;
† home parenterel nutrition; and
† haemodialysis and peritoneal dialysis.
In order to add a new hospital service to the list
of insured hospital services, DHAs are required to
submit a New and/or Expanded Program Proposal
to the Department of Health. This process is
carried out annually through the business planning
process. A Department-developed process format
is forwarded to the DHAs for their guidance. A
Department working group reviews and prioritizes
all requests received. Based on available funding,
a number of top priorities may be approved by the
Minister of Health.
In-patient services include:
† accommodation and meals at the standard
ward level;
1
The number of facilities reported in other documents may differ from the 35 facilities reported here as a result of differences
in defining for the term “facility”.
Canada Health Act Annual Report, 2003-2004
61
Chapter 3 – Nova Scotia
2.2 Insured Physician Services
The legislation covering the provision of insured
physician services in Nova Scotia is the Health
Services and Insurance Act, sections 3(2), 5, 8,
13, 13A, 17(2), 22, 27-31, 35 and the Medical
Services Insurance Regulations.
The Health Services and Insurance Act was
amended in 2002-2003 to include section 13B
stating that:
“Effective November 1, 2002, any agreement
between a provider and a hospital, or
predecessors to a hospital, stipulating
compensation for the provision of insured
professional services, for the provider undertaking
to be on-call for the provision of such services or
for the provider to relocate or maintain a presence
in proximity to a hospital, excepting agreements to
which the Minister and the Society are a party, is
null and void and no compensation is payable
pursuant to the agreement, including
compensation otherwise payable for termination
of the agreement.”
Under the Health Services and Insurance Act,
persons who can provide insured physician
services include:
† general practitioners, who are persons who
engage in the general practice of medicine;
† physicians, who are not specialists within the
meaning of the clause; and
† specialists, who are physicians and are
recognized as specialists by the appropriate
licensing body of the jurisdiction in which he or
she practises.
Physicians (general practitioner or specialist)
must be licensed by the College of Physicians and
Surgeons in Nova Scotia in order to be eligible to
bill the MSI system. Dentists receiving payment
under the MSI Plan must be registered with the
Provincial Dental Board and be recognized as
dentists. In 2003-2004, 2,116 physicians and 28
dentists were paid through the MSI Plan.
Physicians retain the ability to opt into or out of
the MSI Plan. In order to opt out, a physician
notifies MSI, relinquishing his or her billing
number. Patients who pay the physician directly
62
due to opting out are reimbursed for these
services by MSI. As of March 31, 2004, no
physicians had opted out.
Insured services are those medically necessary to
diagnose, treat, rehabilitate or otherwise alter a
disease pattern. There are no limitations on
medically necessary insured services.
No new large-scale services were added to the
list of insured physician services in 2003-2004. On
a quarterly, ongoing basis, new specific fee codes
are approved that represent either enhancements,
new technologies or new ways of delivering a
service.
The addition of new fee codes to the list of
insured physician services is accomplished
through a committee structure. Physicians wishing
to have a new fee code recognized or established
must first present their cases to Doctors Nova
Scotia, which puts a suggested value on the
proposed new fee.
The proposal is then passed to the Joint Fee and
Tariff Committee for review and approval. The
Joint Committee is comprised of equal
representation from Doctors Nova Scotia and the
Department of Health. When approved by the
Joint Fee Schedule Committee, the approved
proposed new fee is forwarded to the Department
of Health for final approval and Atlantic Blue
Cross Care is directed to add the new fee to the
schedule of insured services payable by the MSI
Plan.
2.3 Insured Surgical-Dental
Services
Under the Health Services and Insurance Act, a
dentist is defined as a person lawfully entitled to
practise dentistry in a place where that person
carries on such a practice.
To provide insured surgical-dental services under
the Health Services and Insurance Act, dentists
must be registered members of the Nova Scotia
Dental Association and must also be certified
competent in the practice of dental surgery. The
Health Services and Insurance Act is so written
that a dentist may choose not to participate in the
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Nova Scotia
MSI Plan. To participate, a dentist must register
with MSI. A participating dentist who wishes to
reverse his or her election to participate must
advise MSI in writing and is then no longer eligible
to submit claims to MSI. As of March 31, 2003,
no dentists had opted out. In 2003-2004, 36
dentists were paid through the MSI Plan for
providing insured surgical-dental services.
Insured surgical-dental services must be provided
in a health care facility. Insured services are listed
in the Insured Dental Services Tariff Regulations.
Services under this program are insured when the
conditions of the patient are such that it is
medically necessary for the procedure to be done
in a hospital and the procedure is of a surgical
nature. Generally included as insured surgicaldental services are orthognathic surgery, surgical
removal of impacted teeth and oral and maxillary
facial surgery. Additions to the list of surgicaldental services that are insured are accomplished
by first approaching the Dental Association of
Nova Scotia and having them put forward a
proposal to the Department of Health for the
addition of a new procedure. The Department of
Health, in consultation with specific experts in the
field, renders the decision on whether or not the
new procedure becomes an insured service.
2.4 Uninsured Hospital, Physician
and Surgical-Dental Services
Uninsured hospital services include:
preferred accommodation at the patient’s request;
† telephones;
† televisions;
† drugs and biologicals ordered after discharge
from hospital;
† cosmetic surgery;
† reversal of sterilization procedures;
† surgery for sex reassignment;
† in-vitro fertilization;
† procedures performed as part of clinical
research trials;
† services such as gastric bypass for morbid
obesity, breast reduction/augmentation and
newborn circumcision, except because of
medical necessity; and
Canada Health Act Annual Report, 2003-2004
† services not deemed medically necessary that
are required by third parties, such as insurance
companies.
Uninsured physician services include:
† those a person is eligible for under the
Workers’ Compensation Act or under any
other federal or provincial legislation;
† mileage, travelling or detention time;
† telephone advice or telephone renewal of
prescriptions;
† examinations required by third parties;
† group immunizations or inoculations unless
approved by the Department;
† preparation of certificates or reports;
† testimony in court;
† services in connection with an
electrocardiogram, electromyogram or
electroencephalogram, unless the physician is
a specialist in the appropriate specialty;
† cosmetic surgery;
† acupuncture;
† reversal of sterilization; and
† in-vitro fertilization.
All residents of the province are entitled to
services covered under the Health Services and
Insurance Act. If enhanced goods and services,
such as the foldable interocular lens or a
fibreglass cast can be purchased, it is required to
fully inform patients about the cost. They are not
to be denied service based on their inability to
pay. The Province provides alternatives to any of
the enhanced goods and services.
The Department of Health also carefully reviews
all patient complaints or public concerns that may
indicate that the general principles of insured
services are not being followed.
The de-insurance of insured physician services is
accomplished through a negotiation process
between Doctors Nova Scotia and Department of
Health representatives, who jointly evaluate a
procedure or process to determine its medical
necessity. If a process or procedure is deemed not
to be medically necessary, it is removed from the
physician fee schedule and will no longer be
reimbursed to physicians as an insured service.
Once a service has been de-insured, all
63
Chapter 3 – Nova Scotia
procedures and testing relating to the provision of
that service are also de-insured. The same
process applies to dental and hospital services.
The last time there was any significant amount of
de-insurance of services was in 1997.
3.0 Universality
3.1 Eligibility
Eligibility for insured health care services in Nova
Scotia is outlined under section 2 of the Hospital
Insurance Regulations pursuant to section 17 of
the Health Services and Insurance Act. All
residents of Nova Scotia are eligible. A resident is
defined as anyone who is legally entitled to stay in
Canada and who makes his or her home and is
ordinarily present in Nova Scotia.
Persons moving to Nova Scotia from another
Canadian province will normally be eligible for
MSI on the first day of the third month following
the month of their arrival as permanent residents.
Persons moving permanently to Nova Scotia from
another country are eligible on the date of their
arrival in the province, provided they are Canadian
citizens or hold “Permanent Resident” status as
defined by Citizenship and Immigration Canada.
Members of the Royal Canadian Mounted Police
(RCMP), members of the Canadian Forces,
federal inmates and members of the North
Atlantic Treaty Organization (NATO) are ineligible
for MSI coverage. When their status changes,
they become eligible for provincial Medicare.
3.2 Registration Requirements
To obtain a health card in Nova Scotia, residents
must register with MSI. Once eligibility has been
determined, an application form is generated. The
applicant (and spouse if applicable) must sign the
form before it can be processed. The applicant
must indicate on the application the name and
mailing address of a witness. The witness must be
a Nova Scotia resident who can confirm the
information on the application. The applicant must
64
include proof of Canadian citizenship or provide a
copy of an acceptable immigration document.
When the application has been approved, health
cards will be issued to each family member listed.
Each health card number is unique and is issued
for the lifetime of the applicant. Health cards
expire every four years. The health card number
also acts as the primary health record identifier
for all health service encounters in Nova Scotia
for the life of the recipient. Proof of eligibility for
insured services is required before residents are
eligible to receive insured services. Renewal
notices are sent to most cardholders three months
before the expiry date of the current health card.
Upon return of a signed renewal notice, MSI will
issue a new health card.
There is no legislation in Nova Scotia forcing
residents of the province to apply for MSI. There
may be residents of Nova Scotia who, therefore,
are not members of the health insurance plan.
In 2003-2004, there were 956,820 residents
registered with the health insurance plan.
3.3 Other Categories of Individual
The following persons may also be eligible for
insured health care services in Nova Scotia, once
they meet the specific eligibility criteria for their
situations:
Immigrants: Persons moving from another
country to live permanently in Nova Scotia, are
eligible for health care on the date of arrival. They
must possess a landed immigrant document.
These individuals, formerly called “landed
immigrants”, are now referred to as “Permanent
Residents”.
Non-Canadians who are married to a Canadian
citizen or a Permanent Resident, and Convention
Refugees who have applied in Canada for
Permanent Residence status are eligible for
insured services as of the date of application for
Permanent Resident status. Applicants must
possess a letter from Citizenship and Immigration
Canada verifying their status. A Convention
Refugee is a person designated by the
Immigration Refugee Board to have been found to
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Nova Scotia
fear persecution in his or her country of origin
because of race, religion, nationality, membership
in a social group or political opinion.
the eligibility provisions for the type of
immigration document that they possess.
In 2003-2004, there were 19,345 Permanent
Residents registered with the health care
insurance plan.
4.0 Portability
Work Permits: Persons moving to Nova Scotia
from outside the country who possess a work
permit can apply for coverage on the date of
arrival in Nova Scotia, providing they will be
remaining in Nova Scotia for at least one full year.
A declaration must be signed to confirm that the
worker will not be outside Nova Scotia for more
than 31 consecutive days, except in the course of
employment. MSI coverage is extended for a
maximum of 12 months at a time and only for
services received within Nova Scotia, which is
indicated on their health cards. Each year a copy
of their renewed immigration document must be
presented and a declaration signed. Dependants
of such persons are granted coverage on the
same basis.
4.1 Minimum Waiting Period
In 2003-2004, there were 478 individuals with
Employment Authorizations covered under the
health care insurance plan.
Student Permits: Persons moving to Nova
Scotia from another country, who possess a
Student Authorization will be eligible for MSI on
the first day of the thirteenth month following the
month of their arrival, provided they have not
been absent from Nova Scotia for more than 31
consecutive days. MSI coverage is extended for a
maximum of 12 months at a time and only for
services received within Nova Scotia. Each year, a
copy of their renewed immigration document must
be presented and a declaration signed.
Dependants of such persons will be granted
coverage on the same basis, once the student has
gained entitlement.
In 2003-2004, there were 687 individuals with
Student Authorizations covered under the health
care insurance plan.
Refugees: Refugees are eligible for MSI if they
possess either an employment or student
authorization, or if they have applied for
Permanent Resident status. They are governed by
Canada Health Act Annual Report, 2003-2004
Persons moving to Nova Scotia from another
Canadian province or territory will normally be
eligible for MSI on the first day of the third month
following the month of their arrival as Permanent
Residents.
4.2 Coverage During Temporary
Absences in Canada
The Agreement of Eligibility and Portability is
followed in all matters pertaining to portability of
insured services.
Generally, the Nova Scotia MSI Plan provides
coverage for residents of Nova Scotia who move
to other provinces or territories for a period of
three months as per the Eligibility and Portability
Agreement. Students who are temporarily absent
from Nova Scotia and in full-time attendance at
an educational institution, may remain eligible for
MSI on a yearly basis. To qualify for MSI, the
student must provide, to MSI, a letter obtained
from the educational institution that verifies the
student’s attendance there in each year for which
MSI coverage is requested.
Workers who leave Nova Scotia to seek
employment elsewhere will still be covered by MSI
for up to 12 months, provided they do not
establish residence in another province, territory
or country. Services provided to Nova Scotia
residents in other provinces or territories are
covered by reciprocal agreements. Nova Scotia
participates in the Hospital Reciprocal Billing
Agreement and the Medical Reciprocal Billing
Agreement. Quebec is the only province that does
not participate in the medical reciprocal
agreement. Nova Scotia pays for services
provided by Quebec physicians to Nova Scotia
residents at Quebec rates if the services are
65
Chapter 3 – Nova Scotia
insured in Nova Scotia. The majority of such
claims are received directly from Quebec
physicians. In-patient hospital services are paid
through the interprovincial reciprocal billing
arrangement at the standard ward rate of the
hospital providing the service. The total amounts
paid by the Plan in 2003-2004, for in- and outpatient hospital services received in other
provinces and territories were: $15,859,930 for
out-of-province, in-patient services and
$4,303,236 for out-of-province, out-patient
services. Nova Scotia pays the host province
rates for insured services in all reciprocal-billing
situations.
4.3 Coverage During Temporary
Absences Outside Canada
Nova Scotia adheres to the Agreement on
Eligibility and Portability for dealing with insured
services for residents temporarily outside Canada.
Provided a Nova Scotia resident meets eligibility
requirements, out-of-country services will be paid,
at a minimum, on the basis of the amount that
would have been paid by Nova Scotia for similar
services rendered in this province. Ordinarily, to
be eligible for coverage, residents must not be
outside the country for more than six months in a
calendar year. In order to be covered, procedures
of a non-emergency nature must have prior
approval before they will be covered by MSI.
Students who are temporarily absent from Nova
Scotia and in full-time attendance at an
educational institution outside Canada may remain
eligible for MSI on a yearly basis. To qualify for
MSI, the student must provide to MSI, a letter
obtained from the educational institution that
verifies the student’s attendance there in each
year for which MSI coverage is requested.
Workers who leave Nova Scotia to seek
employment elsewhere are still covered by MSI
for up to 24 months, provided they do not
establish residence in another country.
Emergency out-of-country services are paid at a
minimum on the basis of the amount that would
have been paid by Nova Scotia for similar
66
services rendered in this province. The total
amount spent in 2003-2004 for insured in-patient
services provided outside Canada was $623,896.
4.4 Prior Approval Requirement
Prior approval must be obtained for elective
services outside the country. Application for prior
approval is made to the Medical Director of the
MSI Plan by a physician in Nova Scotia on behalf
of an insured resident. The medical consultant
reviews the terms and conditions and determines
whether or not the service is available in the
province, or if it can be provided in another
province or only out-of-country. The decision of
the Medical Consultant is relayed to the patient’s
physician. The patient is then covered under the
Reciprocal Billing Agreement for elective services
in another province or territory. If approval is
given to obtain service outside the country, the
full cost of that service will be covered under MSI.
5.0 Accessibility
5.1 Access to Insured Health
Services
Insured services are provided to Nova Scotia
residents on uniform terms and conditions. There
are no user charges or extra charges under either
plan.
Nova Scotia continually reviews access situations
across Canada to ensure that it is not falling
behind. In areas where improvement is deemed
necessary, depending on the Province’s financial
situation, extra funding is generally allocated to
that area. The Department of Health accepted the
recommendations of the Provincial Osteoporosis
Committee report, which included placing new
bone density units in Sydney and Yarmouth and
operating the Truro unit at full capacity. These
units will be fully operational in 2004-2005. In
March 2003, MRI services were introduced at the
Cape Breton Regional Hospital to increase access
and reduce provincial wait times.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Nova Scotia
In fiscal year 2004-2005, $7 million will be added
to the Capital District budget to address the issue
of ever-increasing orthopedic wait lists.
In February 2004, the Department of Health
announced the hiring of a French language health
services coordinator to develop a plan to improve
access to health care services for French-speaking
Nova Scotians.
Table 1:
Health Personnel in Nova Scotia (2002)
Health Occupation
Physicians
Registered/
Licensed to
Practice2
2,045
5.2 Access to Insured Hospital
Services
Dentists3
The Government of Nova Scotia continues to
emphasize the provision of sustainable, quality
health care services to its citizens.
Registered Nurses
9,5564
Licensed Practical Nurses
3,3294
In 2003-2004, a total of $9.8 million was provided
to train, recruit and retain nurses. Eighty-three
percent of the nurses from the class of 2003
renewed their licenses, compared with only 51
percent in 2001. This is the highest retention ratio
since 1999.
In November 2003, the Minister of Health
launched a new Web site for nurses and nursing
students. This new Web site, which was designed
by nurses, provides information on training,
retraining, retaining and recruitment for nurses in
Nova Scotia.
In January 2004, the Minister of Health
announced funding to open 25 surgical beds and
an additional operating room in the QEII Health
Sciences Centre in Halifax. This will help ease the
pressure on hospital wait times and emergency
room overcrowding.
Table 1 provides a breakdown of key health
professionals who are licensed to practice in Nova
Scotia. Not all of these health professionals were
actively involved in delivering insured health
services.
Canada Health Act Annual Report, 2003-2004
464
Medical Radiation
Technologists
483
Respiratory Therapists
186
Pharmacists
1,004
Occupational Therapists
240
Speech-Language
Pathologists
156
Chiropractors
Opticians
74
173
Optometrists
76
Dentists
55
Dietitians
402
Psychologists
371
2
3
4
Not all professionals licensed to practice actually work.
A limited number of licensed dentists are approved for
insured dental services.
Data is for 2003.
67
Chapter 3 – Nova Scotia
In Nova Scotia in 2003-2004, Telehealth was also
used to provide the services listed in Table 2.
Table 2:
Telehealth Services in Nova Scotia
Type of Health Event
Tele-radiology Cases
Education Sessions
(attending sites)
Number of
“Events”
67
763
(3,442)
Clinical Consultations
1,823
Administrative Meetings
(attending sites)
378
(988)
Clinical Case Conferences
71
5.3 Access to Insured Physician and
Dental-Surgical Services
In 2003-2004, 2,116 physicians and 28 dentists
actively provided insured services under the
Canada Health Act or provincial legislation.
Innovative funding solutions such as block funding
and personal services contracts have enhanced
recruitment.
The Province has increased the capacity for
medical education, coordinates ongoing
recruitment activities and has provided funding to
create a re-entry program for general practitioners
wishing to enter specialty training after
completing two years of general practice service
in the province.
5.4 Physician Compensation
The Health Services and Insurance Act RS
Chapter 197 governs payment to physicians and
dentists for insured services. Physician payments
are made in accordance with a negotiated
agreement between Doctors Nova Scotia and the
Nova Scotia Department of Health. Doctors Nova
68
Scotia is recognized as the sole bargaining agent
in support of physicians in the province. When
negotiations take place, representatives from
Doctors Nova Scotia and the Department of
Health negotiate the total funding and other terms
and conditions. The current master agreement is
effective from April 1, 2004 through March 31,
2008. The agreement lays out what the medical
services unit value will be for physician services
and addresses other issues such as Canadian
Medical Protective Association, membership
benefits, emergency department payment, on-call
funding, specific fee adjustments, dispute
resolution processes, and other process or
consultation issues.
Fee-for-service is still the most prevalent method
of payment for physician services. However, there
has been significant growth in the number of
alternative funding arrangements in place in Nova
Scotia
In 2003-2004, total payments to physicians for
insured services in Nova Scotia was
$434,000,386. The Department paid an additional
$5,747,516 for insured physician services
provided to Nova Scotia residents outside the
province, but within Canada.
Payment rates for dental services in the province
are negotiated between the Department of Health
and the Dental Association of Nova Scotia and
follow a process similar to physician negotiations.
Dentists are paid on a fee-for-service basis. The
current agreement expires on March 31, 2004.
5.5 Payments to Hospitals
The Department of Health establishes budget
targets for health care services. It does this by
receiving business plans from the nine DHAs, the
IWK Health Centre and other non-DHA
organizations. Approved provincial estimates form
the basis on which payments are made to these
organizations for service delivery.
The Health Authorities Act was given Royal
Assent on June 8, 2000. The Act instituted the
nine DHAs that replaced the former regional
health boards. This change came into effect in
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Nova Scotia
January 2001, under the District Health
Authorities General Regulations. The
implementation of community health boards under
the Community Health Boards’ Member Selection
Regulations was effective in April 2001. The
DHAs are responsible (section 20 of the Act) for
overseeing the delivery of health services in their
districts and are fully accountable for explaining
their decisions on the community health plans
through their business plan submissions to the
Department of Health.
Section 10 of the Health Services and Insurance
Act and sections 9 through 13 of the Hospital
Insurance Regulations define the terms for
payments by the Minister of Health to hospitals
for insured hospital services.
In 2003-2004, there were 2,850 hospital beds in
Nova Scotia (3.05 beds per 1,000 population).
Department of Health direct expenditures for
insured hospital services operating costs were
increased to $1.095 billion. Total separations from
all hospitals are unavailable at this time.
6.0 Recognition Given to
Federal Transfers
In Nova Scotia, the Health Services and Insurance
Act RS Chapter 197 acknowledges the federal
contribution regarding the cost of insured hospital
services and insured health services provided to
provincial residents. The residents of Nova Scotia
are aware, through press releases and media
coverage of ongoing negotiations between the
provinces and the federal government that
Canada Health and Social Transfer (CHST)
funding partially helps provide insured medical
services in the province.
7.0 Extended Health Care
Services
Home Care Services
Broad-based, provincially funded home care
services were introduced in Nova Scotia in 1995.
Home care is part of the continuum of services
available through the Department of Health’s
Continuing Care Branch. Home care services are
available to Nova Scotians of all ages and help
individuals reach and maintain their maximum level
of health and prolong independent community
living. Home care can be provided to people who
are chronically ill, disabled, convalescent or to
individuals with an acute illness. Services can
delay admissions to long-term care facilities or
hospitals as well as facilitate early release from an
acute care facility. The health care and support
services available to individuals in the community
through home care include nursing care,
assistance with personal care, aid with home
support activities, home oxygen services and
respite. Both chronic services over the longer
term and short-term acute services are provided
through home care. Home care services in Nova
Scotia continue to mature and, as resources allow,
additional services will be added in the future.
These may include services such as occupational
therapy, physiotherapy, palliative care, pediatric
services and others as deemed necessary.
The Nova Scotia Department of Health has
implemented a Single Entry Access to its
Continuing Care services. Nova Scotians connect
with home care, long-term care placement and
adult protection services through a single toll-free
number.
The Government of Nova Scotia also recognized
the federal contribution under the CHST in
various published documents including the
following documents released in 2003-2004:
† Public Accounts 2003-2004; and
† Budget Estimates 2003-2004 and 2004-2005.
Canada Health Act Annual Report, 2003-2004
69
Chapter 3 – Nova Scotia
Registered Persons
1. Number as of March 31st (#).
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
944,487
947,963
953,385
955,475
956,820
Insured Hospital Services Within Own Province or Territory
Public Facilities
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
2. Number (#):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
35
not applicable
not applicable
not applicable
35
35
not applicable
not applicable
not applicable
35
35
not applicable
not applicable
not applicable
35
35
not applicable
not applicable
not applicable
35
35
not applicable
not applicable
not applicable
35
3. Payments ($): 1
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
812,776,800
not applicable
not applicable
not applicable
812,776,800
877,019,426
not applicable
not applicable
not applicable
877,019,426
926,797,569
not applicable
not applicable
not applicable
926,797,569
1,021,934,504
not applicable
not applicable
not applicable
1,021,934,504
1,095,584,706
not applicable
not applicable
not applicable
1,095,584,706
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
1
0
1
1
0
1
1
0
1
1
0
1
1
0
1
120
0
0
109
0
0
81
0
0
83
0
0
38
0
38
15,677
0
0
14,627
0
0
10,926
0
0
11,714
0
0
5,531
0
5,531
Private For-Profit Facilities
4. Number (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
5. Number of insured hospital services
provided (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
6. Payments ($):
a. surgical facilities
b. diagnostic imaging facilities
c. total
70
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Nova Scotia
Insured Physician Services Within Own Province or Territory
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
829
1,095
0
1,924
920
1,067
0
1,987
865
1,128
10
2,003
875
1,142
9
2,026
904
1,198
14
2,116
8. Number of opted-out physicians (#):
a. general practitioners
b. specialists
c. other
d. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
9. Number of not participating
physicians (#):
a. general practitioners
b. specialists
c. other
d. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
4,619,083
1,606,842
0
6,225,925
4,498,232
1,645,535
3,951
6,147,718
4,521,991
1,650,685
2,999
6,175,675
4,563,449
1,677,973
2,512
6,243,934
4,629,753
1,924,079
7,098
6,560,930
104,587,110
112,250,617
0
216,837,727
102,332,556
117,891,477
175,890
220,399,923
102,555,964
118,414,434
162,779
221,133,176
113,507,874
127,688,914
165,984
241,362,772
120,455,816
133,964,947
250,201
254,670,965
12. Average payment per fee for service
service ($):
a. general practitioners
b. specialists
c. other
d. all services
22.64
69.86
0.00
34.83
22.75
71.64
44.52
35.85
22.68
71.74
54.28
35.81
24.87
76.10
66.08
38.66
26.02
69.63
35.25
38.82
13. Number of services provided through
all payment methods (#): 3
a. medical
b. surgical
c. diagnostic
d. other
e. total
5,908,054
317,871
1,514,011
0
7,739,936
5,457,153
985,321
1,121,296
291,352
6,147,718
5,462,682
1,009,997
1,124,792
308,326
7,905,797
6,458,299
1,096,509
1,144,383
324,081
9,023,272
6,572,716
1,117,739
1,191,588
317,419
9,199,462
14. Total payments to physicians paid
through all payment methods ($): 2, 3
a. medical
b. surgical
c. diagnostic
d. other
e. total
not available
not available
not available
not available
350,091,235
239,036,017
77,328,861
25,385,064
7,287,248
349,037,190
244,049,190
80,867,051
26,262,276
8,015,345
359,193,862
270,161,897
91,426,158
28,530,589
8,210,021
398,328,665
293,468,260
96,065,557
37,191,400
7,275,169
434,000,386
15. Average payment per service, all
payment methods ($): 3
a. medical
b. surgical
c. diagnostic
d. other
e. all services
not available
not available
not available
not available
45.23
29.40
68.53
57.21
47.78
35.85
29.18
68.49
58.97
53.58
35.81
41.83
83.38
24.93
25.33
44.14
44.65
85.95
31.21
22.92
47.18
7. Number of participating physicians (#):
a. general practitioners
b. specialists
c. other
d. total
10. Number of services provided through
fee for service (#):
a. general practitioners
b. specialists
c. other
d. total
11. Total payments to physicians paid
through fee for service ($): 2
a. general practitioners
b. specialists
c. other
d. total
Canada Health Act Annual Report, 2003-2004
71
Chapter 3 – Nova Scotia
Insured Services Provided to Residents in Another Province or Territory
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
2,382
2,520
2,050
2,300
2,368
30,086
32,859
30,749
34,425
32,968
10,499,281
9,961,995
8,536,691
12,685,659
15,859,930
19. Total payments, out-patient ($).
3,772,315
4,171,365
4,009,667
4,447,816
4,303,236
20. Average payment, in-patient ($).
4,407.75
3,953.17
4,115.45
5,515.50
6,697.61
125.38
126.94
130.39
129.20
130.58
Physicians
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
22. Number of services (#).
not available
180,299
179,833
187,390
180,897
23. Total payments ($).
not available
4,766,189
5,078,794
5,562,125
5,747,516
24. Average payment per service ($).
not available
26.43
28.24
29.68
31.77
16. Total number of claims, in-patient (#).
17. Total number of claims,
out-patient (#).
18. Total payments, in-patient ($).
21. Average payment, out-patient ($).
Insured Services Provided Outside Canada
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
25. Total number of claims, in-patient (#).
not available
not available
not available
not available
not available
not applicable
not applicable
not applicable
not applicable
not applicable
26. Total number of claims,
out-patient (#).
27. Total payments, in-patient ($).
1,053,577
735,834
1,000,023
938,092
623,896
28. Total payments, out-patient ($).
not applicable
not applicable
not applicable
not applicable
not applicable
29. Average payment, in-patient ($).
not available
not available
not available
not available
not available
not applicable
not applicable
not applicable
not applicable
not applicable
Physicians
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
31. Number of services (#).
not available
2,541
2,421
2,748
2,667
32. Total payments ($).
not available
98,461
109,484
121,780
120,977
33. Average payment per service ($).
not available
38.75
45.22
44.32
45.36
30. Average payment, out-patient ($).
Insured Surgical-Dental Services Within Own Province or Territory
34. Number of particpating dentists (#).
35. Number of services provided (#).
36. Total payments ($).
37. Average payment per service ($).
72
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
55
39
35
36
28
17,525
6,853
4,497
5,188
3,780
1,467,485
998,692
884,506
939,004
904,283
83.74
144.27
196.69
181.00
239.23
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Nova Scotia
Endnotes
1. $'s are paid to acute care facilities/DHAs only.
2. Discrepancies may exist between data presented here and the Nova Scotia Annual Statistical Tables due to methodological
differences.
3. Fee- for- service + alternate funded programs.
Canada Health Act Annual Report, 2003-2004
73
Chapter 3 – New Brunswick
primary health care, with physicians working
collaboratively with nurses, nurse practitioners
and other health care providers to serve
community health needs.
New Brunswick
Introduction
New Brunswick’s ongoing commitment to the
principles of public administration,
comprehensiveness, universality, portability and
accessibility in health care services – the
principles that form the foundation of the Canada
Health Act – was reaffirmed in a number of ways
during the 2003-2004 fiscal year.
During the year, the Province took action to make
health care more accessible investing in new
health facilities and medical equipment and
enhanced accountability through reports to its
citizens, the introduction of directly elected
trustees to oversee the management of the
province’s regional health authorities.
Primary Health Care
The Province embarked on a new course toward
community-based, patient-focused primary health
care during 2003-2004 with the establishment of
its first Collaborative Care Practice. This facility,
located in the Devon-Marysville section of
Fredericton, operates seven days a week with a
group of physicians and nurses who work together
to care for their patients. The practice has helped
address primary health care needs in the
Fredericton area and reduced demand on hospital
emergency services. Pilot projects for
collaborative practices involving individual
physicians were also established in Bathurst,
Moncton and Edmundston.
During the year, the Province also moved ahead to
establish its first Community Health Centres
(CHCs). These facilities offer a new approach to
Canada Health Act Annual Report, 2003-2004
The first four CHCs have been established in
Saint John, Minto, Doaktown and Lameque.
Community health needs assessments, to
determine the health care needs of the community
and the mix of health professionals to be located
at each centre, have been conducted. During the
year, the Province announced that three more
CHCs would be established to serve Plaster
Rock, Riverside-Albert and Caraquet. This brings
the total number of CHCs operating in the
province to seven.
Nurse Practitioners
New Brunswick introduced nurse practitioners to
the Province during the 2002-2003 fiscal year as
part of an overall strategy to enhance access to
primary care. Nurse practitioners are now at work
in physician’s offices, collaborative practice sites
and at Community Health Centres around the
province. In order to increase the supply of these
new health professionals, the Minister of Health
and Wellness announced on March 4, 2004 that
education subsidies would be advanced to
students studying to become nurse practitioners.
The subsidy assisted 21 student nurse
practitioners at three institutions during the 20032004 fiscal year.
Regional Health Authorities
The Regional Health Authorities Act, which
provides for the delivery and administration of
health services within specified geographic
regions of the province, came into force on
April 1, 2002. The eight Regional Health
Authorities (RHAs) are responsible for managing
and delivering acute care hospital services, extramural services and addictions services.
The Minister of Health and Wellness appointed
members to serve on the eight new boards for
terms of two to four years. With the expiry of the
two-year terms in May 2004, eight members of
each RHA board were elected by the voters of
75
Chapter 3 – New Brunswick
each health region in conjunction with scheduled
municipal and school board elections. The Minister
continues to appoint the seven remaining
members of each 15-member board.
To further enhance the role of RHAs and
accountability for health services to New
Brunswickers, legislation was introduced to
transfer responsibility for delivering public health
and mental health services from the Department
of Health and Wellness to RHAs. This transfer will
be completed during the 2004- 2005 fiscal year.
Health Human Resources Study
On February 2, 2002, the Minister of Health and
Wellness released a study commissioned by the
Department to determine New Brunswick’s
current and future supply and demand for major
health-related occupations.
The study, conducted by Fujitsu Consulting,
analyzed supply and demand in key health
disciplines to identify future gaps, major issues
and trends in health human resources. The first
phase of the report focused on 27 health-related
professions, while the second phase examined the
situation related to physicians. Health care
provider groups were major contributors to the
study. The report recommends strategies to help
New Brunswick meet its future health human
resources requirements, and thereby assure that
New Brunswickers continue to have appropriate
access to insured health services.
Health Charter of Rights and
Responsibilities
The Minister of Health and Wellness introduced
the Health Charter of Rights and Responsibilities
Act was introduced in the Legislature on April 8,
2003. The Act ensures that all New Brunswickers
have a right to timely access to health care
services; to safe, comfortable and considerate
treatment; to take informed health care decisions;
and to have their complaints investigated. The Act
confirms that New Brunswickers have a
responsibility to use health care services
responsibly; to learn about and make healthy
lifestyle choices; to participate actively in
76
decisions regarding their health care; and to use
complaint mechanisms appropriately and
effectively. The Act would also establish a Health
and Wellness Advocate, reporting directly to the
Legislative Assembly, to help New Brunswickers
deal with the health care system. Following
Second Reading, the Act was referred to the
Select Committee on Health Care for further
study.
Reporting To Our Citizens
The Province also continues to take action to
make New Brunswickers better informed on the
state of their own health and the status of their
health care system.
In September 2002, New Brunswick joined with
other jurisdictions in reporting to its population on
a set of common health indicators, as agreed to
by the First Ministers in September 2000. The
report showed that New Brunswickers have a high
rate of satisfaction with the health services they
receive, but performed relatively poorly on
measures related to personal health. New
Brunswick, along with other jurisdictions will issue
a follow-up report on health indicators in
November 2004.
In January 2003, the Province released the first
New Brunswick Health Care Report Card,
reporting to the province’s citizens on the status
of health care services and the overall health of
New Brunswickers. The report examined key
determinants of health within the province’s
population and considered the challenges that
face New Brunswickers in sustaining the health
care services they have come to cherish. The
Department of Health and Wellness will issue a
follow-up report during the 2004-2005 fiscal year.
Other Developments
On March 31, 2004, the Minister of Health and
Wellness tabled amendments to the Medical
Services Payment Act to clarify eligibility for
health services provided in the State of Maine.
The Act was amended to allow health facilities in
the neighbouring jurisidiction in the United States
to provide insured services to people working and
Canada Health Act Annual Report, 2003-2004
Chapter 3 – New Brunswick
visiting, as well as residing, in proscribed
geographic regions in New Brunswick. The
amended legislation received Royal Assent on
May 28, 2004.
1.0 Public Administration
1.1 Health Care Insurance Plan and
Public Authority
In New Brunswick, the health care insurance plan
is known as the Medical Services Plan. The public
authority responsible for operating and
administering the plan is the Minister of Health
and Wellness, whose authority rests under the
Medical Services Payment Act and its
Regulations, which were proclaimed on January 1,
1971.
The Act and Regulations specify eligibility criteria,
the rights of the beneficiary and the
responsibilities of the provincial authority,
including the establishment of a medical service
plan, the insured and the uninsured services. The
legislation also stipulates the type of agreements
the provincial authority may enter into with
provinces and territories and with the New
Brunswick Medical Society. As well, it specifies
the rights of a medical practitioner, how the
amounts to be paid for entitled services will be
determined, how assessment of accounts for
entitled services may be made and confidentiality
and privacy issues as they relate to the
administration of the Act.
The Minister of Health and Wellness is
responsible for establishing a medical services
plan that identifies beneficiaries, which services
are and are not covered, and the amounts to be
paid for entitled services. Under the Plan, the
Minister assesses and audits physician billings
through inspectors appointed by him or her and
through a professional review committee as
defined in sections 24(1) to 33 of the Medical
Services Payment Act and Regulations. The
Minister also has the authority to recover the cost
Canada Health Act Annual Report, 2003-2004
of entitled services from a person who is
negligent.
1.2 Reporting Relationship
The Medicare Branch of the Department of Health
and Wellness has a mandate to administer the
Medical Services Plan. The Minister reports to the
Legislative Assembly through the Department’s
annual report and through regular legislative
processes.
The Regional Health Authorities Act, which came
into force on April 1, 2002, sets out the
relationship between the eight Regional Health
Authorities (RHAs) and the Department of Health
and Wellness. Under the Act, RHAs must prepare
regional health and business plans that are in
harmony with the provincial health plan developed
by the Department of Health and Wellness. The
business and affairs of the RHA are to be
controlled and managed by a board of directors,
appointed or elected in accordance with the Act
and its regulations. The chief executive officer of
each RHA reports to the Deputy Minister of
Health and Wellness. Under sections 7(1) and
7(2) of the Act, the Minister of Health and
Wellness shall establish an accountability
framework, drafted in consultation with RHAs, to
specify the responsibilities that each party has to
the other in the provincial health system.
1.3 Audit of Accounts
Three groups have a mandate to audit the Medical
Services Plan.
The Auditor-General of New Brunswick
In accordance with the Auditor General Act, the
Office of the Auditor General conducts the
external audit of the accounts of the Province of
New Brunswick, which includes the financial
records of the Department of Health and
Wellness. For 2003-2004, all transactions of the
Department were subject to audit. These
procedures are completed on a routine basis each
year. Following the audit, the Auditor General
issues a management letter or report to identify
77
Chapter 3 – New Brunswick
errors and control weaknesses. The Auditor
General also conducts management reviews on
programs as he or she sees fit. During 2003-2004,
the Auditor General reported on the accountability
of psychiatric hospitals and psychiatric units.
The Office of the Comptroller
The Comptroller is the chief internal auditor for
the Province of New Brunswick and conducts
internal audits in accordance with responsibilities
and authority set out in the Financial
Administration Act. The objective of an internal
audit is to fulfill the Comptroller’s mandate as it
relates to the Appropriations Audit, Information
Systems Audit, Statutory Audits and Value-ForMoney Audits. The audit work performed by the
Office varies, depending on the nature of the
entity audited. During 2003-2004, the Office of
the Comptroller continued to gather risk
assessment data on a number of programs offered
by the Department of Health and Wellness. The
Comptroller also undertook a review of inventory
systems and procedures, and a Harmonized Sales
Tax (HST) recovery project in the Department of
Health and Wellness and other selected
departments.
Department of Health and Wellness Internal
Audit
The Department’s Internal Audit Group was
established to independently review and evaluate
departmental activities as a service to all levels of
management. This group is responsible for
providing management with information about the
adequacy and the effectiveness of its system of
internal controls and adherence to legislation and
stated policy. The unit performs program audits to
report on the effectiveness of programs in
meeting departmental objectives. For 2003-2004,
the Internal Audit reviewed aspects of the Medical
Education Training Program, the physician salaries
component of Medicare and completed a risk
assessment and service review on the Serum
Depot component of the Department’s
Epidemiology Program.
78
2.0 Comprehensiveness
2.1 Insured Hospital Services
Legislation providing for insured hospital services
includes the Hospital Services Act, 1973, and
section 9 of Regulation 84-167 and the Hospital
Act, assented to on May 20, 1992, and its
Regulation 92-84.
There are eight RHAs, established under the
authority of the Regional Health Authorities Act.
Each RHA includes a regional hospital facility and
a number of smaller facilities, all of which provide
insured services for both in- and out-patients.
Each RHA has other health facilities or health
centres, without designated beds, that provide a
range of services to entitled persons.
Under Regulation 84-167 of the Hospital Services
Act, New Brunswick residents are entitled to the
following insured hospital services:
† In-patient services in a hospital facility
operated by an approved regional health
authority as follows:
† accommodation and meals at the standard
ward level,
† necessary nursing service,
† laboratory, radiological and other diagnostic
procedures, together with the necessary
interpretations for the purpose of
maintaining health, preventing disease and
assisting in the diagnosis and treatment of
any injury, illness or disability,
† drugs, biologicals and related preparations,
as provided for under Schedule 2,
† use of operating room, case room and
anaesthetic facilities, including necessary
equipment and supplies,
† routine surgical supplies,
† use of radiotherapy facilities, where
available,
† use of physiotherapy facilities, where
available, and
† services rendered by persons who receive
remuneration therefore from the regional
health authority.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – New Brunswick
† Out-patient services in a hospital facility
operated by an approved regional health
authority as follows:
† laboratory and diagnostic procedures,
together with the necessary interpretations,
when referred by a medical practitioner or
nurse practitioner, when approved facilities
are available,
† laboratory and diagnostic procedures,
together with the necessary interpretations,
where approved facilities are available,
when performed for the purpose of a
mammography screening service that has
been approved by the Minister of Health
and Wellness,
† the hospital component of available outpatient services when prescribed by a
medical practitioner or nurse practitioner
and provided in an out-patient facility of an
approved regional health authority for the
purpose of maintaining health, preventing
disease and assisting in the diagnosis and
treatment of any injury, illness or disability,
excluding the following services:
- the provision of any proprietary
medicines;
- the provision of medications for the
patient to take home;
- diagnostic services performed to satisfy
the requirements of third parties, such
as employers and insurance companies;
- visits solely for the administration of
drugs, vaccines, sera or biological
products;
- any out-patient service which is an
entitled service under the Medical
Services Payment Act.
2.2 Insured Physician Services
The enabling legislation providing for insured
physician services is the Medical Services
Payment Act.
The Act was given Royal Assent on December 6,
1968. Regulation 84-29 was filed on February 13,
1984. Regulation 93-143 was filed on July 26,
1993. Regulation 96-113 was filed on November
Canada Health Act Annual Report, 2003-2004
29, 1996 and Schedule 4 (surgical-dental
services) Regulation 84-20 was filed on April 13,
1999.
No changes to this Act and Regulations were
introduced during 2003-2004.
The New Brunswick Medical Services Plan covers
physicians who provide medically required
services. The conditions that a physician must
meet to participate in the New Brunswick Medical
Services Plan are:
† to maintain current registration with the New
Brunswick College of Physicians and
Surgeons;
† to maintain membership in the New Brunswick
Medical Society;
† to hold privileges in a RHA; and
† to have signed the Participating Physicians
Agreement.
The number of practitioners participating in New
Brunswick’s Medical Services Plan as of March
31, 2004, was 1,496.
Physicians in New Brunswick have the option to
opt out totally or for selected services. Opted-out
practitioners are not paid directly by Medicare for
the services they render and must bill patients
directly in all cases. Patients are not entitled to
reimbursement from Medicare.
The opting-out provision may not be invoked in
the case of an emergency or for continuation of
care commenced on an opted-in basis. Opted-in
physicians wishing to opt out for a service must
first obtain the patient’s agreement to be treated
on an opted-out basis, after which they may bill
the patient directly for the service. In these cases,
the following procedure must be adhered to in
every instance. The physician must advise the
patient in advance and:
† the charges must not exceed the Medicare
tariff. The practitioner must complete the
specified Medicare claim forms and indicate
the exact total amount charged to the patient.
The beneficiary seeks reimbursement by
certifying on the claim form that the services
have been received and by forwarding the
claim form to Medicare.
79
Chapter 3 – New Brunswick
† If the charges will be in excess of the Medicare
tariff, the practitioner must inform the
beneficiary before rendering the service that:
† they are opting out and charging fees above
the Medicare tariff;
† in accepting service under these conditions,
the beneficiary waives all rights to
Medicare reimbursement; and
† the patient is entitled to seek services from
another practitioner who participates in the
Medical Services Plan.
in a hospital, if the condition of the patient
requires services to be rendered in a hospital. In
addition, a general dental practitioner may be paid
to assist another dentist for medically required
services under some conditions.
The physician must obtain a signed waiver from
the patient on the specified form and forward that
form to Medicare.
As of March 31, 2004, there were 14 dentists
registered with the plan.
As of March 31, 2004, no physicians rendering
health care services had elected to completely opt
out of the New Brunswick Medical Services Plan.
The range of entitled services under Medicare
includes the medical portion of all services
rendered by medical practitioners that are
medically required. It also includes certain
surgical-dental procedures when performed by a
physician or a dental surgeon in a hospital facility.
An individual, a physician or the Department of
Health and Wellness may request the addition of a
new service. All requests are considered by the
New Service Items Committee, which is jointly
managed by the New Brunswick Medical Society
and the Department of Health and Wellness. The
decision to add a new service is usually based on
conformity to “medically necessary” and whether
the service is considered generally acceptable
practice (not experimental) within New Brunswick
and Canada. Considerations under the term
“medically necessary” include services required
for maintaining health, preventing disease and/or
diagnosing or treating an injury, illness or
disability. No public consultation process is used.
2.3 Insured Surgical-Dental
Services
Schedule 4 of Regulation 84-20 (filed June 23,
1998, under the Medical Services Payment Act)
identifies the insured surgical-dental services that
can be provided by a qualified dental practitioner
80
The conditions a dental practitioner must meet to
participate in the medical plan are maintaining
current registration with the New Brunswick
Dental Society and completing the Participating
Physician’s Agreement (included in the New
Brunswick Medicare Dental registration form).
Dentists have the same opting-out provision as
previously explained for physicians and must
follow the same guidelines. The Department of
Health and Wellness has no data for the number
of non-enrolled dental practitioners in New
Brunswick.
2.4 Uninsured Hospital, Physician
and Surgical-Dental Services
Uninsured hospital services include the following:
† patent medicines;
† take-home drugs;
† third-party requests for diagnostic services;
† visits to administer drugs, vaccines, sera or
biological products;
† televisions and telephones;
† preferred accommodation at the patient’s
request; and
† hospital services directly related to services
listed under Schedule 2 of the Regulation
under the Medical Services Payment Act.
Services are not insured if provided to those
entitled under other statutes.
There are no specific policies or guidelines, other
than the Act and Regulations, to ensure that
charges for uninsured medical goods and services
(i.e. enhanced medical goods and services such as
intra-ocular lenses, fibreglass casts, etc.),
provided in conjunction with an insured health
service, do not compromise reasonable access to
insured services.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – New Brunswick
Uninsured Physician and Surgical-Dental
Services
The services listed in Schedule 2 of New
Brunswick Regulation 84-20 under the Medical
Services Payment Act are specifically excluded
from the range of entitled services under
Medicare, namely:
† elective surgery or other services for cosmetic
purposes;
† correction of inverted nipple;
† breast augmentation;
† otoplasty for persons over the age of 18;
† removal of minor skin lesions, except where
the lesions are, or are suspected to be, precancerous;
† abortion, unless the abortion is performed by a
specialist in the field of obstetrics and
gynaecology in a hospital facility approved by
the jurisdiction in which the hospital facility is
located and two medical practitioners certify in
writing that the abortion was medically
required;
† surgical assistance for cataract surgery unless
such assistance is required because of risk of
procedural failure, other than the risk inherent
in the removal of the cataract itself, due to the
existence of an illness or other complication;
† medicines, drugs, materials, surgical supplies
or prosthetic devices;
† vaccines, serums, drugs and biological
products listed in sections 106 and 108 of New
Brunswick Regulation 88-200 under the Health
Act;
† advice or prescription renewal by telephone
which is not specifically provided for in the
Schedule of Fees;
† examinations of medical records or certificates
at the request of a third party, or other
services required by hospital regulations or
medical by-laws;
† dental services provided by a medical
practitioner;
† services that are generally accepted within
New Brunswick as experimental or that are
provided as applied research;
† services that are provided in conjunction with,
or in relation to, the services referred to above;
Canada Health Act Annual Report, 2003-2004
† testimony in a court or before any other
tribunal;
† immunization, examinations or certificates for
the purpose of travel, employment, emigration,
insurance, or at the request of any third party;
† services provided by medical practitioners to
members of their immediate family;
† psychoanalysis;
† electrocardiogram (ECG) where not performed
by a specialist in internal medicine or
paediatrics;
† laboratory procedures not included as part of
an examination or consultation fee;
† refractions;
† services provided within the province by
medical practitioners or dental practitioners for
which the fee exceeds the amount payable
under this Regulation;
† the fitting and supplying of eyeglasses or
contact lenses;
† transsexual surgery;
† radiology services provided in the province by
a private radiology clinic;
† acupuncture;
† complete medical examinations when
performed for the purposes of a periodic
check-up and not for medically necessary
purposes;
† circumcision of the newborn;
† reversal of vasectomies;
† second and subsequent injections for
impotence;
† reversal of tubal ligations;
† intrauterine insemination;
† gastric stapling or gastric by-pass; and
† venipuncture for the purposes of the taking of
blood when performed as a stand-alone
procedure in a facility that is not an approved
hospital facility.
Dental services not specifically listed in Schedule
4 of the Dental Schedule are not covered by the
Plan. Those listed in Schedule 2 are considered
the only non-insured medical services.
The decision to de-insure physician or surgicaldental services is based on the conformity of the
service to the definition of “medically necessary,”
a review of medical service plans across the
81
Chapter 3 – New Brunswick
country and the previous use of the particular
service. Once a decision to de-insure is reached,
the Medical Services Payment Act dictates that
the government may not make any change to the
Regulation until the advice and recommendations
of the New Brunswick Medical Society is received
or until the period within which the Society was
requested by the Minister of Health and Wellness
to furnish advice and make recommendations has
expired. Subsequent to receiving their input and
resolution of any issues, a regulatory change is
completed. Physicians are informed in writing
following notification of approval. The public is
usually informed through a media release. No
public consultation process is used.
No medical or surgical-dental services were
removed from the insured service list in
2003-2004.
3.0 Universality
3.1 Eligibility
Sections 3 and 4 of the Medical Services Payment
Act and its Regulation 84-20, define eligibility for
the health care insurance plan in New Brunswick.
Residents are required to complete a Medicare
application and to provide proof of Canadian
citizenship, Native status or a valid Canadian
immigration document. A resident is defined as a
person lawfully entitled to be, or to remain, in
Canada, who makes his or her home and is
ordinarily present in New Brunswick, but does not
include a tourist, transient or visitor to the
province.
All persons entering or returning to New
Brunswick (excluding children adopted from
outside of Canada) have a waiting period before
becoming eligible for Medicare coverage.
Coverage commences on the first day of the third
month following the month of arrival.
Residents who are ineligible for Medicare
coverage include:
† regular members of the Canadian Armed
Forces;
82
† members of the Royal Canadian Mounted
Police (RCMP);
† inmates of federal prisons;
† persons moving to New Brunswick as
temporary residents;
† a family member who moves from another
province to New Brunswick before other family
members move;
† persons who have entered New Brunswick
from another province for the purpose of
furthering their education and who are eligible
to receive coverage under the medical services
plan of that province; and
† non-Canadians who are issued certain types of
Canadian authorization permits (e.g., a
Student Authorization).
Provisions to become eligible for Medicare
coverage include:
† non-Canadians who are issued an immigration
permit that would not normally entitle them to
coverage are eligible if legally married to, or in
a common-law relationship with, an eligible
New Brunswick resident.
Provisions when status changes include:
† persons who have been discharged or released
from the Canadian Armed Forces, the RCMP
or a federal penitentiary. Provided that they
are residing in New Brunswick at the time,
these persons are eligible for coverage on the
date of their release. They must complete an
application, provide the official date of release
and provide proof of citizenship.
3.2 Registration Requirements
A beneficiary who wishes to become eligible to
receive entitled services shall register, together
with any dependents under the age of 19, on a
form provided by Medicare for this purpose, or be
registered by a person acting on his or her behalf.
Upon approval of the application, the beneficiary
and dependents are registered and a Medicare
card with an expiry date is issued to the
beneficiary and each dependent.
A Notice of Expiry form providing all family
information currently existing on the Medicare
Canada Health Act Annual Report, 2003-2004
Chapter 3 – New Brunswick
files is issued to the beneficiary two or three
months before the expiry date of the Medicare
card or cards. A beneficiary who wishes to remain
eligible to receive entitled services is required to
confirm the information on the Notice of Expiry, to
make any changes as appropriate and return the
form to Medicare. Upon receiving the completed
form, the file is updated and new card(s) are
issued bearing a revised expiry date.
Currently in New Brunswick, only those
individuals deemed eligible are registered.
All family members (the beneficiary, spouse and
dependents under the age of 19) are required to
register as a family unit. Residents who are cohabiting, but not legally married, are eligible to
register as a family unit if they so request.
The number of residents registered as of March
31, 2004, was 738,030.
Residents may opt out of Medicare coverage if
they choose. They are asked to provide written
confirmation of their intention. This information is
added to their files and benefits are terminated.
3.3 Other Categories of Individual
Non-Canadians who may be issued an
immigration permit that would not normally entitle
them to Medicare coverage are eligible, provided
that they are legally married to, or living in a
common- law relationship with, an eligible New
Brunswick resident and still possess a valid
immigration permit. At the time of renewal, they
are required to provide an updated immigration
document. As of March 31, 2004, 611 individuals
were covered under immigration permits.
4.0 Portability
4.1 Minimum Waiting Period
There is a three-month waiting period to obtain
eligibility for Medicare coverage in New
Brunswick. Coverage commences the first day of
the third month following the month of arrival.
Canada Health Act Annual Report, 2003-2004
4.2 Coverage During Temporary
Absences in Canada
The legislation that defines portability of health
insurance during temporary absences in Canada is
the Medical Services Payment Act, Regulation
84-20, sections 3(4) and 3(5).
Students in full-time attendance at a university or
other approved educational institution who leave
New Brunswick to further their education in
another province are granted coverage for a 12month period that is renewable provided that they
do the following:
† provide proof of enrolment;
† contact Medicare once every 12-month period
to retain their eligibility;
† do not establish residence outside New
Brunswick; and
† do not receive health coverage in another
province.
Residents temporarily employed in another
province or territory are granted coverage for up
to 12 months provided that they do the following:
† do not establish residence in another province;
† do not receive coverage in another province;
and
† intend to return to New Brunswick.
If absent longer than 12 months, residents should
apply for coverage in the province or territory
where they are employed and should be entitled
to receive coverage there on the first day of the
thirteenth month.
New Brunswick has formal agreements with all
Canadian provinces and territories for reciprocal
billing of insured hospital services. As well, New
Brunswick has reciprocal agreements with all
provinces except Quebec for the provision of
insured physicians’ services. Services provided by
Quebec physicians to New Brunswick residents
are paid at Quebec rates, if the service delivered
is insured in New Brunswick. The majority of such
claims are received directly from Quebec
physicians. Any paid claims submitted by the
patient are reimbursed to the patient according to
New Brunswick Regulations.
83
Chapter 3 – New Brunswick
During 2003-2004, New Brunswick paid the
following amounts to other provinces and
territories for insured health services:
Hospital in-patient
$26,085,533
Hospital out-patient
$5,200,814
Medical Services
$9,911,068
4.3 Coverage During Temporary
Absences Outside Canada
The legislation that defines portability of health
insurance during temporary absences outside
Canada is the Medical Services Payment Act,
Regulation 84-20, sections 3 (4) and 3 (5).
Students: Those in full-time attendance at a
university or other approved educational
institution, who leave New Brunswick to further
their education in another country, will be granted
coverage for a 12-month period that is renewable,
provided that they do the following:
† provide proof of enrolment;
† contact Medicare once every 12-month period
to retain their eligibility;
† do not establish permanent residence outside
New Brunswick; and
† do not receive health coverage elsewhere.
Temporary Workers: Residents temporarily
employed outside the country are granted
coverage for up to 12 months, regardless if it is
known beforehand that they will be absent beyond
the 12- month period, provided they do not
establish residence outside Canada. Any absence
over 182 days, whether it be for work purposes or
vacation, would require the Director’s approval.
This approval can only be up to 12 months in
duration and will only be granted once every three
years. Families of workers temporarily employed
outside Canada will continue to be covered,
provided that they reside in New Brunswick.
Exception to Temporary Workers: Mobile
workers are residents whose employment requires
them to travel frequently outside the province.
Certain guidelines must be met to receive Mobile
Worker designation. These are as follows:
† applications must be submitted in writing;
84
† documentation is required as proof of Mobile
Worker status (e.g., a letter from an employer
or photocopy of an Immigration Permit);
† the worker’s permanent residence must remain
in New Brunswick; and
† the worker must return to New Brunswick
during their off-time.
† the Mobile Worker designation is assigned for
a maximum of two years, after which the
resident must re-apply and re-submit
documentation to confirm their status.
Contract Workers: Any New Brunswick
resident accepting an out-of-country employment
contract must supply the following information
and documentation:
† letter of request from the New Brunswick
resident with their signature, detailing their
absence, including Medicare number, New
Brunswick address, date of departure,
destination and forwarding address, reason for
absence and date of return; and
† copy of the contractual agreement between
employee and employer that defines a start
date and end date of employment.
Contract worker status is assigned for a maximum
of two years. Any further requests for contract
worker status must be forwarded to the Director
of Medicare for approval on an individual basis.
New Brunswick Medicare covers out-of-country
medical and hospital services for emergency outpatients and resulting in-patient services only.
Medicare pays New Brunswick rates for physician
services associated with the emergency
interventions. The associated facility rates, paid in
Canadian funds, are as follows: in-patient services
$100 per day; out-patient services $50 per visit.
Medicare will cover out-of-country services that
are not available in Canada on a prior approval
basis only. Residents may opt to seek nonemergency out-of-country services; however,
those who receive such services will assume
responsibility for the total cost. In 2003-2004,
New Brunswick paid the following amounts for
services received outside Canada:
Hospital in-patient
$487,893
Hospital out-patient
$252,624
Medical Services
$422,544
Canada Health Act Annual Report, 2003-2004
Chapter 3 – New Brunswick
4.4 Prior Approval Requirement
New Brunswick residents may be eligible for
reimbursement if they receive elective medical
services outside the country, provided they fulfill
the following requirements:
† the required service, or equivalent or alternate
service, must be unavailable in Canada;
† it must be rendered in a hospital listed in the
current edition of the American Hospital
Association Guide to the Health Care Field
(guide to United States hospitals, health care
systems, networks, alliances, health
organizations, agencies and providers);
† the services must be rendered by a medical
doctor; and
† the service must be an accepted method of
treatment recognized by the medical
community and be regarded as scientifically
proven in Canada. Experimental procedures
are not covered.
If the above requirements are met, it is mandatory
to request prior approval from Medicare in order
to receive coverage. A physician, patient or family
member may request prior approval to receive
these services outside the country, accompanied
by supporting documentation from a Canadian
specialist or specialists.
The following are considered exemptions under
the out-of-country coverage policy:
† haemodialysis: patients will be required to
obtain prior approval and Medicare will
reimburse the resident at a rate equivalent to
the interprovincial rate of $220 per session;
and
† allergy testing for environmental sensitivity: all
tests sent outside the country will be paid at a
maximum rate of $50 per day, an amount
equivalent to an out-patient visit.
Prior approval is also required for referral of
patients to psychiatric hospitals and addiction
centres outside the province, because they are
excluded from the Interprovincial Reciprocal Billing
Agreement. A request for prior approval must be
received by Medicare from the Addiction Services
or Mental Health branches of the Department of
Health and Wellness.
Canada Health Act Annual Report, 2003-2004
5.0 Accessibilty
5.1 Access to Insured Health
Services
New Brunswick charges no user fees for insured
health services as defined by the Canada Health
Act. Therefore, all residents of New Brunswick
have equal access to these services.
5.2 Access to Insured Hospital
Services
The New Brunswick Hospital Master Plan
identifies the number of approved beds for each
Regional Health Authority.
All facilities that provide insured services in
accordance with the Canada Health Act have
appropriate medical, surgical, rehabilitative and
diagnostic equipment or systems corresponding to
their designated levels of care. As of March 31,
2004, there were nine Computed Tomography
(CT) scanners operating in New Brunswick – one
in each of the eight RHAs, with a second unit
operating in RHA 2. The Province also has two
mobile Magnetic Resonance Imaging (MRI) units
operating and three fixed-site MRI systems.
5.3 Access to Insured Physician and
Dental-Surgical Services
A total of 694 general or family practitioners, 802
specialists, eight dentists and six orthodontists
provided insured services in New Brunswick in
2003-2004.
In fiscal 2003-2004, the Department of Health and
Wellness continued to work on its recruitment and
retention strategy, aimed at attracting newly
licensed family practitioners and specialists. This
strategy, announced in 1999-2000, included a
contingency fund to allow the Department to more
effectively respond to potential recruitment
opportunities, the provision of location grants of
$25,000 for family practitioners and $40,000 for
specialists willing to practice in under-serviced
areas of the province and the purchase of five
85
Chapter 3 – New Brunswick
additional seats at the University of Sherbrooke’s
medical school, which began in September 2002.
The recruitment and retention strategy also
provides for increased government involvement in
post-graduate training of family physicians, the
maintenance of 300 weeks in summer rural
preceptorship training for medical students and
moving physician remuneration toward relative
parity with other Atlantic provinces.
In February 2004, the Minister of Health and
Wellness announced a two-year collaborative
practice project to improve access to primary
health care services. The pilot project will increase
patient access by adding the services of nurses
and nurse practitioners to physician’s offices. A
total of five office sites, three in Edmundston, one
in Bathurst and one in Moncton have been
selected. The project will continue until
March 2006.
5.4 Physician Compensation
Fiscal 2003-2004 marked the second year of an
agreement with fee-for-service physicians that
provides for a 15 percent increase in fees over a
three-year period (2002-2003 to 2004-2005).
Discussions were held during the year with the
New Brunswick Medical Society to implement the
initiatives contained in that agreement.
There is no formal negotiation process for dental
practitioners in New Brunswick.
Payments to physicians and dentists are governed
under the Medical Services Payment Act,
Regulations 84-20, 93-143 and 96-113.
The methods used to compensate physicians for
providing insured health services in New
Brunswick are fee-for-service, salary and
sessional or alternate payment mechanisms that
may also include a blended system.
5.5 Payments to Hospitals
The legislative authorities governing payments to
hospital facilities in New Brunswick are the
Hospital Act, which governs the administration of
hospitals and the Hospital Services Act, which
86
governs the financing of hospitals. The Regional
Health Authorities Act, which provides for the
delivery and administration of health services in
defined geographic areas within the province,
came into force on April 1, 2002.
There were no changes during the 2003-2004
fiscal year affecting the hospital payment process.
The Department of Health and Wellness uses two
components to distribute available funding to New
Brunswick’s eight RHAs.
The main component is a “Current Service Level”
(CSL) base. This component addresses five main
patient-care delivered services as follows:
† tertiary services (cardiac, dialysis, oncology);
† psychiatric services (psychiatric units and
facilities);
† dedicated programs (e.g. addictions services);
† community-based services (Extra-Mural
Program; health service centres); and
† general patient care.
Added to this are non-patient care support
services (e.g. general administration, laundry,
food services, energy).
The CSL approach establishes base budgets for
the eight RHAs for the above-noted programs and
services, with measures for population and
service volumes. The base budgets are then
adjusted annually for inflation and other factors
such as centrally negotiated salary rates.
The population-based funding distribution formula,
which was enhanced during fiscal 2000-2001, was
still in use in fiscal year 2003-2004. This
methodology attempts to predict the appropriate
distribution of available funding for the RHAs
based on demographic characteristics and current
market share of patient volumes, with cases
measured by “Resource Intensity Weights.”
Currently, this methodology is more suitable to inpatient volumes because of a lack of case
grouping and weighting methodologies for outpatient volumes, especially tertiary out-patient
services (e.g., oncology and haemodialysis).
The current budget process may extend over more
than one fiscal year and includes several steps.
By January of each year, RHAs are to provide the
Canada Health Act Annual Report, 2003-2004
Chapter 3 – New Brunswick
Department with their utilization data and revenue
projections for the following fiscal year, as well as
their actual utilization data and revenue figures for
the first nine months of the current fiscal year.
This information, along with the audited financial
statements from the previous two fiscal years, are
used to evaluate the expected funding level for
each RHA.
Budget amendments are provided during the year
to allow for adjustments to applicable programs
and services on either recurring or non-recurring
bases. The “year-end settlement process”
reconciles the total annual approved budget for
each RHA to its audited financial statements and
reconciles budgeted revenues and expenses to
actual revenues and expenses.
6.0 Recognition Given to
Federal Transfers
New Brunswick routinely recognizes the federal
role regarding its contributions under the Canada
Health and Social Transfer (CHST) in public
documentation presented through legislative and
administrative processes. These include the
following:
† the Budget Papers presented by the Minister
of Finance on March 30, 2004;
† the Public Accounts presented by the Minister
of Finance on December 19, 2003; and
† the Main Estimates presented by the Minister
of Finance on March 30, 2004.
New Brunswick does not produce promotional
documentation on its insured medical and hospital
benefits.
7.0 Extended Health Care
Services
The New Brunswick Long Term Care program, a
non-insured service, was transferred to the
1
Department of Family and Community Services on
April 1, 2000. Nursing home care, also a noninsured service, is offered through the Nursing
Home Services program of the Department of
Family and Community Services. Other adult
residential care services and facilities are
available through a variety of agencies and
funding sources within the province.
Residential and Extended Care Services
Nursing homes are private, not-for-profit
organizations, except for one facility that is owned
by the Province. In order to be admitted to a
nursing home, clients go through an evaluation
process based on specific health condition criteria.
Adult Residential Facilities1 are, for the most part,
private and not-for-profit organizations. The
number of available beds fluctuates constantly as
private entrepreneurs open and close residential
facilities. Clients are admitted after going through
the same evaluation process as used for nursing
home admissions.
Public housing units are available for low-income
elderly persons. Admission criteria are based on
age and the applicant’s financial situation. The
Victorian Order of Nurses offers support services
to some units.
Ambulatory Health Care
In New Brunswick, “ambulatory health care”
includes services provided in hospital emergency
rooms, day or night care in hospitals and in clinics
if it is available in hospitals, health centres and
Community Health Centres. This is considered an
insured service under the provincial Hospital
Services Plan.
Extra-Mural Program
The New Brunswick Extra-Mural Program, also
known as the “hospital at home” program, is an
active treatment program of acute, palliative and
long-term health care and rehabilitation services
provided in community settings (an individual’s
home, a nursing home or public school). Since
Adult Residential Facilities include Special Care Homes and Community Residences.
Canada Health Act Annual Report, 2003-2004
87
Chapter 3 – New Brunswick
1996, this Program has been delivered by New
Brunswick’s eight RHAs. Service providers include
nurses, social workers, dieticians, respiratory
therapists, physiotherapists, occupational
therapists and speech language pathologists.
88
These services, although not covered by the
Canada Health Act, are considered an insured
service under the provincial Hospital Services
Plan.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – New Brunswick
Registered Persons
1. Number as of March 31st (#).
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
739,336
738,598
737,299
738,774
738,030
Insured Hospital Services Within Own Province or Territory
Public Facilities
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
31
0
1
0
32
31
0
1
0
32
31
0
1
0
32
31
0
1
0
32
31
0
1
0
32
2. Number (#):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
3. Payments ($):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
not available
not available
not available
not available
722,600,000 1
not available
not available
not available
not available
768,400,000 1
not available
not available
not available
not available
839,100,000 1
not available
not available
not available
not available
893,400,000 1
not available
not available
not available
not available
961,200,000 1
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
4. Number (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
5. Number of insured hospital services
provided (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
6. Payments ($):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
Private For-Profit Facilities
Canada Health Act Annual Report, 2003-2004
89
Chapter 3 – New Brunswick
Insured Physician Services Within Own Province or Territory
1999-2000
2000-2001
2001-2002
2002-2003
7. Number of participating physicians (#):
a. general practitioners
b. specialists
c. other
d. total
2003-2004
629
721
not available
1,350
645
710
not available
1,355
689
799
not available
1,488
675
731
not available
1,406
694
802
not available
1,496
8. Number of opted-out physicians (#):
a. general practitioners
b. specialists
c. other
d. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
9. Number of not participating
physicians (#):
a. general practitioners
b. specialists
c. other
d. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
10. Number of services provided through
fee for service (#):
a. general practitioners
b. specialists
c. other
d. total
3,721,782
2,612,744
not available
6,334,526
3,668,781
2,590,346
not available
6,259,127
3,611,747
2,552,018
not available
6,163,765
3,731,076
2,669,294
not available
6,400,370
3,580,740
2,678,372
not available
6,259,112
11. Total payments to physicians paid
through fee for service ($):
a. general practitioners
b. specialists
c. other
d. total
77,958,130
111,554,173
not available
189,512,303
78,139,070
111,224,207
not available
189,363,277
85,584,720
120,128,708
not available
205,713,428
100,812,443
137,047,629
not available
237,860,072
100,358,397
140,873,627
not available
241,232,024
12. Average payment per fee for service
service ($):
a. general practitioners
b. specialists
c. other
d. all services
20.95
42.70
not available
29.92
21.30
42.94
not available
30.25
23.70
47.07
not available
33.37
27.02
51.34
not available
37.16
28.03
52.60
not available
38.54
739,911
852,725
728,947
839,980
1,020,108
3,721,782
6,334,526
1,021,419
3,668,781
6,259,127
41,795,791
48,732,272
41,068,744
47,840,045
21,026,109
77,958,130
189,512,302
56.49
57.15
20.61
20.95
29.92
13. Number of services provided through
all payment methods (#): 2
a. medical
b. surgical
Radiology services- auto FFS
c. diagnostic
d. other
e. total
14. Total payments to physicians paid
through all payment methods ($): 2
a. medical
b. surgical
Radiology payments- auto FFS
c. diagnostic
d. other
e. total
15. Average payment per service, all
payment methods ($): 2
a. medical
b. surgical
c. diagnostic
d. other
e. all services
90
705,799
826,342
23,289
1,019,877 3
3,611,747 4
6,163,765
749,181
887,993
186,140
1,032,120 3
3,731,076 4
6,400,370
699,298
913,827
177,185
1,065,247 3
3,580,740 4
6,259,112
22,315,418
78,139,070
189,363,277
43,830,630
52,103,502
516,903
24,194,576 3
85,584,720 4
205,713,428
50,457,210
60,579,805
3,928,001
26,010,614 3
100,812,443 4
237,860,072
51,311,084
61,017,689
4,011,187
28,544,854 3
100,358,397 4
241,232,024
56.34
56.95
21.85
21.30
30.25
62.10
63.05
22.20
23.70 4
33.37
67.35
68.22
21.10
27.02 4
37.16
73.38
66.77
22.64
28.03 4
38.54
Canada Health Act Annual Report, 2003-2004
Chapter 3 – New Brunswick
Insured Services Provided to Residents in Another Province or Territory
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
16. Total number of claims,
in-patient (#).
3,900 pts /
4,130 pts /
3,796 pts /
4,168 pts /
3,338 pts /
25,655 days
26,572 days
23,342 days
23,949 days
27,933 days
17. Total number of claims,
out-patient (#).
32,796
35,834
36,687
40,145
38,096
22,473,974
21,561,907
19,110,500
23,477,103
26,085,533
4,235,429
4,702,219
5,261,500
5,387,946
5,200,814
20. Average payment, in-patient ($).
876.01
811.45
818.72
980.30
933.86
21. Average payment, out-patient ($).
129.14
131.22
143.42
134.21
136.52
1999-2000
2000-2001
18. Total payments, in-patient ($).
19. Total payments, out-patient ($).
Physicians
22. Number of services (#).
23. Total payments ($).
24. Average payment per service ($).
2001-2002
2002-2003
2003-2004
137,950
141,014
161,415
178,569
200,706
6,050,729
6,280,048
7,721,995
9,303,055
9,911,068
40.50
43.86
47.84
52.10
49.38
2002-2003
2003-2004
Insured Services Provided Outside Canada
Hospitals
25. Total number of claims,
in-patient (#).
26. Total number of claims,
out-patient (#).
1999-2000
2000-2001
2001-2002
212 pts /
166 pts /
148 pts /
180 pts /
166 pts /
1,691 days
1,096 days
1,447 days
843 days
1,367 days
524
639
1,003
1,000
1,013
27. Total payments, in-patient ($).
487,760
458,759
440,088
420,659
487,893
28. Total payments, out-patient ($).
105,783
180,712
133,360
244,217
252,624
29. Average payment, in-patient ($).
288.44
418.58
304.14
290.71
356.91
30. Average payment, out-patient ($).
201.88
282.80
132.96
244.22
249.38
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
4,554
4,202
4,360
5,018
5,419
356,128
362,994
482,915
395,061
422,544
58.17
78.20
110.76
78.73
77.97
Physicians
31. Number of services (#).
32. Total payments ($).
33. Average payment per service ($).
Insured Surgical-Dental Services Within Own Province or Territory
1999-2000
34. Number of particpating dentists (#).
35. Number of services provided (#).
36. Total payments ($).
37. Average payment per service ($).
2000-2001
2001-2002
2002-2003
2003-2004
12
16
12
16
14
751
1,004
1,010
1,283
1,232
136,491
189,777
186,944
208,946
188,634
181.75
189.02
185.09
162.86
153.11
Canada Health Act Annual Report, 2003-2004
91
Chapter 3 – New Brunswick
Endnotes
1.
2.
3.
4.
92
Gross hospital facility expenditures as shown in the New Brunswick Annual Reports.
Fee-for-service payments only.
Actual Radiology payments from Fee-for-Service Manual Payments.
Includes General Practitioners.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Quebec
2.0 Comprehensiveness
2.1 Insured Hospital Services
Quebec
1.0 Public Administration
1.1 Health Insurance Plan and
Public Authority
The hospital insurance plan, the Régime
d’assurance-hospitalisation du Québec [Quebec
Health Insurance Plan], is administered by the
Ministère de la Santé et des Services sociaux
[Quebec Department of Health and Social
Services] (MSSS).
The health insurance plan, the Régime
d’assurance-maladie du Québec, is administered
by the Régie de l’assurance maladie du Québec
[Quebec Health Insurance Board] (RAMQ), a
public body established by the provincial
government and responsible to the Minister of
Health and Social Services.
1.2 Reporting
The Public Administration Act (R.S.Q., chapter A6.01) sets out the government criteria for
preparing reports on the planning and
performance of public authorities, including the
MSSS and the RAMQ.
1.3 Financial Audit
Both plans (the Quebec Hospital Insurance Plan
and the Quebec Health Insurance Plan) are
operated on a non-profit basis. All books and
accounts are audited by the Auditor General of
Quebec.
Canada Health Act Annual Report, 2003-2004
Insured in-patient services include: standard ward
accommodation and meals; necessary nursing
services; routine surgical supplies; diagnostic
services; use of operating rooms, delivery rooms
and anaesthetic facilities; medications, prosthetic
and orthotic devices that can be integrated with
the human body; biologicals and related
preparations; use of radiotherapy, radiology and
physiotherapy facilities; and services rendered by
hospital centre staff.
Out-patient services include: clinical services for
psychiatric care; electroshock, insulin and
behaviour therapies; emergency care; minor
surgery (day surgery); radiotherapy; diagnostic
services; physiotherapy; occupational therapy;
inhalation therapy, audiology, speech therapy and
orthoptic services; and other services or
examinations required under Quebec legislation.
Other services covered by insurance are:
mechanical, hormonal or chemical contraception
services; surgical sterilization services (including
tubal ligation or vasectomy); reanastomosis of the
fallopian tubes or vas deferens; and ablation of a
tooth or root when the health status of the person
makes hospital services necessary.
The MSSS administers an ambulance
transportation program free of charge to persons
aged 65 or older.
In addition to the basic insured health services,
the RAMQ also covers the following, with some
limitations for certain residents of Quebec as
defined by the Health Insurance Act and for
employment assistance recipients: optometric
services; dental care for children and employment
assistance recipients, and acrylic dental
prostheses for employment assistance recipients;
prostheses, orthopaedic appliances, locomotion
and postural aids, and other equipment that helps
with a physical disability; external breast
prostheses; ocular prostheses; hearing aids,
assistive listening devices and visual aids for
93
Chapter 3 – Quebec
people with a visual or auditory disability; and
permanent ostomy appliances.
Since January 1, 1997, in terms of drug
insurance, the RAMQ covers, over and above its
regular clientele (employment assistance
recipients and persons 65 years of age or older),
individuals who do not have access to a private
drug insurance plan. The new drug insurance plan
covers 3.2 million insured persons.
†
†
†
2.2 Insured Medical Services
The services insured under this plan include
medical and surgical services that are provided by
physicians and are required from a medical
standpoint.
2.3 Insured Dental Surgery Services
The services insured under this plan include oral
surgery performed in a hospital centre or
university institution determined by regulation, by
dental surgeons and specialists in oral and
maxillo-facial surgery.
2.4 Uninsured Hospital, Medical and
Dental Surgery Services
Uninsured hospital services include: plastic
surgery; in-vitro fertilization; a private or semiprivate room at the patient’s request; televisions;
telephones; drugs and biologicals ordered after
discharge from hospital; and services for which
the patient is covered under the Act Respecting
Industrial Accidents and Occupational Diseases or
other federal or provincial legislation.
The following services are not considered insured:
† any examination or service not related to a
process of cure or prevention of illness;
† psychoanalysis of any kind, unless such service
is rendered in an institution authorized for this
purpose by the Minister of Health and Social
Services;
† any service rendered solely for aesthetic
purposes;
† any refractive surgery, except in cases where
there is documented failure for astigmatism of
94
†
†
†
†
†
†
†
†
†
†
more than 3.00 diopters or for anisometropia
of more than 5.00 diopters, measured at the
cornea, when corrective lenses or corneal
lenses are worn;
any consultation by telecommunication or by
correspondence;
any service rendered by a professional to his
or her spouse or children;
any examination, expert appraisal, testimony,
certificate or other formality required for legal
purposes or by a person other than the one
who has received an insured service, except in
certain cases;
any visit made for the sole purpose of
obtaining the renewal of a prescription;
any examinations, vaccinations, immunizations
or injections, where the service is provided to a
group or for certain purposes;
any service rendered by a professional on the
basis of an agreement or a contract with an
employer, an association or an organization;
any adjustment of eyeglasses or contact
lenses;
any surgical ablation of a tooth or tooth
fragment performed by a physician, except
where the service is provided in a hospital
centre in certain cases;
all acupuncture procedures;
injection of sclerosing substances and the
examination done at that time;
thermography or mammography used for
screening purposes, unless this service is
delivered on a doctor’s order in a place
designated by the Minister, in either case, to a
recipient who is age 35 or older, on condition
that such an examination has not been
performed on the recipient in the previous
year;
tomodensitometry, magnetic resonance
imaging and use of radionuclides in vivo in a
human, unless these services are rendered in a
hospital centre;
ultrasonography, unless this service is
rendered in a hospital centre or, for obstetrical
purposes, in a local community service centre
(CLSC) recognized for that purpose;
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Quebec
† any radiological or anaesthetic service
provided by a physician if required with a view
to providing an uninsured service, except for a
dental service provided in a hospital centre, or,
in the case of a radiology service, if required
by a person other than a physician or dentist;
† any sex-reassignment surgical service, unless
it is provided on the recommendation of a
physician specializing in psychiatry and is
provided in a hospital centre recognized for
this purpose; and
† any services that are not associated with a
pathology and that are rendered by a physician
to a patient between 18 and 65 years of age,
unless that individual is the holder of a claim
card, for colour blindness or a refraction
problem, in order to provide or renew a
prescription for eyeglasses or contact lenses.
3.0 Universality
3.1 Eligibility
Registration with the hospital insurance plan is
not required. Registration with the Régie de
l’assurance maladie du Québec (RAMQ) or proof
of residence is sufficient to establish eligibility. All
persons who reside or stay in Quebec must be
registered with the RAMQ to be eligible under the
health insurance plan.
3.2 Requirements Concerning
Registration with the Plan
Certain categories of resident, for example
permanent residents under the Immigration Act
and persons returning to Canada to live, become
eligible under the plan following a waiting period
of up to three months. Persons receiving last
resort financial assistance are eligible when they
register. Members of the Canadian Forces and
Royal Canadian Mounted Police who have not
acquired the status of Quebec resident become
eligible the day they arrive. Inmates of federal
penitentiaries become eligible the day they are
released. Immediate coverage is provided to
certain seasonal workers, repatriated Canadians,
persons from outside Canada who are living in
Quebec under an official bursary or internship
program of the Ministère de l’Éducation [Quebec
Department of Education], and refugees. Persons
from outside Canada who have work permits and
are living in Quebec for the purpose of holding an
office or employment for a period of more than six
months become eligible for the plan following a
waiting period.
4.0 Portability
4.1 Minimum Period of Residence
Persons settling in Quebec after moving from
another province of Canada are entitled to
coverage under the Quebec Health Insurance Plan
when they cease to be entitled to benefits from
their province of origin, provided they register
with the RAMQ.
Registration with the hospital insurance plan is
not required. Registration with the RAMQ or proof
of residence is sufficient to establish eligibility.
4.2 Coverage During Temporary
Absences Outside Quebec (in
Canada)
3.3 Other Categories of Persons
If living outside Quebec in another province or
territory for 183 days or more, students and fulltime unpaid trainees may retain their status as
residents of Quebec; in the first case for four
consecutive calendar years at most, and in the
second case for two consecutive calendar years at
most.
Services received by regular members of the
Canadian Forces, members of the Royal Canadian
Mounted Police and inmates of federal
penitentiaries are not covered by the plan. No
premium payment exists.
Canada Health Act Annual Report, 2003-2004
95
Chapter 3 – Quebec
This is also the case for persons living in another
province or territory for the purpose of holding
temporary employment or working on contract
there. Their resident status can be maintained for
no more than two consecutive calendar years.
Persons directly employed or working on contract
outside Quebec in another province or territory,
for a company or corporate body having its
headquarters or a place of business in Quebec, or
employed by the federal government and posted
outside Quebec also retain their status as
residents of the province, provided their families
remain in Quebec or they retain a dwelling there.
Status as a resident of the province is also
maintained by persons who remain outside the
province for 183 days or more, but less than 12
months within a calendar year, provided such
absence occurs only once every seven years and
provided they notify the RAMQ of their absence.
The costs of medical services received in another
province or a territory of Canada are reimbursed
at the amount actually paid or the rate that would
have been paid by the RAMQ for such services in
Quebec, whichever is less. However, Quebec has
negotiated a permanent arrangement with Ontario
to pay Ottawa doctors at the Ontario fee rate for
emergency care and when the specialized services
provided are not offered in the Outaouais region.
This agreement became effective on November 1,
1989. A similar agreement was signed in
December 1991 between the Centre de santé
Témiscamingue [Témiscamingue Health Centre]
and North Bay.
Costs of hospital services received in another
province or territory of Canada are paid according
to the terms and conditions of the interprovincial
agreement on reciprocal billing in the area of
hospital insurance agreed on by the provinces and
territories of Canada. In-patient costs are paid at
standard ward rates approved by the host
province or territory. Out-patient costs or the
costs of expensive procedures are paid at
approved interprovincial/territorial rates.
However, since November 1, 1995, Quebec
reimburses the Ottawa hospital centre a maximum
of $450 per day of hospitalization when an
96
Outaouais resident is hospitalized in a hospital
centre in Ottawa for non-urgent care or when
services are not available in the Outaouais.
Insured persons who leave Quebec to settle in
another province or a territory of Canada are
covered for up to three months after leaving the
province.
4.3 Coverage During Temporary
Absences Outside Quebec –
Outside Canada
Students, unpaid trainees, Quebec government
officials posted abroad and employees of nonprofit organizations working under programs of
international aid or co-operation recognized by the
MSSS must contact the RAMQ to determine their
eligibility. If the RAMQ recognizes them as having
special status, they receive full reimbursement of
their hospital costs in case of emergency or
sudden illness, and 75 percent reimbursement in
other cases.
Persons directly employed or working on contract
outside Canada, for a company or corporate body
having its headquarters or place of business in
Quebec, or employed by the federal government
and posted outside Quebec, also retain their
status as residents of the province, provided their
families remain in Quebec or they retain a
dwelling there.
As of September 1, 1996, hospital services
provided outside Canada in case of emergency or
sudden illness are reimbursed by the RAMQ,
usually in Canadian funds, to a maximum of
C$100 per day if the patient was hospitalized
(including in the case of day surgery) or to a
maximum of C$50 per day for out-patient
services.
However, haemodialysis treatments are covered to
a maximum of C$220 per treatment. In such
cases, the RAMQ reimburses the costs for the
associated professional services. The services
must be dispensed in a hospital or hospital centre
recognized and accredited by the competent
authorities. No reimbursements are made for
nursing homes, spas or similar establishments.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Quebec
Costs for insured services provided by physicians,
dentists, oral surgeons and optometrists are
reimbursed at the rate that would have been paid
by the RAMQ to a health professional recognized
in Quebec, up to the amount of the expenses
actually incurred. The costs of all services insured
in the province are reimbursed at the Quebec
rate, usually in Canadian funds, when they are
incurred abroad.
Coverage is discontinued on the day of departure
for insured residents who move permanently to
another country.
4.4 Need for prior approval
Insured persons requiring medical services in a
hospital abroad, if those services are unavailable
in Quebec or elsewhere in Canada, are
reimbursed 100 percent with prior consent for
medical and hospital services that meet certain
conditions. Consent is not given by the plan’s
officials if the medical service in question is
available in Quebec or elsewhere in Canada.
5.0 Accessibility
5.1 Access to Insured Health
Services
Everyone has the right to receive adequate health
care services without any kind of discrimination.
There is no extra-billing by Quebec physicians.
5.2 Access to Insured Hospital
Services
On March 31, 2004, Quebec had 125 institutions
operating as hospital centres for a clientele
suffering from acute illness, with 21,667 beds for
persons requiring care for acute physical or
psychiatric ailments allotted to these institutions.
From April 1, 2002, to March 31, 2003, Quebec
hospital institutions had nearly 685,600
admissions for short stays and close to 287,100
registrations for day surgeries. These
Canada Health Act Annual Report, 2003-2004
hospitalizations and registrations accounted for
more than 5,000,000 patient days.
Restructuring of the health network: In
November 2003, Quebec announced the
implementation of local services networks
covering all of Quebec. At the heart of each local
network is a new local authority, the “health and
social services centre”. These centres resulted
from merging the public institutions whose mission
it was to provide CLSC (local community service
centre) services, residential and long-term care,
and, in most cases, neighbourhood hospital
services. The health and social services centres
also provide the people in their territory with
access to other medical services, general and
specialized hospital services and social services.
To do so, they will have to enter into service
agreements with other health sector
organizations. The linking of services within a
territory forms the local services network. Thus,
the integrated local health and social services
networks lead all the stakeholders in a given
territory to make themselves collectively
responsible for the health and well-being of the
people in that territory.
Management of waiting lists: In October
2003, the MSSS began publishing its waiting lists
on its Web site for each hospital. It now provides
physicians and institutions with a computerized
service access management system. This tool is
based on the concept of “access within a clinically
acceptable period,” as defined by committees of
medical experts in certain fields and, within
waiting times for access, as defined by
committees of physicians. Once applied uniformly
throughout the province of Quebec, these
guidelines will ensure that all patients, regardless
of their place of origin, will be treated according
to the same criteria. Once deployed, this system
will supply the data for the new waiting lists site
and will enable the patients and professionals
concerned to obtain appropriate, reliable and upto-date information on activities of hospital
centres and waiting periods for various services.
97
Chapter 3 – Quebec
5.3 Access to Insured Medical and
Dental Surgery Services
Primary care: In 2003-2004, family medicine
groups (FMGs) were established. They work in
close collaboration with the local community
service centres (CLSCs) and other network
resources to provide services such as health
assessment, case management and follow-up,
diagnosis, treatment of acute and chronic
problems, and disease prevention. Their services
are available 24 hours a day, seven days a week.
5.4 Compensation/Remuneration of
Physicians
Physicians are paid according to the negotiated
fee schedule. Physicians who have withdrawn
from the health insurance plan are paid directly by
the patient according to the fee schedule after the
patient has collected from the RAMQ. Nonparticipating physicians are paid directly by the
patients according to the amount charged.
Provision is made in law for reasonable
compensation for all insured health services
rendered by health professionals. The Minister
may enter into an agreement with the
organizations representing any class of health
professional. This agreement may prescribe a
different rate of compensation for medical
services in a territory where the number of
professionals is considered insufficient. The
Minister may also provide for a different rate of
compensation for general practitioners and
medical specialists during the first years of
practice, depending on the territory or the activity
involved. These provisions are preceded by
consultation with the organizations representing
the professional groups.
While most physicians practise within the
provincial plan, Quebec allows two other options:
that where professionals withdraw from the plan
and practise outside the plan, but agree to
remuneration according to the provincial fee
98
schedule; and that where non-participating
professionals practise outside the plan and neither
they nor their patients receive reimbursement
from the RAMQ.
In 2003-2004, the RAMQ paid $3,064.2 million to
doctors in the province, while the amount for
medical services outside the province reached an
estimated $10.0 million.
5.5 Payments to Hospital Centres
Hospital centres are funded by the Minister of
Health and Social Services through payments in
respect of the cost of insured services provided.
The payments made in 2002-2003 to institutions
operating as hospital centres for insured health
services provided to persons living in Quebec
were more than $6.4 billion; payments to hospital
centres outside Quebec were approximately
$82.8 million.
7.0 Extended Health Care
Services
Intermediate care, adult residential care and home
care services are available, with admission
coordinated on a regional level and based on a
single assessment tool. The local community
service centres (CLSCs) receive individuals,
evaluate their care requirements and either
arrange for the provision of such services as day
centre programs or home care, or refer them to
the appropriate agencies.
The MSSS offers some home care services,
including nursing care and assistance, homemaker
services and medical surveillance.
Residential facilities and long-term care units in
acute-care hospitals focus on maintaining their
clients’ autonomy and functional abilities by
providing them with a variety of programs and
services, including health care services.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Ontario
insured services provided in hospitals and health
facilities and by physicians and other health care
practitioners.
Ontario
There were no amendments to the Health
Insurance Act in 2003-2004.
1.2 Reporting Relationship
OHIP is administered by MOHLTC.
Introduction
Ontario has one of the largest and most complex
publicly funded health care systems in the world.
Administered by the province’s Ministry of Health
and Long-Term Care (MOHLTC), Ontario’s health
care system was supported by over $29 billion in
spending for 2003-2004. MOHLTC is responsible
for providing services to the Ontario public
through such programs as:
† health insurance;
† drug benefits;
† assistive devices;
† mental health services;
† home care;
† community support services;
† public health; and
† health promotion and disease prevention.
MOHLTC also regulates and funds hospitals and
long-term care homes (nursing homes and homes
for the aged), operates psychiatric hospitals and
medical laboratories, and funds and regulates or
directly operates emergency health services.
1.0 Public Administration
1.1 Health Care Insurance Plan and
Public Authority
The Ontario Health Insurance Plan (OHIP) is
administered on a non-profit basis by MOHLTC.
OHIP is established under the Health Insurance
Act (HIA), Revised Statutes of Ontario, 1990, c.
H-6, to provide insurance in respect of the cost of
Canada Health Act Annual Report, 2003-2004
1.3 Audit of Accounts
MOHLTC is audited annually by the Provincial
Auditor. The Provincial Auditor’s 2004 Annual
Report was released on November 30, 2004.
MOHLTC’s accounts and transactions are
published annually in the Public Accounts of
Ontario. The 2003-2004 Public Accounts of
Ontario was released on September 27, 2004.
2.0 Comprehensiveness
2.1 Insured Hospital Services
Insured in-patient and out-patient hospital
services in Ontario are prescribed under the
Health Insurance Act and Regulation 552 under
that Act.
Insured in-patient hospital services include
medically required:
† use of operating rooms, obstetrical delivery
rooms and anaesthetic facilities.
† necessary nursing services;
† laboratory, radiological and other diagnostic
procedures;
† drugs, biologicals and related preparations;
and
† accommodation and meals at the standard
ward level;
Insured out-patient services include medically
required:
† laboratory, radiological and other diagnostic
procedures;
99
Chapter 3 – Ontario
† use of radiotherapy, occupational therapy,
physiotherapy and speech therapy facilities,
where available;
† use of diet counseling services;
† use of the operating room, anesthetic facilities,
surgical supplies, necessary nursing service,
and supplying of drugs, biologicals and related
preparations (subject to some exceptions)
† provision of equipment, supplies and
medication to haemophiliac patients for use at
home;
† cyclosporine to transplant patients;
† zidovudine, didanosine, zalcitabine and
pentamidine to patients with HIV infection;
† biosynthetic human growth hormone to
patients with endogenous growth hormone
deficiency;
† drugs for treatment of cystic fibrosis and
thalassemia;
† erythropoeitins to patients with anaemia of
end-stage renal disease;
† alglucerase to patients with Gaucher disease;
† clozapine to patients with treatment-resistant
schizophrenia; and
† the administration of a rabies vaccine.
In 2003-2004 there were 152 public hospital
corporations (excluding specialty hospitals, private
hospitals, provincial psychiatric hospitals, federal
hospitals and long-term care homes) staffed and
in operation in Ontario. This includes 135 acute
care hospital corporations, 13 chronic care
hospitals and four general and special
rehabilitation units.
Hospitals are categorized by major activity, though
they provide a mix of services. For example, many
acute care hospitals offer chronic care services,
just as many chronic care facilities also offer
rehabilitation.
When insured physician services are provided in
licensed facilities outside of hospitals and where
the total cost paid for these insured services is
not included in the physician fees paid under the
Health Insurance Act, MOHLTC provides funding
through the payment of facility fees under the
Independent Health Facilities Act (IHFA). Facility
fees cover the cost of the premises, equipment,
100
supplies and personnel utilized to render an
insured service. Under the IHFA, patient charges
for facility fees are prohibited.
Facility fees are charged to the government only
by facilities that are licensed under the IHFA.
Examples of facilities that are licensed under the
IHFA include surgical/treatment facilities (e.g.
those providing abortions, cataract surgery,
dialysis and non-cosmetic plastic surgery) and
diagnostic facilities (e.g. those providing x-ray,
ultrasound, nuclear medicine, sleep studies and
pulmonary function studies). New facilities are
ordinarily established through a request for
proposals process based on an assessment of
need for the service.
2.2 Insured Physician Services
Insured physician services are prescribed under
the Health Insurance Act and regulations under
that Act.
Under subsection 37.1(1) of Regulation 552 of the
Health Insurance Act, a service provided by a
physician in Ontario is an insured service if it is
medically necessary, contained in the Schedule of
Benefits and rendered in such circumstances or
under such conditions as outlined in the Schedule
of Benefits. Physicians provide primary health
care services as well as medical, surgical and
diagnostic services. Services are provided in a
variety of settings including private physician
offices, health service organizations, community
health centres, hospitals, mental health facilities,
independent health facilities, walk-in clinics and
long-term care homes.
In general terms, insured physician services
include:
† diagnosis and treatment of medical disabilities
and conditions;
† medical examinations and tests;
† surgical procedures;
† maternity care;
† anaesthesia;
† radiology and laboratory services in approved
facilities; and
† immunizations, injections and tests.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Ontario
The Schedule of Benefits is regularly reviewed
and revised to reflect current medical practice and
new technologies. New services may be added,
existing services revised or obsolete services
removed through regulatory amendment. This
process involves consultation with the Ontario
Medical Association.
During 2003-04 physicians could submit claims for
all insured services rendered to insured persons
directly to OHIP, in accordance with section 15 of
the Health Insurance Act, or they could bill the
insured person, as specified in section 15 of the
Act (see also Part II of the Commitment to the
Future of Medicare Act). Physicians who do not
bill OHIP directly are commonly referred to as
having “opted-out”. When a physician has optedout, the physician bills the patient (not exceeding
the amount payable for the service under the
Schedule of Benefits), and the patient is then
entitled to reimbursement by OHIP. However,
opting-out is no longer generally allowed following
proclamation of the Commitment to the Future of
Medicare Act on September 23, 2004. Physicians
who did not bill OHIP directly prior to May 13,
2004 may continue to do so if they notify the
ministry of their intent to do so by December 23,
2004.
Physicians must be registered to practice
medicine in Ontario by the College of Physicians
and Surgeons of Ontario.
There were approximately 21,000 physicians who
submitted claims to OHIP in 2003-2004.
2.3 Insured Surgical-Dental
Services
Insured surgical-dental services are prescribed
under section 16 and the Dental Schedule of
Benefits under Regulation 552 of the Health
Insurance Act. These services, for which
hospitalization is medically necessary, include the
following:
† repair of traumatic injuries;
† surgical incisions;
† excision of tumours and cysts;
† treatment of fractures;
Canada Health Act Annual Report, 2003-2004
†
†
†
†
homeografts;
implants;
plastic reconstructions; and
all other specified dental procedures.
Approximately 320 dentists and dental/oral
surgeons provided insured surgical-dental services
in Ontario in 2003-2004.
2.4 Uninsured Hospital, Physician
and Surgical-Dental Services
Services prescribed by and rendered in
accordance with the Health Insurance Act and
regulations under that Act are insured. Section 24
of Regulation 552 details those services that are
specifically prescribed as uninsured. Uninsured
hospital services include:
† additional charges for preferred
accommodation unless prescribed by a
physician, oral-maxillofacial surgeon, or
midwife;
† telephones and televisions;
† charges for private-duty nursing;
† cosmetic surgery under most circumstances;
† provision of medications for patients to take
home from hospital, with certain exceptions;
and
† in-province hospital visits solely for the
administration of drugs, subject to certain
exceptions.
Uninsured physician services include:
† services that are not medically necessary;
† toll charges for long-distance telephone calls;
† preparing or providing a drug, antigen,
antiserum or other substance unless the drug,
antigen or antiserum is used to facilitate a
procedure;
† advice given by telephone at the request of the
insured person or the person’s representative;
† an interview or case conference (in limited
circumstances);
† preparation and transfer of records at the
insured person’s request;
† a service that is received wholly or partly for
the production or completion of a document or
the transmission of information to a “third
party” in specified circumstances;
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Chapter 3 – Ontario
† the production or completion of a document or
the transmission of information to any person
other than the insured person in specified
circumstances;
† provision of a prescription when no
concomitant insured service is rendered;
† cosmetic surgery;
† acupuncture procedures;
† psychological testing; and
† research and survey programs.
Effective September 23, 2004 Part II of the
Commitment to the Future of Medicare Act
(CFMA) prohibits physicians from charging
patients or accepting payments from patients for
more than the amount payable by OHIP for the
insured service. The Commitment to the Future of
Medicare Act also prohibits payment or accepting
payment to obtain preferred access to an insured
service. Prior to the CFMA, the Health Insurance
Act and the Health Care Accessibility Act
prohibited physicians from charging patients or
accepting payments from patients for more than
the amount payable by OHIP for the insured
service.
3.0 Universality
3.1 Eligibility
With certain exceptions in which the waiting
period is waived, residents of Ontario, as defined
in Regulation 552 of the Health Insurance Act, are
eligible for Ontario health coverage subject to a
three-month waiting period. To be considered a
resident of Ontario for the purpose of obtaining
Ontario health coverage, a person must:
† hold Canadian citizenship or an immigration
status as prescribed in Regulation 552;
† make his or her permanent and principal home
in Ontario;
† be physically present in Ontario for at least
153 days in any 12-month period; and
† be physically present in Ontario for 153 of the
first 183 days following the date that the
person establishes residency in Ontario (a
person cannot be away from the province for
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more than 30 days in the first 6 months of
residency).
With certain exceptions as set out in Regulation
552, most new and returning residents are subject
to a three-month waiting period. MOHLTC will
determine whether or not an individual is subject
to the three-month waiting period at the time of
their application for health coverage. Those who
are exempt from the three-month waiting period
include Convention Refugees and Protected
Persons, newborn babies born in Ontario and
insured residents from another province/territory
who move to Ontario and immediately become
residents of approved charitable homes, homes
for the aged or nursing homes in Ontario.
Individuals who are not eligible for Ontario health
coverage include those who hold an immigration
status that is not set out in Regulation 552 such
as refugee claimants (who are not Convention
Refugees) and visitors to the province. Other
individuals such as federal penitentiary inmates,
Canadian Forces and Royal Canadian Mounted
Police personnel are also not provided with
Ontario health coverage if they are provided with
health coverage under a federal health care plan.
Persons who were previously ineligible for Ontario
health coverage but whose status has changed
(e.g. change in immigration status or release from
a federal penitentiary) may, upon application, be
eligible subject to the requirements of Regulation
552.
3.2 Registration Requirements
Every resident of Ontario who seeks Ontario
health coverage is required to register with the
MOHLTC.
A health card is issued to eligible residents upon
application to the General Manager of OHIP,
pursuant to sections 2 and 3 of Regulation 552.
Eligible persons should apply for coverage upon
establishing their permanent and principal home in
the province. Registration is done through local
OHIP offices. Applicants for Ontario health
coverage must complete and sign a Registration
for Ontario Health Coverage form and provide the
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Ontario
ministry with original documents to prove their
Canadian citizenship or eligible immigration
status, their residency in Ontario and their
identity. Eligible applicants over the age of 15.5
are also generally required to have their
photographs and signatures captured for their
photo health cards.
Each photo health card has a card renewal/expiry
date in the bottom right-hand corner of the card.
MOHLTC mails renewal notices to registrants
approximately six weeks before the card’s renewal
date.
MOHLTC is the sole payer for insured health
services. An eligible Ontario resident may not
register with or obtain any benefits from another
insurance plan for any insured service that is
covered by OHIP.
Approximately 12.2 million Ontario residents were
registered with OHIP and held valid and active
Health Cards as of as of March 31, 2004.
3.3 Eligible Residents of Ontario
MOHLTC provides health coverage to other
residents of Ontario other than Canadian citizens
and Permanent Residents/Landed Immigrants .
These residents are required to provide
acceptable documentation to support their eligible
immigration status, their residency in Ontario and
their identity in the same manner as Canadian
citizen or Permanent Resident/Landed Immigrant
applicants.
The individuals listed below who are ordinarily
resident in Ontario will be eligible for Ontario
health coverage in accordance with Regulation
552 and prevailing ministry policy. Clients applying
for coverage under any of these categories should
contact their local OHIP office for further details.
Applicants for Permanent Residence/
Applicants for Landing – These are persons
who are being processed for Permanent
Resident/Landed Immigrant status by Citizenship
and Immigration Canada (CIC) and have met
CIC’s medical requirements.
Convention Refugees and Protected
Persons – The federal Immigration and Refugee
Canada Health Act Annual Report, 2003-2004
Board designates a person as a Convention
Refugee when that person has been found to fear
persecution in his or her country of origin because
of race, religion, nationality, membership in a
social group, or political opinion. CIC may also
determine that a person is a Protected Person
under the terms of the Immigration and Refugee
Protection Act if returning to their country of
origin would pose a substantial risk to the
person’s life or to torture or cruel and unusual
punishment.
Holders of Temporary Resident
Permits/Minister’s Permits – Temporary
Resident Permits/Minister’s Permits are
documents that indicate that the holder has not
immediately met CIC’s requirements to remain
permanently in Canada. Holders of a Temporary
Resident Permit/Minister’s Permit with a case
type of 80 (adoption only), 86, 87, 88, or 89 are
typically being processed towards Permanent
Resident status and are eligible for Ontario health
coverage for the duration of their permit if they
will be residing in Ontario. Holders of a Temporary
Resident Permit/Minister’s Permit with a case
type of 80, 81, 84, 85, 90, 91, 92, 93, 94, 95 and
96 are typically refused applicants for Permanent
Resident status on medical or criminal grounds or
are merely visiting for a short period of time and
are not eligible for Ontario health coverage.
Clergy, Foreign Workers and their
Accompanying Family Members – An eligible
foreign clergy is a person who is sponsored by a
religious organization or denomination and has
finalized an agreement to minister full-time to a
religious congregation in Ontario for a period of at
least six consecutive months.
A foreign worker is a person who has a finalized
contract of employment or an agreement of
employment with a Canadian employer situated in
Ontario and has been issued a Work
Permit/Employment Authorization by CIC that
names the Canadian employer, states the
person’s prospective occupation, and has been
issued for a period of at least six months.
Spouses, same sex partners and/or dependant
children (under 19 years of age) of an eligible
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Chapter 3 – Ontario
foreign member of the clergy or an eligible foreign
worker are also eligible for Ontario health
coverage if the member of the clergy or the
foreign worker is to be employed in Ontario for at
least three consecutive years and if the family
member will be ordinarily a resident of Ontario.
4.2 Coverage During Temporary
Absences in Canada
Live-in Caregivers – Live-in Caregivers are
persons who have been issued a Work
Permit/Employment Authorization under the Livein Caregivers in Canada Program (LCP) or the
Foreign Domestic Movement (FDM) administered
by CIC. An eligible Live-in Caregiver is a person
who holds a valid LCP or FDM Work
Permit/Employment Authorization issued by CIC
and who is ordinarily a resident of Ontario. The
Work Permit/Employment Authorization for LCP
or FDM workers does not have to list the three
specific employment conditions required by all
other foreign workers.
Ontario adheres to the terms of the Interprovincial
Agreement on Eligibility and Portability. In
accordance with that agreement, insured residents
who are outside Ontario temporarily can use their
Ontario Health Cards to obtain insured health
services.
Migrant Farm Workers – Migrant farm workers
are persons who have been issued a Work
Permit/Employment Authorization under the
Caribbean, Commonwealth and Mexican Seasonal
Agriculture Workers Program administered by
CIC. Due to the special nature of their
employment, migrant farm workers are not
required to present residency documents generally
required to establish eligibility for OHIP coverage.
Members of this group are also exempt from the
three-month waiting period.
4.0 Portability
4.1 Minimum Waiting Period
In accordance with subsection 3(3) of Regulation
552 under the Health Insurance Act and Ministry
policy, individuals who move to Ontario are
entitled to OHIP coverage beginning three months
after establishing residency in the province, unless
listed as an exception in section 3(4).
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Out-of-province services are covered under
sections 28, 30(1) and 32 of Regulation 552 of
the Health Insurance Act.
An insured person who leaves Ontario temporarily
to travel within Canada without establishing
residency in another province or territory will
continue to be covered by OHIP for a period of up
to 12 months.
An insured person who seeks or accepts
employment in another province or territory will
continue to be covered for a period of up to 12
months. If the individual plans to remain outside
Ontario beyond the 12-month maximum, he or she
should apply for coverage in the province or
territory where that person has been working or
seeking work.
Insured students who are temporarily absent from
Ontario, but remain within Canada, are eligible for
continuous health coverage for the duration of
their full-time studies, provided they do not
establish permanent residency elsewhere during
this period. To ensure that they maintain
continuous OHIP eligibility, a student should
provide MOHLTC with letters from their
educational institution confirming registration as a
full-time student. Family members of students
who are studying in another province or territory
are also eligible for continuous OHIP eligibility
while accompanying students for the duration of
their studies.
Ontario participates in reciprocal agreements with
all other provinces and territories for insured
hospital in- and out-patient services. Payment is
at the in-patient rate of the plan in the province or
territory where hospitalization occurs. Ontario
pays the standard out-patient charges authorized
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Ontario
by the Coordinating Committee on Reciprocal
Billing.
In addition, section 28 of Regulation 552 of the
Health Insurance Act sets out payment for insured
hospital services outside Ontario but within
Canada that are not billed through the reciprocal
arrangements.
Ontario also participates in reciprocal billing
arrangements with all other provinces and
territories, except Quebec (which has not signed a
reciprocal agreement with any other province or
territory), for insured physician services. Ontario
residents who may be required to pay for doctors’
services received in Quebec can submit their
receipts to the Ministry of Health and Long-Term
Care for repayment.
4.3 Coverage During Extended
Absences Outside Canada
Health coverage for insured Ontario residents
during extended absences outside Canada is
governed by sections 28.1 through 29 (inclusive)
and section 31 of Regulation 552 of the Health
Insurance Act.
In accordance with sections 1.1(3), 1.1 (4), 1.1(5)
and 1.1(6) of Regulation 552 of the Health
Insurance Act, MOHLTC may provide insured
Ontario residents with continuous Ontario health
coverage during absences outside Canada of
longer than 212 days (seven months) in a
12-month period.
Residents are required to apply to the MOHLTC
for this coverage prior to their departure and must
provide a document explaining the reason for their
absence outside Canada. In accordance with the
regulations and ministry policy, most applicants
must also have been present in Ontario for at
least 153 days in each of the two consecutive 12month periods prior to their expected date of
departure.
The length of time that the MOHLTC will provide a
person with continuous Ontario health coverage
during an extended absence outside Canada
varies depending on the reason for the absence.
Canada Health Act Annual Report, 2003-2004
Please refer to the information below for further
details:
Reason
OHIP Coverage
Study
Duration of a full-time
academic program
(unlimited)
Work
Five-year terms
Missionary Work
Duration of missionary
activities (unlimited)
Vacation/Other
Up to two years in a
lifetime
Family members may also qualify for continuous
Ontario health coverage while accompanying the
primary applicant on an extended absence outside
Canada and should contact their local OHIP office
for details.
Out-of-country services are covered under section
28.1 to 28.6 inclusive, and sections 29 and 31 of
Regulation 552 of the Health Insurance Act.
Effective September 1, 1995, out-of-country
emergency hospital costs are reimbursed at
Ontario fixed per diem rates of:
† a maximum $400 Canadian for in-patient
services;
† a maximum $50 Canadian for out-patient
services (except dialysis); and
† a maximum $210 Canadian per dialysis
treatment.
During 2003-2004 emergency medically necessary
out-of-country physician and other eligible
practitioner services (chiropractors, dentists,
optometrists, podiatrists and osteopaths) were
reimbursed at the Ontario rates detailed in
regulation under the HIA, or the amount billed,
whichever is less. Charges for medically
necessary emergency or out-of-country in-patient
and out-patient services are reimbursed only when
rendered in a licensed or approved hospital or
health facility. Medically necessary out-of-country
laboratory services when done on an emergency
basis by a physician are reimbursed in accordance
with the formula set out in section 29(1)(b) of the
Regulation or the amount billed, whichever is less;
and when done on an emergency basis by a
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Chapter 3 – Ontario
laboratory, in accordance with the formula set out
in section 31 of the Regulation.
5.0 Accessibility
In 2003-2004 payments for out-of-country
emergency in-patient and out-patient insured
hospital and medical services amounted to
$41.9 million.
5.1 Access to Insured Health
Services
4.4 Prior Approval Requirement
As set out in section 28.4 of Regulation 552 of the
Health Insurance Act, prior approval from
MOHLTC is required for payment for nonemergency services provided outside of Canada.
Where medically accepted treatment is not
available in Ontario, or in those instances where
the patient faces a delay in accessing treatment in
Ontario that would threaten the patient’s life or
cause irreversible tissue damage, the patient may
be entitled to full funding of out-of-country health
services.
Under section 28.5 of Regulation 552 of the
Health Insurance Act, laboratory tests performed
outside of Canada are paid for, with prior approval
from MOHLTC, if the following conditions are met:
† the kind of service or test is not performed in
Ontario;
† the service or test is generally accepted in
Ontario as appropriate for a person in the
same circumstances as the insured person;
† the service or test is not experimental; and
† the service or test is not performed for
research purposes.
In 2003-2004, total payments for prior approved
treatment outside of Canada were $31.3 million.
There is no formal prior approval process for
services provided to Ontario residents outside of
the province but within Canada. The
Interprovincial Agreement on Eligibility and
Portability includes a schedule for high-cost
services. In rare circumstances where this
schedule does not cover the costs in another
province, Ontario may be asked to guarantee
payment before the service is provided.
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All insured hospital, physician and surgical-dental
services are available to Ontario residents on
uniform terms and conditions.
All insured persons are entitled to all insured
hospital and physician services, as defined in the
Health Insurance Act.
Public hospitals in Ontario are not permitted to
refuse to provide services in life-threatening
situations by reason of the fact that the person is
not insured.
Under the Health Care Accessibility Act (now
revoked and governed by Part II of the
Commitment to the Future of Medicare Act) and
Health Insurance Act, extra billing is prevented
because physicians (both opt-in and opt-out) are
prohibited from charging more than the amount
for an insured service prescribed in the Schedule
of Benefits for Physician Services. Under that
same legislation, hospitals are also prohibited
from charging insured residents for insured
services.
MOHLTC implemented Health Number/Card
Validation to aid health care providers and
patients with access to health services and claim
payment. Providers may subscribe for validation
privileges to verify their patient eligibility and
health number/version code status (card status).
If patients require access to health services and
do not have a health card in their possession, the
provider may obtain the necessary information by
submitting to MOHLTC a Health Number Release
Form signed by the patient. An accelerated
process for obtaining health numbers for patients
who are unable to provide a health number and
require emergency treatment is available to
emergency room facilities through the Health
Number Look Up service.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Ontario
5.2 Access to Insured Hospital
Services
In 2003-2004, there were 152 public hospital
corporations staffed and in operation in Ontario,
which included chronic, general and special
rehabilitation units. There were 7,025,267 acute
patient days, 2,102,449 chronic patient days and
743,590 rehabilitation patient days delivered by
public hospitals during fiscal year 2003-2004.
Priority services are designated highly specialized
hospital-based services that respond to lifethreatening conditions. These services are often
high-cost and rapidly growing which makes access
of concern. Generally, these programs are
managed provincially and are designed to ensure
equitable access.
Priority services include:
† bone marrow transplantation;
† selected cardiovascular services;
† selected cancer services;
† end stage renal disease; and
† selected organ transplants.
In addition, the Ministry supports a number of
major provincial strategies, including:
† The Ontario Stroke Strategy;
† Organ and Tissue Donation and
Transplantation Action Plan;
† Visudyne Therapy Service;
† Ontario Joint Replacement Registry (OJRR);
† Telemedicine;
† Provincial Cancer Plan & Ontario Cancer
Quality Council; and
† Paediatric Oncology.
5.3 Access to Insured Physician and
Dental-Surgical Services
The Underserviced Area Program (UAP) is one of
a number of supports provided by MOHLTC to
help communities across Ontario recruit and retain
health care professionals. It offers recruitment and
retention tools (financial incentives) to
underserviced communities. In order to access the
UAP’s recruitment and retention benefits, a
community must be designated as underserviced.
Canada Health Act Annual Report, 2003-2004
A number of programs exist to enhance access to
health care services for residents of northern and
rural remote areas of Ontario:
† the Community Sponsored Contracts provide
alternative funding arrangements that fund
primary care services in communities with one
or two physicians, to ensure the availability of
primary care services as well as 24-hour seven
days a week emergency care, where possible;
† the Incentive Grant Program for Physicians
provides financial incentives to general
practitioners and specialists who establish
practice in designated underserviced areas;
† the Free Tuition Program provides up to
$40,000 in tuition reimbursement to eligible
final-year medical students, residents and
newly graduated physicians in exchange for a
three or four-year full-time return-of-service
commitment in an underserviced community;
† the Northern Physician Retention Initiative, a
three-year initiative, provided eligible family
practitioners and specialists who maintained
practices in northern Ontario for at least four
years with a retention incentive as well as
access to funding for continuing medical
education;
† The Northern Group Funding Plan (NGFP)
Agreements in 13 northern communities
provide alternative funding arrangements for
groups of between three and seven physicians
to provide primary care services, as well as
ensuring 24-hour seven days a week access to
emergency care in local hospitals; and
† The Northern Health Travel Grant helps to
defray transportation costs for the residents of
northern Ontario who must travel long
distances to access insured non-emergency
hospital and specialist medical services that
are not locally available and also promotes the
use of specialist services located in northern
Ontario, which encourages more specialists to
practice and remain in the north.
Currently, there are 132 communities in Ontario
designated as underserviced for general/family
practitioners and 15 communities designated as
underserviced for specialists.
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Chapter 3 – Ontario
Under the Physician Outreach Program, regularly
scheduled primary care clinics may be provided to
remote communities which have UAP-funded
nursing stations and to provide telephone back-up
to the nurse/nurse practitioners working at the
nursing station.
During 2003-2004, Ontario continued to be at the
forefront of Primary Care Renewal. Ontario has a
number of innovative primary care delivery
models. During this year the province began to
align its new and existing primary care models to
ensure that they all provide the same key
elements including: comprehensive and
preventative care, 24-hour seven days a week
access through telephone advisory services, and
increased after hours coverage.
5.4 Physician Compensation
Physicians are paid for the services they provide
through a number of mechanisms. Most physician
payments are provided through fee-for-service
arrangements (>90 percent of registered
physicians), with remuneration based on the
Schedule of Benefits under the Health Insurance
Act. Other physicians are paid through Alternate
Payment Plans, such as capitation, global budget
and volumes-based arrangements (<10 percent).
In partnership with the Ontario Medical
Association, the MOHLTC is implementing new
payment mechanisms through primary care reform
initiatives, such as Family Health Networks and
Family Health Groups and new funding models for
physicians in Academic Health Science Centres.
MOHLTC negotiates payment rates and other
changes to the Schedule of Benefits with the
Ontario Medical Association. The four-year
Physician Services Agreement with the Ontario
Medical Association expired on March 31, 2004.
The Agreement provided an annual increase of
1.95 percent, effective April 1, 2000 and two
percent for each of the following three years. The
Agreement also introduces new fees aimed at
easing the pressure on hospital emergency wards,
providing improved access to specialists,
facilitating the expansion of in-home health
services and providing better care to an aging
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population. In addition, the Agreement included
provisions for maternity benefits for female
physicians.
The Agreement also committed the parties to
meet in March 2003 regarding the fourth year
commitments. A Memorandum of Agreement was
reached in April 2003. The Memorandum of
Agreement provided for additional investment
beyond the previously committed funding.
In January 2004, the MOHLTC and the Ontario
Medical Association commenced negotiations to
develop a new agreement.
With respect to insured surgical-dental services,
MOHLTC negotiates changes to the Schedule of
Benefits with the Ontario Dental Association. In
2002-2003, MOHLTC and the Ontario Dental
Association agreed upon a new multi-year funding
agreement for dental services which became
effective on April 1, 2003.
5.5 Payments to Hospitals
Hospitals submit annual Hospital Planning Brief
Submissions that are the product of a broad
consultation within the facilities (e.g. all levels of
staff, unions, physicians and board) and within the
community and region. The business plan is first
and foremost a planning document but it also has
a substantial budget component, both financial
and statistical. The District Health Council and
MOHLTC staff then review this business plan.
MOHLTC’s review is conducted by regional staff,
specialized program staff and senior management,
and follows standard guidelines. It may involve
extensive discussions and clarification with the
facility.
Payments made by the health care plan to
hospitals for insured services and are calculated
on an annual budget basis. The Ontario budget
system is a prospective reimbursement system
that reflects the effects of workload increases,
costs related to provincial priority programs and
cost increases in respect of above-average growth
in volume of service in specific geographic
locations. Payments are made to hospitals on a
semi-monthly basis.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Ontario
MOHLTC reviews chronic care co-payment
regulations and rates annually, taking into account
changes in the Consumer Price Index, Old Age
Security, Guaranteed Income Supplement and
Guaranteed Annual Income Supplement each year,
and determines whether revisions to the
regulations and rates are appropriate.
MOHLTC is beginning to measure and reward
relative cost efficiency in hospitals through the
Integrated Population-Based Allocation model,
which also takes into consideration the individual
characteristics of the hospital.
In addition, specialized methodologies are used for
incremental funding for specific policy and
program initiatives (i.e. Nursing Enhancements,
60-hour postpartum guarantee length of stay).
Funding for hospital operations was well in excess
of $10 billion for 2003-2004.
6.0 Recognition Given to
Federal Transfers
The Government of Ontario publicly acknowledged
the federal contributions provided through the
Canada Health and Social Transfer in its
2003-2004 publications.
7.0 Extended Health Care
Services
7.1 Nursing Home Intermediate
Care and Adult Residential Care
Services
MOHLTC funds 563 long-term care homes and
over 68,000 beds. MOHLTC also conducts the
compliance monitoring program for long-term care
Canada Health Act Annual Report, 2003-2004
homes, which includes monitoring resident health
and well-being, safety, security, environmental and
dietary services to determine compliance with
legislation, regulations and standards. MOHLTC
receives and monitors the implementation of
corrective action plans to achieve compliance,
where necessary.
7.2 Home Care Services
Ontario home and community care programs
provide a range of services that support
independent community living. These services are
available through Community Care Access
Centres (CCAC), Community Support Service
(CSS) agencies, and Children’s Treatment
Centres (CTC).
CCACs provide simplified access for eligible
Ontario residents of all ages to community-based
health care and support services. CCACs assess
individual care needs and arrange professional and
personal support services in the home or school.
CCACs also provide information and refer
persons to other community services and arrange
admission to institutional care when necessary.
Community Support Service (CSS) agencies
provide support services, including homemaking,
attendant care, adult day programs, caregiver
support, meal services, home maintenance and
escorted transportation. These services
complement in-home and other health services
and the assistance provided by family and friends.
Children receive out-patient rehabilitative and
habilitative therapy services from Children’s
Treatment Centres. All CTCs provide occupational
therapy, physiotherapy, and speech-language
pathology services. A wide range of other
services may be provided, depending on
community needs and the availability of other
services locally. Children too ill to leave home are
served through CCAC in-home services.
109
Chapter 3 – Ontario
Registered Persons
1. Number as of March 31st (#).
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
11,400,000
11,700,000
11,800,000
12,100,000
12,200,000
Insured Hospital Services Within Own Province or Territory
Public Facilities
2. Number (#):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
3. Payments ($):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
Private For-Profit Facilities
1999-2000
154
12
4
3
173 1
2000-2001
150
12
4
3
169 1
2001-2002
139
11
4
3
157 1
2002-2003
139
11
4
3
157 1
2003-2004
139
11
4
3
157 1
not available 2
not available 2
not available 2
not available 2
not available 2
2
2
2
2
not available
not available
not available
not available 2
not available
not available 2
not available 2
not available 2
not available 2
not available 2
2
2
2
2
not available
not available
not available
not available 2
not available
7,700,000,000
8,700,000,000
9,200,000,000 10,300,000,000 10,300,000,000
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
4. Number (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
5. Number of insured hospital services
provided (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
6. Payments ($):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
not available 3
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Canada Health Act Annual Report, 2003-2004
Chapter 3 – Ontario
Insured Physician Services Within Own Province or Territory
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
7. Number of participating physicians (#):
a. general practitioners
b. specialists
c. other
d. total
10,227
10,284
not available 4
20,511
10,281
10,392
not available 4
20,673
10,395
10,520
not available 4
20,915
10,508
10724
not available 4
21232
10,611
10,703
not available 4
21,314
8. Number of opted-out physicians (#):
a. general practitioners
b. specialists
c. other
d. total
25
188
not available 4
213
25
177
not available 4
202
22
165
not available 4
187
17
134
not available 4
151
15
114
not available 4
129
9. Number of not participating
physicians (#):
a. general practitioners
b. specialists
c. other
d. total
not available 5
not available 5
not available 5
not available 5
not available 5
not available 5
not available 5
not available 5
not available 5
not available 5
not available 5
not available 5
not available 5
not available 5
not available 5
not available 5
not available 5
not available 5
not available 5
not available 5
10. Number of services provided through
fee for service (#):
a. general practitioners
b. specialists
c. other
d. total
79,600,000
91,400,000
not available 6
171,000,000
79,700,000
93,600,000
not available 6
173,300,000
77,800,000
99,600,000
not available 6
177,400,000
76,800,000
102,300,000
not available 6
179,100,000
78,700,000
103,300,000
not available 6
182,000,000
11. Total payments to physicians paid
through fee for service ($):
a. general practitioners
b. specialists
c. other
d. total
1,725,200,000 1,734,100,000 1,741,400,000 1,733,200,000
1,820,200,000
2,699,200,000 2,824,300,000 2,936,700,000 3,065,100,000
3,152,800,000
not available 6
not available 6
not available 6
not available 6
not available 6
4,424,400,000 4,558,400,000 4,678,100,000 4,798,300,000
4,973,000,000
12. Average payment per fee for service
service ($):
a. general practitioners
b. specialists
c. other
d. all services
21.67
29.53
not available 6
25.87
21.77
30.19
not available 6
26.32
22.40
29.50
not available 6
26.40
22.57
29.96
not available 6
26.79
23.14
30.52
not available 6
27.33
13. Number of services provided through
all payment methods (#):
a. medical
b. surgical
c. diagnostic
d. other
e. total
84,100,000
2,200,000
64,800,000
not available 6
170,900,000
82,900,000
22,300,000
68,100,000
not available 6
173,300,000
81,800,000
22,700,000
72,900,000
not available 6
177,400,000
81,800,000
23,900,000
73,400,000
not available
179,100,000
80,900,000
27,100,000
74,000,000
not available 6
182,000,000
14. Total payments to physicians paid
through all payment methods ($):
a. medical
b. surgical
c. diagnostic
d. other
e. total
15. Average payment per service, all
payment methods ($):
a. medical
b. surgical
c. diagnostic
d. other
e. all services
2,678,600,000 2,699,800,000 2,731,400,000 2,742,800,000
633,800,000
670,800,000
706,800,000
735,000,000
1,112,000,000 1,187,800,000 1,239,800,000 1,320,500,000
not available 6
not available 6
not available 6 not available
4,424,400,000 4,558,400,000 4,678,100,000 4,798,300,000
31.84
28.78
17.15
not available 6
25.87
Canada Health Act Annual Report, 2003-2004
32.59
30.09
17.45
not available 6
26.32
33.40
33.53
31.10
30.75
17.00
17.99
6
not available not available
26.40
26.79
6
6
6
2,818,000,000
787,700,000
1,367,300,000
not available 6
4,973,000,000
34.84
29.04
18.48
not available 6
27.33
111
Chapter 3 – Ontario
Insured Services Provided to Residents in Another Province or Territory
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
9,031
9,540
8,633
9,306
9,023
155,648
161,882
144,831
140,692
167,143
18. Total payments, in-patient ($).
41,300,000
39,900,000
36,800,000
48,500,000
63,000,000
19. Total payments, out-patient ($).
18,700,000
22,000,000
18,000,000
16,500,000
20,000,000
4,573.00
4,182.00
4,262.70
5,211.70
6,982.00
120.00
136.00
124.30
117.30
119.66
Physicians
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
22. Number of services (#).
455,136
433,463
469,146
497,880
557,720
14,000,000
14,400,000
15,500,000
17,700,000
18,600,000
31.00
33.00
33.00
35.00
33.34
16. Total number of claims, in-patient (#).
17. Total number of claims,
out-patient (#).
20. Average payment, in-patient ($).
21. Average payment, out-patient ($).
23. Total payments ($).
24. Average payment per service ($).
Insured Services Provided Outside Canada
Hospitals
25. Total number of claims, in-patient (#).
26. Total number of claims,
out-patient (#).
27. Total payments, in-patient ($).
28. Total payments, out-patient ($).
29. Average payment, in-patient ($).
30. Average payment, out-patient ($).
Physicians
31. Number of services (#).
32. Total payments ($).
33. Average payment per service ($).
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
20,657
20,503
18,542
23295
21,458
not available 7
not available 7
not available 7
17,000,000
18,800,000
19,300,000
not available 8
not available 8
not available 8
823.00
not available
1999-2000
918.00
9
not available
2000-2001
not available
2001-2002
7
not available 7
8
not available 8
27,200,000
1,043.20
9
not available
not available
32,000,000
1,167.40
9
not available
2002-2003
1,490.80
9
not available 9
2003-2004
184,107
179,679
157,191
200428
180,395
11,600,000
15,500,000
8,200,000
10,200,000
9,900,000
63.00
86.00
51.90
51.00
55.10
Insured Surgical-Dental Services Within Own Province or Territory
1999-2000
34. Number of particpating dentists (#).
35. Number of services provided (#).
36. Total payments ($).
37. Average payment per service ($).
112
2000-2001
2001-2002
2002-2003
2003-2004
350
357
327
319
323
69,400
71,660
74,000
75600
72,900
8,100,000
8,200,000
8,600,000
9,300,000
9,200,000
116.71
115.21
116.00
123.02
126.20
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Ontario
Endnotes
1. Excludes the three Provincial Psychiatric Hospitals.
2. Facilities in Ontario tend to be mixed (acute/chronic, chronic/rehabilitative beds) with only a minority having one type of bed.
Separating by facility type gives a small sample size and significantly understates the amount actually spent on chronic and
rehabilitative beds.
3. Data is not collected within a single system in the ministry.
4. All physicians are categorized as general practitioner or specialist.
5. Ontario has no non-participating physicians, only opted-out physicians who are reported under item #8.
6. All physicians are categorized within general practitioner, specialist and within medical, surgical or diagnostic.
7. Included in #25.
8. Included in #27.
9. Included in #29.
Canada Health Act Annual Report, 2003-2004
113
Chapter 3 – Manitoba
Manitoba
Introduction
Manitoba Health provides leadership and support
to protect, promote and preserve the health of all
Manitobans. The Department is organized into
five distinct but related functional areas: Finance,
Regional Affairs, Provincial Health Programs,
Health Accountability, Policy and Planning, and
Health Workforce. Their mandates are derived
from established legislation and policy pertaining
to health and wellness issues. The roles and
responsibilities of Manitoba Health include policy,
program and standards development, fiscal and
program accountability and evaluation.
On November 4, 2003, a new Cabinet position,
Minister of Healthy Living, was announced. This
has created additional profile and focus on
Manitoba Health’s goals related to promoting and
maintaining good health.
Health services are delivered through 11 Regional
Health Authorities, hospitals and other health care
facilities.
Manitoba Health continues to improve the quality
of the health care system and meet the public’s
expectations by working to reduce waiting lists, to
provide service enhancements and to recruit and
retain health care professionals. Other strategic
challenges are to provide services to maintain the
quality of life for Manitobans living with chronic
diseases, to reform mental health services,
1
2
Pharmacare, primary health care and to invest in
continuing care. In addition, Manitoba Health
continues to improve access to care and to reduce
waitlists for services through a variety of
strategies that include a broader influenza
vaccination program and better coordination of
hospital resources. Other measures to reduce the
demand for hospital beds include ambulatory care
initiatives, community access centres and home
care and long-term care investments.
Mental Health Renewal, which began in 2001,
highlights mental health within the health system
and focuses on improved integration of mental
health services within the primary health care
system; enhanced consumer and family
participation in the design and delivery of mental
health services; improved public understanding of
mental illness and mental wellness; and the
importance of early identification and intervention.
Manitoba’s Pharmacare Program has been
enhanced by adding new drugs to the formulary,
streamlining administration and interacting with
other provinces regarding common approaches,
such as a common drug review mechanism.
Patient safety and quality care continue to be high
priorities for Manitoba Health. An integrated
patient safety strategy based on priorities
identified by the National Patient Safety Steering
Committee and the recommendations of the
Sinclair Inquiry1 and Thomas Report2 is under
development.
Overall, Manitoba Health is building a culture of
accountability for both the work of the
Department of Health and the work of various
stakeholders in the health care system.
Clarifying roles and responsibilities of partners
and expectations for performance is essential to
strengthening accountability relationships. Early in
2003, Manitoba Health initiated a process of
developing annual performance agreements with
the Regional Health Authorities, CancerCare
The Sinclair Inquiry (Pediatric Cardiac Surgery Inquest) was tasked with conducting an inquiry into the deaths of 12 infants in
cardiac care in Winnipeg. Associate Chief Justice Murray Sinclair headed the inquiry and wrote the recommendations
contained in the Pediatric Cardiac Surgery Inquest Report.
University of Manitoba Prof. Paul Thomas headed the Review and Implementation Committee that was appointed to respond
to the recommendations of the Sinclair Inquiry.
Canada Health Act Annual Report, 2003-2004
115
Chapter 3 – Manitoba
Manitoba and the Addictions Foundation of
Manitoba. These agreements provide clear
direction regarding performance deliverables in
key areas and outline how such performance will
be monitored and measured. The first agreements
were signed in spring 2003 for the 2003-2004
fiscal year.
The Role and Mission of
Manitoba Health
Manitoba Health is a line department within the
government structure and operates under the
provisions of statutes and responsibilities charged
to the Ministers of Health and Healthy Living. The
formal mandates contained in legislation,
combined with mandates resulting from responses
to emerging health and health care issues,
establish a framework for planning and delivering
services.
It is Manitoba Health’s vision to lead the way in
quality health care, built with creativity,
compassion, confidence, trust and respect to
empower Manitobans through knowledge, choices
and access to the best possible health resources,
and to build partnerships and alliances for health
and supportive communities.
It is the mission of Manitoba Health to lead a
health care system that meets the needs of
Manitobans and to promote their health and wellbeing. This is accomplished through a structure of
comprehensive envelopes encompassing program,
policy and fiscal accountability; by the
development of a healthy public policy; and by the
provision of appropriate, effective and efficient
health and health care services. Services are
provided through regional delivery systems,
hospitals and other health care facilities. The
Department also makes payments on behalf of
Manitobans for insured health benefits related to
the costs of medical, hospital, personal care,
Pharmacare and other health services.
It is also the role of Manitoba Health to foster
innovation in the health care system. This is
3
accomplished by developing mechanisms to
assess and monitor quality of care, utilization and
cost-effectiveness; fostering behaviours and
environments that promote health; and promoting
responsiveness and flexibility of delivery systems
and alternative, less expensive services.
1.0 Public Administration
1.1 Health Care Insurance Plan and
Public Authority
The Manitoba Health Services Insurance Plan
(MHSIP) is administered by the Department of
Health under the Health Services Insurance Act,
R.S.M. 1987, c. H35. The Act3 was significantly
amended in 1992, dissolving the Manitoba Health
Services Commission and transferring all assets
and responsibilities to Manitoba Health. The
dissolution took effect on March 31, 1993.
The MHSIP is administered under this Act for
insurance in respect of the costs of hospital,
personal care and medical and other health
services referred to in acts of the Legislature or
regulations thereunder. The Act was amended on
January 1, 1999, to provide insurance for outpatient services relating to insured medical
services provided in surgical facilities.
The Minister of Health is responsible for
administering and operating the Plan. Under
section 3(2), the Minister has the power:
† to provide insurance for residents of the
province in respect of the costs of hospital,
medical and other health services, and
personal care;
† to plan, organize and develop throughout the
province a balanced and integrated system of
hospitals, personal care homes and related
health facilities and services commensurate
with the needs of the residents of the province;
† to ensure that adequate standards are
maintained in hospitals, personal care homes
and related health facilities, including
Where reference is made to "the Act" in the text, this refers to the Health Services Insurance Act (1999).
116
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Manitoba
standards concerning supervision, licensing,
equipment and inspection, or to make such
arrangements that the Minister considers
necessary to ensure that adequate standards
are maintained;
† to provide a consulting service, exclusive of
individual patient care, to hospitals and
personal care homes in the province or to
make such arrangements that the Minister
considers necessary to ensure that such a
consulting service is provided;
† to require that the records of hospitals,
personal care homes and related health
facilities are audited annually and that the
returns relating to hospitals, which are required
by the Government of Canada, are submitted;
and
† in cases where residents do not have available
medical and other health services, to take such
measures that are necessary to plan, organize
and develop medical services and other health
services commensurate with the needs of the
residents.
The Minister may also enter into contracts and
agreements with any person or group that he or
she considers necessary for the purposes of the
Act. The Minister may also make grants to any
person or group for the purposes of the Act on
such terms and conditions that are considered
advisable. Also, the Minister may, in writing,
delegate to any person any power, authority, duty
or function conferred or imposed upon the
Minister under the Act or under the Regulations.
There were no legislative amendments to the Act
or the Regulations in the 2003-2004 fiscal year
that affected the public administration of the Plan.
1.2 Reporting Relationship
Section 6 of the Act requires the Minister to have
audited financial statements of the Plan showing
separately the expenditures for hospital services,
medical services and other health services. The
Minister is required to prepare an annual report,
which must include the audited financial
statements, and to table the report before the
Legislative Assembly within 15 days of receiving
Canada Health Act Annual Report, 2003-2004
it, if the Assembly is in session. If the Assembly is
not in session, the report must be tabled within 15
days of the beginning of the next session.
1.3 Audit of Accounts
Section 7 of the Act requires that the Office of
the Auditor General of Manitoba (or another
auditor designated by the Office of the Auditor
General of Manitoba) audit the accounts of the
Plan annually and prepare a report on that audit
for the Minister. The most recent audit reported to
the Minister and available to the public is for the
2003-2004 fiscal year and is contained in the
Manitoba Health Annual Report, 2003-2004.
2.0 Comprehensiveness
2.1 Insured Hospital Services
Sections 46 and 47 of the Act, as well as the
Hospital Services Insurance and Administration
Regulation (M.R. 48/93), provide for insured
hospital services.
As of March 31, 2004, there were 98 facilities,
including one provincial psychiatric centre in
Manitoba, providing insured hospital services to
both in- and out-patients. Hospitals are
designated by the Hospitals Designation
Regulation (M.R. 47/93) under the Act.
Services specified by the Regulation as insured in
and outpatient hospital services include:
† accommodation and meals at the standard
ward level;
† necessary nursing services;
† laboratory, radiological and other diagnostic
procedures;
† drugs, biologics and related preparations;
† routine medical and surgical supplies;
† use of operating room, case room and
anaesthetic facilities; and
† use of radiotherapy, physiotherapy,
occupational and speech therapy facilities,
where available.
117
Chapter 3 – Manitoba
All hospital services are added to the list of
available hospital services through the health
planning process.
Manitoba residents maintain high expectations for
quality health care and insist that the best
available medical knowledge and service be
applied to their personal health situations.
Manitoba Health is sensitive to new developments
in the health sciences.
2.2 Insured Physician Services
The enabling legislation that provides for insured
physician services is the Medical Services
Insurance Regulation (M.R. 49/93) made under
the Act.
Physicians providing insured services in Manitoba
must be lawfully entitled to practise medicine in
Manitoba, registered and licensed under the
Medical Act. As of March 31, 2004, there were
2,124 physicians on the Manitoba Health Registry.
A physician, by giving notice to the Minister in
writing, may elect to collect the fees for medical
services rendered to insured persons other than
from the Minister, in accordance with section 91
of the Act and section 5 of the Medical Services
Insurance Regulation. The election to opt out of
the health insurance plan takes effect on the first
day of the month following a 90-day period from
the date the Minister receives the notice.
Before rendering a medical service to an insured
person, physicians must give the patient
reasonable notice that they propose to collect any
fee for the medical service from them or any other
person except the Minister. The physician is
responsible for submitting a claim to the Minister
on the patient’s behalf and cannot collect fees in
excess of the benefits payable for the service
under the Act or Regulations. To date, no
physicians have opted out of the medical plan in
Manitoba.
The range of physician services insured by
Manitoba Health is listed in the Payment for
Insured Medical Services Regulation (M.R.
95/96). Coverage is provided for all medically
required personal health care services, rendered
118
to an insured person by a physician that are not
excluded under the Excluded Services Regulation
(M.R. 46/93) of the Act. During fiscal year
2003-2004, a number of new insured services
were added to a revised fee schedule.
In order for a physician’s service to be added to
the list of those covered by Manitoba Health,
physicians must put forward a proposal to their
specific section of the Manitoba Medical
Association (MMA). The proposals are forwarded
to the Manitoba College of Physicians and
Surgeons for review to ensure the service is
scientifically valid and not developmental or
experimental. The MMA will negotiate the item,
including the fee, with Manitoba Health. Manitoba
Health may also initiate this process.
2.3 Insured Surgical-Dental
Services
Insured surgical and dental services are listed in
the Hospital Services Insurance and
Administration Regulation (M.R. 48/93) under the
Act. Surgical services are insured when performed
by a certified oral and maxillofacial surgeon or a
licensed dentist in a hospital, when hospitalization
is required for the proper performance of the
procedure. This Regulation also provides benefits
relating to the cost of insured orthodontic services
in cases of cleft lip and/or palate for persons
registered under the program by their 18th
birthday, when provided by a registered
orthodontist. As of March 31, 2004, 570 dentists
were registered with Manitoba Health.
Providers of dental services may elect to collect
their fees directly from the patient in the same
manner as physicians and may not charge to or
collect from an insured person a fee in excess of
the benefits payable under the Act or Regulations.
No providers of dental services had opted out as
of March 31, 2004.
In order for a dental service to be added to the
list of insured services, a dentist must put forward
a proposal to the Manitoba Dental Association
(MDA). The MDA will negotiate the fee with
Manitoba Health.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Manitoba
2.4 Uninsured Hospital, Physician
and Surgical-Dental Services
The Excluded Services Regulation (M.R. 46/93)
made under the Act sets out those services that
are not insured. These include:
† examinations and reports for reasons of
employment, insurance, attendance at
university or camp, or performed at the
request of third parties;
† group immunization or other group services
except where authorized by Manitoba Health;
† services provided by a physician, dentist,
chiropractor or optometrist to him or herself or
any dependants;
† preparation of records, reports, certificates,
communications and testimony in court;
† mileage or travelling time;
† services provided by psychologists,
chiropodists and other practitioners not
provided for in the legislation;
† in-vitro fertilization;
† tattoo removal;
† contact lens fitting;
† reversal of sterilization procedures; and
† psychoanalysis.
The Hospital Services Insurance and
Administration Regulation states that hospital
in-patient services include routine medical and
surgical supplies, thereby ensuring reasonable
access for all residents. The Regional Health
Authorities and Manitoba Health monitor
compliance.
All Manitoba residents have equal access to
services. Third parties such as private insurers or
the Workers Compensation Board do not receive
priority access to services through additional
payment. Manitoba has no formalized process to
monitor compliance; however, feedback from
physicians, hospital administrators, medical
professionals and staff allows Regional Health
Authorities and Manitoba Health to monitor usage
and service concerns.
To de-insure services covered by Manitoba Health,
the Ministry prepares a submission for approval
by Cabinet. The need for public consultation is
Canada Health Act Annual Report, 2003-2004
determined on an individual basis depending on
the subject.
No services were removed from the list of those
insured by Manitoba Health in 2003-2004.
3.0 Universality
3.1 Eligibility
The Health Services Insurance Act defines the
eligibility of Manitoba residents for coverage
under the provincial health care insurance plan.
Section 2(1) of the Act states that a resident is a
person who is legally entitled to be in Canada,
resides in Manitoba, is physically present in
Manitoba for at least six months in a calendar
year, and includes any other person classified as a
resident in the Regulations, but does not include a
person who holds a Minister’s permit under the
Immigration Act (Canada), unless the Minister
determines otherwise, or is a visitor, transient or
tourist.
The Residency and Registration Regulation (M.R.
54/93) extends the definition of residency. The
extensions are found in sections 7(1) and 8(1).
Section 7(1) allows missionaries, individuals with
out-of-country employment and individuals
undertaking sabbatical leave to be outside
Manitoba for up to two years while still remaining
residents of Manitoba. Students are deemed to be
Manitoba residents while in full-time attendance
at an accredited educational institution. Section
8(1) extends residency to individuals who are
legally entitled to work in Manitoba and have an
employment authorization of 12 months or more.
The Residency and Registration Regulation,
section 6, defines Manitoba’s waiting period as
follows:
“A resident who was a resident of another
Canadian province or territory immediately
before his or her arrival in Manitoba is not
entitled to benefits until the first day of the
third month following the month of arrival.”
There are currently no other waiting periods in
Manitoba.
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Chapter 3 – Manitoba
The MHSIP excludes residents covered under the
following federal statutes: Aeronautics Act;
Civilian War-related Benefits Act; Government
Employees Compensation Act; Merchant Seaman
Compensation Act; National Defence Act; Pension
Act; Royal Canadian Mounted Police Act; or under
legislation of any other jurisdiction (Excluded
Services Regulations subsection 2(2)). The
excluded are residents who are members of the
Canadian Forces, the Royal Canadian Mounted
Police (RCMP) and federal inmates. These
residents become eligible for Manitoba Health
coverage upon discharge from the Canadian
Forces, the RCMP, or if an inmate of a
penitentiary has no resident dependants. Upon
change of status, these persons have one month
to register with Manitoba Health (Residency and
Registration Regulation (M.R. 54/93, subsection
2(3)).
3.2 Registration Requirements
The process of issuing health insurance cards
requires that individuals inform Manitoba Health
that they are legally entitled to be in Canada, and
that they intend to be physically present in
Manitoba for six months. They must also provide a
primary residence address in Manitoba. Upon
receiving this information, Manitoba Health will
provide a registration certificate for the individual
and all qualifying dependants.
Manitoba has two health-related numbers. The
registration number is a six-digit number assigned
to an individual 18 years of age or older who is
not classified as a dependant. This number is used
by Manitoba Health to pay for all hospital and
medical service claims for that individual and all
designated dependants. A nine-digit Personal
Health Identification Number (PHIN) is used for
the provincial drug program.
As of March 31, 2004, there were 1,159,784
residents registered with the health care
insurance plan.
There is no provision for a resident to opt-out of
the Manitoba health plan.
120
3.3 Other Categories of Individual
The Residency and Registration Regulation (M.R.
54/93, sub-section 8(1)) requires that temporary
workers possess a work permit issued by
Citizenship and Immigration Canada (CIC) for at
least 12 months, be physically present in
Manitoba and be legally entitled to be in Canada
before receiving Manitoba Health coverage.
As of March 31, 2004, there were 3,234
individuals on work permits covered under the
MHSIP.
The definition of “resident” under the Health
Services Insurance Act allows the Minister of
Health or the Minister’s designated representative
to provide coverage for holders of a Minister’s
permit under the Immigration Act (Canada).
No legislative amendments to the Act or the
Regulations in the 2003-2004 fiscal year affected
universality.
4.0 Portability
4.1 Minimum Waiting Period
The Residency and Registration Regulation (M.R.
54/93, section 6) identifies the waiting period for
insured persons from another province or territory.
A resident who lived in another Canadian province
or territory immediately before arriving in
Manitoba is entitled to benefits on the first day of
the third month following the month of arrival.
4.2 Coverage During Temporary
Absences in Canada
The Residency and Registration Regulation (M.R.
54/93 section 7(1)) defines the rules for
portability of health insurance during temporary
absences in Canada.
Students are considered residents and will
continue to receive health coverage for the
duration of their full-time enrollment at any
accredited educational institution. The additional
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Manitoba
requirement is that they intend to return and
reside in Manitoba after completing their studies.
Residents on sabbatical or educational leave from
employment will be covered by Manitoba Health
for up to 24 consecutive months. These individuals
must return and reside in Manitoba after
completing their leave.
Manitoba has formal agreements with all
Canadian provinces and territories for the
reciprocal billing of insured hospital services.
Manitoba has a bilateral agreement with the
Province of Saskatchewan for Saskatchewan
residents who receive care in Manitoba border
communities.
In-patient costs are paid at standard rates
approved by the host province or territory.
Payments for in- patient, high-cost procedures
and out-patient services are based on national
rates agreed to by provincial or territorial health
plans. These include all medically necessary
services as well as costs for emergency care.
Except for Quebec, medical services incurred in all
provinces or territories are paid through a
reciprocal billing agreement at host province or
territory rates. Claims for medical services
received in Quebec are submitted by the patient
or physician to Manitoba Health for payment at
host province rates.
In 2003-2004, Manitoba Health made payments of
approximately $20,660,315 for hospital services
and $7,579,028 for medical services provided in
Canada.
4.3 Coverage During Temporary
Absences Outside Canada
The Residency and Registration Regulation (M.R.
54/93, sub-section 7(1)) defines the rules for
portability of health insurance during temporary
absences from Canada.
Residents on full-time employment contracts
outside Canada will receive Manitoba Health
coverage for up to 24 consecutive months.
Individuals must return and reside in Manitoba
after completing their employment terms. Clergy
Canada Health Act Annual Report, 2003-2004
serving as missionaries on behalf of a religious
organization approved as a registered charity
under the Income Tax Act (Canada) will be
covered by Manitoba Health for up to 24
consecutive months. Students are considered
residents and will continue to receive health
coverage for the duration of their full-time
enrollment at an accredited educational
institution. The additional requirement is that they
intend to return and reside in Manitoba after
completing their studies. Residents on sabbatical
or educational leave from employment will be
covered by Manitoba Health for up to 24
consecutive months. These individuals also must
return and reside in Manitoba after completing
their leave.
Coverage for all these categories is subject to
amounts detailed in the Hospital Services
Insurance and Administration Regulation (M.R.
48/93). Hospital services received outside
Canada due to an emergency or a sudden illness,
while temporarily absent, are paid as follows:
In-patient services are paid based on a per-diem
rate according to hospital size:
† 1-100 beds:
$280
† 101-500 beds:
$365
† over 500 beds:
$570
Out-patient services are paid at a flat rate of
$100 per visit or $215 for haemodialysis.
The calculation of these rates is complex due to
the diversity of hospitals in both rural and urban
areas.
Manitobans requiring medically necessary hospital
services unavailable in Manitoba or elsewhere in
Canada may be eligible for costs incurred in the
United States by providing Manitoba Health with
a recommendation from a specialist stating that
the patient requires a specific, medically
necessary service. Physician services received in
the United States are paid at no less than 100
percent of the equivalent Manitoba rate for similar
services. Hospital services are paid at up to 75
percent of the hospital’s charges for insured
services. Payment for hospital services is made in
U.S. funds (the Hospital Services Insurance and
Administration Regulation, sections 15-23).
121
Chapter 3 – Manitoba
Manitoba Health made payments of approximately
$2,564,221 for hospital care provided in hospitals
outside Canada in the 2003-2004 fiscal year. In
addition, Manitoba Health made payments of
approximately $519,782 for medical care outside
Canada.
individuals who receive insured surgical
services or to anyone else on that person’s
behalf; and
† ensuring that a surgical facility cannot perform
procedures requiring overnight stays and
thereby function as a private hospital.
In instances where Manitoba Health has given
prior approval for services provided outside
Canada and payment is less than 100 percent of
the amount billed for insured services, Manitoba
Health will consider additional funding based on
financial need.
On February 10, 2004, Manitoba officially opened
the expanded Health Links/Info Santé, a 35-seat,
state-of-the-art call centre with a call capacity of
300,000 per year.
4.4 Prior Approval Requirement
Prior approval is not required for services
provided in other provinces or territories. Prior
approval is required for elective hospital and
medical care provided outside Canada. An
appropriate medical specialist must apply to
Manitoba Health to receive approval.
No legislative amendments to the Act or the
Regulations in the 2003-2004 fiscal year had an
effect on portability.
5.0 Accessibility
5.1 Access to Insured Health
Services
Manitoba Health ensures that medical services
are equitable and reasonably available to all
Manitobans. Effective January 1, 1999, the
Surgical Facilities Regulation (M.R. 222/98) under
The Health Services Insurance Act came into
force to prevent private surgical facilities from
charging additional fees for insured medical
services.
In July 2001, the Health Services Insurance Act,
the Private Hospitals Act and the Hospitals Act
were amended to strengthen and protect public
access to the health care system. The
amendments include:
† changes to definitions and other provisions to
ensure that no charges can be made to
122
Manitobans now have access to vital health
information and assistance in 110 languages
24-hours a day, seven days a week.
Public demand for Health Links/Info Santé has
increased steadily since it began as a six station
call centre in 1994. Manitobans value the service.
Providing this information source relieves pressure
on other areas of the health care system,
particularly emergency rooms.
Through the Primary Health Care Transition Fund
Multi-jurisdictional Envelope funds have been
made available to implement a program to
manage patients with congestive heart failure.
Beginning in November 2004, this 17-month
initiative will evaluate the benefits of using health
lines to manage patients with chronic diseases.
5.2 Access to Insured Hospital
Services
All Manitobans have access to hospital services
including acute care, psychiatric extended
treatment, mental health, palliative, chronic, longterm assessment/rehabilitation and to personal
care facilities. There has been a shift in focus from
hospital beds to community services, out-patients
and day surgeries, which are also insured
services.
As a result of investments in nursing education,
Manitoba’s nursing shortage has improved
significantly in Winnipeg, with a more gradual
improvement noted in rural and northern regions
over the past year. Interest in nursing education
continues to be high.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Manitoba
Manitoba also has a wide range of other health
care professionals. Shortages in some of the
technology fields such as nuclear medicine,
medical radiation and laboratory technology
continue to be an issue.
Manitoba currently has access to four Magnetic
Resonance Imaging (MRI) machines for clinical
testing. All units are in Winnipeg. The first unit
was installed in 1990 by the St. Boniface
Research Foundation and replaced in October
1998. The second, located at the Health Sciences
Centre, began operating in September 1998. This
unit was a joint initiative with the National
Research Council (NRC). A third unit began
operating in January 2000. The fourth and newest
MRI, located at the Health Sciences Centre,
began operating in March 2004.
Manitoba has 17 Computerized Tomography (CT)
scanners: three (one for paediatric patients) at
the Health Sciences Centre, two at the St.
Boniface General Hospital, one each at Victoria
General Hospital, Dauphin Regional Health
Centre, Thompson General Hospital, Brandon
Regional Health Centre, Boundary Trails Health
Centre, Misericordia Health Centre, Seven Oaks,
Grace and Concordia Hospitals, and newly
installed scanners in Steinbach and Selkirk. The
newest CT scanner, located in The Pas, began
operating in October 2003. One of the scanners
at the Health Sciences Centre was replaced and
one scanner was upgraded, both by 16-slice
scanners. As well, ultrasound scanners are located
in seven Winnipeg health facilities and 16 rural
and northern health facilities. Bone density testing
is funded by Manitoba Health on two machines
located in Winnipeg and Brandon.
In March 2003, CancerCare Manitoba completed
the opening of their 205,000 square foot worldclass facility for treatment, education and
research with an on-site laboratory for the
Manitoba Institute of Cell Biology. The Manitoba
School of Radiation Technology now has
classroom space in the new CancerCare facility. In
January 2004, seven students graduated from the
Manitoba School of Radiation Therapy and two
Canada Health Act Annual Report, 2003-2004
were retained by CancerCare Manitoba. The next
class will graduate in January 2005.
Prostate brachytherapy treatment began in April
2003 at CancerCare Manitoba. This treatment will
reduce the number of patients on the waiting list
and, therefore, will reduce the waiting time for
radiation therapy.
Gamma Knife Neurosurgery was established in
November 2003. It provides patients with an
opportunity for alternative treatment to
conventional radiotherapy, linear acceleratorbased treatments and certain microsurgeries.
Manitoba Health allocated funding to a Cardiac
Critical Shortages Fund to send patients, who
have waited longer for medically recommended
surgery, out-of-province for cardiac surgery, if
they so choose. No patients on the cardiac
surgery waitlist chose the option of being sent
out-of-province. Targeted funding was provided to
Regional Health Authorities to address specific
capacity issues including funding to increase
diagnostic and surgical procedures such as
cataract surgery, orthopaedic surgery and cardiac
surgery.
Manitoba is a partner in the Western Canada
Waiting List project. The Winnipeg Regional
Health Authority is implementing and evaluating
two of the tools developed through this project:
the Child and Adolescent Mental Health tool and
the General Surgery tool. The Child and
Adolescent Mental Health tool project team has
developed priority criteria and forms were entered
into a computerized database. Centralized Intake
staff have been trained to complete priority forms
on line. The priority criteria score is used as an
assessment tool to prioritize child and adolescent
mental health clients.
The Emergency Care Task Force was initiated in
January 2004 to develop and oversee the
implementation of recommendations for the shortand long-term improvement of emergency care in
Winnipeg hospitals.
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Chapter 3 – Manitoba
5.3 Access to Insured Physician and
DentalSurgical Services
In 2003-2004, Manitoba Health continued to
support initiatives to improve access to physicians
in rural and northern areas of the province. In
October 2003, Manitoba supported a co-ordinated
process to assist with changes in recruiting
foreign-trained physicians to rural regions, as a
result of changes in the regulation for registration
of medical practitioners in early 2003. Issues
addressed through the co-ordinated process
include the immigration process and clinical
assessment processes, as well as other issues
related to eligibility criteria for conditional medical
registration.
The co-ordinated process will help Regional Health
Authorities with the logistics of recruiting foreigntrained physicians and avoid duplication of effort.
It will introduce future physician candidates to
opportunities available in Manitoba. The process
will also explore possible new markets made
available through the new legislation around
physician licensure.
A Recruitment Co-ordinator was recruited by the
Regional Health Authorities of Manitoba, Inc. to
support this initiative effective on October 20,
2003.
Manitoba continues to experience a small increase
in the number of new physicians registering with
the licensing body. To encourage retention of
Manitoba graduates, the Province continued to
provide a financial assistance grant for students
and residents. In return for financial assistance
during their training, the student or resident
agrees to work in Manitoba for a specific period
after graduating. The program was introduced in
May 2001. There are plans to expand the program
to include family doctors from outside Manitoba
and family doctors who have left the province and
want to return. Increased enrolment in the
undergraduate medical program at the University
of Manitoba is under consideration and is being
discussed with the Manitoba Department of
Advanced Education and Training.
124
The Manitoba Telehealth Network under the
leadership of the Winnipeg Regional Health
Authority has implemented the infrastructure to
link 23 Telehealth sites across the province. This
modern telecommunications link means patients
can be seen by specialists and medical staff can
consult with each other without having to endure
the expense and inconvenience of travelling from
the North to Winnipeg. In September 2002,
Manitoba Health launched the new Manitoba
Telehealth site at St. Boniface General Hospital,
officially linking its medical specialists to patients
and colleagues province-wide.
5.4 Physician/Dentist
Compensation
Manitoba continues to employ the following
methods of payment for physicians: fee-forservice, salaried, sessional and blended.
Fee-for-service remains the dominant method of
payment for physician services. Notwithstanding,
alternate payment arrangements constitute a
significant portion of the total compensation to
physicians in Manitoba. Alternate-funded
physicians are those who receive either a salary
(employer-employee relationship) or those who
work on an independent contract. Manitoba also
uses blended payment methods to “top-up” the
wages of physicians whose fee-for-service income
may not be competitive, yet whose services
remain vital to the province. As well, physicians
may receive sessional payments for providing
medical services, as well as stipends for on-call
responsibilities.
Representatives from the Manitoba Medical
Association (MMA) and Manitoba Health typically
negotiate compensation agreement for physicians.
Representatives from Manitoba Health and the
Manitoba Dental Association (MDA) are usually
involved in negotiating agreements with dental
surgeons, oral surgeons and periodontists.
The Health Services Insurance Act governs
payment to both physicians and dentists/oral
surgeons for insured services.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Manitoba
There were no amendments to the Health
Services Insurance Act (HSIA) during the 20032004 fiscal year.
Manitoba Health and the MDA negotiated an
agreement that covers the period of April 1, 2002
to March 31, 2005. The agreement includes the
following:
† fee increases to the Oral Surgery Schedule,
Cleft Lip/Palate Schedule and Assistant
Surgeons’ Fee Schedule (3 percent on
April 1, 2002; 3 percent on April 1, 2003; and
3 percent on April 1, 2004, non-compounded);
† introduction of 10 new tariffs;
† amendment to five existing tariffs; and
† deletion of 14 tariffs.
On June 2, 2002, Manitoba Health and the MMA
signed an arbitration agreement for fee-forservice and alternate funded physicians.
In accordance with the June 2, 2002 Arbitration
Agreement between Manitoba Health and the
MMA, the issue of an overall award for fee-forservice physician services was referred to a threeperson Board of Arbitration in February 2003.
On June 23, 2003 the parties reached a
comprehensive negotiated settlement for all feefor-service and alternate funded physicians
represented by the MMA. This terminated the
arbitration process.
The settlement maintained the terms of the
June 2, 2002 Arbitration Agreement, including:
† the establishment of a Physician Retention
Fund ($5 million per annum over the duration
of this agreement as well as the subsequent
agreement);
† the continuation of the Professional Liability
Insurance Fund ($5 million per annum for
calendar years 2003, 2004, 2005 and 2006);
† the continuation of the Continuing Medical
Education Fund ($1 million per annum for the
calendar years 2002, 2003 and 2004);
† the establishment of a Maternity/Parental
Benefits Fund ($1 million per annum for
calendar years 2002, 2003 and 2004);
† a mechanism to initiate arbitration proceedings
with respect to a subsequent agreement, if
Canada Health Act Annual Report, 2003-2004
notice is given by either party by January 1,
2005;
† physicians covered by the Agreement shall
refrain from stoppage of work or curtailment of
services and to continue to provide services
without interruption; and
† continuation of the Grievance Arbitration
procedure set forth in the March 8, 1994 FeeFor-Service Agreement between the parties.
The highlights of the June 23, 2003 Negotiated
Settlement include:
† a three-year term from April 1, 2002 to March
31, 2005;
† an overall increase of 9 percent (noncompounded) to the Fee-For-Service Schedule
of Benefits, as well as alternate-funded
agreements/arrangements) – 3 percent
effective October 1, 2002; 3 percent effective
April 1, 2003; and 3 percent effective April 1,
2004;
† an additional $10 million ($5 million effective
April 1, 2003 and $5 million effective April 1,
2004) was applied to the schedule of benefits.
Approximately $7 million of the $10 million has
been applied to the fee tariffs for family
physicians. The remaining $3 million was used
to address fee and income disparities in the
other blocs of practice, such as Rheumatology,
Physical Medicine, Geriatric Medicine, etc.;
† an extension of maternity and parental benefits
to all Manitoba physicians, including interns
and residents;
† increased incentives for family doctors to
provide full-service care and to maintain
hospital privileges;
† the incremental cost of this increase was
approximately $38 million for fee-for-service
physicians (exclusive of increases in volume).
Of this amount, over 50 percent was allocated
to the fee tariffs for family physician; and
† increases to the rates for physicians under
alternate funding agreements in the amount of
3 percent effective October 1, 2002; 3 percent
effective April 1, 2003; and 3 percent effective
April 1, 2004 (non-compounded) were also
applied over and above the fee-for-service
increase.
125
Chapter 3 – Manitoba
5.5 Payments to Hospitals
Division 3.1 of Part 4 of the Regional Health
Authorities Act sets out the requirements for
operational agreements between Regional Health
Authorities and the operators of hospitals and
personal care homes, defined as “health
corporations” under the Act.
Pursuant to the provisions of this division,
Authorities are prohibited from providing funding
to a health corporation for operational purposes
unless the parties have entered into a written
agreement for this purpose that enables the
health services to be provided by the health
corporation, the funding to be provided by the
Authority for the health services, the term of the
agreement and a dispute resolution process and
remedies for breaches. If the parties cannot reach
an agreement, the Act enables them to request
that the Minister of Health appoint a mediator to
help them resolve outstanding issues. If the
mediation is unsuccessful, the Minister is
empowered to resolve the matter or matters in
dispute. The Minister’s resolution is binding on
the parties.
The Regional Health Authorities have concluded
the required agreements. The operating
agreements between the Winnipeg Regional
Health Authority and the health corporations
operating facilities in Winnipeg will expire on
March 31, 2006. The operating agreements enable
the Authority to determine funding based on
objective evidence, best practices and criteria that
are commonly applied to comparable facilities.
In addition to the Winnipeg Regional Health
Authority, there are two other Regional Health
Authorities that continue to have hospitals
operated by health corporations in their health
regions. In all other regions, the hospitals are
operated by the Regional Health Authorities or by
the federal government. The agreements in place
between the Authorities and the health
corporations do not have expiry dates. The
Authorities are empowered to determine the
funding to be provided each year.
126
The allocation of resources by Regional Health
Authorities for providing hospital services is
approved by Manitoba Health through the
approval of the Authorities’ regional health plans,
which the Authorities are required to submit for
approval pursuant to section 24 of the Regional
Health Authorities Act. Section 23 of the Act
requires that Authorities allocate their resources
in accordance with the approved regional health
plan.
Pursuant to subsection 50(2.1) of the Health
Services Insurance Act, payments from the
MHSIP for insured hospital services are to be paid
to the Regional Health Authorities. In relation to
those hospitals that are not owned and operated
by an Authority, the Authority is required to pay
each hospital in accordance with any agreement
reached between the Authority and the hospital
operator.
No legislative amendments to the Act or the
Regulations in 2003-2004 had an effect on
payments to hospitals.
6.0 Recognition Given to
Federal Transfers
Manitoba routinely recognizes the federal role
regarding the contributions provided under the
Canada Health and Social Transfer (CHST) in
public documents.
7.0 Extended Health Care
Services
Manitoba has established community-based
service programs as appropriate alternatives to
hospital services. These service programs are
provided by Manitoba Health through the Regional
Health Authorities. The services include the
following:
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Manitoba
Personal Care Home Services
The Personal Care Services Insurance and
Administration Regulation under the Health
Services Insurance Act authorizes the provision of
services to personal care homes. Both proprietary
and non-proprietary homes are licensed by
Manitoba Health. Residents of personal care
homes also pay a residential charge. The total
Manitoba Health operating expenditures for
personal care services during fiscal year 20032004 amounted to $410,806,691, supporting a
total of 9,597 licensed set-up personal care beds.
In addition, there were estimated capital and
equipment expenditures of $21,040,157.
Home Care Services
The Manitoba Home Care Program is the oldest
comprehensive, province-wide, universal home
care program in Canada. Manitoba Home Care
provides effective, reliable and responsive
community health care services to support
independent living; to develop appropriate care
options to support continued community living;
and to facilitate admission to institutional care
when community living is no longer a viable
alternative. Home care services are delivered
through the local offices of the Regional Health
Authorities and include a broad range of services
based on a multidisciplinary assessment of
individual needs. Services may be co-ordinated by
a Case Co-ordinator or are self/family-managed
and may include personal care assistance, home
support, health care, family relief, respite care,
supplies and equipment, adult day programs
and/or volunteer services.
Mental Health and Addictions Services
All Regional Health Authorities provide community
mental health services. Community Mental Health
Workers provide assessment, service planning,
short-term counselling interventions, rehabilitation
and recovery planning, crisis intervention,
community consultation and education. In addition
to community mental health workers, some
regions have a variety of intensive and supportive
programs such as Intensive Case Management,
Canada Health Act Annual Report, 2003-2004
Supported Employment, Supported Housing and,
in Winnipeg, the Program for Assertive
Community Treatment and the Early Psychosis
Prevention and Intervention Service.
Addictions services and supports are provided
through provincially funded agencies, the largest
being the Addictions Foundation of Manitoba;
however, there are several other addictions
agencies funded by Manitoba Health. These
agencies work to reduce the harm associated with
alcohol, other drugs and gambling through
education, prevention, rehabilitation and research.
Primary Health Care
In 2003-2004, each Regional Health Authority
developed and submitted a regional primary
health care (PHC) operational plan to the
Manitoba government.
These plans are based on the findings of regional
community health assessments, include
implementation and communication strategies,
measurable outcomes and alignment with the
Province’s PHC Policy Framework (approved
April 9, 2002).
With the federal Primary Health Care Transition
Fund (PHCTF) per capita allocation, Manitoba
Health developed a two-phase approach to
developing PHC in Manitoba.
Phase 1 focused on five initiatives to address
challenges to the effective delivery of PHC and
provide a foundation for future Regional Health
Authority-based reforms.
Phase 2 provided PHCTF dollars for initiatives
developed by the Regional Health Authorities in
partnership with key stakeholders. Seventeen
projects were approved. Themes for the initiatives
include service integration, community access to
primary care, interdisciplinary training, change
management techniques, community capacity
building, information technology and capital
infrastructure.
A provincial standard for the provision of
midwifery care was introduced in 2002. The
standard provides provincial direction in terms of
annual workload, service levels for priority
127
Chapter 3 – Manitoba
population clients, and requirements that the
midwives be integrated into the Regional Health
Authority health care system. Midwifery resources
in Manitoba comprise 30 midwives working in nine
practice groups in six Regional Health Authorities.
cost-effective services to the local community.
Access River East opened to the public in
February 2004. Access Transcona and Access
Inkster are in the planning stages.
In 1999, the Manitoba government approved-inprinciple the Winnipeg Regional Health Authority's
concept for the Health Access Model based on
the principles of primary health care. Key
components of the centres are service integration,
primary care clinics and the organizational
infrastructure to facilitate timely, efficient and
Ambulatory Health Care Services
128
The Health Services Insurance Act includes a
provision authorizing the designation of non profit
publicly administered ambulatory health (primary
care) centres as institutions within the meaning of
the Act.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Manitoba
Registered Persons
1. Number as of March 31st (#).
1
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
1,144,424
1,149,904
1,152,982
1,156,217
1,159,784
Insured Hospital Services Within Own Province or Territory
Public Facilities
1999-2000
2000-2001
2001-2002
2. Number (#):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
95
42
not available
not applicable
99
95
32
not available
not applicable
98
96
32
not available
not applicable
99
3. Payments ($):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
not available
not available
not available
not available
not available
953,834,797
65,153,895
not available
not available
not available
1,046,407,229
70,872,152
not available
not available
not available
1,148,652,940
107,840,132
not available
not available
not available
1,220,253,362
117,642,127
not available
not available
not available
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
4. Number (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
1
0
1
1
0
1
5. Number of insured hospital services
provided (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not available
0
not available
not available
0
not available
6. Payments ($):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not available
0
not available
1,252,657
0
1,252,657
Private For-Profit Facilities
Canada Health Act Annual Report, 2003-2004
2002-2003
2003-2004
92
52
not available
not available
97
92
52
not available
not available
97
129
Chapter 3 – Manitoba
Insured Physician Services Within Own Province or Territory
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
7. Number of participating physicians (#):
a. general practitioners
915
b. specialists
939
c. other
not applicable
d. total
1,854
948
not available
not applicable
not available
not available
not available
not applicable
not available
954
1,010
not applicable
1,964
959
980
not applicable
1,939
8. Number of opted-out physicians (#):
a. general practitioners
b. specialists
c. other
d. total
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
9. Number of not participating
physicians (#):
a. general practitioners
b. specialists
c. other
d. total
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
10. Number of services provided through
fee for service (#):
a. general practitioners
b. specialists
c. other
d. total
5,931,022
8,147,749
not applicable
14,078,771
6,211,011
8,741,628
not applicable
14,952,639
6,244,197
9,198,787
not applicable
15,442,984
6,161,451
9,779,269
not applicable
15,940,720
6,224,463
10,044,381
not applicable
16,268,844
11. Total payments to physicians paid
through fee for service ($):
a. general practitioners
b. specialists
c. other
d. total
114,868,502
178,359,474
not applicable
293,227,976
132,200,004
199,231,274
not applicable
331,431,278
140,703,474
214,392,377
not applicable
355,095,851
143,846,209
221,948,290
not applicable
365,794,499
152,393,920
232,153,861
not applicable
384,547,781
12. Average payment per fee for service
service ($):
a. general practitioners
b. specialists
c. other
d. all services
19.37
21.89
not applicable
20.83
21.28
22.79
not applicable
22.17
22.53
23.31
not applicable
22.99
23.35
22.70
not applicable
22.95
24.48
23.11
not applicable
23.64
13. Number of services provided through
all payment methods (#):
a. medical
b. surgical
c. diagnostic
d. other
e. total
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
14. Total payments to physicians paid
through all payment methods ($):
a. medical
b. surgical
c. diagnostic
d. other
e. total
not available
not available
not available
not available
416,902,176
not available
not available
not available
not available
467,886,678
not available
not available
not available
not available
496,268,700
not available
not available
not available
not available
521,611,200
not available
not available
not available
not available
559,271,513
15. Average payment per service, all
payment methods ($):
a. medical
b. surgical
c. diagnostic
d. other
e. all services
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
130
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Manitoba
Insured Services Provided to Residents in Another Province or Territory
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
2,571
3,037
2,892
2,714
2,928
21,570
29,217
26,479
26,059
31,100
18. Total payments, in-patient ($).
8,655,520
12,152,757
11,427,627
12,918,117
16,290,426
19. Total payments, out-patient ($).
2,694,973
4,089,018
3,776,489
3,783,059
4,369,889
20. Average payment, in-patient ($).
3,366.60
4,001.57
3,951.50
4,759.81
5,563.67
124.94
139.87
142.60
145.17
140.51
Physicians
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
22. Number of services (#).
183,497
192,272
211,464
212,795
210,294
5,568,205
6,148,444
7,381,785
7,691,159
30.340
31.980
34.900
36.14
7,579,028
1
36.00
16. Total number of claims, in-patient (#).
17. Total number of claims,
out-patient (#).
21. Average payment, out-patient ($).
23. Total payments ($).
24. Average payment per service ($).
Insured Services Provided Outside Canada
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
565
567
557
569
418
6,053
6,335
6,676
6,025
6,069
1,028,127
1,065,302
2,008,580
1,847,910
, 1,348,148
,
28. Total payments, out-patient ($).
905,479
2,435,560
3,267,764
914,251
1,216,073
29. Average payment, in-patient ($).
1,819.69
1,878.84
3,607.40
3,249.89
3,225.00
149.59
384.46
489.00
151.73
200.00
Physicians
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
31. Number of services (#).
7,116
6,763
6,345
5,826
5,324
520,712
500,757
529,029
607,066
519,782
73.17
74.04
83.40
104.20
98.00
25. Total number of claims, in-patient (#).
26. Total number of claims,
out-patient (#).
27. Total payments, in-patient ($).
30. Average payment, out-patient ($).
32. Total payments ($).
33. Average payment per service ($).
Insured Surgical-Dental Services Within Own Province or Territory
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
105
101
not available
116
102
3,318
3,256
3,401
3,455
3,498
590,125
660,870
677,295
714,590
750,122
177.86
202.97
199.15
206.83
214.44
34. Number of particpating dentists (#).
35. Number of services provided (#).
36. Total payments ($).
37. Average payment per service ($).
Canada Health Act Annual Report, 2003-2004
131
Chapter 3 – Manitoba
Endnotes
1. The population data is based on records of residents registered with Manitoba Health as of June 1.
2. Includes both chronic care and rehabilitative care.
132
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Saskatchewan
new policies and initiatives to ensure diversity
within the health care sector; negotiations to
increase compensation for physicians and nurses;
and many, many more.
Saskatchewan
Introduction
In 2003-2004, Saskatchewan Health continued to
progress toward fulfilling the goals outlined in our
Action Plan. Released in December 2001, Healthy
People. A Healthy Province. The Action Plan for
Saskatchewan Health Care outlines our vision for
the future of health care and provides a blueprint
for the continued delivery of accessible, quality
health care in Saskatchewan.
Saskatchewan Health continues to look ahead, to
plan and to build a health care system that can
provide access to quality services today and into
the future. However, we recognize that there are a
number of issues that need to be factored into our
future plans including: sustainability, recruitment
and retention of health care providers, access to
services and changing demographics.
Saskatchewan Health plays a leadership role in
health program and policy development for our
province. This involves working in partnership with
regional health authorities and key stakeholders
including community organizations, professional
associations, post-secondary educational
institutions, unions, consumers and other
provincial and federal government departments.
Our top priority is to improve the quality of health
care and services, while ensuring our health
system remains sustainable into the future. In
2003-2004, we progressed towards this goal with
initiatives such as: the development and launch of
HealthLine; our work with the regional health
authorities and physicians’ organizations to better
manage surgical access by implementing the
Surgical Patient Registry and Target Time Frames;
Canada Health Act Annual Report, 2003-2004
In 2003-2004, the Saskatchewan government
invested $2.527 billion in health care. This
represents an increase of 7.9 percent or
$184 million over the previous year. Health care
continues to be a priority for the people of
Saskatchewan. The government responded to this
priority by increasing our health care investment
to 42 percent of program spending in 2003-2004.
The following list provides only a snapshot of
some of the successes related to The Action Plan
for Saskatchewan Health Care over the past year.
† HealthLine was introduced in August 2003.
During its first eight months of
implementation, registered nurses answered
over 40,000 health care questions.
† In its first full year of operation, the Health
Quality Council helped enhance the efficiency
and accountability of the health care system
and inform the public about the quality of
health services in the province through:
† developing its first strategic plan to improve
evidence-based decision making in the
sector;
† developing and launching the Quality
Improvement Network; and,
† launching an Innovation Fund, which
invested $170,000 to support new ideas in
quality improvement.
† Surgical access was improved by developing
and launching the Surgical Patient Registry
and target time frames.
† 165 students received $700,000 in
undergraduate nursing bursaries, and another
nine bursaries were awarded to Registered
Nurses studying to become primary care nurse
practitioners.
† Several capital projects were launched and
several were completed in 2003-2004: the
Parkland Regional Care Centre in Melfort; the
All Nations Healing Hospital in Fort
Qu’Appelle; the Tatagwa View Long-term Care
Facility in Weyburn; a jointly used facility in Ileà-la Crosse; the maternal and newborn care
133
Chapter 3 – Saskatchewan
centre at the Regina General Hospital; and the
new Cypress Hills Regional Hospital.
In 2003-2004, we continued to build a foundation
for change, as outlined in The Action Plan for
Saskatchewan Health Care. The first step was to
reconfigure the 32 health districts into 12 regional
health authorities in 2002-2003. In 2003-2004,
regional health authorities worked with
Saskatchewan Health to implement a better way
of managing investment, linking dollars to results,
and promoting quality and accountability.
In 2003-2004, the government invested almost
$1.7 billion in the regional health authorities for
hospital-based services, long-term and community
care, primary health care, and other locally
targeted health care services such as:
† about 800,000 days of in-patient hospital
stays;
† about 72,000 Computed Tomography (CT)
scans and 12,750 Magnetic Resonance
Imaging (MRI) scans; and
† about 94,000 surgeries or about 258 per day.
In Canada, both the federal and provincial
governments play a role in providing health care.
The federal government provides funding to
support health, education and social services
through Canada Health and Social Transfer
(CHST). It also provides health services to certain
members of the population (e.g., veterans,
military personnel and First Nations on reserve)
and maintains safety for food and drugs in
Canada. Provincial governments have
responsibility for most other aspects of health
care delivery. Saskatchewan Health sets policy
and standards for health services and administers
the Province’s annual health budget of almost
$2.6 billion.
1.0 Public Administration
1.1 Health Care Insurance Plan and
Public Authority
hospital, physician and surgical-dental services in
Saskatchewan. Section 6.1 of The Department of
Health Act authorizes that the Minister of Health
may:
† pay part of, or the whole of, the cost of
providing health services for any persons or
classes of person that may be designated by
the Lieutenant Governor in Council;
† make grants or loans or provide subsidies to
regional health authorities, health care
organizations or municipalities for providing
and operating health services or public health
services;
† pay part of or the whole of the cost of
providing health services in any health region
or part of a health region in which those
services are considered by the Minister to be
required;
† make grants or provide subsidies to any health
agency that the Minister considers necessary;
and
† make grants or provide subsidies to stimulate
and develop public health research and to
conduct surveys and studies in the area of
public health.
Sections 8 and 9 of The Saskatchewan Medical
Care Insurance Act provide the authority for the
Minister of Health to establish and administer a
plan of medical care insurance for residents. The
Regional Health Services Act provides the
authority to establish 12 regional health
authorities, replacing the former 32 district health
boards.
Sections 5 and 11 of The Cancer Foundation Act
provide for establishing a Saskatchewan Cancer
Agency and for the Agency to coordinate a
program for diagnosing, preventing and treating
cancer.
The mandates of the Department of Health,
regional health authorities and the Saskatchewan
Cancer Agency for 2003-2004 are outlined in The
Department of Health Act, The Regional Health
Services Act and The Cancer Foundation Act.
The provincial government is responsible for
funding and ensuring the provision of insured
134
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Saskatchewan
1.2 Reporting Relationship
The Department of Health is directly accountable
to, and regularly reports to, the Minister of Health
on the funding and administering funds for insured
physician, surgical-dental and hospital services.
Section 36 of The Saskatchewan Medical Care
Insurance Act prescribes that the Minister of
Health submit an annual report concerning the
medical care insurance plan to the Legislative
Assembly.
The Regional Health Services Act prescribes that
a regional health authority shall submit to the
Minister of Health:
† a report on the activities of the regional health
authority; and
† a detailed, audited set of financial statements.
Section 54 of The Regional Health Services Act
requires that the regional health authority shall
submit to the Minister any reports that the
Minister may request from time to time. All
regional health authorities are required to submit
a financial and health service plan to
Saskatchewan Health.
The Cancer Foundation Act prescribes that the
Cancer Foundation shall, in each fiscal year,
submit a report about its business and a financial
statement to the Minister of Health for the fiscal
year immediately preceding.
1.3 Audit of Accounts
The Provincial Auditor conducts an annual audit of
government departments and agencies, including
Saskatchewan Health. It includes an audit of
departmental payments to regional health
authorities, the Saskatchewan Cancer Agency and
to physicians and dental surgeons for insured
physician and surgical-dental services. The
Provincial Auditor may also conduct audits of
regional health authority boards. The Provincial
Auditor independently determines the scope and
frequency of his or her audits based on accepted
professional standards.
Section 57 of The Regional Health Services Act
requires that an independent auditor, who
Canada Health Act Annual Report, 2003-2004
possesses the prescribed qualification and is
appointed for that purpose by the regional health
authority, shall audit the accounts of a regional
health authority at least once in every fiscal year.
A detailed, audited set of financial statements
must be submitted annually, by each regional
health authority, to the Minister of Health.
Section 34 of The Cancer Foundation Act
prescribes that the records and accounts of the
Foundation shall be audited at least once a year
by the Provincial Auditor or by a designated
representative.
2.0 Comprehensiveness
2.1 Insured Hospital Services
The Regional Health Services Act was proclaimed
on August 1, 2002, to replace The Health Districts
Act as the authority to amalgamate the existing
32 health districts into 12 regional health
authorities. Section 8 of The Regional Health
Services Act gives the Minister the authority to
provide funding to a regional health authority or a
health care organization for the purpose of the
Act.
Section 10 of The Regional Health Services Act
permits the Minister to designate facilities
including hospitals, special-care homes and health
centres. Section 11 prescribes standards for
delivering services in those facilities by regional
health authorities and health care organizations
that have entered into service agreements with a
regional health authority.
The Act sets out new accountability requirements
for regional health authorities and health care
organizations. These requirements include
submitting annual operational and financial and
health service plans for Ministerial approval
(sections 50-51), establishing community advisory
networks (section 28) and reporting critical
incidents (section 58). The Minister also has the
authority to establish a provincial surgical registry
to help manage surgical wait times (section 12).
The Minister retains authority to inquire into
135
Chapter 3 – Saskatchewan
matters (section 59), appoint a public
administrator if necessary (section 60) and
approve general and staff practitioner bylaws
(sections 42-44).
Funding for hospitals is included in the funding
provided to regional health authorities.
As of March 31, 2004, the following facilities were
providing insured hospital services to both in- and
out-patients:
† 66 acute care hospitals provided in- and outpatient services; and
† one rehabilitation hospital provided treatment,
recovery and rehabilitation care for patients
disabled by injury or illness. Rehabilitation
services are also provided in a geriatric
rehabilitation unit in one other hospital and in
two special-care facilities.
The Hospital Standards Act and The Hospital
Standards Regulations (1980) established
minimum standards for care and certain
administrative requirements for hospitals.
With the passage of The Regional Health Services
Act, Saskatchewan plans to incorporate those
provisions relating to hospital organization and
program standards under the new Act; thereby,
allowing for the repeal of The Hospital Standards
Act and The Hospital Standards Regulations
(1980).
A comprehensive range of insured services is
provided by hospitals. These may include:
† public ward accommodation;
† necessary nursing services;
† the use of operating room and case room
facilities;
† required medical and surgical materials and
appliances;
† x-ray, laboratory, radiological and other
diagnostic procedures;
† radiotherapy facilities;
† anaesthetic agents and the use of anaesthesia
equipment;
† physiotherapeutic procedures;
† all drugs, biological and related preparations
required for hospitalized patients; and
† services rendered by individuals who receive
remuneration from the hospital.
136
The Action Plan for Saskatchewan Health Care
establishes new hospital categories and outlines a
standard array of services that should be available
in each hospital. Hospitals are grouped into the
following five categories: Community Hospitals,
Northern Hospitals, District Hospitals, Regional
Hospitals and Provincial Hospitals.
One of the elements of the Action Plan is to
provide reliable, predicable hospital services, so
people know what they can expect 24 hours a day,
365 days a year. While not all hospitals will offer
the same kinds of services, reliability and
predictability means:
† it is widely understood which services each
hospital offers; and
† these services are always there when needed.
This service delivery framework will ensure
quality, predictable hospital services and help
guide decisions about where to invest new funds.
Regional health authorities have the authority to
change the manner in which they deliver insured
hospital services based on an assessment of their
population health needs and available health
professional funding resources.
The process for adding a hospital service to the
list of services covered by the health care
insurance plan involves a comprehensive review,
considering such factors as service need,
anticipated service volume, health outcomes by
the proposed and alternative services, cost and
human resource requirements, including
availability of providers as well as initial and
ongoing competency assurance demands.
Depending on the specific service request,
consultations could involve several branches
within Saskatchewan Health as well as external
stakeholder groups such as health regions, service
providers and the public.
2.2 Insured Physician Services
Sections 8 and 9 of The Saskatchewan Medical
Care Insurance Act enable the Minister of Health
to establish and administer a plan of medical care
insurance for provincial residents. Amendments
were made in April and October 2003, to the
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Saskatchewan
Physician Payment Schedule of The
Saskatchewan Medical Care Insurance Payment
Regulations (1994) in accordance with an
agreement reached with the Saskatchewan
Medical Association. Those amendments provided
for the addition of new insured physician services,
changes in payment levels for selected services,
and definition or assessment rule revisions to
existing selected services with significant
monetary impact.
Physicians may provide insured services in
Saskatchewan if they are licensed by the College
of Physicians and Surgeons of Saskatchewan and
have agreed to accept payment from the
Department of Health without extra billing for
insured services.
As of March 31, 2004, there were 1,662
physicians licensed to practice in the province and
eligible to participate in the medical care
insurance plan.
Physicians may opt out or not participate in the
Medical Services Plan, but if doing so, must fully
opt out of all insured physician services. The
“opted out” physician must also advise
beneficiaries that the physician services to be
provided are not insured and that the beneficiary
is not entitled to be reimbursed for those services.
Written acknowledgement from the beneficiary
indicating that he or she understands the advice
given by the physician is also required.
As of March 31, 2004, there were no “opted out”
physicians in Saskatchewan.
Insured physician services are those that are
medically necessary, are covered by the Medical
Services Plan of the Department of Health and
are listed in the Physician Payment Schedule of
The Saskatchewan Medical Care Insurance
Payment Regulations (1994) of The Saskatchewan
Medical Care Insurance Act.
There were approximately 3,000 different insured
physician services as of March 31, 2004.
A process of formal discussion between the
Medical Services Plan and the Saskatchewan
Medical Association addresses new insured
physician services and definition or assessment
Canada Health Act Annual Report, 2003-2004
rule revisions to existing selected services
(modernization) with significant monetary impact.
The Executive Director of the Medical Services
Branch manages this process. When the Medical
Services Plan covers a new insured physician
service or significant revisions occur to the
Physician Payment Schedule, a regulatory
amendment is made to the Physician Payment
Schedule.
Although formal public consultations are not held,
any member of the public may make
recommendations about physician services to be
added to the Plan.
2.3 Insured Surgical-Dental
Services
Dentists registered with the College of Dental
Surgeons of Saskatchewan and designated by the
College as specialists able to perform dental
surgery may provide insured surgical-dental
services under the Medical Services Plan. As of
March 31, 2004, 94 dental specialists were
providing such services.
Amendments were made in April 2003, to The
Saskatchewan Medical Insurance Branch Payment
Schedule for Insured Services Provided by a
Dentist. Those amendments provided for changes
in payment levels for selected services.
Dentists may opt out or not participate in the
Medical Services Plan, but if doing so, must opt
out of all insured surgical-dental services. The
dentist must also advise beneficiaries that the
surgical-dental services to be provided are not
insured and that the beneficiary is not entitled to
reimbursement for those services. Written
acknowledgement from the beneficiary indicating
that he or she understands the advice given by
the dentist is also required.
There were no “opted out” dentists in
Saskatchewan as of March 31, 2004.
Insured surgical-dental services are those that are
medically necessary and must be carried out in a
hospital. Such services include:
† oral surgery required in hospital as a result of
trauma;
137
Chapter 3 – Saskatchewan
† treatment for infants with cleft palate;
† hospital-based dental care to support
medical/surgical care (e.g., extractions when
medically necessary); and
† surgical treatment for temporomandibular joint
dysfunction.
Surgical-dental services can be added to the list
of insured services covered under the Medical
Services Plan through a process of discussion and
consultation with provincial dental surgeons. The
Executive Director of the Medical Services Branch
manages the process of adding a new service.
Although formal public consultations are not held,
any member of the public may recommend that
surgical-dental services be added to the Medical
Services Plan.
2.4 Uninsured Hospital, Physician
and Surgical-Dental Services
Uninsured hospital, physician and surgical-dental
services in Saskatchewan include:
† in-patient and out-patient hospital services
provided for reasons other than medical
necessity;
† the extra cost of private and semi-private
hospital accommodation not ordered by a
physician;
† physiotherapy and occupational therapy
services not provided by or under contract with
a regional health authority;
† services provided by health facilities other than
hospitals unless through an agreement with
Saskatchewan Health;
† non-emergency cataract and non-emergency
diagnostic imaging services provided outside
Saskatchewan without prior written approval;
† non-emergency insured hospital, physician or
surgical-dental services obtained outside
Canada without prior written approval;
† non-medically required elective physician
services;
† surgical-dental services that are not medically
necessary or are not required to be performed
in a hospital; and
† services covered by the Saskatchewan
Workers’ Compensation Board.
138
As a matter of policy and principle, insured
hospital, physician and surgical-dental services
are provided to residents on the basis of assessed
clinical need. Compliance is periodically monitored
through consultation with regional health
authorities, physicians and dentists. There are no
charges allowed in Saskatchewan for medically
necessary hospital, physician or surgical-dental
services. Charges for enhanced medical services
or products are permitted only if the medical
service or product is not deemed medically
necessary. Compliance is monitored through
consultations with regional health authorities,
physicians and dentists.
Insured hospital services could be de-insured by
the government if they were determined to be no
longer medically necessary. The process is based
on discussions among regional health authorities,
practitioners and officials from the Department of
Health.
Insured surgical-dental services could be deinsured if they were determined to not be
medically necessary or if they were not required
to be carried out in a hospital. The process is
based on discussion and consultation with the
dental surgeons of the province and managed by
the Executive Director of the Medical Services
Branch.
Insured physician services could be de-insured if
they were determined to not be medically
required. The process is based on consultations
with the Saskatchewan Medical Association and
managed by the Executive Director of the Medical
Services Branch.
Formal public consultations about de-insuring
hospital, physician or surgical-dental services may
be held if warranted.
No health services were de-insured in 2003-2004.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Saskatchewan
3.0 Universality
3.1 Eligibility
The Saskatchewan Medical Care Insurance Act
(sections 2 and 12) and The Medical Care
Insurance Beneficiary and Administration
Regulations define eligibility for insured health
services in Saskatchewan. Section 11 of the Act
requires that all residents register for provincial
health coverage. There were no changes to this
legislation during 2003-2004.
Eligibility is limited to residents. A “resident”
means a person who is legally entitled to remain
in Canada, who makes his or her home and is
ordinarily present in Saskatchewan, or any other
person declared by the Lieutenant Governor in
Council to be a resident. Canadian citizens and
permanent residents of Canada relocating from
within Canada to Saskatchewan are generally
eligible for coverage on the first day of the third
month of establishing residency in Saskatchewan.
Returning Canadian citizens, the families of
returning members of the Canadian Forces,
international students and international workers
are eligible for coverage on establishing residency
in Saskatchewan, provided that residency is
established before the first day of the third month
following their admittance to Canada.
The following persons are not eligible for insured
health services in Saskatchewan:
† members of the Canadian Forces and the
Royal Canadian Mounted Police (RCMP),
federal inmates and refugee claimants;
† visitors to the province; and
† persons eligible for coverage from their home
province or territory for the period of their stay
in Saskatchewan (e.g., students and workers
covered under temporary absence provisions
from their home province or territory).
Such people become eligible for coverage as
follows:
† discharged members of the Canadian Forces
and the RCMP, if stationed in or resident in
Saskatchewan on their discharge date;
Canada Health Act Annual Report, 2003-2004
† released federal inmates (this includes those
prisoners who have completed their sentences
in a federal penitentiary and those prisoners
who have been granted parole and are living in
the community); and
† refugee claimants, on receiving Convention
Refugee status (immigration documentation is
required).
3.2 Registration Requirements
The following process is used to issue a health
services card and to document that a person is
eligible for insured health services:
† every resident, other than a dependent child
under 18 years, is required to register;
† registration should take place immediately
following the establishment of residency in
Saskatchewan;
† registration can be carried out either in person
in Regina or by mail;
† each eligible registrant is issued a plastic
health services card bearing the registrant’s
unique lifetime nine-digit health services
number; and
† cards are renewed every three years. (Current
cards expire in December 2005.)
All registrations are family-based. Parents and
guardians can register dependent children in their
family units if they are under 18 years of age.
Children 18 and over living in the parental home
or on their own must self-register.
The number of persons registered for health
services in Saskatchewan on June 30, 2003, was
1,007,753.
3.3 Other Categories of Individual
Other categories of individual who are eligible for
insured health service coverage include persons
allowed to enter and remain in Canada under
authority of a work permit, student permit or
Minister’s permit issued by Citizenship and
Immigration Canada. Their accompanying family
may also be eligible for insured health service
coverage.
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Chapter 3 – Saskatchewan
Refugees are eligible on confirmation of
Convention status combined with an
employment/student permit, Minister’s permit or
permanent resident, that is, landed immigrant,
record.
As of June 30, 2003, there were 4,622 such
temporary residents registered with
Saskatchewan Health.
4.0 Portability
4.1 Minimum Waiting Period
In general, insured persons from another province
or territory who move to Saskatchewan are
eligible on the first day of the third month
following establishment of residency. However,
where one spouse arrives in advance of the other,
the eligibility for the later arriving spouse is
established on the earlier of a) the first day of the
third month following arrival of the second spouse;
or b) the first day of the thirteenth month
following the establishment of residency by the
first spouse.
4.2 Coverage During Temporary
Absences in Canada
Section 3 of The Medical Care Insurance
Beneficiary and Administration Regulations of The
Saskatchewan Medical Care Insurance Act
prescribes the portability of health insurance
provided to Saskatchewan residents while
temporarily absent within Canada. There were no
changes to this legislation in 2003-2004.
Continued coverage during a period of temporary
absence is conditional upon the registrant’s intent
to return to Saskatchewan residency immediately
on expiration of the approved absence period as
follows:
† education: for the duration of studies at a
recognized educational facility (written
confirmation by a Registrar of full-time student
status is required annually);
140
† employment of up to 12 months (no
documentation required); and
† vacation and travel of up to 12 months.
Section 6.6 of The Department of Health Act
provides the authority for payment of in-patient
hospital services to Saskatchewan beneficiaries
temporarily residing outside the province. Section
10 of The Saskatchewan Medical Care Insurance
Payment Regulations (1994) provides payment for
physician services to Saskatchewan beneficiaries
temporarily residing outside the province.
Saskatchewan has bilateral reciprocal billing
agreements with all provinces for hospital services
and all but Quebec for physician services. Rates
paid are at the host province rates. The reciprocal
arrangement for physician services applies to
every province except Quebec. Payments/
reimbursement to Quebec physicians, for services
to Saskatchewan residents, are made at
Saskatchewan rates (Saskatchewan Physician
Payment Schedule). However, the physician fees
will be paid at Quebec rates with prior approval.
The out-of-province reciprocal hospital per diem
billing rates have recently increased significantly.
In 2003-2004, expenditures for insured physician
services in other provinces were $19.48 million.
Insured hospital services in other provinces were
$36.93 million.
4.3 Coverage During Temporary
Absences Outside Canada
Section 3 of The Medical Care Insurance
Beneficiary and Administration Regulations of The
Saskatchewan Medical Care Insurance Act
describes the portability of health insurance
provided to Saskatchewan residents who are
temporarily absent from Canada.
Continued coverage for students, temporary
workers and vacationers and travelers during a
period of temporary absence from Canada is
conditional on the registrant’s intent to return to
Saskatchewan residence immediately on the
expiration of the approved period as follows:
† education: for the duration of studies at a
recognized educational facility (written
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Saskatchewan
confirmation by a Registrar of full-time student
status is required annually);
† employment of up to 24 months (written
confirmation from the employer is required);
and
† vacation and travel of up to 12 months.
Section 6.6 of The Department of Health Act
provides the authority under which a resident is
eligible for health coverage when temporarily
outside Canada. In summary, a resident is eligible
for medically necessary hospital services at the
rate of $100 per in-patient and $50 per outpatient visit per day.
In 2003-2004, $728,400 was paid for in-patient
hospital services and $373,300 was spent on outpatient hospital services outside Canada. In 20032004, expenditures for insured physician services
outside Canada were $583,200.
4.4 Prior Approval Requirement
Out-of-Province
Saskatchewan Health covers most hospital and
medical care received by its residents in Canada
through a reciprocal billing arrangement. This
arrangement means that residents do not need
prior approval and may not be billed for most
services received in other provinces or territories
while travelling within Canada. The cost of travel,
meals and accommodation are not covered.
Prior approval is required for the following
services provided out-of-province:
† alcohol and drug, mental health and problem
gambling services; and
† cataract surgery services, bone densitometry
(outside of hospitals) and non-urgent Magnetic
Resonance Imaging (MRI), because
Saskatchewan Health does not normally cover
these services out-of-province.
Before the Department of Health funds nonurgent services for a Saskatchewan resident in
another province or territory, prior approval from
the Department must be obtained by the patient’s
specialist.
Canada Health Act Annual Report, 2003-2004
Out-of-Country
Prior approval is required for the following
services provided outside Canada:
† If a specialist physician refers a patient outside
Canada for treatment not available in
Saskatchewan or another province, the
referring specialist must seek prior approval
from the Medical Services Plan of
Saskatchewan Health. Requests for out-ofcountry cancer treatment must be approved by
the Saskatchewan Cancer Agency. If approved,
Saskatchewan Health will pay the full cost of
treatment, excluding any items that would not
be covered in Saskatchewan.
† Saskatchewan Health does not normally cover
elective (non-emergency) hospital, physician,
optometric and chiropractic services; therefore,
prior approval is required.
5.0 Accessibility
5.1 Access to Insured Health
Services
To ensure that access to insured hospital,
physician and surgical-dental services is not
impeded or precluded by financial barriers, extrabilling by physicians or dental surgeons and user
charges by hospitals for insured health services
are not allowed in Saskatchewan.
The Saskatchewan Human Rights Code prohibits
discrimination in providing public services, which
include insured health services on the basis of
race, creed, religion, colour, sex, sexual
orientation, family status, marital status, disability,
age, nationality, ancestry or place of origin.
5.2 Access to Insured Hospital
Services
As of March 31, 2004, Saskatchewan had 3,015
staffed hospital beds in 66 acute care hospitals,
including 2,446 acute care beds, 236 psychiatric
beds and 333 other beds. The Wascana
Rehabilitation Centre had 43 rehabilitation beds
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Chapter 3 – Saskatchewan
and 205 extended care beds. Rehabilitation
services are also provided in a Geriatric
Rehabilitation Unit in one acute care hospital and
in two special care facilities.
Keeping and attracting key health providers, such
as nurses, to provide insured hospital services
continues to be a top priority for Saskatchewan
Health. Tracking the actual number of people who
work in the health professions can be difficult
because people move and change jobs, hours of
work or even careers.
One way to measure our health care workforce is
to count how many providers are registered in the
province. The professional regulatory bodies in
Saskatchewan do this every year. Much of this
information is reported to the Canadian Institute
for Health Information (CIHI), allowing
comparisons with other provinces.
According to the three professional regulatory
bodies for nursing in Saskatchewan, in 2003 there
were 12,063 nurses in Saskatchewan, an overall
increase from the 11,940 nurses reported in 2002.
The number of nurses and ratio of nurses to the
provincial population has stabilized over the past
five years. This is a positive trend. Other trends
such as the aging of the nursing workforce
indicate we need to continue efforts at retaining
and recruiting nurses.
There are signs of progress that show nursing
graduates are more enthusiastic about remaining
in Saskatchewan. Over the past couple of years,
our province has retained about 80 percent of
graduates from our nursing education program.
The number of Registered Nurses (RN) per capita
in Saskatchewan in 2002 (81.8 per 10,000
population) is higher than the Canadian average
(73.4 per 10,000 population). This also represents
a slight decrease from 1998 for Saskatchewan
(82.4). There is also considerable variation in RN
per population ratios across Canada, from a low
of 65 per 10,000 in Ontario to a high of 117.6 in
the Northwest Territories.
Listed below are some of the 2003-2004
initiatives implemented to improve the retention
and recruitment of health care providers:
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† A nursing bursary program of $500,000
provided to students training to be future
Registered Nurses, Licensed Practical Nurses
and Registered Psychiatric Nurses was
continued. The Province introduced Primary
Care Nurse Practitioner bursaries for
individuals studying to become nurse
practitioners in Saskatchewan.
† A northern nursing program with 40 seats for
Aboriginal students delivered through the First
Nations University of Canada was continued.
† Access to the Nursing Education Program of
Saskatchewan (NEPS) has been enhanced
through distance delivery. The entire first year
of the program is available by distance
learning. The development of a Bachelor of
Science in Nursing second-degree program will
begin in 2005-2006.
† Over the past three years, $960,000 has been
provided for projects related to quality
workplaces, nursing workforce casualization
and the retention of nursing graduates. The
Quality Workplace Program pilot projects were
evaluated and new sites in other locations in
the province were added to the program.
† Saskatchewan Health provided professional
development funding to the regional health
authorities to support the orientation and
workload relief for nurse preceptors and also
made conflict resolution workshops available to
all regional health authority staff.
† Saskatchewan Health provided funding to
regional health authorities to support
Aboriginal Awareness training in the health
care system.
† Saskatchewan Health initiated a supplydemand study of medical diagnostic
disciplines. Results of the study will be
available in fall 2004 and will be used to
determine future need.
† A new four-seat cytology program at the
Saskatchewan Institute of Applied Science and
Technology (SIAST) started in fall 2003.
† Nuclear Medicine graduates from a program
purchased from the Southern Alberta Institute
of Technology (SAIT), Calgary, entered the
labour force for the first time. SAIT continues
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Saskatchewan
†
†
†
†
†
to accept four Saskatchewan students
annually.
SAIT has also entered into a contract with the
Province of Saskatchewan to train respiratory
therapy students for the Saskatchewan
market. Eight students are accepted annually.
The first graduates will be available to work in
Saskatchewan in 2004-2005.
The 2003 Health Human Resource Report on
the health providers working in
Saskatchewan’s regional health authorities
was produced.
Saskatchewan Health provided funding to
explore the challenges and opportunities for
entry-level staff to achieve job satisfaction and
career advancement through career laddering.
This project is ongoing.
Provincial health human resource planning
guidelines were developed and serve as a
foundation for building future strategies and
initiatives. Human resource performance
expectations and indicators were developed
and will form the basis of accountability
frameworks between major third parties and
the Province.
Saskatchewan Health worked with
Saskatchewan Government Relations and
Aboriginal Affairs and a variety of nursing
partners to expand the Saskatchewan
Immigrant Nominee Program to include the
nursing professions.
Aside from nurses and physicians, there is a wide
range of other health care professionals who are
also vital to the provision of quality care.
Registration data for these professionals –
including technologists, therapists and
pharmacists – indicates that the number of these
professionals working in Saskatchewan has for
the most part increased over the past decade.
Regarding the availability of selected diagnostic,
medical, surgical and treatment equipment and
services in facilities providing insured hospital
services, Saskatchewan Health notes the
following.
† MRI machines are located in Saskatoon (2)
and Regina (1). Regina Qu’Appelle Regional
Health Authority has received approval and is
Canada Health Act Annual Report, 2003-2004
†
†
†
†
†
in the process of acquiring a second MRI. It is
planned to be operating in 2005-2006.
CT scanners are available in Saskatoon (3),
Regina (3), Prince Albert (1) and Swift
Current/Moose Jaw (1). In 2003-2004, three
additional CT scanners were purchased for the
following regional health authorities: one each
for Five Hills (Moose Jaw), Cypress (Swift
Current) and Sunrise (Yorkton). These
machines will be operating in 2004-2005. The
portable scanner that was shared between
Swift Current and Moose Jaw was traded in.
Renal dialysis is provided at Saskatoon,
Regina, Lloydminster, Prince Albert, Tisdale,
Yorkton, Swift Current and North Battleford.
Another satellite unit will begin operating in
2004-2005 in Moose Jaw.
Cancer treatment services are provided by the
Saskatchewan Cancer Agency’s two cancer
clinics, the Saskatoon Cancer Centre and the
Allan Blair Cancer Centre in Regina. In 20032004, approximately 4,700 new patients began
treatment for cancer. Both centres provided
approximately 35,000 radiation therapy
treatments and 14,000 chemotherapy
treatments to cancer patients in Saskatoon
and Regina.
Twenty-one sites are involved in the
Community Oncology Program of
Saskatchewan (COPS) that allows patients to
receive chemotherapy and other supports
closer to home, while maintaining a close link
to expertise at the Cancer Centres in Regina
and Saskatoon. In 2003, over 800 patients
made approximately 6,000 visits to COPS
centres.
Approximately 73 percent of surgery services
are provided in Saskatoon and Regina, where
there are specialized physicians and staff and
the equipment to perform a full range of
surgical services. An additional 22 percent is
provided in six mid-sized hospitals in Prince
Albert, Moose Jaw, Yorkton, Swift Current,
North Battleford and Lloydminster. , with the
remaining surgery performed in smaller
hospitals across the province.
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Chapter 3 – Saskatchewan
† Telehealth Saskatchewan links continue to
provide residents in a number of rural and
remote areas with access to specialist, family
physician and other health provider services
without having to travel long distances.
A number of measures were taken in 2003-2004
to improve access to insured hospital services.
† Access and use of specialized medical imaging
services, including MRI, CT and bone mineral
density testing has grown steadily in
Saskatchewan. In 2003-2004, approximately
13,000 MRI tests and 82,000 CT tests were
performed.
† Access to renal dialysis services continues to
improve, with the opening in fall 2003 of the
dialysis satellite at the Battlefords Union
Hospital.
† The Northern Telehealth Network (NTN) has
proven to be an effective tool for clinical
consultation and continuing education in
northern Saskatchewan. Saskatchewan Health
continues to support the network and was
successful in August 2001, in securing funding
(approximately $1 million) from Health Canada
under the Canadian Health Infostructure
Partnership Program (CHIPP) for further
development of the Telehealth Saskatchewan
program. As of March 31, 2004, the Telehealth
Saskatchewan network has been established
at 17 sites in 15 communities.
† The Chronic Renal Insufficiency Clinics that
were established in the Regina and Saskatoon
regions in summer 2001 continue to grow. The
goals of these clinics are to delay the need for
dialysis and to better prepare patients in
making their treatment choices: haemodialysis,
peritoneal or home dialysis or transplant.
† The Cancer Agency is responsible for the
provincial Screening Program for Breast
Cancer. The Screening Program has seven
sites around the province and one mobile
mammography unit that travels into
communities not served by a stationary site.
The Screening Program provides mammograms
to between 34,000 and 37,000 women
annually.
144
† The Cancer Agency began implementing the
Prevention Program for Cervical Cancer in
2003. This program consists of the following
components:
† a comprehensive information system;
† recruitment and recall strategies;
† results notification;
† quality patient/client management; and
† quality assurance processes.
† The Provincial Malignant Hematology/Stem
Cell Transplant Program continues to grow. In
2003-2004, 49 patients with aggressive or
advanced blood or other system cancers
received stem cell or bone marrow transplants.
The program also became part of the
hematology clinic rotation for residents of
Internal Medicine at the University of
Saskatchewan.
Capital equipment purchases by regional health
authorities is consistent with the criteria
established under the February 2003 Health
Accord. Regional health authority acquisitions are
reviewed to ensure consistency with provincial
health strategies and priorities and Health Accord
principles. Capital equipment acquisitions in 20032004 supported enhanced access to diagnostic
imaging and surgical services.
Saskatchewan Health continues to place priority
on promoting surgical access and improving the
province’s surgical system. Saskatchewan Health,
with advice from the Saskatchewan Surgical Care
Network (SSCN) is leading several initiatives
designed to improve the management of wait
times.
One such initiative is the Surgical Patient
Registry. Information from this comprehensive
database allows the surgical care system to better
predict who will require what type of surgery in
what time frames. The Registry will improve
waitlist management, help determine system
capacity and resource requirements, and reduce
wait times for patients. The Surgical Patient
Registry operates in the following regional health
authorities: Five Hills (Moose Jaw), Sunrise
(Yorkton), Prince Albert Parkland, Prairie North
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Saskatchewan
(North Battleford/Lloydminster), Cypress (Swift
Current), Regina Qu’Appelle and Saskatoon.
Saskatchewan Health continues to participate in
the Western Canada Waiting List (WCWL)
Project, along with partner organizations from the
four western provinces. The project works closely
with physicians, the public, regional health
authorities and governments to develop and test
clinical assessment tools.
The SSCN has formed a joint Research and
Evaluation Working Group with the Western
Canada Waiting List project to formally evaluate
the Patient Assessment Tools/Process. The
Working Group will review the reliability and
validity of the tools in the context of the overall
process that combines the assessment score from
the tools with the urgency profiles of the specific
procedure. The Patient Assessment Process will
help increase consistency and fairness by
standardizing the factors physicians use to assess
their patients’ level of need for surgery. This will
help to ensure those with the greatest need for
surgeries receive it first.
In March 2004, the Minister of Health announced
Target Time Frames for Surgery. These Targets are
“performance goals” for the surgical care system
and will allow the surgical care system to better
monitor and track patients and help ensure they
receive care according to their level of need.
In January 2003, the Saskatchewan surgical Web
site was launched www.sasksurgery.ca. It
allows patients to obtain information on how long
they may expect to wait for their particular
procedure. Saskatchewan Health is currently
redesigning the Web site to improve the ability of
the site to capture and present the surgical care
system data produced by the Surgical Patient
Registry. It is anticipated that a revised Web site
launch will occur in fall 2004.
5.3 Access to Insured Physician and
Dental-Surgical Services
As of March 31, 2004, there were 1,662
physicians licensed to practice in the province and
eligible to participate in the Medical Care
Canada Health Act Annual Report, 2003-2004
Insurance Plan. Of these, 946 (56.9 percent) were
family practitioners and 716 (43.1 percent) were
specialists. This shift to more specialists in the
last two years is the result of provincial review
and certification of foreign-trained specialists and
their inclusion in the category previously occupied
by only Canadian certified specialists.
As of March 31, 2004, there were approximately
375 practising dentists and dental surgeons
located in all major centres in Saskatchewan.
Ninety-four provided services insured under the
Medical Services Plan.
A number of new or continuing initiatives were
underway in 2003-2004 to enhance access to
insured physician services and reduce waiting
times.
† A Specialist Physician Enhancement Training
Program provides grants of up to $80,000 per
year to allow practising specialists the
opportunity to obtain additional training and
requires a return service commitment.
† A pilot Regional Practice Establishment
Program provides grants of $10,000 to eligible
family physicians who establish a practice in a
regional centre for a minimum of 18 months.
† A Long-term Service Retention Program
rewards physicians who work in the province
for 10 or more years.
† A Specialist Emergency Coverage Program
compensates specialist physicians who make
themselves available to provide emergency
coverage to acute care facilities.
† A Re-entry Training Program provides two
grants annually to rural family physicians
wishing to enter specialty training, and
requires a return service commitment.
† The Specialist Recruitment and Retention Fund
Program provides bursaries to eligible
residents in specialty training for a maximum of
three years funding in return for a service
commitment.
† A Physician Recruitment Coordinator is
assisting regional health authorities and
physicians in the recruitment process.
† Rural physicians are supported through an
integrated Emergency Room Coverage and
Weekend Relief Program, which compensates
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Chapter 3 – Saskatchewan
†
†
†
†
†
†
†
†
physicians providing emergency room coverage
in rural areas and helps those communities
with fewer than three physicians to gain
access to other physicians to provide weekend
relief.
The Rural Practice Establishment Grant
Programs make grants of $18,000 to
Canadian-trained or landed immigrant
physicians who establish new practices in rural
Saskatchewan for a minimum of 18 months.
The Medical Resident Bursary Program
provides bursaries of $25,000 to family
medicine residents to help them with medical
educational expenses in return for a rural
service commitment.
The Undergraduate Medical Student Bursary
Program provides an annual grant of $15,000
to medical students who sign a return service
commitment to a rural community.
The Rural Practice Enhancement Training
Program provides income replacement to
practising rural physicians and assistance to
medical residents wishing to take specialized
training in an area of need in rural
Saskatchewan. A return service commitment is
required.
The Rural Emergency Care Continuing Medical
Education Program provides funds to rural
physicians for certification and re-certification
of skills in emergency care and risk
management. Approved physicians are
required to provide service in rural
Saskatchewan after completing an educational
program.
The Saskatchewan Medical Association is
funded to provide locum relief to rural
physicians through the Locum Service Program
while they take vacation, education or other
leave.
Support is provided to initiatives for physicians
to use allied health professionals and enhance
the integration of medical services with other
community-based services through the
Alternate Payments and Primary Health
Services Program.
The Northern Medical Services Program is a
tripartite endeavour of Saskatchewan Health,
146
Health Canada and the University of
Saskatchewan to help stabilize the supply of
physicians in northern Saskatchewan.
† The Rural Extended Leave Program supports
physicians in rural practice who want to
upgrade their skills and knowledge in areas
such as anaesthesia, obstetrics and surgery by
reimbursing educational costs and foregone
practice income for up to six weeks.
† The Rural Travel Assistance Program provides
travel assistance to rural physicians
participating in educational activities.
† The Northern Telehealth Network provides
physicians in remote or isolated areas with
access to colleagues, specialty expertise and
continuing education.
5.4 Physician Compensation
The process for negotiating compensation
agreements for insured services with physicians
and dentists is prescribed by Section 48 of The
Saskatchewan Medical Care Insurance Act as
follows:
† a Medical Compensation Review Committee is
established within 15 days of either the
Saskatchewan Medical Association or the
government providing notice to begin
discussing a new agreement;
† each party shall appoint no more than six
representatives to the Committee;
† the objective of the Committee is to prepare
an agreement respecting insured services that
is satisfactory to both parties;
† in the case that a satisfactory agreement
cannot be reached, the matter may be referred
to the Medical Compensation Review Board,
consisting of an appointee by either party who
in turn select a third member; and
† the Board has the authority to make a decision
binding on the parties.
In June 2003, a new three-year agreement
(retroactive to April 1, 2003) was successfully
negotiated with the Saskatchewan Medical
Association. It provides an increase in the
Physician Payment Schedule of 8.3 percent
effective October 1, 2003, and 6 percent on
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Saskatchewan
April 1, 2004 and 2005. Similar increases were
applied to non fee-for-service physicians.
Additional improvements include a total of $11.2
million to bolster recruitment and retention
programs and $3 million per year for new items
and modernization of the Payment Schedule.
Section 6 of The Saskatchewan Medical Care
Insurance Payment Regulations, 1994, outlines
the obligation of the Minister of Health to make
payment for insured services in accordance with
the Physician Payment Schedule and the Dentist
Payment Schedule.
Fee-for-service is the most widely used method of
compensating physicians for insured health
services in Saskatchewan, although sessional
payments, salaries, capitation arrangements and
blended methods are also used. Fee-for-service is
the only mechanism used to fund dentists for
insured surgical-dental services. Total
expenditures for in-province physician services
and programs in 2003-2004 amounted to $465.5
million - $303.3 million for fee-for-service billings,
$20.4 million for Emergency Coverage Programs,
$125.4 million in non-fee-for-service expenditures,
and $16.3 million for Saskatchewan Medical
Association programs as outlined in the
agreement.
5.5 Payments to Hospitals
In 2003-2004, funding to regional health
authorities was based on historical funding levels
adjusted for inflation, collective agreement costs
and utilization increases. Each regional health
authority is given a global budget and is
responsible for allocating funds within that budget
to address service needs and priorities identified
through its needs assessment processes.
Regional health authorities may receive additional
funds for providing specialized hospital programs
(e.g., renal dialysis, specialized medical imaging
services, specialized respiratory services) or for
providing services to residents from other health
regions.
Payments to regional health authorities for
delivering services are made pursuant to section 8
Canada Health Act Annual Report, 2003-2004
of The Regional Health Services Act. The
legislation provides the authority for the Minister
of Health to make grants to regional health
authorities and health care organizations for the
purposes of the Act and to arrange for providing
services in any area of Saskatchewan if it is in the
public interest to do so.
Regional health authorities provide an annual
report on the aggregate financial results of their
operations.
6.0 Recognition Given to
Federal Transfers
The Government of Saskatchewan publicly
acknowledged the federal contributions provided
through the Canada Health and Social Transfer
(CHST) in the Department of Health 2003-2004
Annual Report, the 2003-2004 Annual Budget and
related budget documents, its 2003-2004 Public
Accounts, and the Quarterly and Mid-Year
Financial Reports. These documents were tabled
in the Legislative Assembly and are publicly
available to Saskatchewan residents.
Federal contributions have also been
acknowledged on the Saskatchewan Health Web
site, news releases, issue papers, in speeches and
remarks made at various conferences, meetings
and public policy forums. Federal assistance was
also recognized in The Action Plan progress
reports released in both spring and fall 2002.
7.0 Extended Health Care
Services
As of March 31, 2003, the range of extended
health care services provided by the provincial
government included long-term residential care
services for Saskatchewan residents, certain
community-based health services such as home
care, as well as a wide range of other health,
social support, mental health, addiction treatment
and drug benefit programs.
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Chapter 3 – Saskatchewan
Nursing Home Intermediate Care Services
† Special-care homes provide institutional longterm care services to meet the needs of
individuals, primarily with heavy care needs.
Services offered include care and
accommodation, respite care, day programs,
night care, palliative care and, in some
instances, convalescent care. These facilities
are publicly funded through regional health
authorities and are governed by The Housing
and Special-care Homes Act and regulations.
† Public Health Services of regional health
authorities provide immunization for residents
in long-term care facilities and other similar
residential facilities under the provincial
immunization program. Saskatchewan Health
purchases the vaccines and provides them free
of charge to Public Health Services. This
applies to influenza and pneumococcal
vaccines.
Home Care Services
† The Home Care Program provides an option
for people with varying degrees of short and
long-term illness or disabilities to remain in
their own homes rather than in a care facility.
The Program is designed to provide care and
services for individuals with palliative, acute
and supportive care needs. Services include
assessment and care coordination, nursing,
personal care, respite care, homemaking,
meals, home maintenance, therapy and
volunteer services. Individualized funding is an
option of the Home Care Program and provides
funding directly to people so they can arrange
and manage their own supportive services. The
Home Care Program is governed by The
Regional Health Services Act.
Ambulatory Health Care Services
† Saskatchewan regional health authorities
provide a full range of mental health and
alcohol and drug services in the community.
Mental health services are governed by The
Mental Health Services Act.
148
† Regional health authorities offer podiatry
services. Services include assessment,
consultation and treatment. The Chiropody
Services Regulation of The Department of
Health Act provides chiropodists and
podiatrists with the ability to self-regulate their
profession.
† Regina/Qu’Appelle and Saskatoon regional
health authorities provide a Hearing Aid
Program. Services include hearing testing,
assessments for at-risk infants, and the selling,
fitting and maintenance of hearing aids. The
Hearing Aid Act and Regulations and The
Regional Health Services Act govern these
programs.
† Rehabilitation therapies, including occupational
and physical therapies and speech and
language pathology, are offered by the regional
health authorities and help individuals of all
ages improve their functional independence.
Services are provided in hospitals,
rehabilitation centres, long-term care facilities,
community health centres, schools and private
homes and include assessment, consultation
and treatment. The Regional Health Services
Act and The Community Therapy Regulations,
which are under the authority of The
Department of Health Act, govern these
programs.
Adult Residential Care Services
Mental Health Services
† Apartment Living Programs and Group Homes
provide a continuum of support and living
assistance to individuals with long-term mental
illnesses. These programs are governed by The
Residential Services Act.
† Saskatchewan Health, in partnership with the
Heartland Regional Health Authority, offers a
rehabilitation program for people and families
struggling with eating disorders. BridgePoint
Centre delivers this program and is currently
governed by The Non-profit Corporations Act
(1995) and The Co-operatives Act (1996).
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Saskatchewan
Alcohol and Drug Services
† The provision of Alcohol and Drug services
generally falls under The Regional Health
Services Act. Facilities that provide residential
alcohol and drug services are licensed as listed
below. Saskatchewan Health or the regional
health authorities contract with communitybased and non-profit organizations governed
by The Non-profit Corporations Act to provide
services.
† Detoxification services provide a safe and
supportive environment in which the client is
able to undergo the process of alcohol and/or
other drug withdrawal and stabilization.
Accommodation, meals and self-help groups
are offered for up to 10 days. The Adult and
Youth Group Homes Regulations of The
Housing and Special-care Homes Act govern
licensure of detoxification services.
Canada Health Act Annual Report, 2003-2004
† In-patient services are provided to individuals
requiring intensive rehabilitative programming
for their own or others’ use of alcohol or drugs.
Services offered include assessments,
counselling, education and support for up to
four weeks or longer depending on individual
needs. The Adult and Youth Group Homes
Regulations of The Housing and Special-care
Homes Act govern licensure for in-patient
services.
† Long-term residential services provide
maintenance and transition programs for an
extended period to individuals recovering from
chemical dependency and addiction. These
facilities offer counselling, education and
relapse prevention in a safe and supportive
environment. The Adult and Youth Group
Homes Regulations of The Housing and
Special-care Homes Act govern licensure for
long-term residential services.
149
Chapter 3 – Saskatchewan
Registered Persons
1. Number as of March 31st (#).
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
1,041,256
1,021,762
1,024,788
1,024,827
1,007,753
Insured Hospital Services Within Own Province or Territory
Public Facilities
2. Number (#):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
3. Payments ($):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
71
0
1
0
72
68
0
1
0
69
66
0
1
0
67
65
0
1
0
66
66
0
1
0
67
619,538,151 1
not applicable
36,824,546
not applicable
656,362,697
680,326,248 1
not applicable
38,249,010
not applicable
718,575,258
720,174,393 1
not applicable
39,656,384
not applicable
759,830,777
not available
not applicable
not available
not applicable
not available
811,561,671 2
not applicable
not available 3
not applicable
811,561,671
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
4. Number (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5. Number of insured hospital services
provided (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
6. Payments ($):
a. surgical facilities
b. diagnostic imaging facilities
c. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Private For-Profit Facilities
150
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Saskatchewan
Insured Physician Services Within Own Province or Territory
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
940
610
0
1,550
1,016
593
0
1,609
937
696
0
1,633
936
700
0
1,636
946
716
0
1,662
8. Number of opted-out physicians (#):
a. general practitioners
b. specialists
c. other
d. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
9. Number of not participating
physicians (#):
a. general practitioners
b. specialists
c. other
d. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
6,785,673
3,163,046
0
9,948,719
6,873,539
3,250,953
0
10,124,492
6,760,156
3,700,801
0
10,460,957
6,631,582
3,637,879
0
10,269,461
6,719,074
3,688,232
0
10,407,306
133,042,948
125,735,201
0
258,778,149
134,989,267
129,470,569
0
264,459,836
137,541,402
144,566,069
0
282,107,471
139,410,263
151,061,558
0
290,471,821
147,068,263
157,468,972
0
304,537,235
19.61
39.75
0.00
26.01
19.64
39.83
0.00
26.12
20.35
39.06
0.00
26.97
21.02
41.52
0.00
28.29
21.89
42.69
0.00
29.26
7. Number of participating physicians (#):
a. general practitioners
b. specialists
c. other
d. total
10. Number of services provided through
fee for service (#):
a. general practitioners
b. specialists
c. other
d. total
11. Total payments to physicians paid
through fee for service ($):
a. general practitioners
b. specialists
c. other
d. total
12. Average payment per fee for service
service ($):
a. general practitioners
b. specialists
c. other
d. all services
13. Number of services provided through
all payment methods (#): 4
a. medical
b. surgical
c. diagnostic
d. other
e. total
14. Total payments to physicians paid
through all payment methods ($): 4
a. medical
b. surgical
c. diagnostic
d. other
e. total
15. Average payment per service, all
payment methods ($): 4
a. medical
b. surgical
c. diagnostic
d. other
e. all services
6,028,070 5
723,626 6
2,312,606 7
884,417 8
9,948,719
6,071,567 5
787,655 6
2,288,038 7
977,232 8
10,124,492
6,017,477 5
994,321 6
2,262,256 7
1,186,903 8
10,460,957
5,788,055 5
984,405 6
2,179,286 7
1,317,715 8
10,269,461
5,841,196 5
998,297 6
2,174,220 7
1,393,593 8
10,407,306
148,848,496 5
50,843,890 6
41,503,336 7
17,582,427 8
258,778,149
151,152,270 5
51,681,286 6
43,216,810 7
18,409,471 8
264,459,837
160,742,594 5
56,027,014 6
44,488,404 7
20,849,458 8
282,107,470
162,032,557 5
58,596,690 6
48,355,683 7
21,486,890 8
290,471,821
170,595,840 5
60,515,275 6
51,280,830 7
22,145,286 8
304,537,231
24.69 5
70.26 6
17.95 7
19.88 8
26.01
24.90 5
65.61 6
18.89 7
18.84 8
26.12
26.71 5
56.35 6
19.67 7
17.57 8
26.97
27.99 5
59.52 6
22.19 7
16.31 8
28.29
29.21 5
60.62 6
23.59 7
15.89 8
29.26
Canada Health Act Annual Report, 2003-2004
151
Chapter 3 – Saskatchewan
Insured Services Provided to Residents in Another Province or Territory
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
4,917
4,527
4,692
4,422
4,561
43,296
46,199
45,320
50,401
45,510
21,235,200
20,208,100
22,037,200
23,447,100
30,528,100
19. Total payments, out-patient ($).
5,622,500
6,046,600
5,836,500
7,144,800
6,405,900
20. Average payment, in-patient ($).
4,318.73
4,463.91
4,696.76
5,302.37
6,693.29
129.86
130.88
128.78
141.76
140.76
Physicians
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
22. Number of services (#).
392,400
425,800
444,430
458,100
509,784
12,237,200
13,767,600
15,520,000
16,948,900
19,477,300
31.19
32.33
34.92
37.00
38.21
16. Total number of claims, in-patient (#).
17. Total number of claims,
out-patient (#).
18. Total payments, in-patient ($).
21. Average payment, out-patient ($).
23. Total payments ($).
24. Average payment per service ($).
Insured Services Provided Outside Canada
Hospitals
25. Total number of claims, in-patient (#).
26. Total number of claims,
out-patient (#).
27. Total payments, in-patient ($).
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
380
272
252
287
231
1,553
1,369
1,172
1,049
875
1,891,000
1,039,500
1,009,400
1,891,800
728,400
28. Total payments, out-patient ($).
481,600
377,600
375,900
359,400
373,300
29. Average payment, in-patient ($).
4,976.32
3,821.69
4,005.56
6,591.64
3,153.25
310.11
275.82
320.73
342.61
426.63
Physicians
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
31. Number of services (#).
not available
not available
not available
not available
not available
1,186,900
722,400
588,100
1,129,300
583,200
not available
not available
not available
not available
not available
30. Average payment, out-patient ($).
32. Total payments ($).
33. Average payment per service ($).
Insured Surgical-Dental Services Within Own Province or Territory
1999-2000
34. Number of particpating dentists (#).
35. Number of services provided (#).
36. Total payments ($).
37. Average payment per service ($).
152
2000-2001
2001-2002
2002-2003
2003-2004
97
92
94
94
94
18,100
19,900
18,900
18,500
18,300
1,309,000
1,404,700
1,275,400
1,264,200
1,345,900
72.32
70.59
67.48
68.34
73.55
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Saskatchewan
Endnotes
1. Based on provincial government funding summaries provided to the former health districts.
2. "This number includes estimated government funding to Regional Health Authorities (RHAs)( based on total projected
expenditures less non-government revenue), as provided to Saskatchewan Health through the RHA annual operational plans.
Acute care funding includes: acute care services , specialized hospital services, and in-hospital specialist services. Does not
include inpatient rehabilitative care, inpatient mental health, or addiction treatment services. Does not include payments to
Saskatchewan Cancer Agency for outpatient chemotherapy and radiation ."
3. Comparable annual information is not available at this time.
4. Fee-for-service only.
5. Includes visits, hospital care, psychotherapy.
6. Includes surgeries, surgical assistance, obstetrics, anaesthesia.
7. Includes x-rays, laboratory services, diagnostics.
8. Includes surcharges, premiums, on-call physician services.
Canada Health Act Annual Report, 2003-2004
153
Chapter 3 – Alberta
Alberta
Introduction: Alberta’s Health
Care System
Alberta provides medically necessary, insured
services in a public system that follows the
principles of the Canada Health Act: public
administration, comprehensiveness, universality,
portability and accessibility. Medically necessary
services include hospital and physician services
and specific kinds of services provided by oral
surgeons and other dental professionals.
Alberta also provides full and partial coverage for
health care services not required by the Canada
Health Act. They include:
† home care and long-term care;
† mental health services;
† dental and eyeglass benefits for recipients of
the Alberta Widow’s pension and their eligible
dependents;
† palliative care;
† immunization programs for children;
† allied health services such as optometry (for
residents under 19 and over 64 years),
chiropractic and podiatry services;
† drug benefits through Alberta Blue Cross; and
† Alberta Aids to Daily Living.
Health System Governance
Alberta’s health care system is defined in
legislation and is governed by the Minister of
Health and Wellness. The Regional Health
Authorities Act makes regional health authorities
responsible to the Minister for ensuring the
provision of acute care hospital services,
community and long-term care services, public
Canada Health Act Annual Report, 2003-2004
health protection and promotion services and
other related services. The Alberta Cancer Board
Act makes the Alberta Cancer Board responsible
to the Minister for providing cancer care,
education and research. The Alberta Mental
Health Board advises the Minister on strategic
and policy matters related to mental health
programs and services. Alberta’s health legislation
can be accessed at
http://www.health.gov.ab.ca/about/minister/
legislation.html.
Significant Events in 2003/2004
Effective on April 1, 2003, responsibility and
funding for mental health services was transferred
from the Alberta Mental Health Board to regional
health authorities. Regional health authority
boundaries were changed, reducing them from 17
to nine. HealthLink Alberta, a telephone
information service, was launched. The service
provides information and advice to Albertans. An
eight-year, tri-lateral agreement was reached
among Alberta Health and Wellness, the Alberta
Medical Association and regional health
authorities. The agreement provides new
incentives and compensation arrangements for
innovative programs in the area of primary care,
physician on-call services and the automation of
medical practice. More significant events are
described in detail in the 2003-2004 Annual
Report of the Alberta Ministry of Health and
Wellness at
http://www.health.gov.ab.ca/resources/
publications/AR03_04/index.html.
1.0 Public Administration
1.1 Health Care Insurance Plan and
Public Authority
The Alberta Health Care Insurance Plan is publicly
administered in accordance with The Canada
Health Act. Since 1969, the Alberta Health Care
Insurance Act has governed the operation of the
Alberta Health Care Insurance Plan. Alberta
155
Chapter 3 – Alberta
Health and Wellness administers the plan on a
non-profit basis.
Alberta Health and Wellness registers eligible
Alberta residents for coverage under the plan and
compensates practitioners for insured services
provided in accordance with negotiated
agreements, the Schedule of Medical Benefits
and the Schedule of Oral and Maxillofacial
Surgery Benefits. Alberta Health and Wellness
also provides funding to regional health authorities
and provincial boards for the provision of insured
hospital services.
1.2 Reporting Relationship
The Alberta Health Care Insurance Plan is fully
accountable to the Minister of Health and
Wellness and is managed by the Minister’s
departmental staff.
Each year the Ministry issues an annual report
that documents key activities of the health care
system including the Alberta Health Care
Insurance Plan. The Annual Report provides
consolidated financial statements for the previous
fiscal year. The annual report also provides
information about key achievements and results in
a response to key performance measures and
targets included in the previous year’s business
plan. The 2003-2004 Annual Report of the Alberta
Ministry of Health and Wellness can be accessed
at http://www.health.gov.ab.ca/resources/
publications/AR03_04/index.html. The Ministry
also issues an annual Statistical Supplement on
data related to the Alberta Health Care Insurance
Plan. The Statistical Supplement is accessible at
http://www.health.gov.ab.ca/resources/
publications/pdf/AHCIPStatSupR03.pdf.
1.3 Audit of Accounts
The Auditor General of Alberta audits the records
and financial statements of the Ministry of Health
and Wellness.
156
2.0 Comprehensiveness
2.1 Insured Hospital Services
In Alberta, except for cancer hospitals, regional
health authorities are responsible to the Minister
for ensuring the provision of insured hospital
services. The Hospitals Act, the Hospitalization
Benefits Regulation (AR244/90), the Health Care
Protection Act and the Health Care Protection
Regulation define how insured services are
provided by hospitals or designated surgical
facilities. According to the legislation, the Minister
must approve all hospitals and surgical facilities.
The services provided by approved hospitals in
Alberta range from the most advanced levels of
diagnostic and treatment services for in-patients
and out-patients to the routine care and
management of patients with previously
diagnosed chronic conditions. The benefits
available to hospital patients in Alberta are
defined in the Hospitalization Benefits Regulation
(AR244/90).
The Health Care Protection Act in Alberta governs
the provision of surgical services through nonhospital surgical facilities. Ministerial approval of a
contract between the facility operator and a
regional health authority is required for providing
insured services. Ministerial designation of a nonhospital surgical facility and accreditation by the
College of Physicians and Surgeons of Alberta are
also required. According to the College, there are
currently 53 non-hospital surgical facilities with
accreditation status.
According to the Health Care Protection Act,
Ministerial approval for a contractual agreement
shall not be given unless:
† the insured surgical services are consistent
with the principles of the Canada Health Act;
† there is a current and likely future need for the
services in the geographical area;
† the proposed surgical services will not have a
negative impact on the province’s public health
system;
† there will be an expected benefit to the public;
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Alberta
† the regional health authority has an acceptable
business plan to pay for the services;
† the proposed agreement contains performance
expectations and measures; and
† the physicians providing the services will
comply with the conflict of interest and ethical
requirements of the Medical Profession Act
and bylaws.
2.2 Insured Physician Services
Insured physician services are paid for under the
Alberta Health Care Insurance Plan. Only
physicians and dentists who meet the
requirements stated in the Alberta Health Care
Insurance Act are allowed to provide insured
services under the Albert Health Care Insurance
Plan. In addition to insured services, a number of
other practitioner services are covered under the
Alberta Health Care Insurance Plan. They include
opticians, podiatrists, denturists, optometrists,
chiropractors, oral surgeons and dentists.
Before being registered with the Alberta Health
Care Insurance Plan, a practitioner must complete
the appropriate registration forms and include a
copy of his or her license issued by the
appropriate governing body or association, such
as the College of Physicians and Surgeons of
Alberta or the Alberta Dental Association and
College.
Under section 8 of the Alberta Health Care
Insurance Act, physicians and dentists may opt
out of the Alberta Health Care Insurance Plan. As
of March 31, 2004, there were no opted-out
medical practitioners in the province.
The Medical Benefits Regulation defines which
medical services are insured. These services are
documented in the Schedule of Medical Benefits,
which can be accessed at
http://www.health.gov.ab.ca/professionals/
SOMB/Procedure_List.pdf.
2.3 Insured Surgical Dental
Services
Alberta insures a number of medically necessary
oral surgical and dental procedures that are listed
in the Schedule of Oral and Maxillofacial Surgery
Benefits available at
http://www.health.gov.ab.ca/professionals/
allied/Dental_Procedure.pdf. A dentist may
perform a small number of these procedures, but
the majority of the procedures can be billed to the
Alberta Health Care Insurance Plan only when
performed by an oral or maxillofacial surgeon.
2.4 Uninsured Hospital, Physician
and Surgical – Dental Services
Section 21 of the Alberta Health Care Insurance
Regulation defines what services are not
considered to be insured services. Section 4(1) of
the Hospitalization Benefits Regulation provides a
list of uninsured hospital services.
The Minister of Health and Wellness determines
what services are covered by the Alberta Health
Care Insurance Plan. Alberta Health and Wellness
reviews scientific literature, consults with expert
advisors and assesses policy, funding and training
when considering which medical products,
services or devices will be covered under the
Alberta Health Care Insurance Plan. Insured
physician services and any changes to the
Schedule of Medical Benefits are negotiated
among Alberta Health and Wellness, the Alberta
Medical Association (AMA) and the regional
health authorities. All changes to the Schedule of
Medical Benefits require ministerial approval.
3.0 Universality
3.1 Eligibility
Under the terms of the Alberta Health Care
Insurance Act, all Alberta residents are eligible to
receive publicly funded health care services under
the Alberta Health Care Insurance Plan. A
resident is defined as a person lawfully entitled to
Canada Health Act Annual Report, 2003-2004
157
Chapter 3 – Alberta
be or to remain in Canada who makes the
province his or her home and is ordinarily present
in Alberta. The term “resident” does not include a
tourist, transient or visitor to Alberta.
Persons moving permanently to Alberta from
outside Canada are eligible for coverage if they
are landed immigrants, returning landed
immigrants or returning Canadian citizens.
Temporary residents may also be eligible for
coverage, if they intend to remain in Alberta for
12 months and their Canada entry documents are
in order.
Residents who are not eligible for coverage under
the Alberta Health Care Insurance Plan include:
† members of the Canadian Forces;
† members of the Royal Canadian Mounted
Police (RCMP) who are appointed to a rank;
and
† persons serving a term in a federal
penitentiary.
3.2 Registration Requirements
All new Alberta residents are required to register
themselves and their eligible dependents with the
Alberta Health Care Insurance Plan. New
residents in Alberta should apply for coverage
within three months of arrival. Family members
are registered on the same account for premium
billing purposes. As of March 31, 2004, there
were 3,165,157 Alberta residents registered with
the Alberta Health Care Insurance Plan.
3.3 Other Categories of Individual
Temporary residents arriving from outside Canada
who may be deemed residents include persons on
Visitor Records, Student or Employment
Authorization and Minister’s Permits. There were
18,860 people covered under these conditions as
of March 31, 2004.
3.4 Premiums
All Alberta residents, except dependents and
individuals excluded from liability, are required to
pay premiums. Exceptions include individuals
158
enrolled in special groups (such as Alberta
Widow’s Pension or Support for Independence), or
people entitled to full premium assistance.
Although Albertans are required to pay premiums,
no resident is denied coverage due to an inability
to pay.
Two programs help lower-income, non-senior
Albertans with the cost of their premiums: the
Premium Subsidy Program and the Waiver of
Premiums Program. Premium assistance for
seniors was available under the Alberta Seniors
Benefit Program.
4.0 Portability
4.1 Minimum Waiting Period
Persons moving permanently to Alberta from
another part of Canada are eligible for coverage
on the first day of the third month following their
arrival, provided they register within three months
of arrival.
4.2 Coverage During Temporary
Absences in Canada
The Alberta Health Care Insurance Plan provided
the following coverage to eligible Alberta
residents who are temporarily absent within
Canada:
† Visit/Vacation: up to 24 months coverage;
† Work/Business/Missionary Work: up to 48
months; and
† Post-secondary Education: no limit (coverage
continues until studies are completed).
Requests to extend coverage for a period longer
than 24 months are reviewed on a case-by-case
basis. Individuals who are routinely absent from
Alberta every year normally need to spend a
cumulative total of 183 days in a 12-month period
in Alberta to maintain continuous coverage.
Individuals not present in Alberta for the required
183 days may be considered residents of Alberta
if they satisfy Alberta Health and Wellness that
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Alberta
Alberta is their permanent and principal place of
residence.
Alberta participates in the Hospital Reciprocal
Agreement with other provinces and territories.
This agreement allows payments for hospital
services provided by the host province to
residents to be processed. Alberta also
participates in the Medical Reciprocal Billing
Agreement with provinces and territories (except
Quebec). This agreement allows payments for
physician services in the host province to be
processed. Payments are paid at the host
province or territorial rates.
4.3 Coverage During Temporary
Absences Outside Canada
The Alberta Health Care Insurance Plan provides
coverage for the first six consecutive months of
absence outside Canada. Residents who wish to
maintain coverage for a longer period may request
an extension of coverage for a maximum of 24
consecutive months from the month of departure.
Extension requests for longer than 24 months will
be reviewed case-by-case on the same basis as
for Albertans living temporarily in another
province.
The maximum amount payable for out-of-country
in-patient hospital services is $100 (Canadian)
per day (not including day of discharge). The
maximum hospital out-patient per visit rate is $50
(Canadian), with a limit of one visit per day. The
only exception is haemodialysis, which is paid at a
maximum of $220 per visit, with a limit of one visit
per day. Physician and allied health practitioner
services are paid according to Alberta rates. More
information on coverage during temporary
absences outside Canada or Alberta is accessible
at http://www.health.gov.ab.ca/ahcip/pdf/
travel.pdf.
4.4 Prior Approval Requirement
Prior approval is not required for elective services
received outside Alberta, except for treating
alcohol and substance abuse, eating disorders and
similar addictive or behavioural disorders.
Canada Health Act Annual Report, 2003-2004
Approval by the Minister must be received before
these services can be covered.
5.0 Accessibiltiy
5.1 Access to Insured Health
Services
All Alberta residents have access to provincially
funded and insured health services regardless of
where they live in the province. Alberta has nine
regional health authorities that cooperate with
each other in ensuring that all Albertans have
access to needed health services. There are two
major metropolitan regions, Calgary Health
Region and Capital Health (Edmonton), which
provide provincially funded, province-wide
services to Alberta residents who need tertiarylevel diagnostic and treatment services.
5.2 Access to Insured Hospital
Services
Alberta Health and Wellness and regional health
authorities actively participate in a five-year
health workforce planning process to ensure an
adequate supply of key personnel.
Health authorities are required to develop capital
equipment plans as part of their annual business
plan submissions to the Minister of Health and
Wellness. Funding for regional health services in
2003-2004 (which includes hospitals and provincewide services) was $4,550 million, an increase of
$282 million or 6.6 percent from 2002-2003. The
2003-2004 Alberta Health and Wellness Annual
Report can be accessed at
http://www.health.gov.ab.ca/resources/publica
tions/AR03_04/index.html.
A significant step forward in improving access to
insured health services was taken with the
development of the Web-based Alberta Waitlist
Registry. The registry provides information on wait
times for hip and knee replacement surgery,
cataract surgery, cardiac surgery and MRI and CT
examinations for both hospitals and community
159
Chapter 3 – Alberta
providers. The registry is accessible at
http://www.health.gov.ab.ca/waitlist/
WaitListPublicHome.jsp.
that will manage 24-hour access to front-line
services.
5.5 Payments to Hospitals
5.4 Physician Compensation
Most physicians are compensated through the
Alberta Health Care Insurance Plan on a
traditional, volume-driven, fee-for-service basis.
Alternative relationship plans offer alternative
compensation models to the fee-for-service
payment system and contribute to better health
outcomes by supporting innovative health care
delivery.
A new tri-lateral agreement involving the AMA,
Alberta Health and Wellness and regional health
authorities contains provisions to improve access
to physician services. Under this agreement,
Alternative Relationship Plans (ARPs) are being
established to enhance physician recruitment and
retention, team-based approaches to service
delivery, access to services, patient satisfaction
and value for money. Also under the agreement,
local physicians can partner with their health
regions to create Local Primary Care Initiatives
160
Insured hospital services in Alberta are funded
through a population-based funding formula for
regional health authorities. The health authorities
are responsible for planning the allocation of
funds for insured hospital services in accordance
with regional needs assessments and services
plans.
6.0 Recognition
The consolidated financial statements in the
Ministry’s Annual Report recognize the federal
contributions provided under the Canada Health
and Social Transfer (CHST). The 2003-2004
Annual Report of the Alberta Ministry of Health
and Wellness can be accessed at
http://www.health.gov.ab.ca/resources/
publications/AR03_04/index.html.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Alberta
Registered Persons
1. Number as of March 31st (#).
1999-2000
2000-2001
2001-2002
2002-2003
2,957,045
3,007,582
3,072,384
3,124,487
2003-2004
1
3,165,157
Insured Hospital Services Within Own Province or Territory
Public Facilities
1999-2000
2000-2001
2001-2002
2002-2003
102
104
1
3
210
102
105
1
3
211
103
106
1
3
213
100
110
1
3
214
102
107
1
3
213
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
1999-2000
2000-2001
2001-2002
2002-2003
4. Number (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
5. Number of insured hospital services
provided (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
6. Payments ($):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
2. Number (#):
a. acute care
b. chronic care (Aux. Hospital only)
c. rehabilitative care
d. other
e. total
3. Payments ($):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
Private For-Profit Facilities
Canada Health Act Annual Report, 2003-2004
2003-2004
2003-2004
1
1
161
Chapter 3 – Alberta
Insured Physician Services Within Own Province or Territory
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
7. Number of participating physicians (#):
a. general practitioners
2,545
b. specialists
2,096
c. other
not applicable
d. total
4,641
2,659
2,197
not applicable
4,856
2,746
2,333
not applicable
5,079
2,841
2,365
not applicable
5,206
2,937
2,426
not applicable
5,363
8. Number of opted-out physicians (#):
a. general practitioners
b. specialists
c. other
d. total
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
0
0
0
0
0
1
0
1
0
0
0
0
0
0
0
0
0
0
0
0
15,914,666
11,319,078
0
27,233,744
16,132,591
11,710,080
0
27,842,671
16,132,591
11,710,080
0
27,842,671
16,450,512
12,878,411
0
29,328,923
16,924,877
13,119,523
0
30,044,400
410,502,506
493,040,446
0
903,542,952
430,681,658
528,392,197
0
959,073,855
12. Average payment per fee for service
service ($):
a. general practitioners
b. specialists
c. other
d. all services
25.79
43.56
0.00
33.18
26.70
45.12
0.00
34.45
29.39
50.14
0.00
38.11
33.05
52.96
0.00
41.79
33.38
53.95
0.00
42.36
13. Number of services provided through
all payment methods (#):
a. medical
b. surgical
c. diagnostic
d. other
e. total
19,829,029
1,238,043
5,274,903
0
26,341,975
20,328,498
1,316,312
5,588,934
0
27,233,744
20,647,611
1,396,422
5,798,638
0
27,842,671
21,153,134
2,417,363
5,758,426
0
29,328,923
21,680,907
2,513,638
5,849,855
0
30,044,400
586,587,852
140,067,988
176,887,112
0
903,542,952
618,596,110
150,223,933
190,253,812
0
959,073,855
29.58
113.14
33.53
0.00
34.30
30.43
114.12
34.04
0.00
35.22
9. Number of not participating
physicians (#):
a. general practitioners
b. specialists
c. other
d. total
10. Number of services provided through
fee for service (#):
a. general practitioners
b. specialists
c. other
d. total
11. Total payments to physicians paid
through fee for service ($):
a. general practitioners
b. specialists
c. other
d. total
14. Total payments to physicians paid
through all payment methods ($):
a. medical
b. surgical
c. diagnostic
d. other
e. total
15. Average payment per service, all
payment methods ($):
a. medical
b. surgical
c. diagnostic
d. other
e. all services
162
1
474,076,958
543,635,736
564,936,923
587,092,735
681,990,901
707,843,059
0
0
0
1,061,169,693 1,225,626,637 1,272,779,982
684,971,654
788,450,446
816,374,918
164,427,152
190,259,821
196,291,136
211,770,887
246,916,370
260,113,928
0
0
0
1,061,169,693 1,225,626,637 1,272,779,982
33.17
117.75
36.52
0.00
38.11
37.27
78.71
42.88
0.00
41.79
37.65
78.09
44.47
0.00
42.36
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Alberta
Insured Services Provided to Residents in Another Province or Territory
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
4,820
4,656
4,205
4,275
4,651
59,443
56,408
61,230
67,975
68,469
13,632,730
14,699,049
12,328,205
15,753,884
19,411,517
19. Total payments, out-patient ($).
6,920,702
5,287,271
7,115,105
7,953,195
7,982,851
20. Average payment, in-patient ($).
2,828.37
3,157.01
2,931.80
3,685.12
4,173.62
116.43
93.73
116.20
117.00
116.59
Physicians
1999-2000
2000-2001
2001-2002
2002-2003
22. Number of services (#).
380,635
418,587
493,798
559,503
485,841
11,397,620
12,436,188
11,998,825
13,880,981
15,139,409
29.94
29.71
24.30
24.81
31.16
16. Total number of claims, in-patient (#).
17. Total number of claims,
out-patient (#).
18. Total payments, in-patient ($).
21. Average payment, out-patient ($).
23. Total payments ($).
24. Average payment per service ($).
2003-2004
2003-2004
1
1
Insured Services Provided Outside Canada
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
25. Total number of claims, in-patient (#).
5,215
4,151
4,457
3,698
3,319
26. Total number of claims,
out-patient (#).
5,097
3,945
3,942
3,739
3,405
27. Total payments, in-patient ($).
483,648
374,005
416,635
340,169
300,233
28. Total payments, out-patient ($).
364,087
298,725
309,119
206,684
212,949
29. Average payment, in-patient ($).
92.74
90.10
93.48
91.99
90.46
30. Average payment, out-patient ($).
71.43
75.72
78.42
55.28
62.54
1999-2000
2000-2001
2001-2002
2002-2003
Physicians
31. Number of services (#).
32. Total payments ($).
33. Average payment per service ($).
2003-2004
2003-2004
21,989
20,891
22,928
21,289
20,753
871,292
907,010
1,043,997
976,232
963,299
39.62
43.42
45.53
45.86
46.42
1
1
Insured Surgical-Dental Services Within Own Province or Territory
1999-2000
34. Number of particpating dentists (#).
35. Number of services provided (#).
36. Total payments ($).
37. Average payment per service ($).
2000-2001
2001-2002
2002-2003
2003-2004
250
232
250
234
216
14,292
14,708
14,585
16,759
14,802
2,092,003
2,116,386
2,167,898
2,394,458
2,404,042
146.38
143.89
148.64
142.88
162.41
Canada Health Act Annual Report, 2003-2004
1
163
Chapter 3 – Alberta
Endnotes
1. These figures are considered preliminary until the release of the Alberta Ministry of Health and Wellness' Alberta Health Care
Insurance Plan Statistical Supplement, 2003-2004.
164
Canada Health Act Annual Report, 2003-2004
Chapter 3 – British Columbia
Activities for 2003-2004
British Columbia
Introduction
British Columbia has a progressive and integrated
health care system. The British Columbia health
system includes insured services under the
Canada Health Act as well as services funded
wholly or partially by the Government of British
Columbia and services regulated by, not funded
by, the government. This system is based on
regional delivery and self-regulating professions
providing quality, accessible and affordable health
care.
Five regional health authorities are responsible for
managing and delivering a range of health
services, including acute and hospital care, home
and community care, mental health, addictions,
and public health services. These five regional
health authorities encompass 15 health services
delivery areas, which were established to reflect
natural patient referral patterns. In addition to the
regional health authorities, the Provincial Health
Services Authority coordinates and delivers highly
specialized services that cannot be offered in all
regions, and facilitates coordination of provincial
initiatives. Health authorities receive three-year
budgets, which assist in planning, and are
accountable to government through performance
agreements that define expectations and
performance deliverables for three fiscal years.
The performance agreements also set out the
major change requirements in areas of service
such as emergency care, surgical services, home
and community care, public and preventive health
and mental health.
Health care is a top priority for the Government
and people of British Columbia.
Canada Health Act Annual Report, 2003-2004
Over the past year, the Ministry of Health
Services has made significant progress in some
key goals and priorities for British Columbia’s
health care system. These include protecting
public health, ensuring patients get timely access
to appropriate quality care, and planning for a
dependable and sustainable health system. We
are making progress in every one of these areas.
Maintaining the status quo in British Columbia’s
health system has not been an option. Over the
past decade, health care costs have been rapidly
rising and consuming an ever increasing portion of
the government’s overall budget. With limited
resources and greater demands, this trend is not
sustainable. Therefore, fundamental changes have
to be made.
Making innovative changes and improvements,
especially those that challenge long-standing or
traditional approaches or methods, is not easy.
However, new health research and leading
journals show us there are new, creative and
efficient ways of improving health care and health
outcomes for British Columbians. This means
making some difficult decisions, and we are now
well on our way to re-engineering and redesigning
the health system to meet British Columbians’
diverse needs in a sustainable way. British
Columbians – patients, care providers and the
public – are beginning to see positive results from
the long-term planning and hard work being
undertaken across the health sector.
Significant achievements in 2003-2004 include:
Protecting Public Health
The Minister of Health Services approved an
additional $800,000 in annual funding to expand
the provincial immunization program for British
Columbian children to include protection for
adolescents from whooping cough. In addition,
$9.6 million in base funding was provided to
health authorities to annualize the pneumococcal
and meningococcal high-risk program
implemented the previous year.
165
Chapter 3 – British Columbia
New measures governing drinking water help to
protect the health and safety of British
Columbians. The amended Drinking Water
Protection Act and Regulations came into force on
May 16, 2003. The changes establish a
comprehensive and coordinated framework for
protecting the province’s drinking water from
source to tap.
A project to renew the Health Act (British
Columbia’s primary Public Health legislation) was
initiated in 2003. This project will complete the
modernization of British Columbia’s public health
legislation, complementing the newly developed
Drinking Water Protection Act and Food Safety
Act. In 2003 BC continued development of “Core
Programs in Public Health”, a project designed to
establish the core requirements for public health
service delivery.
British Columbia invested $2.6 million for research
to accelerate the development of a vaccine
against SARS. In addition, the British Columbia
obtained a permit under the Pesticide Control Act
to control mosquitoes should they pose a public
health risk due to the West Nile Virus.
The BC Centre for Disease Control and the
Michael Smith Genome Sciences Centre are
placing British Columbia at the forefront of
Canada and the world in health research. The
ministry has contributed $15 million to Genome
BC, one of five not-for-profit genome centres
established to coordinate genomics research in
Canada. Genome BC research includes
developing ways to track how cells transform into
malignancies and become cancerous.
The government has provided over $24 million to
the Michael Smith Foundation for Health Research
for new programs in British Columbia which
continue to develop, attract and retain
outstanding health scientists and researches. This
funding supports research in priority areas such as
health care re-engineering and innovation.
Providing High Quality,
Patient Centred Care
Supported by an investment of $73.5 million over
four years, through the Primary Care Transition
166
Fund, British Columbia’s health authorities have
been implementing a range of initiatives to
support more comprehensive, coordinated and
accessible primary health care services. Initiatives
include: networks linking family physician
practices; community health centres; shared care
arrangements providing family practices with
specialist consultation and expertise; nurse
managed care in regions with limited access to
physicians; and chronic disease management. This
funding also supported the Ministry of Health
Services’ addition of pharmacist services to the
BC NurseLine and creation of the Chronic
Disease Management Toolkit for Practitioners,
using secure web-based technology to provide
tools and information to support optimal chronic
disease management.
In 2003, British Columbia invested $2.8 million on
expanded resources for doctors to help them
better manage the care they provide to patients
suffering from chronic diseases. The funding is
targeted for doctor- and medical-related
organizations with the aim of improving
professional development opportunities for
doctors in the areas of preventative care and
managing ongoing conditions of chronic illness.
In September 2003, the $20 million Full Services
Family Incentive Program was implemented,
supporting physicians through new standardized
patient-care guidelines of treatment for patients
with diabetes or congestive heart failure.
Physicians will be compensated for each patient
successfully involved in the treatment plan, with
the goal of having fewer disease-related
complications with less need for hospitalization
and associated health-care costs. The second
component of the program encourages doctors to
continue delivering babies in their communities.
Renal services have been expanded beyond the
major urban centres with new kidney dialysis
services in Kelowna, Penticton, Creston, Terrace
and Nanaimo.
New investments in telehealth technology allow
patients to access the specialist care they need
from BC Children’s, Sunny Hill and BC Women’s
Canada Health Act Annual Report, 2003-2004
Chapter 3 – British Columbia
Hospitals without having to travel from their own
communities.
New funding of $1.3 million per year for cochlear
implants was announced in December 2003 to
significantly reduce wait times for adults and
children awaiting this surgery.
Managing for Sustainability
The end of the 2003-2004 fiscal year marks the
mid-way point in a three-year process to achieve a
more accountable, patient-centered and coherent
system of health care in British Columbia.
In 2002-2003, the formation of British Columbia’s
new health authorities created a strong foundation
for making fundamental improvements to the
management and delivery of hospital and
community based health services. In 2003-2004,
their second full year of operation, health
authorities took significant strides toward meeting
the specific challenges set out in the Performance
Agreements1 and began to fully assume their role
in shaping British Columbia’s overall health care
system.
With the expectation to implement service
redesign and improvement initiatives within
available funding, health authorities are making
system improvements largely by redirecting and
reallocating existing funding to maximize the
benefit to patients and return on investment.
Health authorities are guided in their strategies by
the priority strategies outlined by government
through the Ministry of Health Services’ three
year Service Plan.
The ministry and health authorities continue to
work together to develop performance
measurement, monitoring and evaluation
processes to improve health care, and increase
accountably in the health care system in British
Columbia.
1
Fair PharmaCare was implemented on May 1,
2003, as an equitable way to offer British
Columbia families assistance with prescription
drug costs based on family income.
Before Fair PharmaCare, many families with low
incomes were paying more for their prescription
drug costs than those with higher incomes. Fair
PharmaCare helps to address these inequities by
focusing on financial assistance to those families
that need it most. Under Fair PharmaCare, the
majority of British Columbia families pay the same
or less for prescription drugs than they did before
the new plan.
In October 2003, the Health Professions
Amendment Act was passed in the legislature
allowing for the regulation of nurse practitioners.
The new program of nurse practitioners improves
health services by expanding the range of health
professionals to care for patients.
The $700,000 Interprofessional Rural Program of
British Columbia was announced in May 2003.
This program unites teams of students from
different health-care disciplines and provides
opportunities for qualified students to be placed in
small and remote communities for periods of 10 to
12 weeks. The students gain hands-on clinical
experience and patients in rural and remote areas
gain more health services immediately.
In April 2003, the Minister of Health Services
appointed a community advisory group, (the
UNBC Northern Medical Program Community
Action Group), to focus on promoting a successful
northern medical school program and making
Prince George a strong regional health centre. The
advisory group produced a report, Building for the
Future of Health Care in Northern BC, which
focuses on the recruitment and retention of core
clinicians as well as improving appropriate use of
hospital care in the north and providing academic
support. The Minister of Health Services
announced in March 2004 that $2.2 million is
In April 2002, the government introduced Performance Agreements between the new health authorities and the BC Ministry
of Health Services as a means of increasing accountability for the delivery of patient services, health outcomes and health
care spending. The Performance Agreements define expectations, performance deliverables and service requirements in the
areas of emergency care, surgical services, home and community care, and mental health services for three fiscal years.
Canada Health Act Annual Report, 2003-2004
167
Chapter 3 – British Columbia
being invested in response to the report which
contains recommendations promoting the success
of the Northern Medical program and making
Prince George a centre of excellence in rural and
remote health care.
Significant improvements to the regulatory
framework for health professions in British
Columbia were accomplished in 2003. The
umbrella framework of the Health Professions Act
was enhanced significantly by implementing
recommendations of the former Health
Professions Council in its 2001 report, Safe
Choices: A New Model for Regulating Health
Professions in British Columbia.
The Health Professions Amendment Act, 2003
extends the umbrella framework to all health
professions, and provides for the repeal of six
stand-alone statutes governing medicine,
optometry, dentistry, podiatry, chiropractic
services and registered nursing. In addition,
pharmacy is to be regulated under the Health
Professions Act and the new Pharmacy
Operations and Drug Scheduling Act will replace
the Pharmacists, Pharmacy Operations and Drug
Scheduling Act.
Information on health and health care in British
Columbia is available from the following website:
www.gov.bc.ca/healthservices
1.0 Public Administration
1.1 Health Care Insurance Plan and
Public Authority
On January 1, 1949, the British Columbia
provincial government commenced making
payments to hospitals for treatment provided to
qualified residents under the authority of the
Hospital Insurance Act. Hospital services are
funded, on a non-profit basis, through the
Regional Health Sector budget of the Ministry of
Health Services. This program is responsible to
the provincial government for the ongoing funding
of the province’s public hospitals, delivered via
funding and transfer agreements with the six
168
health authorities, under the terms of the Hospital
Act, the Hospital Insurance Act (section 9), and
the Hospital District Act (section 20).This entails
expenditures and commitment controls for the
operation of hospitals, provision of funds for
hospital construction and equipment and payment
of out-of-province hospital costs for qualified
British Columbia residents.
The Medical Services Plan of British Columbia is
administered and operated on a non-profit basis
by the Medical Services Commission. The Medical
Services Commission is responsible to the
Minister of Health Services and facilitates, in the
manner provided for under the Medicare
Protection Act, reasonable access to insured
benefits under British Columbia’s Medical
Services Plan by beneficiaries (residents). The
day-to-day administration is currently carried out
by employees of the Medical Services Plan of the
Ministry of Health Services. Beginning in April
2005, routine administrative functions will be
delivered by a private sector service provider. In
addition to its role in managing the contract with
the private provider, the ministry will continue to
be accountable for overall service delivery and will
retain responsibility for areas such as legislation,
regulations, setting of policy, complex decisions
and appeals.
The Commission’s powers (set out under section
5 of the Medicare Protection Act) include
determining benefits, registering beneficiaries,
enrolling practitioners, processing and paying
practitioners’ bills for benefits rendered,
registering diagnostic facilities, establishing
advisory committees, authorizing research and
surveys related to the provision of benefits,
auditing claims for payment and patterns of
practice or billings submitted and hearing appeals
from practitioners and beneficiaries.
In May 2003, the Health Services Statutes
Amendment Act, 2003, was passed by the
Legislature. It made minor amendments to the
Food Safety Act, Hospital Insurance Act, and
Medicare Protection Act. As amended, the
Medicare Protection Act authorizes the making of
rules by the Medical Services Commission
Canada Health Act Annual Report, 2003-2004
Chapter 3 – British Columbia
concerning practice and procedure for
applications, for orders and replies, and for the
conduct of hearings. The Ministry of Health
Services will also have recourse to order
mediation to resolve disputes regarding medical
service plan billings. Amendments to the Hospital
Insurance Act reflect the new regional structure of
health-care delivery as well as the fact that
ministry funding now goes directly to health
authorities rather than to individual hospitals.
1.2 Reporting Relationship
Health authorities are required to report health
information data respecting hospitals in their
jurisdictions to the Ministry of Health Services in
accordance with provincial policy. The
Performance Management and Improvement
Division reports to government through the
Ministry of Health Services Annual Service Plan
Report. This report compares actual results for
the preceding fiscal year with the expected results
identified in the service plan for that fiscal year. In
accordance with the Budget Transparency and
Accountability Act, this report, as well as the
Ministry of Health Services Service Plan, is made
public by the minister.
The Medical Services Commission reports
annually to the Minister of Health Services in a
separate Financial Statement. The 2003-2004
Financial Statement was tabled in June 2004.
In the Annual Service Plan Report, the Ministry of
Health Services provides extensive information on
the performance of British Columbia’s publicly
funded health care system. Tracking and reporting
this information is consistent with the ministry’s
increasingly strategic approach and
responsibilities for performance planning and
reporting, under the Budget Transparency and
Accountability Act, which was passed in 2000.
The Ministry of Health Services plays a role in
various reports including:
† Ministry Annual Report
† Report on Health Authority Performance
(annual)
† Nationally comparable Indictors Report
Canada Health Act Annual Report, 2003-2004
† Provincial Health Officer’s Annual Report (on
the health of the population)
1.3 Audit of Accounts
The ministry is subject to audit of accounts and
financial transactions through two types of
auditor:
† The Office of the Comptroller General’s
Internal Audit and Advisory Services is the
provincial government’s internal auditor. The
Comptroller General determines the scope of
the internal audits and timing of the audits in
consultation with the audit committee of the
Ministry of Health Services.
† The Office of the Auditor General (OAG) of
British Columbia is responsible for conducting
audits and reporting its findings to the
Legislative Assembly. The OAG initiates its
own audits and the scope of its audits. The
Public Accounts Committee of the Legislative
Assembly reviews the recommendations of the
OAG and determines when the ministry has
complied with the audit recommendations.
2.0 Comprehensiveness
2.1 Insured Hospital Services
The Hospital Insurance Act establishes public
insurance coverage for general hospital services.
Eligibility is defined by the Regulations, which
include both a residency requirement and a
waiting period. Insured hospital services are
provided in facilities specified in section 1 of the
Hospital Insurance Act. In 2003-2004 there were
92 acute care hospitals, three rehabilitation
hospitals, 18 free-standing extended care
hospitals and 24 diagnostic and treatment and
other health centres.
Insured hospital services are provided as
recommended by the attending physician or
midwife. These services, and the conditions under
which they are provided, are listed in the Hospital
Insurance Act Regulations, Division 5. Insured inpatient services provided by hospitals are:
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Chapter 3 – British Columbia
† accommodation and meals at the standard or
public ward level;
† necessary nursing services;
† laboratory and radiological procedures and
necessary interpretations together with such
other diagnostic procedures as approved by
the minister in a particular hospital with the
necessary interpretations, for the purpose of
maintaining health, preventing disease and
assisting in the diagnosis and treatment of
illness, injury or disability;
† clinically approved drugs, biologicals and
medical supplies, when administered in a
general hospital specified in the Hospital
Insurance Act;
† routine surgical supplies;
† use of operating room and case room facilities;
† anaesthetic equipment and supplies;
† use of radiotherapy, physiotherapy and
occupational therapy facilities, where available;
and
† other services approved by the Minister that
are rendered by persons who receive
remuneration from the hospital.
Beneficiaries not requiring in-patient hospital care
may receive emergency treatment for injuries or
illness and operating room or emergency room
services for surgical day care and minor surgery,
including the application and removal of casts.
Listed hospital out-patient benefits include:
† out-patient renal dialysis treatments in
designated hospitals or other approved
facilities;
† diabetic day-care services in designated
hospitals;
† out-patient dietetic counseling services at
hospitals with qualified staff dieticians;
† psychiatric out-patient and day-care services;
physiotherapy and rehabilitation out-patient
day care, and services;
† cancer therapy and cytology services;
† out-patient psoriasis treatment;
† abortion services; and
† MRI services.
Insured hospital services are provided at no
charge to beneficiaries. Incremental charges for
170
preferred medical/surgical supplies, when
approved, are made on the basis of a patient’s
request. The patient is not required to pay the
incremental charge if the preferred service is
deemed medically necessary by the attending
physician.
Ambulance services are provided within the
province by the British Columbia Ministry of
Health Services through the Emergency Health
Services Commission, with a partial charge to the
patient.
There is no regular process to review insured
hospital services. As the list of insured services
included in the Regulations is intended to be both
comprehensive and generic, it does not require
routine review and updating.
2.2 Insured Physician Services
Insured physician services are provided under the
authority of the Medicare Protection Act. Section
13 of the Medicare Protection Act (MPA) provides
that practitioners (including medical practitioners
and health care practitioners, such as dentists)
who are enrolled and who render benefits to a
beneficiary are eligible to be paid for services
rendered in accordance with the appropriate
payment schedule.
The Medical Services Plan (MSP) provides for
medically required services of medical
practitioners. Unless specifically excluded, the
following medical services are insured as MSP
benefits under the MPA and in accordance with
the Canada Health Act:
† medically required services provided to
“beneficiaries” (residents of British Columbia)
by a medical practitioner enrolled with MSP;
and
† medically required services performed in an
approved diagnostic facility under the
supervision of an enrolled medical practitioner.
To practice in British Columbia, physicians must
be registered and in good standing with the
College of Physicians and Surgeons of British
Columbia. To receive payment for insured
services, they must be enrolled with the MSP.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – British Columbia
There were 8,083 physicians enrolled and billing
fee-for-service in fiscal year 2003-2004. In
addition, some physicians practice solely on
salary, receive sessional payments, or are on
contract (service agreements) arrangements with
the health authorities. Many physicians paid by
such alternative mechanisms also practice on a
fee-for-service basis.
A physician may choose not to enroll or to deenroll with the Medical Services Commission.
Enrolled physicians may cancel their enrollment by
giving 30 days’ written notice to the Commission.
Services provided by non-enrolled physicians are
not benefits and patients are responsible for the
full cost of the service. There was one previously
enrolled physician who had de-enrolled as of
March 31, 2004.
Enrolled physicians can elect to be paid directly by
beneficiaries by giving written notice to the
Commission. The Commission will specify the
effective date between 30 and 45 days following
receipt of the notice. In this case, beneficiaries
may apply to the MSP for reimbursement of the
fee for insured services rendered. Only six
physicians had elected to be paid in this manner
as of March 2004.
Under the Master Agreement between the
Government, the Commission and the British
Columbia Medical Association (BCMA), additions,
deletions, fee changes or other modifications to
the Commission Payment Schedule are made by
the Commission, upon advice from the BCMA.
Physicians who wish to have modifications to the
Schedule considered submit their proposals to the
BCMA Tariff Committee through the appropriate
section of the BCMA. On recommendation of the
BCMA Tariff Committee, interim listings may be
designated by the Commission for new
procedures or other services for a limited period
of time to allow definitive listings to be
established, if appropriate.
A number of new or revised clinical practice
guidelines were also approved by the Commission
in 2003-2004:
† initiation and maintenance of Warfarin therapy;
Canada Health Act Annual Report, 2003-2004
† treatment of patients over-anticoagulated with
Warfarin;
† management of Warfarin therapy during
invasive procedures and surgery;
† diabetes care (revised 2004);
† detection of colorectal neoplasms in
asymptomatic patient;
† identification, evaluation and management of
patients with chronic kidney disease;
† microscopic hematuria (persistent);
† diagnosis and management of major
depressive disorder;
† clinical approach to adult patients with
dyspepsia (revised 2004);
† follow-up of patients after curative resection of
colorectal cancer (revised 2004);
† evaluation and interpretation of abnormal liver
chemistry in adults;
† clinical approach to adult patients with
gastroesophageal reflux disease (revised
2004);
† thyroid function tests in the diagnosis and
monitoring of adults with thyroid disease; and
† primary care management of sleep complaints
(revised 2004).
2.3 Insured Surgical-Dental
Services
The Medical Services Plan provides for specified
dental or oral surgery when it is medically or
dentally necessary for it to be performed in
hospital by a dental or oral surgeon. Surgicaldental services are covered by the Medical
Services Plan when hospitalization is medically
required for the safe and proper performance of
the surgery and the procedure is listed in the
Dental Payment Schedule. The Medicare
Protection Act defines patient eligibility and
provider criteria. Additions or changes to the list
of insured services are managed by the Medical
Services Plan on the advice of the Dental Liaison
Committee, which has equal representation from
the Dental Association and the Ministry of Health
Services. Additions and changes must be
approved by the Medical Services Commission.
Included as insured surgical-dental procedures are
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Chapter 3 – British Columbia
those related to the remedying of a disorder of
the oral cavity or a functional component of
mastication. Generally this would include, oral
surgery related to trauma, orthognathic surgery,
medically required extractions, and surgical
treatment of temporomandibular joint dysfunction.
Any dental or oral surgeon in good standing with
the College of Dental Surgeons and enrolled in
the Medical Services Plan may provide insured
surgical-dental services in hospital. There were
243 dentists enrolled and billing fee-for-service in
2003-2004. None have de-enrolled and none have
opted out of the Medical Services Plan.
2.4 Uninsured Hospital, Physician
and Surgical-Dental Services
For out-patients, take-home drugs and certain
hospital drugs are not insured, except those
provided under the provincial Pharmacare
program. Other procedures not insured under the
Hospital Insurance Act are:
† the services of medical personnel not
employed by the hospital;
† treatment for which the Workers’
Compensation Board, the Department of
Veterans Affairs or any other agency is
responsible;
† services solely for the alteration of
appearance; and
† reversal of sterilization procedures.
Uninsured hospital services also include:
† preferred accommodation at the patient’s
request;
† televisions, telephones and private nursing
services;
† preferred medical/surgical supplies;
† dental care that could be provided in a dental
office including prosthetic and orthodontic
services; and
† preferred services provided to patients of
extended care units or hospitals.
Services not insured under the Medical Services
Plan include:
† those covered by the Workers’ Compensation
Act or by other federal or provincial legislation;
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†
†
†
†
†
†
†
†
†
†
†
provision of non-implanted prostheses;
orthotic devices;
proprietary or patent medicines;
any medical examinations that are not
medically required;
oral surgery rendered in a dentist’s office;
acupuncture;
telephone advice unrelated to insured visits;
reversal of sterilization procedures;
in-vitro fertilization;
medico-legal services; and
most cosmetic surgery.
Medical necessity, as determined by the attending
physician and hospital, is the basis for access to
hospital and medical services.
The Medicare Protection Act, section 45 prohibits
the sale or issuance of health insurance by private
insurer to beneficiaries for services that would be
benefits if performed by a practitioner. Section 17
of the Act prohibits persons from charging a
beneficiary for a benefit or for “materials,
consultations, procedures, use of an office, clinic
or other place or for any other matters that relate
to the rendering of a benefit.” The Ministry of
Health Services responds to complaints made by
patients and is prepared to take appropriate
actions to correct situations identified to the
ministry.
In September 2002, the Ministry of Health
Services issued a Policy Communiqué to all health
authorities on Hospital-Based Revenue
Generation. Among the categories of services
covered by this policy is use of hospital facilities
to provide services covered by third party
insurers, such as the Workers’ Compensation
Board. The policy specifies that health authorities’
primary obligation is to provide insured health
services to beneficiaries, and that revenue
generating practices must not occur at the
expense of providing appropriate and timely
service to beneficiaries. It also reinforces that
health authorities must follow the requirements of
the Canada Health Act, as well as relevant
provincial legislation. Health authorities are
required to report new initiatives of this type
within their annual Health Service Plans, and the
Canada Health Act Annual Report, 2003-2004
Chapter 3 – British Columbia
Ministry of Health Services monitors compliance
with the policy within the overall performance
monitoring plan and service design plans.
However, if discharged outside British Columbia,
they must wait the prescribed period.
The Medical Services Commission determines
which services are benefits and has the authority
to de-list insured services. Proposals to de-insure
services must be made to the Commission.
Consultation may take place through a subcommittee of the Commission and usually includes
a review by the British Columbia Medical
Association’s Tariff Committee. No services were
de-listed in 2003-2004.
3.2 Registration Requirements
3.0 Universality
3.1 Eligibility
Provincial policy on eligibility for hospital services
is set out in Chapter 2 of the Ministry of Health
Service’s Acute Care Policy Manual.
Section 7 of the Medicare Protection Act defines
the eligibility and enrollment of beneficiaries for
insured services. Part 2 of the Medical and Health
Care Services Regulation made under the
Medicare Protection Act details residency
requirements. A person must be a resident of
British Columbia in order to qualify for provincial
health care benefits. The Medicare Protection Act,
in section 1, defines a resident as a person who is
a citizen of Canada or is lawfully admitted to
Canada for permanent residence, makes his or
her home in British Columbia, and is physically
present in British Columbia at least six months in
a calendar year. The definition of resident includes
a person who is deemed under section 2 of the
Medical and Health Care Services Regulations to
be a resident but does not include a tourist or
visitor to British Columbia.
All residents, excluding those eligible for
compensation from another source, are entitled to
hospital and medical care insurance coverage. The
Medical Services Plan provides first-day coverage
to discharged members of the Royal Canadian
Mounted Police and the Canadian Forces, and to
released inmates of federal penitentiaries.
Canada Health Act Annual Report, 2003-2004
Residents must be enrolled in the Medical
Services Plan to receive insured hospital and
physician services. Those who are eligible for
coverage are required to enroll. Once enrolled,
there is no expiration date for coverage. New
residents are advised to make application
immediately upon arrival in the province. Each
person who enrolls with the Medical Services Plan
is issued a CareCard. Renewal of cancelled
enrollment can usually take place over the
telephone, by calling the Medical Services Plan.
Beneficiaries may cover their dependents,
provided the dependents are residents of the
province. Dependents include the account holder’s
spouse (either married to or living and cohabiting
in a marriage-like relationship), any unmarried
child or legal ward, supported by the beneficiary,
and either under the age of 19 or under the age of
25 and in full-time attendance at a school or
university.
The number of residents registered with the
Medical Services Plan as of March 31, 2004, was
4.10 million. Enrollment in the Medical Services
Plan is mandatory. Only those adults who formally
opt out of all provincial health care programs are
exempt. As of March 31, 2004, 173 people had
opted out.
3.3 Other Categories of Individual
Refugee claimants are not generally eligible for
benefits. Individuals who are approved for refugee
status and who are, therefore entitled to reside in
Canada on a permanent basis, are eligible. Under
specific circumstances, special consideration is
given to these individuals regarding the effective
date of benefits. Holders of Minister’s
Permits/Temporary Resident Permits are eligible
for benefits where deemed to be residents under
the Medical and Health Care Services Regulation.
A waiting period applies which consists of the
balance of the month in which a person first
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Chapter 3 – British Columbia
meets the Medical Services Plan’s definition of a
resident, plus two months.
3.4 Premiums
Enrollment in the Medical Services Plan is
mandatory, and payment of premiums is ordinarily
a requirement for coverage. However, failure to
pay premiums is not a barrier to coverage for
those who meet the basic enrollment eligibility
criteria. Monthly premiums for the Medical
Services Plan are $54 for one person, $96 for a
family of two, and $108 for a family of three or
more. Residents with limited incomes may be
eligible for premium assistance. There are five
levels of assistance, ranging from 20 percent to
100 percent of the full premium. Premium
assistance is available only to beneficiaries who,
for the last 12 consecutive months, have been
resident in Canada and a Canadian citizen or
holder of permanent resident (landed immigrant)
status.
There are no additional premiums for insured
hospital services. However, there is a daily charge
for extended-care hospital services for patients
over the age of 19. The client rate, representing
the cost of accommodation and meals, is
established once a year. As of March 31, 2004,
the rates ranged from $27.60 a day to $66.30 a
day, depending on client income. In certain
circumstances where clients cannot afford to pay
their assessed rate, there is a provision to waive a
portion of the daily fee. Client rates are increased
on January 1st of each year by the percentage
increase in the Consumer Price Index.
4.0 Portability
Persons moving permanently to another part of
Canada are entitled to coverage to the end of the
second month following the month of departure.
Such persons may be extended coverage, not to
exceed three months, for a reasonable period of
travel.
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Persons moving permanently outside Canada are
entitled to coverage to the end of the month of
departure.
4.1 Minimum Waiting Period
The minimum residence requirement for hospital
insurance and medical care coverage is a waiting
period ending at midnight on the last day of the
second month following the month in which the
individual becomes a resident.
Coverage is available to landed immigrants who
have completed the waiting period. Also after the
waiting period, coverage is available to persons
from outside Canada who are in the Province on
work permits or student visas, provided the
permits or visas are valid for at least six months,
and have been issued at the time of admission to
Canada.
4.2 Coverage During Temporary
Absences In Canada
Sections 3, 4 and 5 of the Medical and Health
Care Services Regulations define portability
provisions for persons temporarily absent from
British Columbia in Canada with regard to insured
services. In 2003-2004, there were no
amendments to the Medical and Health Care
Services Regulation, made under the Medicare
Protection Act, with respect to the portability
provisions.
Section 17 of the Hospital Insurance Act
empowers the Minister of Health to enter into an
agreement with any other province or territory to
bring about a high degree of liaison and
cooperation among the Provinces concerning
hospital insurance matters, and to make
arrangements under which a qualified person may
move his or her home from one province or
territory to the other without ceasing to be
entitled to benefits.
Individuals who leave the province temporarily on
extended vacations or for temporary employment
may be covered for up to 12 months. Approval is
limited to once in five years for such absences
exceeding six months in a calendar year.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – British Columbia
Residents who spend part of every year outside
British Columbia must be physically present in
Canada for at least six months in a calendar year
and continue to maintain their homes in British
Columbia. Students attending a recognized school
in another province or territory on a full-time basis
are entitled to coverage for the duration of their
studies.
According to inter-provincial and inter-territorial
reciprocal billing arrangements, physicians, except
in Quebec, bill their own medical plans directly for
services rendered to eligible British Columbia
residents, on presentation of a valid Medical
Services Plan Card (CareCard). British Columbia
then reimburses the province or territory at the
rate of the fee schedule in the province or
territory in which services were rendered. For inpatient hospital care, charges are paid at the
standard ward rate actually charged by the
hospital. For out-patient services, the payment is
at the interprovincial and interterritorial reciprocal
billing rate. Payment for these services, except for
excluded services that are billed to the patient, is
handled though interprovincial and interterritorial
reciprocal billing procedures. In 2003-2004, the
total amounts paid to other provinces and
territories for both in-patient and out-patient
hospital services was $56.4 million. The amount
paid to physicians in other provinces and
territories was $24.2 million.
As Quebec does not participate in reciprocal
billing agreements for physician services, claims
for services provided to British Columbia
beneficiaries by Quebec physicians must be
handled individually. Reimbursement may be made
either to the physician providing the service, or
directly to the beneficiary who received the
service, whomever submits the claim.
2003-2004, there were no amendments to the
Medical and Health Care Services Regulation with
respect to portability provisions.
A qualified person leaving British Columbia to
attend university, college or other educational
institutions recognized by the Medical Services
Commission, on a full-time basis, retains eligibility
during the absence for study until the last day of
the month in which the person ceased full-time
attendance at that educational institution, or if
studying outside Canada, the last day of the
sixtieth month since the date of departure from
British Columbia.
A qualified person who is absent from British
Columbia for vacation or work for more than six
months is deemed a resident for the purpose of
determining beneficiary status for up to the initial
12 consecutive months of absence, if this person
obtains prior approval from the Medical Services
Commission, does not establish residency outside
British Columbia and has not been granted
approval for a similar absence during the
preceding 60 months.
With prior authorization, coverage is provided for
hospital services not available in Canada at the
hospital’s usual and customary rate. In other
circumstances, with prior authorization, in-patient
coverage is at the established standard ward rate.
Out-patient renal dialysis treatment is available at
the interprovincial and interterritorial Canadian
rate. In all other cases, including emergency or
sudden illness during temporary absences from
the Province, in-patient hospital or daycare
surgical care is paid up to $75 Canadian per day
for adults and children, and $41 Canadian per day
for newborns. Payments for insured services
provided outside Canada in 2003-2004 totaled
$2.7 million to hospitals and $2.5 million to
physicians.
4.3 Coverage During Temporary
Absences Outside Canada
4.4 Prior Approval Requirement
The Hospital Insurance Act Regulations, division 4
and sections 3, 4, and 5 of the Medical and Health
Care Services Regulations define portability of
insured hospital and physician services during
temporary absences outside Canada. In
No prior approval is required for elective
procedures that are covered under the
interprovincial reciprocal agreements with other
provinces. Prior approval from the Medical
Services Commission is required for procedures
Canada Health Act Annual Report, 2003-2004
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Chapter 3 – British Columbia
that are not covered under the reciprocal
agreements. Some treatments may require the
approval of Performance Management and
Improvement Division (e.g., treatment for
anorexia). All non-emergency procedures
performed outside of Canada require approval
from the Commission prior to the procedure.
5.0 Accessibility
5.1 Access to Insured Health
Services
British Columbia believes that all residents have
reasonable access to hospital and medical care
services. Beneficiaries, as defined in section 1 of
the Medicare Protection Act and the Ministry of
Health Services’ Acute Care Policy Manual, are
eligible for all insured hospital and medical care
services as required. To ensure equal access to
all, regardless of income, the Medicare Protection
Act, Part 4, prohibits extra-billing by enrolled
practitioners.
5.2 Access to Insured Hospital
Services
The number of practicing Registered Nurses as of
December 2003 was 29,982. British Columbia
hospitals also employ Registered Psychiatric
Nurses (RPNs) and Licensed Practical Nurses
(LPNs). In 2003 there were 2,149 RPNs and
4,923 LPNs. In September 2003 the British
Columbia government announced that a further
$6.7 million would be added to its nursing
strategy to continue to strengthen recruitment,
retention and education of nurses across BC.
Since August 2001, government’s total
commitment to nursing strategies has grown to
$59 million.
British Columbia’s nursing strategies are
identified, developed and implemented by the
Ministry of Health Services with input from nurses
and other stakeholders. They are intended to
improve the recruitment, retention, education and
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workplace needs of British Columbia nurses and
nursing students. Through consultation with
stakeholders, input from the Nursing Advisory
Committee of BC and review of national trends
and policies, the following priorities were
identified:
† human resources planning for recruitment,
retention and education of nurses in British
Columbia to address provincial health care
needs;
† enhancing nursing practice environments by
supporting health authorities and government
to make sound nursing policy in keeping with
current research and provincial, national and
global trends;
† compiling nursing data to enhance our
understanding of trends and changing needs in
nursing and health care; and
† promoting nursing as a career of choice to
ensure the future of a quality British Columbia
health care system.
In October 2003, the Health Professions
Amendment Act was passed in the Legislature
allowing for the regulation of nurse practitioners.
Thirty new spaces for nurse practitioners were
added at the University of British Columbia and
University of Victoria in September 2003. An
additional 15 new student spaces at University of
Northern British Columbia was announced in
March 2004.The new program of nurse
practitioners improves health services by
expanding the range of health professionals to
care for patients. Nurse practitioners are one
component of the province’s primary-care
initiative, which is aimed at providing a broader
range of integrated health services that are more
appropriate to meet the needs of patients.
British Columbia midwives are publicly funded and
perform 4 percent of total annual births in British
Columbia. This percentage is expected to increase
by 2005 due to student graduation from the new
UBC School of Midwifery. As of December 2004,
there were 101 midwives practicing throughout
British Columbia. Midwives are practicing within
both rural and urban settings; however, 75 percent
of midwives are working in urban settings.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – British Columbia
Telehealth (supported by the Provincial Health
Services Authority since mid 2002) continues to
provide improved access to services in British
Columbia.
March 31, 2003 marked the conclusion of the
federal funding period through the Canada Health
Infostructure Partnerships Program (CHIPP), and
the regional health authorities now support the
equipment and infrastructure deployed during
CHIPP.
Services established through the different
projects continue to be delivered, and new
applications are being implemented on an ongoing
basis. Four domains in Telehealth have now been
defined: Telemedicine, Telehomecare; Telelearning
and Teletriage. There is growing focus on
increasing access to Telehealth in aboriginal, rural
and remote, and First Language Minority
communities.
With respect to active Telehealth programs in the
province of British Columbia, services are
available in approximately 20 clinical program
areas. Oncology, mental health/psychiatry,
maternal/fetal medicine, medical genetics,
orthopedics, pharmacy, thoracic surgery, trauma,
and wound care program areas are all applying
telehealth technology to service delivery. Services
for children are available in the areas of
psychiatry, rehabilitation and development, eating
disorders/nutrition, neonatology, cardiology,
oncology, palliative care, physiotherapy, and
speech therapy.
A provincial Telehealth Steering Committee is in
the process of identifying and defining the
provincial priorities for telehealth.
Acute care access standards are used by health
authorities in the redesign of hospital services.
The standards specify the maximum travel time
for accessing emergency services, in-patient
services and core specialty services. They also
ensure that the majority of British Columbians, in
all regions, have reasonable access to these
services. Within the Ministry of Health Services
Service Plan 2002/2003 - 2004/2005,
performance measures were included regarding
waiting times for key services (radiotherapy and
Canada Health Act Annual Report, 2003-2004
chemotherapy). For 2003-2004, the targets for
both chemotherapy and radiotherapy were met.
Over the past year, the Ministry of Health
Services has continued to work with health
authorities to improve capital planning and
processes to better serve the needs of the health
sector. Ongoing implementation of the new
provincial capital policy framework (Capital Asset
Management Framework, 2002) promotes best
practices and supports a more flexible approach
to meeting service delivery needs. In 2003-2004,
in accordance with the Framework guidelines,
health authorities prepared capital plans designed
to more clearly integrate capital planning with
redesign and budget plans, and to enhance a more
strategic approach to providing capital assets
such as hospital facilities and equipment. A more
rigorous approach to planning will encourage
efficient use of health care dollars to meet
increasing demand upon existing assets, and to
allow health authorities to maintain and upgrade
capital stock.
The ministry provides capital funding to health
authorities for maintenance, renovation,
replacement and expansion of health facilities. For
the 2003-2004 fiscal year, the ministry’s multiyear capital spending plan included:
† $115 million in general funding to maintain and
improve facilities and to purchase equipment;
† ongoing expenditures from a $100 million
allocation established in 2002-2003 to convert
existing health facilities to uses consistent with
regional and provincial priorities, achieve
building and operational efficiencies, and
implement best practices;
† ongoing expenditures from a $138 million
allocation established in 2002-2003 for
development of mental health beds from
Riverview Hospital to be relocated to suitable
locations in the health regions; and
† The first year of funding from the 2003 First
Ministers’ Accord on Health Care Renewal. Of
the $1.5 billion national fund, $200.1 million
has been allocated to British Columbia for
acquisition of diagnostic and medical
equipment, and specialized training of staff. In
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Chapter 3 – British Columbia
2003-2004, health authorities purchased
equipment totaling $21.7 million, including:
† diagnostic imaging equipment (e.g.
Computed Tomography scanners);
† equipment for other diagnostic and
therapeutic use (e.g. laboratory
equipment);
† medical and surgical equipment (e.g.
anesthetic machines); and
† equipment for comfort and safety (e.g.
lifting devices, mobility aids).
In 2003-2004, the ministry commenced a
province-wide inventory and assessment of health
authority-owned facilities, land, major equipment
and leased premises. This is the first time that
such a comprehensive inventory of public and notfor-profit health system assets has been
conducted in British Columbia, and it is
anticipated the results will significantly enhance
decision-making for health authorities. A
comprehensive database will allow health
authorities to compare assets in a more
meaningful way, prioritize projects, and assess the
nature and cost of capital investment required to
meet future service delivery needs.
The BC HealthGuide Program, started in 2001,
has a comprehensive approach to self-care unique
in Canada, and based on information delivered in
a variety of formats:
† BC HealthGuide Handbook – delivered free to
every household in British Columbia, it
contains tips for prevention and early
identification of illnesses, when to see a
doctor, self-care “home treatment” tips, and
information on managing chronic diseases. A
French version of the handbook was released
in June 2004 (Guide-santé – ColombieBritannique). The BC First Nations Health
Handbook was developed in partnership with
the BC First Nations Chiefs’ Health
Committee – the handbook provides specific
information on health services available to
Aboriginal communities. The BC First Nations
Health Handbook was distributed to Aboriginal
communities in January 2003. The handbook
provides Aboriginal communities with tools and
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†
†
†
†
information necessary to help improve their
health.
BC HealthGuide OnLine – expands on the
information in the BC HealthGuide Handbook
with more than 35,000 medically reviewed
pages covering over 3,000 detailed health
topics on symptoms and conditions. The Web
site, www.bchealthguide.org is updated
quarterly.
BC NurseLine – toll-free 24 hours a day, seven
days a week nursing triage and health
education by telephone. Registered nurses are
specially trained to use medically approved
protocols for acute and chronic health
symptoms and conditions. The BC NurseLine
gives people the information they need, when
they need it, where they need it, and includes
services for people who are deaf and hearing
impaired as well as translation services in over
130 different languages - improving access for
all British Columbians. In 2003-2004, the BC
NurseLine received 250,018 calls – an increase
of 44.6 percent over the previous year.
On June 19, 2003, the pharmacist
enhancement to the BC NurseLine was
implemented. Callers from British Columbia
can speak with a pharmacist about medication
related questions, between 5:00 pm and 9:00
am, seven days a week, 365 days per year.
Since the implementation of the pharmacist
advice line, 10,742 medication-related calls
were transferred from the BC NurseLine to the
BC NurseLine pharmacists. Over this period,
1,118 calls were identified as being triggered
by adverse drug reactions – over 10 percent of
all medication-related calls transferred from
the BC NurseLine. As a result of these calls,
BC NurseLine pharmacists have submitted 324
Adverse Drug Reaction (ADRs) Reports to the
British Columbia Regional ADR Centre. These
are submitted in turn to Health Canada to
monitor adverse effects that are either
unexpected, serious, or for newly marketed
medications. The pharmacist service is
responsible for over 20 percent of all ADR
reports submitted to Health Canada by the
British Columbia Regional ADR Centre, making
Canada Health Act Annual Report, 2003-2004
Chapter 3 – British Columbia
it a large and integral contributor to patient
safety – not only for British Columbians, but
for all Canadians.
† BC Health Files – a series of over 170 onepage, easy-to-understand fact sheets about a
wide range of public and environmental health
and safety issues. The fact sheets are available
in the province’s 120+ health units and
departments and other offices.
5.3 Access to Insured Physician and
Dental-Surgical Services
In 2003-2004, there were 4,573 general
practitioners, 3,510 specialists and 243 dentists
who provided insured fee-for-service physician
and dental-surgical services. Approximately 2,292
general practitioners and specialists received all
or part of their income through British Columbia’s
Alternative Payments Program (APP). The APP
provides funding to regional health authorities for
their contracting with physicians for the delivery
of insured clinical services.
The Ministry of Health Services implemented
several programs under the 2002 Subsidiary
Agreement for Physicians in Rural Practice to
enhance the availability and stability of physician
services in smaller urban, rural and remote areas
of British Columbia. The Rural Retention Program
provides eligible rural physicians (approximately
1,200) with fee premiums and is available for
visiting physicians and locums. Through the
Northern and Isolation Travel Assistance Outreach
Program, funding was provided for an estimated
1,400 visits by family doctors and specialists to
rural communities. The Rural General Practitioner
Locum Program assisted physicians practicing in
approximately 55 small communities to secure
subsidized continuing medical education and
vacation relief. The Rural Specialist Locum
Program provides locum support for core
specialists in 17 rural communities while physician
recruitment efforts are underway. The Rural
Education Action Plan supported the training of
physicians in rural practice through several
components, including rural practice experience
for medical students and enhanced skills for
Canada Health Act Annual Report, 2003-2004
practising physicians. Effective April 1, 2004, the
Isolation Allowance Fund was established to
provide funding to communities with fewer than
four physicians and no hospital and which do not
receive Medical On-call/Availability Program, callback, or Doctor of the Day payments. The Rural
Loan Forgiveness Program decreases BC student
loans by 20 percent for each year of rural practice
for physicians, nurses, midwives and pharmacists.
In November 2002, British Columbia received
$73.5 million in federal funding over four years
(2002-2006) to develop sustainable improvements
to primary health care (PHC) and increase patient
access to comprehensive, high-quality services in
physicians’ offices and community clinics - the
usual first points of contact with the health care
system. Since 2002, the number of new model
PHC sites, providing interdisciplinary care and
extended hours, has increased to a total of nine
sites. Regional health authorities have plans to
establish up to 30 PHC sites by March 2006.
The University of British Columbia’s (UBC)
medical school is expanding in collaboration with
the University of Northern British Columbia, the
University of Victoria and British Columbia’s
health authorities to almost double the number of
medical students. In 2002, as part of British
Columbia’s commitment to expand the province’s
only medical school, the provincial government
announced $134 million to build a new Life
Sciences Centre at UBC in Vancouver and
distributed sites for medical programs in Prince
George and Victoria. In 2004, the number of
first-year medical school spaces increased to 200,
up from 128 in 2003. A further increase of 24
spaces in 2005 means UBC will graduate a
potential of 224 medical students per year by
2009.
In addition to the medical school expansion, the
government has begun a stepped expansion to
postgraduate medical education. Thirty-two firstyear residency positions were added in 2004. By
2010, the number of first-year postgraduate
positions will double to 256, up from 128 in 2003.
179
Chapter 3 – British Columbia
5.4 Physician Compensation
The Province of British Columbia negotiates with
the British Columbia Medical Association (BCMA)
to establish the conditions, benefits and overall
compensation for both fee-for-service physicians
and physicians paid under alternative payment
mechanisms, including contracted, sessional and
salaried physicians.
Physicians in British Columbia received significant
increases in 2002, placing them among the
highest compensated in all of Canada. Funding for
physicians accounts for over $2.5 billion or 23 per
cent of the health care budget. In June 2004 the
Government and BCMA, signed three Letters of
Agreement pertaining to the Working Agreement,
Laboratory Reform and Related Matters. The
agreement reallocates $100 million of savings to
improve the quality of patient care.
The three-year contract puts physician
compensation increases on hold for two years,
expands communications between government
and physicians through a variety of committees
and consultations, reallocates benefit funds,
improves maternity care, provides additional
funding for recruitment and retention of rural
physicians and specialists, supports GPs and their
role in chronic disease management, and reforms
and modernizes laboratories.
The Agreement covers the period April 1, 2004 to
March 31, 2007 and was reached through
negotiation rather than the conciliation panel
process. Compensation increases will be the
subject of further negotiations with physicians in
the third year of the agreement. The option of
binding arbitration in the third year of the contract
ensures it is consistent with the Canada Health
Act.
Section 13 of the Medicare Protection Act
provides that medical practitioners and dentists,
who are enrolled under the Act and render
benefits to a beneficiary of the Medical Services
Plan (MSP), are eligible to be paid for services in
accordance with the appropriate payment
schedule. In 2003-2004, there were no
180
amendments to section 13 of the Medicare
Protection Act.
Payment for medical services delivered in the
province is made through the MSP to individual
physicians, based on submitted claims, and
through the Alternative Payments Program (APP)
to health authorities, also based on claims, for
contracted physicians’ services. The patient is not
normally involved in the payment system. Ninetynine point nine percent of MSP claims are
submitted electronically through the Teleplan
System, while the remainder are submitted on
claim cards. Approximately 9.5 percent of
physicians’ compensation was distributed through
the APP in 2003-2004.
The APP provides program-specific funding to
British Columbia’s six health authorities and the
Nisga’a, which in turn, contract with physicians for
their services or time through service contracts or
sessional payments. Provincial agreements,
negotiated as subsidiaries to the Master and
Working agreements between the Government of
British Columbia and BCMA, set the terms and
conditions of physician compensation for
government-funded services, including those
funded by the APP. Approximately 2,292
physicians are supported, either wholly or in part,
through APP funding arrangements.
5.5 Payments to Hospitals
In 2003-2004, the total payments to health
authorities were $6.2 billion. These payments
were for the provision of the full range of
regionally delivered health care services which
includes acute, residential, community care, public
and preventive health, adult mental health and
addictions programs. This does not include
Medical Services Plan or other Ministry of Health
Services’ program payments to health authorities.
Payments to out-of-province hospitals within
Canada for insured services (both in- and outpatient) provided to British Columbia residents
totaled $56.4 million, while payment to hospitals
outside the country totaled $2.7 million in
2003-2004.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – British Columbia
6.0 Recognition
Funding provided by the federal government
through the Canada Health and Social Transfer
has been recognized and reported by the
Government of British Columbia through various
government websites and provincial government
documents. For the fiscal year 2003-2004, these
documents included the following:
† Public Accounts 2003/04 (tabled June 29,
2004);
http://www.fin.gov.bc.ca/ocg/pa/
03_04/PA_2004_all.pdf
† Budget and Fiscal Plan, 2004/05 to 2006/07
(tabled February 17, 2004);
http://www.bcbudget.gov.bc.ca/bfp/
default.htm
† Estimates, Fiscal Year Ending March 31, 2005
(tabled February 17, 2004)
http://www.bcbudget.gov.bc.ca/est/
25-26_Health_Services.html
7.0 Extended Health Care
Services (EHCS)
The Ministry of Health Services allocates funds to
the health authorities to provide a comprehensive
range of community-based supportive care
services to assist people whose ability to function
independently is affected by long-term healthrelated problems or who have acute care needs
that can be met at home. Services include case
management; in-home support services (home
support, community home care nursing,
physiotherapy, occupational therapy, nutrition
counseling, social worker services and meals
programs); assisted living; residential care
services (family care homes, group homes and
residential care facilities); community palliative
care; residential hospice; and special support
services (adult day centres, respite care and
assessment and treatment centres). Services are
delivered at the community level through the
health authorities.
Canada Health Act Annual Report, 2003-2004
Residential care services provide 24-hour
professional nursing care and supervision in a
protective, supportive environment for adults who
can no longer be looked after in their own homes.
Assisted living services provide a housing
arrangement that consists of a private housing
unit with a lockable door, hospitality services and
personal care services.
Hospice services provide a residential home-like
setting where supportive and professional care
services are provided to British Columbians of any
age who are in the end stages of a terminal illness
or preparing for death. Services may include
medical and nursing care, advance care planning,
pain and symptom management, and
psychosocial, spiritual and bereavement support.
A variety of housing alternatives are also available
through health authorities for persons with mental
illness and substance use disorders. Residential
care facilities provide 24-hour care and intensive
treatment services. Supported housing facilities
provide stable and secure housing while residents
receive treatment or community re-integration
services in the community. In addition, persons
with mental illnesses can reside and receive lifeskills support in family care homes, which are
private homes operated by families or individuals
who are compensated for the services provided.
Home care nursing and community rehabilitation
services are professional services, delivered to
people of all ages in the community by registered
nurses and rehabilitation therapists. These
services are available on a non-emergency basis
and include assessment, teaching and
consultation, care coordination and direct care or
treatment for clients with chronic, acute, palliative
or rehabilitative needs.
Home support services provide assistance with
activities of daily living and personal care. Adult
day centres offer a centre-based program of
health, social and recreational activities.
End-of-life care preserves clients' comfort, dignity
and quality of life by relieving or controlling
symptoms so those facing death, and the loved
ones, can devote their energies to embracing the
time they have together. Professional care givers
181
Chapter 3 – British Columbia
and support staff provide supportive and
compassionate care in the client's home, in
hospital, hospice, an assisted living residence or a
residential care facility.
182
A Palliative Care Benefits Program was
implemented in 2001 to provide home-based
palliative care clients with medication for pain and
symptom relief and medical supplies and
equipment, at no charge.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – British Columbia
Registered Persons
1. Number as of March 31st (#).
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
3,785,150
3,804,133
3,981,617
4,019,744
4,084,463
Insured Hospital Services Within Own Province or Territory
Public Facilities
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
2. Number (#): 1
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
94
17
3
25
139
94
18
3
25
140
94
18
3
25
140
92
18
3
25
138
92
18
3
24
137
3. Payments ($): 2
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
1999-2000
2000-2001
2001-2002
2002-2003
4. Number (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
1
not available
1
1
not available
1
1
not available
1
1
not available
1
5. Number of insured hospital services
provided (#): 4
a. surgical facilities
b. diagnostic imaging facilities
c. total
810
not available
810
634
not available
634
689
not available
689
612
not available
612
not available 5
not available
not available
6. Payments ($):
a. surgical facilities
b. diagnostic imaging facilities
c. total
558,000
not available
558,000
348,700
not available
348,700
353,100
not available
353,100
358,600
not available
358,600
1,470,370
not available
1,470,370
Private For-Profit Facilities
Canada Health Act Annual Report, 2003-2004
2003-2004
3
11
0
11
183
Chapter 3 – British Columbia
Insured Physician Services Within Own Province or Territory
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
4,277
3,268
0
7,545
4,359
3,297
0
7,656
4,430
3,380
0
7,810
4,471
3,421
0
7,892
4,573
3,510
0
8,083
4
10
0
14
3
5
0
8
3
3
0
6
3
3
0
6
3
2
0
5
1
0
0
1
1
0
0
1
1
0
0
1
1
0
0
1
1
0
0
1
10. Number of services provided through
fee for service (#):
a. general practitioners
b. specialists
c. other
d. total
22,942,977
32,791,108
not applicable
55,734,085
23,037,717
34,565,990
not applicable
57,603,707
22,786,171
36,207,479
not applicable
58,993,650
23,099,256
38,541,400
not applicable
61,640,656
23,930,105
39,828,847
not applicable
63,758,952
11. Total payments to physicians paid
through fee for service ($):
a. general practitioners
b. specialists
c. other
d. total
658,975,987
933,134,582
not applicable
1,592,110,569
665,989,273
969,589,022
not applicable
1,635,578,295
720,487,209
1,076,322,482
not applicable
1,796,809,691
749,875,492
1,154,109,934
not applicable
1,903,985,426
772,938,345
1,193,934,257
not applicable
1,966,872,602
12. Average payment per fee for service
service ($):
a. general practitioners
b. specialists
c. other
d. all services
28.72
28.46
not applicable
28.57
28.91
28.05
not applicable
28.39
31.62
29.73
not applicable
30.46
32.46
29.94
not applicable
30.89
32.30
29.98
not applicable
30.85
13. Number of services provided through
all payment methods (#): 6
a. medical
b. surgical
c. diagnostic
d. other
e. total
25,129,877
4,431,716
26,172,492
not applicable
55,734,085
25,201,483
4,417,069
27,985,155
not applicable
57,603,707
24,994,070
4,317,461
29,682,119
not applicable
58,993,650
25,423,944
4,393,613
31,823,099
not applicable
61,640,656
25,921,437
4,520,151
33,317,364
not applicable
63,758,952
14. Total payments to physicians paid
through all payment methods ($): 6
a. medical
b. surgical
c. diagnostic
d. other
e. total
928,286,068
250,524,151
413,300,350
not applicable
1,592,110,569
942,736,513
252,828,480
440,013,302
not applicable
1,635,578,295
1,025,581,421
279,710,272
491,517,998
not applicable
1,796,809,691
1,068,441,470
296,852,610
538,691,346
not applicable
1,903,985,426
1,093,491,339
307,627,814
565,753,449
not applicable
1,966,872,602
15. Average payment per service, all
payment methods ($): 6
a. medical
b. surgical
c. diagnostic
d. other
e. all services
36.94
56.53
15.79
not applicable
28.57
37.41
57.24
15.72
not applicable
28.39
41.03
64.78
16.56
not applicable
30.46
42.03
67.56
16.93
not applicable
30.89
42.18
68.06
16.98
not applicable
30.85
7. Number of participating physicians (#):
a. general practitioners
b. specialists
c. other
d. total
8. Number of opted-out physicians (#):
a. general practitioners
b. specialists
c. other
d. total
9. Number of not participating
physicians (#):
a. general practitioners
b. specialists
c. other
d. total
184
Canada Health Act Annual Report, 2003-2004
Chapter 3 – British Columbia
Insured Services Provided to Residents in Another Province or Territory
Hospitals
16. Total number of claims, in-patient (#).
17. Total number of claims,
out-patient (#).
18. Total payments, in-patient ($).
19. Total payments, out-patient ($).
20. Average payment, in-patient ($).
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
7,231
8,113
8,113
7,618
7,294
70,070
83,765
80,732
83,152
81,911
34,477,406
35,882,521
40,898,996
40,195,515
45,318,174
9,585,916
9,149,496
10,604,141
11,223,254
11,105,322
5,041.17
5,276.39
6,213.08
4,768.00
21. Average payment, out-patient ($).
Physicians 7
22. Number of services (#).
23. Total payments ($).
24. Average payment per service ($).
4,422.84
136.80
109.23
131.35
134.97
135.58
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
552,822
579,390
543,210
625,939
647,761
17,016,961
18,541,081
18,934,857
22,687,705
24,151,538
30.78
32.00
34.86
36.25
37.28
Insured Services Provided Outside Canada
Hospitals
25. Total number of claims, in-patient (#).
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
2,494
2,097
1,964
1,795
1,970
324
720
637
949
611
5,375,289
6,463,676
9,246,228
2,294,341
2,365,051
65,137
134,789
119,928
543,969
294,712
2,155.29
3,082.34
4,707.86
1,278.18
1,200.53
26. Total number of claims,
out-patient (#).
27. Total payments, in-patient ($).
28. Total payments, out-patient ($).
29. Average payment, in-patient ($).
30. Average payment, out-patient ($).
Physicians 8
31. Number of services (#).
32. Total payments ($).
33. Average payment per service ($).
201.04
187.21
188.27
573.20
482.34
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
77,424
77,973
71,940
71,377
57,093
3,485,618
3,281,934
3,013,045
3,083,949
2,458,027
45.02
42.09
41.88
43.21
43.05
Insured Surgical-Dental Services Within Own Province or Territory
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
272
283
275
249
243
54,638
55,643
43,505
36,680
36,809
5,893,820
6,321,864
5,401,691
5,379,450
5,164,249
107.87
113.61
124.16
146.66
140.30
34. Number of particpating dentists (#).
35. Number of services provided (#).
36. Total payments ($).
37. Average payment per service ($).
Canada Health Act Annual Report, 2003-2004
185
Chapter 3 – British Columbia
Endnotes
1.
2.
3.
4.
5.
6.
7.
8.
For items 1-3: All data is preliminary for 2003-2004. Historical and current data may differ from report to report because of
changes in data sources, definitions and methodology from year to year.
In British Columbia, the categories under which these facilities are reported in this Health Act report table do not match those
normally used in the Ministry. For example, BC does not use the category 'chronic care facilities'.
- For this table, the BC facilities have been assigned to the Health Act categories as closely as possible.
- The 'Other' category is Diagnostic and Treatment Centres.
- The count of facilities in this table may not match counts produced from the Discharge Abstract Database, the MIS
reporting system, or the Societies Act because each reporting system has different approaches to counting multiple site
facilities and categorizing them by function.
Payments to Health Authorities for the provision of the full range of regionally delivered services are as follows: $4.4 billion in
1999-2000, $5.1 billion in 2000-2001, $5.4 billion in 2001-2002, and $6.1 billion in 2002-2003. Payments to Health Authorities
in 2003-2004, (base and one-time payments), was $6.2 billion.
Seven of these 11 contracts provide restorative dentistry to children who are clients of the Ministry of Human Resources. The
remaining four are surgical contracts for the Fraser Health Authority.
There are approximately 49 private facilities licensed by the College of Physicians and Surgeons of British Columbia. These
facilities provide mostly non-Canada Health Act services. Under the Medicare Protection Act, they are prohibited from extrabilling for any insured services. The numbers reported here reflect the number of private surgical facilities contracted with
health authorities.
Data from the Provincial Health Services Authority contracts for the clients of the Ministry of Human Resources is 1,465. This
figure reflects the number of patients served rather than the number of services provided. Data form the Fraser Health
Authority is not available.
Data is available for "Fee-for-Service" only. Information is not available for the Alternative Payments Program.
The data summarizes the most current information about services and payments made each fiscal year based on the date of
service.
The data summarizes the most current information about services and payments made each fiscal year based on the date of
service.
186
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Yukon
Program, Pharmacare and Extended Benefits
Programs, and the Children’s Drug and Optical
Program. Non-insured health service programs
include Continuing Care, Community Nursing,
Community Health and Mental Health Services.
Yukon
Introduction
The health care insurance plans operated by the
Government of the Yukon Territory are the Yukon
Health Care Insurance Plan (YHCIP) and the
Yukon Hospital Insurance Services Plan (YHISP).
The YHCIP is administered by the Director, as
appointed by the Executive Council Member
(Minister). The YHISP is administered by the
Administrator, as appointed by the Commissioner
in Executive Council (Commissioner of the Yukon
Territory). The Director of the YHCIP and the
Administrator of the YHISP are hereafter referred
to as the Director, Insured Health and Hearing
Services. References in this text to the “Plan”
refer to either the Yukon Health Care Insurance
Plan or the Yukon Hospital Insurance Services
Plan. There are no regional health boards in the
Territory.
The objective of the Yukon health care system is
to ensure access to, and portability of, insured
physician and hospital services according to the
provisions of the Health Care Insurance Plan Act
and the Hospital Insurance Services Act.
Coverage is provided to all eligible residents of
the Yukon Territory on uniform terms and
conditions. The Minister, Department of Health
and Social Services, is responsible for the delivery
of all insured health care services. Service
delivery is administered centrally by the
Department of Health and Social Services. There
were 30,917 eligible persons registered with the
Yukon health care plan on March 31, 2004.
Other insured services provided to eligible Yukon
residents include the Travel for Medical Treatment
Program, Chronic Disease and Disability Benefits
Canada Health Act Annual Report, 2003-2004
Health care initiatives in the Territory target areas
such as access and availability of services,
recruitment and retention of health care
professionals, primary health care, systems
development and alternative payment and service
delivery systems, specifically:
† tele-health continues to expand and link
patients and health care providers;
† primary care initiatives are proceeding that will
broaden and strengthen service delivery and
modernize and improve system capabilities;
and
† physician recruitment and retention programs
have been established that are funded by
government and administered by the Yukon
Medical Association.
The 2003-2004 health care expenditures increased
over the 2002-2003 expenditures as follows:
† Insured Health Services increased by
$3,208,000.
† Yukon Hospital Services increased by
$2,317,000.
† Continuing Care increased by $394,000.
† Community Nursing and Emergency Medical
Services increased by $279,000.
† Community Health Programs increased by
$456,000.
Some of the major challenges facing the
advancement of insured health care service
delivery in the Territory are:
† effective linkages and co-ordination of existing
services and service providers;
† recruitment and retention of qualified health
care professionals;
† increasing costs related to service delivery;
† increasing costs related to changing
demographics; and
† acquiring and maintaining new and advanced
high-technology diagnostic and treatment
equipment.
187
Chapter 3 – Yukon
1.0 Public Administration
1.1 Health Care Insurance Plan and
Public Authority
The Health Care Insurance Plan Act sections 3(2)
and 4 establish the public authority to operate the
health medical care plan. There were no
amendments made to these sections of the
legislation in 2003-2004.
The Hospital Insurance Services Act sections 3(1)
and 5 establish the public authority to operate the
health hospital care plan. There were no
amendments made to these sections of the
legislation in 2003-2004.
Subject to the Health Care Insurance Plan Act,
(section 5) and Regulations, the mandate and
function of the Director, Insured Health and
Hearing Services, is to:
† develop and administer the Plan;
† determine eligibility for entitlement to insured
health services;
† register persons in the Plan;
† make payments under the Plan, including the
determination of eligibility and amounts;
† determine the amounts payable for insured
health services outside the Yukon;
† establish advisory committees and appoint
individuals to advise or assist in operating the
Plan;
† conduct actions and negotiate settlements in
the exercise of the Government of the Yukon’s
right of subrogation under this Act to the
rights of insured persons;
† conduct surveys and research programs and
obtain statistics for such purposes;
† establish what information is required under
this Act and the form such information must
take;
† appoint inspectors and auditors to examine and
obtain information from medical records,
reports and accounts; and
† perform such other functions and discharge
such other duties as are assigned by the
Executive Council Member under this Act.
188
Subject to the Hospital Insurance Services Act
(section 6) and Regulations, the mandate and
function of the Director, Insured Health and
Hearing Services, is to:
† develop and administer the hospital insurance
plan;
† determine eligibility for and entitlement to
insured services;
† determine the amounts that may be paid for
the cost of insured services provided to
insured persons;
† enter into agreements on behalf of the
Government of the Yukon with hospitals in or
outside the Yukon, or with the Government of
Canada or any province or an appropriate
agency thereof, for the provision of insured
services to insured persons;
† approve hospitals for purposes of this Act;
† conduct surveys and research programs and
obtain statistics for such purposes;
† appoint inspectors and auditors to examine and
obtain information from hospital records,
reports and accounts;
† prescribe the forms and records necessary to
carry out the provisions of this Act; and
† perform such other functions and discharge
such other duties as may be assigned by the
Regulations.
1.2 Reporting Relationship
The Department of Health and Social Services is
accountable to the Legislative Assembly and the
Government of Yukon through the Minister.
Section 6 of the Health Care Insurance Plan Act
and section 7 of the Hospital Insurance Services
Act require that the Director, Insured Health and
Hearing Services, make an annual report to the
Executive Council Member respecting the
administration of the two health insurance plans.
A Statement of Revenue and Expenditures is
tabled in the Legislature and is subject to
discussion at that level.
The Statement of Revenue and Expenditures for
the health care insurance programs of the Health
Services Branch is tabled annually in the fall
session of the Legislature. The report, to be
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Yukon
tabled December 2004, covers the fiscal years
1998-1999 to 2003-2004.
2.0 Comprehensiveness
1.3 Audit of Accounts
2.1 Insured Hospital Services
The Health Care Insurance Plan and the Hospital
Insurance Services Plan are subject to audit by
the Office of the Auditor General of Canada. The
Auditor General of Canada is the auditor of the
Government of the Yukon in accordance with
section 30 of the Yukon Act (Canada). The
Auditor General is required to conduct an annual
audit of the transactions and consolidated
financial statements of the Government of the
Yukon. Further, the Auditor General of Canada is
to report to the Yukon Legislative Assembly on
any matter falling within the scope of the audit
that, in his or her opinion, should be reported to
the Assembly.
The Hospital Insurance Services Act, sections 3,
4, 5 and 9, establish authority to provide insured
hospital services to insured residents. There were
no amendments made to these sections of the
legislation in 2003-2004.
The most recent audit was for the year ended
March 31, 2004.
Regarding the Yukon Hospital Corporation, section
11(2) of the Hospital Act requires every hospital
to submit a report on the operations of the
Corporation for that fiscal year. The report must
include the financial statements of the
Corporation and the auditor’s report. The report is
to be provided to the Department of Health and
Social Services within six months of the end of
each fiscal year.
1.4 Designated Agency
The YHCIP has no other designated agencies
authorized to receive monies or to issue payments
pursuant to the Health Care Insurance Plan Act or
the Hospital Insurance Services Act.
1
2
3
In 2003-2004, insured in-patient and out-patient
hospital services were delivered in 15 facilities
throughout the Territory. These facilities include
one general hospital, one cottage hospital1 and 12
Health Centres.2 Additional visiting nursing
services are provided from one satellite health
station.3
Adopted on December 7, 1989, the Hospital Act
establishes the responsibility of the Legislature
and the Government to ensure “compliance with
appropriate methods of operation and standards
of facilities and care”. Adopted on November 11,
1994, the Hospital Standards Regulation sets out
the conditions under which all hospitals in the
Territory are to operate. Section 4(1) provides for
the Ministerial appointment of one or more
investigators to report on the management and
administration of a hospital. Section 4(2) requires
that the hospital’s Board of Trustees establishes
and maintains a quality assurance program.
Currently, the Yukon Hospital Corporation
operates under a three-year accreditation through
the Canadian Council on Health Services
Accreditation.
The Yukon government assumed responsibility for
operating Health Centres from the federal
government in April 1997. These facilities,
including the Watson Lake Cottage Hospital,
operate in compliance with the adopted Medical
Services Branch Scope of Practice for Community
Health Nurses/Nursing Station Facility/Health
Centre Treatment Facility, and the Community
This facility provides 24-hour emergency treatment, short-term admissions and respite care.
Community Nurse Practitioners, in the absence of a physician, provide daily clinics for medical treatment, community health
programs and 24-hour emergency services.
Community Nurse Practitioners provide itinerant services on a regularly scheduled basis.
Canada Health Act Annual Report, 2003-2004
189
Chapter 3 – Yukon
Health Nurse Scope of Practice. The General
Duty Nurse Scope of Practice was completed and
implemented in February 2002.
Pursuant to the Hospital Insurance Services
Regulations, sections 2(e) and (f), services
provided in an approved hospital are insured.
Section 2(e) defines in-patient insured services as
all of the following services to in-patients, namely:
† accommodation and meals at the standard or
public ward level;
† necessary nursing service;
† laboratory, radiological and other diagnostic
procedures together with the necessary
interpretations for the purpose of maintaining
health, preventing disease and assisting in the
diagnosis and treatment of an injury, illness or
disability;
† drugs, biologicals and related preparations as
provided in Schedule B of the Regulations,
when administered in the hospital;
† use of operating room, case room and
anaesthetic facilities, including necessary
equipment and supplies;
† routine surgical supplies;
† use of radiotherapy facilities where available;
† use of physiotherapy facilities where available;
and
† services rendered by persons who receive
remuneration therefore from the hospital.
Section 2(f) of the same Regulations defines outpatient insured services as all of the following
services to out-patients, when used for
emergency diagnosis or treatment within 24 hours
of an accident, which period may be extended by
the Administrator, provided the service could not
be obtained within 24 hours of the accident,
namely:
† necessary nursing service;
† laboratory, radiological and other diagnostic
procedures, together with the necessary
interpretations for the purpose of assisting in
the diagnosis and treatment of an injury;
† drugs, biologicals and related preparations as
provided in Schedule B, when administered in
a hospital;
190
† use of operating room and anaesthetic
facilities, including necessary equipment and
supplies;
† routine surgical supplies;
† services rendered by persons who receive
remuneration from the hospital;
† use of radiotherapy facilities where available;
and
† use of physiotherapy facilities where available.
Pursuant to the Hospital Insurance Services
Regulations, all in- and out-patient services
provided in an approved hospital by hospital
employees are insured services. Standard nursing
care, pharmaceuticals, supplies, diagnostic and
operating services are provided. Any new
programs or enhancements with significant
funding implications or reductions to services or
programs require the prior approval of the
Minister, Department of Health and Social
Services. This process is managed by the
Director, Insured Health and Hearing Services.
Public representation regarding changes in service
levels is made through membership on the
hospital board.
A new Yukon Computed Tomography Scan
Program was implemented at the Whitehorse
General Hospital in fall 2002. The Government
provided $1.5 million toward purchasing a
Computed Tomography (CT) scanner and picture
archiving system. The program has been very
successful and provides Yukon residents with local
access to a standard diagnostic service.
These measures will help reduce the Territory’s
reliance on out-of-territory services.
2.2 Insured Physician Services
Sections 1 to 8 of the Health Care Insurance Plan
Act and sections 2, 3, 7,10 and 13 of the Health
Care Insurance Plan Regulations provide for
insured physician services. There were no
amendments made to these sections of the
legislation in 2003-2004.
The YHCIP covers physicians providing medically
required services. The conditions a physician must
meet to participate in the YHCIP are to:
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Yukon
† register for licensure pursuant to the Medical
Professions Act; and
† maintain licensure pursuant to the Medical
Professions Act.
The estimated number of resident physicians
participating in the YHCIP in 2003-2004 was 63.
Section 7(5) of the YHCIP Regulations allows
physicians in the Territory to bill patients directly
for insured services by giving notice in writing of
this election. In 2003-2004, no physicians
provided written notice of their election to collect
fees other than from the YHCIP.
Insured physician services in the Yukon are
defined as medically required services rendered
by a medical practitioner. Services not insured by
the Plan are listed in section 3 of the Regulations.
Services not covered by the Plan include advice
by telephone, medical-legal services, preparation
of records and reports, services required by a
third party, cosmetic services and services
determined not to be medically required.
The process used to add a new fee to the relative
Value Guide to Fees4 is administered through a
committee structure. This process requires
physicians to submit requests in writing to the
YHCIP/Yukon Medical Association Liaison
Committee.
Following review by this committee, a decision is
made to include or exclude the service. The
relevant costs or fees are normally set in
accordance with similar costs or fees in other
jurisdictions. Once a fee-for-service value has
been determined, notification of the service and
the applicable fee is provided to all Yukon
physicians. Public consultation is not required.
Alternatively, new fees can be implemented as a
result of the fee negotiation process between the
Yukon Medical Association and the Department of
Health and Social Services. The Director, Insured
Health and Hearing Services, manages this
process and no public consultation is required.
4
2.3 Insured Surgical-Dental
Services
Dentists providing insured surgical-dental services
under the Territory’s health care insurance plan
must be licensed pursuant to the Dental
Professions Act and are given billing numbers for
the purpose of billing the YHCIP for providing
insured dental services. In 2003-2004, six dentists
billed the Plan for insured dental services that
were provided to Yukon residents. The Plan is also
billed directly for services provided outside the
Territory.
Dentists are able to opt out of the health care
plan in the same manner as physicians. In 20032004, no dentists provided written notice of their
election to collect fees other than from the YHCIP.
Insured dental services are limited to those
surgical-dental procedures listed in Schedule B of
the Regulations and require the unique capabilities
of a hospital for their performance (e.g., surgical
correction of prognathism or micrognathia).
The addition or deletion of new surgical-dental
services to the list of insured services requires
amendment by Order-in-Council to Schedule B of
the Regulations Respecting Health Care Insurance
Services. Coverage decisions are made on the
basis of whether or not the service must be
provided in hospital under general anaesthesia.
The Director, Insured Health and Hearing
Services, administers this process.
2.4 Uninsured Hospital, Physician
and Surgical-Dental Services
Only services prescribed by and rendered in
accordance with the Health Care Insurance Plan
Act and Regulations and the Hospital Insurance
Services Act and Regulations are insured. All
other services are uninsured.
Uninsured physician services include:
† services that are not medically necessary;
† charges for longdistance telephone calls;
† preparing or providing a drug;
Physician’s fee guide manual.
Canada Health Act Annual Report, 2003-2004
191
Chapter 3 – Yukon
† advice by telephone at the request of the
insured person;
† medico-legal services including examinations
and reports;
† cosmetic services;
† acupuncture; and
† experimental procedures.
Section 3 of the YHCIP Regulations contains a
non-exhaustive list of services that are prescribed
as non-insured.
Uninsured hospital services include:
† non-resident hospital stays;
† special/private nurses requested by the
patient or family;
† additional charges for preferred
accommodation unless prescribed by a
physician;
† crutches and other such appliances;
† nursing home charges;
† televisions;
† telephones; and
† drugs and biologicals following discharge.
(These services are not provided by the
hospital.)
Uninsured dental services include:
† procedures considered to be restorative; and
† procedures that are not performed in a hospital
under general anaesthesia.
Further, the Act states that any service that a
person is eligible for, and entitled to, under any
other Act is not insured.
All Yukon residents have equal access to services.
Third parties such as private insurers or the
Worker’s Compensation Health and Safety Board
do not receive priority access to services through
additional payment.
The purchase of non-insured services, such as
fibreglass casts, does not delay or prevent access
to insured services at any time. Insured persons
are given treatment options at the time of service.
The Territory has no formal process to monitor
compliance; however, feedback from physicians,
hospital administrators, medical professionals and
staff allows the Director, Insured Health and
192
Hearing Services, to monitor usage and service
concerns.
Physicians in the Territory may bill patients
directly for non-insured services. Block fees are
not used at this time; however, some do bill by
service item. Billable services include, but are not
limited to, completion of employment forms,
medical legal reports, transferring records, thirdparty examinations, some elective services, and
telephone prescriptions, advice or counseling.
Payment does not affect patient access to
services because not all physicians or clinics bill
for these services and other agencies or
employers may cover the cost.
The process used to de-insure services covered by
the YHCIP is as follows:
† Physician services – the YHCIP/Yukon
Medical Association Liaison Committee is
responsible for reviewing changes to the
Relative Value Guide to Fees, including
decisions to de-insure certain services. In
consultation with the Yukon Medical Advisor,
decisions to de-insure services are based on
medical evidence that indicates the service is
not medically necessary, ineffective or a
potential risk to the patient’s health. Once a
decision has been made to de-insure a service,
all physicians are notified in writing. The
Director, Insured Health and Hearing Services,
manages this process. No services were
removed from the Relative Value Guide to Fees
in fiscal year 2003-2004.
† Hospital services – an amendment by
Order-In-Council to section 2 (e)(f) of the
Yukon Hospital Insurance Services Regulations
would be required. As of March 31, 2004, no
insured in-patient or out- patient hospital
services, as provided for in the Regulations,
have been de-insured. The Director, Insured
Health and Hearing Services, is responsible for
managing this process in conjunction with the
Yukon Hospital Corporation.
† Dental-surgical services – an amendment
by Order-In-Council to Schedule B of the
Regulations Respecting Health Care Insurance
Services is required. A service could be de-
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Yukon
insured if determined not to be medically
necessary or is no longer required to be
carried out in a hospital under general
anaesthesia. The Director, Insured Health and
Hearing Services, manages this process.
3.0 Universality
3.1 Eligibility
Eligibility requirements for insured health services
are set out in the Health Care Insurance Plan Act
and Regulations, sections 2 and 4 respectively
and the Hospital Insurance Services Act and
Regulations, sections 2 and 4 respectively.
Subject to the provisions of these Acts and
Regulations, every Yukon resident is eligible for
and entitled to insured health services on uniform
terms and conditions. The term “resident” is
defined using the wording of the Canada Health
Act and “means a person lawfully entitled to be or
to remain in Canada, who makes his home and is
ordinarily present in the Yukon, but does not
include a tourist, transient or visitor to the Yukon”.
Where applicable, the eligibility of all persons is
administered in accordance with the Interprovincial Agreement on Eligibility and Portability.
Under section 4(1) of both Regulations “an
insured person is eligible for and entitled to
insured services after midnight on the last day of
the second month following the month of arrival to
the Territory”.
Changes affecting eligibility made to the
legislation in 2003-2004 now require that all
persons returning to or establishing residency in
Yukon complete the waiting period. The only
exception is for children adopted by insured
persons.
The following persons are not eligible for coverage
in the Yukon:
† persons entitled to coverage from their home
province or territory (e.g., students and
workers covered under temporary absence
provisions);
† visitors to the Territory;
Canada Health Act Annual Report, 2003-2004
† refugee claimants;
† members of the Canadian Forces;
† members of the Royal Canadian Mounted
Police (RCMP);
† inmates in federal penitentiaries;
† study permit holders; and
† employment authorizations of less than one
year.
The above persons may become eligible for
coverage if they meet one or more of the
following conditions:
† establish residency in the Territory;
† become a permanent resident;
† the day following discharge or release if
stationed in or resident in the Territory.
3.2 Registration Requirements
Section 16 of the Health Care Insurance Plan Act
states: “Every resident other than a dependant or
a person exempted by the Regulations from so
doing, shall register himself and his dependants
with the Director, Insured Health and Hearing
Services, at the place and in the manner and form
and at the times prescribed by the Regulations.”
Registration is administered in accordance with
the Inter-provincial Agreement on Eligibility and
Portability.
Persons and dependants under the age of 19 who
move permanently to the Yukon are advised to
apply for health care insurance upon arrival.
Application is made by completing a registration
form available from the Insured Health and
Hearing Services office or community Territorial
Agents. Once coverage becomes effective, a
health care card is issued. Family members
receive separate health care cards and numbers.
Health care cards expire every year on the
resident’s birthday and an updated label with the
new expiry date is mailed out accordingly.
As of March 31, 2004, there were 30,917
residents registered with the YHCIP.
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Chapter 3 – Yukon
3.3 Other Categories of Individual
The YHCIP provides health care coverage for
other categories of individuals as follows:
Foreign Workers
Returning
Canadians
Waiting period is applied.
Permanent
Residents5
Waiting period is applied.
Minister’s
Permit
Waiting period is applied if
authorized.
Convention
Refugees
Waiting period is applied if holding Employment Authorization.*
Foreign
Workers
Waiting period is applied if holding Employment Authorization.*
Clergy
Waiting period is applied if holding Employment Authorization.*
*
The estimated number of individuals receiving
coverage in 2003-2004, under the following
conditions is:
Employment Authorization must be
in excess of 12 months
The estimated number of new individuals receiving
coverage in 2003-2004 under the following
conditions is:
Returning Canadians
19
Permanent Residents
32
Minister’s Permit
0
Convention Refugees
0
22
Clergy
0
3.4 Premiums
The payment of premiums by Yukon residents was
eliminated on April 1, 1988.
4.0 Portability
4.1 Minimum Waiting Period
Pursuant to section 4(1) of the YHCIP
Regulations and the Yukon Hospital Insurance
Services Regulations, “an insured person is
eligible for and entitled to insured services after
midnight on the last day of the second month
following the month of arrival to the Territory.” All
persons entitled to coverage are required to
complete the minimum waiting period with the
exception of children adopted from outside
Canada by insured persons. (See section 3.1)
4.2 Coverage During Temporary
Absences in Canada
The provisions relating to portability of health care
insurance during temporary absences outside
Yukon, but within Canada, are defined in sections
5, 6, 7 and 10 of the YHCIP Regulations and
sections 6, 7(1), 7(2), and 9 of the Yukon Hospital
Insurance Services Regulations. No amendments
were made to these sections of the legislation in
2003-2004.
The Regulations state that “where an insured
person is absent from the Territory and intends to
return, he is entitled to insured services during a
5
Previously referred to as “landed immigrants”.
194
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Yukon
period of 12 months continuous absence”.
Persons leaving the Territory for a period
exceeding two months are advised to contact the
YHCIP and complete a form of “Temporary
Absence”. Failure to do so may result in the
cancellation of coverage.
The Medical Reciprocal Billing Agreements
provide for payment of insured physician services
on behalf of eligible residents receiving insured
services outside the Yukon, but within Canada.
Payment is made to the host province at the rates
established by that province.
Students attending educational institutions
outside the Territory remain eligible for the
duration of their academic studies. The Director,
Insured Health and Hearing Services, may
approve other absences in excess of 12
continuous months on receiving a written request
from the insured person. Requests for extensions
must be renewed yearly and are subject to
approval by the Director.
Insured services provided to Yukon residents while
temporarily absent from the Territory are paid at
the rates established by the host province. The
following amounts were paid to out-of-territory
hospitals for the fiscal year 2003-2004.
For temporary workers and missionaries, the
Director, Insured Health and Hearing Services,
may approve absences in excess of 12 continuous
months on receiving a written request from the
insured person. Requests for extensions must be
renewed yearly and are subject to approval by the
Director, Insured Health and Hearing Services.
The provisions regarding coverage during
temporary absences in Canada fully comply with
the terms and conditions of the Inter-provincial
Agreement on Eligibility and Portability effective
February 1, 2001. Definitions are consistent in
Regulations, policies and procedures.
The Yukon participates fully with the Interprovincial Medical Reciprocal Billing Agreements
and Hospital Reciprocal Billing Agreements in
place with all other provinces and territories
except for Quebec, which does not participate in
the medical reciprocal billing arrangement.
Persons receiving medical (physician) services in
Quebec may be required to pay directly and
submit claims to the YHCIP for reimbursement.
The Hospital Reciprocal Billing Agreements
provide for payment of insured in-patient and
out-patient hospital services to eligible residents
receiving insured services outside the Yukon, but
within Canada.
6
In-patient services
Out-patient services
$7,587,906
$936,376
Note: Figures are by date of service and
subject to adjustment.
In 2003-2004, payments to out-of-territory
physicians totaled $1,833,654. This figure includes
out-of-Canada costs and is by payment date.6
4.3 Coverage During Temporary
Absences Outside Canada
The provisions that define portability of health
care insurance to insured persons during
temporary absences outside Canada are defined
in sections 5, 6, 7, 9, 10 and 11 of the YHCIP
Regulations and sections 6, 7(1), 7(2) and 9 of
the Yukon Hospital Insurance Services
Regulations. No amendments were made to these
sections of the legislation in 2003-2004.
Sections 5 and 6 state that “Where an insured
person is absent from the Territory and intends to
return, he is entitled to insured services during a
period of 12 months continuous absence”.
Persons leaving the Territory for a period
exceeding two months are advised to contact
YHCIP and complete a form of “Temporary
Absence”. Failure to do so may result in the
cancellation of coverage.
Out-of-country costs are reported under elements 18 and 19 in the Yukon statistical tables.
Canada Health Act Annual Report, 2003-2004
195
Chapter 3 – Yukon
The provisions for portability of health insurance
during out-of-country absences for students,
temporary workers and missionaries are the same
as for absences within Canada (see section 4.2).
Insured physician services provided to eligible
Yukon residents temporarily outside the country
are paid at rates equivalent to those paid had the
service been provided in the Yukon.
Reimbursement is made to the insured person by
the YHCIP or directly to the provider of the
insured service.
Insured in-patient hospital services provided to
eligible Yukon residents outside Canada are paid
at the rate established in the Standard Ward
Rates Regulation for the Whitehorse General
Hospital. The standard ward rate for the
Whitehorse General Hospital as of April 1, 2004,
was $1,155, which increased July 1, 2004 to
$1,246. This rate is established through
Order-in-Council and are derived as follows:
† Standard Ward Rate = (total operating
expenses - non-related in-patient costs related newborn costs - associated out-patient
costs) / (total patient days - patient days for
other services; for example, non-Canadians).
Insured out-patient hospital services provided to
eligible Yukon residents outside Canada are paid
at the rate established in the Charges for OutPatient Procedures Regulation. The out-patient
rate is currently $153 and is established through
Order-in-Council and derived by the Interprovincial Health Insurance Agreements
Coordinating Committee (IHIACC).
The following amounts were paid in 2003-2004 for
elective and emergency services provided to
eligible Yukon residents outside Canada:
In-patient services
Out-patient services
$13,563
$5,994
Note: Figures are by service date and subject
to adjustment.
196
4.4 Prior Approval Requirement
There is no legislated requirement that eligible
residents must seek prior approval before seeking
elective or emergency hospital or physician
services outside Canada.
5.0 Accessibility
5.1 Access to Insured Health
Services
There are no user fees or co-insurance charges
under the YHCIP or the Yukon Hospital Insurance
Services Plan. All services are provided on a
uniform basis and are not impeded by financial or
other barriers.
Access to hospital or physician services not
available locally are provided through the Visiting
Specialist Program, Telehealth Program or the
Travel for Medical Treatment Program. These
programs ensure that there is minimal or no delay
in receiving medically necessary services.
There is no extra-billing in the Yukon for any
services covered by the Plan.
5.2 Access to Insured Hospital
Services
Pursuant to the Hospital Act, the “Legislature and
Government have responsibility to ensure the
availability of necessary hospital facilities and
programs”. The Minister must approve any
significant changes to the level of service delivery.
Acute care beds are readily available and no
waitlist for admission exists at either of these two
acute care facilities.
The estimated number of full-time equivalent
(FTEs) nurses and other health care professionals
working in facilities providing insured hospital
services in the Yukon as of March 31, 2003, is:
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Yukon
Profession
Whitehorse
General
Hospital
Watson
Lake
Cottage
Hospital
# of FTEs
# of FTEs
Registered Nurses
72
8
Licensed Practical
8
0
Nurse Pract.
0
0
Social Worker
1
0
Pharmacist
2
0
4.40
0
Occup. Therapist
1
0
Psychologist
0
0
Medical Lab/X-Ray
21
0
Dietician
3.5
0
Public Health
0
2
Home Care
0
1
Physiotherapist
The Whitehorse General Hospital and Community
Nursing manage the supply of nurses and health
care professionals in the Territory’s two hospitals
with the Department of Health and Social
Services. Shortfalls in staffing are covered by
temporary, casual or auxiliary workers to ensure
residents have continued access to insured
services.
Recruitment and Retention
Recruitment and retention initiatives include:
Community Nursing: A Yukon Advisory
Committee on Nursing was struck to advise the
Department of Health and Social Services on
nursing issues. Recommendations will help the
Yukon recruit and retain nurses in both the long
and short term. Yukon is providing:
Canada Health Act Annual Report, 2003-2004
† competitive salaries;
† recruitment and retention bonuses;
† participation at job fairs;
† training and educational opportunities;
† travel bonus/$2,000 after one year; and
† relief positions.
Whitehorse General Hospital:
† competitive salaries;
† wage scale recognizes experience;
† cooperative work schedules;
† onsite fitness centre/24hour;
† monthly clinical skill development;
† continuing education/development; and
† travel bonus/$2,000 after one year.
Facilities
Whitehorse General Hospital: As the only
major acute care hospital facility in the Territory,
this facility provides in-patient, out-patient and
24-hour emergency services. Local physicians
provide Emergency Department services on
rotation.
Emergency surgery patients at the Whitehorse
General Hospital are normally seen within 24
hours. Elective surgery patients are normally seen
within one to two weeks. The number of Visiting
Specialist clinics is routinely adjusted to address
wait times, particularly for orthopaedics,
ear/nose/throat and ophthalmology (see section
5.3).
Surgical services provided include:
† minor orthopaedics;
† selected major orthopaedics;
† gynecology;
† paediatrics;
† general abdominal;
† mastectomy;
† emergency trauma;
† ear/nose/throat/otolaryngology; and
† ophthalmology including cataracts.
Diagnostic services include:
† radiology (including ultrasound, computed
tomography, xray and mammography;
† laboratory; and
† electrocardiogram.
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Chapter 3 – Yukon
Selected rehabilitative services are available
through out-patient therapies.
Watson Lake Cottage Hospital: A second
acute care facility is located in Watson Lake.
Medical services include emergency trauma,
maternity, minor orthopaedics, cellulitis, failure to
thrive and respite care. Diagnostic services
include x-ray, laboratory and electrocardiogram.
This is a 12-bed facility and there is no waitlist for
admission.
Health Centres: Out-patient and 24-hour
emergency services are provided at the remaining
13 community Health Centres by Community
Nurse Practitioners and auxiliary nursing staff.
Patients requiring insured hospital services not
available locally are transferred to acute care
facilities in-territory or out-of-territory through the
Travel for Medical Treatment Program.
Measures to Improve Access
A number of measures have been taken to better
manage access to insured hospital services. The
Department of Health and Social Services
continues to work with the Yukon Hospital
Corporation and Community Nursing to ensure
the current waiting time for insured hospital
services in the Territory is reduced or maintained
at existing levels. For example:
† Heart defibrillators were made available in all
rural Yukon Health Centres. This provides an
important tool to Community Nurse
Practitioners and improves local access to
cardiac care.
† Officials from the Department attend nursing
recruitment fairs across Canada. Information
on working in the Territory was provided to
nurses who attended.
† The Technical Review Committee continues to
make recommendations to the Department on
health programs and services in the Yukon as
required. Its mandate is to develop criteria
initiating, eliminating, expanding or reducing
programs or services.
† Telehealth in nine communities provides realtime video to support access and delivery of
services between outlying rural communities
198
with Whitehorse, and Whitehorse with outside
centres in British Columbia or Alberta. Funding
was provided through the Canada Health
Infostructure Partnerships Program (CHIPP) to
October 31, 2003.
Telehealth educational sessions have occurred
regularly between Whitehorse and rural Yukon
as well as between Whitehorse and British
Columbia. These sessions have been attended
by patients, physicians, nurses, social workers,
psychiatrists, mental health counsellors and
allied professionals such as Community Health
Representatives and First Nation Wellness
workers.
5.3 Access to Insured Physician and
DentalSurgical Services
Existing legislation and administration of services
provide all eligible Yukon residents with equal
access to insured physician and dental services on
uniform terms and conditions.
The following resident physicians, specialists and
dentists provided services in the Yukon as of
March 31, 2004 (see element #7 of the Yukon
statistical tables):
General Practitioners/Family Practitioners
55
Specialists
8
Dentists
6
Outside the usual distribution of physicians and
specialists in the Territory, uniform access to
insured physician and dental services is ensured
through the Travel for Medical Treatment Program.
This program covers the cost of medically
necessary transportation, allowing eligible persons
to access services that are not available in their
home communities. Eligible persons are routinely
sent to Whitehorse, Vancouver, Edmonton or
Calgary to receive services.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Yukon
Most physicians in the Yukon are located in
Whitehorse. Outside Whitehorse, only two rural
communities have resident fee-for-service
physicians: Dawson City and Watson Lake. Two
contracted physicians provide resident services in
Faro and Mayo.
The Visiting Physician Program provides local
access to insured physician services to 10 rural
and remote locations. The frequency of visiting
clinics is based on demand and utilization.
Physicians providing visiting services through this
program are compensated under contract for lost
practice time, mileage, meals and accommodation,
in addition to a sessional rate or fee-for-service
billings.
In addition, the Department of Health and Social
Services and the Visiting Specialist Program
provide local access at the Whitehorse General
Hospital, Mental Health Services or the Yukon
Communicable Disease Unit to non-resident,
visiting specialist services not regularly available
in the Territory. Visiting specialists are reimbursed
for expenses in addition to a sessional rate or feefor-service billings.
The number of specialists providing services under
the Visiting Specialist Program and the
Department of Health and Social Services is:
Ophthalmology
1
Oncology
3
Orthopaedics
3
Internal Medicine
1
Otolaryngology
2
Neurology
1
Rheumatology
1
Dermatology
1
Dental Surgery*
3
Infectious Disease*
1
Psychiatry*
3
*
Services not provided through the Visiting Specialist as
administered by the Whitehorse General Hospital.
Visiting Specialist clinics are held between one
and eight times per year depending on demand
and the availability of specialists. As of March 31,
2004, the waitlist for non-emergency specialist
services was estimated at:
Ophthalmology
0-3 months
Orthopaedics
1-24 months
Otolaryngology
5-14 months
Neurology
4-10 months
Rheumatology
7-11 months
Dental Surgery*
2-3 months
*
Services not provided through the Visiting Specialist as
administered by the Whitehorse General Hospital.
Note:
Canada Health Act Annual Report, 2003-2004
There is no waitlist for visiting services not included
in the above listing. Patients are seen on the next
scheduled visit (i.e., Oncology, Internal Medicine,
Dermatology, Infectious Disease and Psychiatry).
199
Chapter 3 – Yukon
The Department of Health and Social Services
has taken several measures to reduce waiting
times for insured physician services. A variety of
recruitment and retention initiatives began in
2001-2002 and 2002-2003 such as a Resident
Support Program, Locum Support Program,
Physician Relocation Program, Office Start-Up
Fund, Education Support and a Rural Training
Fund. The Department of Health and Social
Services continues to work with the Yukon
Medical Association to find additional cooperative
initiatives to be implemented within the terms of
the renewed Memorandum of Understanding in
April 1, 2004.
Amendments were made to the Medical
Professions Act in 2002-2003 to provide for the
issuance of special licenses in response to a
demonstrated need. The candidate must have
already been offered a position in the Territory
subject to special licensing and the Minister of
Health and Social Services must state in writing
that a demonstrated need exists within an area of
practice.
5.4 Physician Compensation
The Department of Health and Social Services
seeks its negotiating mandate from the
Government of Yukon, before entering
negotiations with the Yukon Medical Association
(YMA). The YMA and the Government each
appoint members to the negotiating team.
Meetings are held as required until an agreement
has been reached. The YMA’s negotiating team
then seeks approval of the tentative agreement
from the YMA membership. The Department
seeks ratification of the agreement from the
Government of Yukon. The final agreement is
signed with the concurrence of both parties.
The most recent four-year Memorandum of
Understanding comes into effect April 1, 2004,
and shall remain in effect to March 31, 2008. This
MOU establishes the terms and conditions for
payment of physicians and established two new
programs: New Patient Program and Physician
Retention Program.
200
The legislation governing payments to physicians
and dentists for insured services are the Health
Care Insurance Plan Act and the Health Care
Insurance Plan Regulations. No amendments were
made to these sections of the legislation in 20032004.
The fee-for-service system is used to reimburse
the majority of physicians and dentists providing
insured services to residents. In 2003-2004, two
full-time resident rural physicians and four
resident specialists were compensated on a
contractual basis. Two physicians providing visiting
clinics in outlying communities were paid a
sessional rate for services.
5.5 Payments to Hospitals
The Government of Yukon funds the Yukon
Hospital Corporation (Whitehorse General
Hospital) through global contribution agreements
with the Department of Health and Social
Services. Global operations and maintenance (O
and M) and capital funding levels are negotiated
and adjusted based on operational requirements
and utilization projections from prior years. In
addition to the established O and M and capital
funding set out in the agreement, provision is
made for the hospital to submit requests for
additional funding assistance for implementing
new or enhanced programs.
Only the Whitehorse General Hospital is funded
directly through a contribution agreement. The
Watson Lake Cottage Hospital and all Health
Centres are funded through the Government of
the Yukon’s budget process.
The legislation governing payments made by the
health care plan to facilities that provide insured
hospital services is the Hospital Insurance
Services Plan Act and Regulations. The legislation
and Regulations set out the legislative framework
for payment to hospitals for insured services
provided by that hospital to insured persons. No
amendments were made to these sections of the
legislation in 2003-2004.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Yukon
6.0 Recognition Given to
Federal Transfers
The Government of the Yukon has acknowledged
the federal contributions provided through the
Canada Health and Social Transfer (CHST) in its
2002-2003 annual Main Estimates and Public
Accounts publications, which are available
publicly. Section 3(1)(d)(e) of the Health Care
Insurance Plan Act and section 3 of the Hospital
Insurance Services Act, acknowledge the
contribution of the Government of Canada.
7.0 Extended Health Care
Services
Residential Care Services
Continuing Care Health Services are available to
eligible Yukon residents. In 2003-2004, there were
three facilities providing services in the Yukon.
These facilities provide one or more of the
following services:
† personal care;
† extended care services;
† nursing home intermediate care;
† special care;
† respite;
† day program; and
† meals on wheels.
A new continuing care facility was opened in
Whitehorse in summer 2002 with 72 beds staffed
and in operation. Twenty-four additional beds can
be made available should future occupancy trends
indicate a need.
In total, there was 113 continuing care or
extended care beds in the Territory in 2003-2004.
No other major changes were made in the
administration of these services in 2003-2004.
Home Care Services
The Yukon Home Care Program provides
assessment and treatment, care management,
Canada Health Act Annual Report, 2003-2004
personal support, homemaking services, social
support, respite services and palliative care. In
Whitehorse, services are provided by home
support workers, nurses, social workers and
therapists. In most rural communities, nursing
services are provided through the community
nursing program and home support workers assist
clients with personal care, homemaking and
respite services. Therapy services are provided by
a travelling regional team of physiotherapists and
occupational therapists. Services are available
Monday through Friday. In Whitehorse, additional
services such as planned weekend and evening
support may be provided to 9:00 pm during endstage palliative care. Twenty-four hour care is not
provided.
Ambulatory Health Care Services
The Yukon Home Care Program provides the
majority of ambulatory health care services
outside institutional settings. Most other services
are provided through Community Nursing or public
health. All residents have equal access to
services.
The above services are not provided for in
legislation.
In addition to the services described above, the
following are also available to eligible Yukon
residents outside the requirements of the Canada
Health Act:
† The Chronic Disease and Disability
Benefits Program provides benefits for
eligible Yukon residents who have specific
chronic diseases or serious functional
disabilities: coverage of related prescription
drugs and medical-surgical supplies and
equipment. (Chronic Disease and Disability
Benefits Regulation)
† The Pharmacare Program and Extended
Benefits Programs are designed to assist
registered senior citizens with the cost of
prescription drugs, dental care, eye care,
hearing services and medical-surgical supplies
and equipment. (Pharmacare Plan Regulation
and Extended Health Care Plan Regulation)
201
Chapter 3 – Yukon
† The Travel for Medical Treatment
Program covers eligible Yukon residents with
the cost of emergency and non-emergency
medically necessary air and ground
transportation to receive services not available
locally. (Travel for Medical Treatment Act and
Travel for Medical Treatment Regulation)
† The Children’s Drug and Optical
Program is designed to assist eligible lowincome families with the cost of prescription
drugs, eye exams and eye glasses for children
18 and younger. (Children’s Drug and Optical
Program Regulation)
† Mental Health Services provide
assessment, diagnostic, individual and group
treatment, consultation and referral services to
individuals experiencing a range of mental
health problems. (Mental Health Act and
Mental Health Act Regulations)
† Public Health is designed to promote health
and well-being throughout the Territory through
a variety of preventive and education
programs. This is a non legislated program.
202
† Emergency Medical Services is
responsible for the emergency stabilization and
transportation of sick and injured persons from
an accident scene to the nearest health care
facility capable of providing the required level
of care. This is a non legislated program.
† Hearing Services provides services
designed to help people of all ages with a
variety of hearing disorders, through the
provision of routine and diagnostic hearing
evaluations and community outreach. This is a
non legislated program.
† Dental Services provides a comprehensive
diagnostic, prevent and restorative dental
service to children from pre school to grade
eight in Whitehorse and Dawson City. All other
Yukon communities receive services for pre
school to grade twelve. This is a non legislated
program.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Yukon
Registered Persons
1. Number as of March 31st (#).
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
31,255
31,133
31,036
30,534
30,917
2002-2003
2003-2004
Insured Hospital Services Within Own Province or Territory
Public Facilities
1999-2000
2000-2001
2001-2002
2. Number (#):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
2
0
0
13 1
15
2
0
0
13 1
15
2
0
0
13 1
15
2
0
0
13 1
15
2
0
0
13 1
15
3. Payments ($):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
19,587,158
not applicable
not applicable
5,502,144 1
25,089,302
20,350,026
not applicable
not applicable
5,483,948 1
25,833,974
21,920,937
not applicable
not applicable
5,997,920 1
27,918,907
22,515,448
not applicable
not applicable
6,133,453 1
28,648,901
24,877,479
not applicable
not applicable
6,318,565 1
31,196,044
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
4. Number (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5. Number of insured hospital services
provided (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
6. Payments ($):
a. surgical facilities
b. diagnostic imaging facilities
c. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Private For-Profit Facilities
Canada Health Act Annual Report, 2003-2004
203
Chapter 3 – Yukon
Insured Physician Services Within Own Province or Territory
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
41
5
0
46
43
6
0
49
49
5
0
54
53
6
0
59
55
8
0
63
8. Number of opted-out physicians (#):
a. general practitioners
b. specialists
c. other
d. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
9. Number of not participating
physicians (#):
a. general practitioners
b. specialists
c. other
d. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
153,542
11,704
0
165,246
164,497
14,789
0
179,286
160,932
11,881
0
172,813
186,479
11,040
0
197,519
191,002
10,460
0
200,462
5,248,704
1,189,271
0
6,437,975
5,803,619
1,263,380
0
7,066,999
5,692,583
1,143,968
0
6,836,551
6,740,552
971,283
0
7,711,835
7,336,403
984,711
0
8,321,114
34.18
101.61
0.00
38.96
35.28
85.43
0.00
39.42
35.38
96.29
0.00
39.56
36.15
87.98
0.00
39.04
38.61
94.14
0.00
41.51
123,333
22,092
19,822
0
165,247
131,685
25,670
18,978
0
176,333
131,004
26,653
15,156
0
172,813
154,591
26,388
16,540
0
197,519
151,825
31,894
16,472
0
200,461
5,144,453
978,628
314,893
0
6,437,975
5,729,729
1,028,529
308,741
0
7,066,999
5,550,975
1,057,467
228,109
0
6,836,551
6,386,109
1,029,697
296,029
0
7,711,835
6,802,367
1,257,750
260,997
0
8,321,114
41.71
44.30
15.89
0.00
38.96
43.51
40.07
16.27
0.00
40.08
42.38
39.68
15.05
0.00
39.56
41.31
39.02
17.90
0.00
39.04
44.80
39.44
15.04
0.00
41.51
7. Number of participating physicians (#):
a. general practitioners
b. specialists
c. other
d. total
3
10. Number of services provided through
fee for service (#):
a. general practitioners
b. specialists
c. other
d. total
11. Total payments to physicians paid
through fee for service ($):
a. general practitioners
b. specialists
c. other
d. total
12. Average payment per fee for service
service ($):
a. general practitioners
b. specialists
c. other
d. all services
13. Number of services provided through all
payment methods (#): 4
a. medical
b. surgical
c. diagnostic
d. other
e. total
14. Total payments to physicians paid
through all payment methods ($): 4
a. medical
b. surgical
c. diagnostic
d. other
e. total
15. Average payment per service, all
payment methods ($): 4
a. medical
b. surgical
c. diagnostic
d. other
e. all services
204
2
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Yukon
Insured Services Provided to Residents in Another Province or Territory
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
735
719
663
666
783
7,025
6,760
6,547
7,241
6,938
4,683,562
4,218,846
4,299,055
5,861,530
7,587,906
19. Total payments, out-patient ($).
920,769
861,375
945,804
1,037,692
936,376
20. Average payment, in-patient ($).
6,372.20
5,867.66
6,484.25
8,801.10
9,690.81
131.07
127.43
144.47
143.31
134.96
Physicians
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
22. Number of services (#).
31,020
36,828
32,461
34,853
34,037
1,404,195
1,642,495
1,601,642
1,799,019
1,833,654
45.27
44.60
49.34
51.62
53.87
16. Total number of claims, in-patient (#).
17. Total number of claims,
out-patient (#).
18. Total payments, in-patient ($).
21. Average payment, out-patient ($).
23. Total payments ($).
24. Average payment per service ($).
Insured Services Provided Outside Canada
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
25. Total number of claims, in-patient (#).
11
9
15
9
8
26. Total number of claims,
out-patient (#).
67
54
40
26
46
22,125
27,520
50,599
9,339
13,536
7,080
8,368
4,431
2,451
5,994
2,011.37
3,057.78
3,373.27
1,037.67
1,692.00
105.68
154.97
110.78
94.27
130.30
Physicians
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
31. Number of services (#).
not available
not available
not available
not available
not available
32. Total payments ($).
not available
not available
not available
not available
not available
33. Average payment per service ($).
not available
not available
not available
not available
not available
27. Total payments, in-patient ($).
28. Total payments, out-patient ($).
29. Average payment, in-patient ($).
30. Average payment, out-patient ($).
Insured Surgical-Dental Services Within Own Province or Territory 5
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
9
11
11
8
6
214
222
214
150
104
36. Total payments ($).
59,458
50,876
51,078
37,342
25,093
37. Average payment per service ($).
277.84
229.17
238.69
248.95
241.28
34. Number of particpating dentists (#).
35. Number of services provided (#).
Canada Health Act Annual Report, 2003-2004
205
Chapter 3 – Yukon
Insured Physician Services Within Own Province or Territory
Visiting Specialists, Locum Doctors and Member Reimbursements 6
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
27,757
11,332
39,089
32,986
7,009
39,995
18,663
11,323
29,986
21,896
12,830
34,726
21,109
6,165
27,274
907,848
727,972
1,635,820
1,156,197
303,424
1,459,621
699,718
885,944
1,585,662
788,293
1,192,364
1,980,657
819,490
1,020,988
1,840,478
40. Average payment per fee for service
service ($):
a. general practitioners
b. specialists
c. total
32.71
64.24
41.85
35.05
43.29
36.50
37.50
78.25
52.88
36.00
92.94
57.04
38.82
165.61
67.48
41. Number of services provided through
fee for service (#): 4
a. medical
b. surgical
c. diagnostic
d. total
31,609
5,141
2,339
39,089
31,099
6,121
2,775
39,995
23,431
4,888
1,667
29,986
25,402
7,510
1,814
34,726
23,466
2,097
1,711
27,274
1,436,115
132,349
67,356
1,635,820
1,133,717
260,188
65,716
1,459,621
1,224,899
285,503
75,261
1,585,663
1,392,766
481,940
105,951
1,980,657
1,371,373
374,435
94,671
1,840,479
45.43
25.74
28.80
41.85
36.46
42.51
23.68
36.50
52.28
58.41
45.15
52.88
54.82
64.17
58.41
57.04
58.44
178.56
55.33
67.48
38. Number of services provided through
fee for service (#):
a. general practitioners
b. specialists
c. total
39. Total payments to physicians paid
through fee for service ($):
a. general practitioners
b. specialists
c. total
42. Total payments to physicians paid
through fee for service ($): 4
a. medical
b. surgical
c. diagnostic
d. total
43. Average payment per fee for service
service ($): 4
a. medical
b. surgical
c. diagnostic
d. all services
Endnotes
1.
2.
3.
4.
5.
6.
Includes 12 health centres and one satellite health station.
Includes on-call payments to physicians.
Includes only resident family physicians and specialists.
Excludes services and costs provided by physicians under alternative payment agreements.
Includes direct billings for insured surgical-dental services received outside the territory.
Excludes services and costs provided by alternative payment agreements.
206
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Northwest Territories
Services System Action Plan 2002-2005. This plan
identifies 45 action items along with specific
deliverables and timelines for improvements in the
following areas:
Northwest
Territories
Introduction
The Northwest Territories (NWT) Department of
Health and Social Services, together with eight
Health and Social Services Authorities (HSSAs),
plan, manage and deliver a full spectrum of
community and facility-based services for health
care and social services. Community health
programs include daily sick clinics, public health
clinics, home care, school health programs and
educational programs. Physicians and specialists
routinely visit communities without resident
physicians. Services also include early
intervention and support to families and children,
mental health and addictions.
Boards of trustees for each HSSA provide NWT
residents with the opportunity to shape priorities
and service delivery for their communities. Nurses
are the largest group of health care practitioners
in the NWT.
As of April 1, 2004, there were an estimated
42,274 people in the NWT, of which half were
Aboriginal people.1 The NWT continues to have a
relatively young population and a high birth rate.
According to 2003 population estimates,
approximately 25 percent of the NWT population
was under 15 years of age, compared with
18 percent in the overall Canadian population.2
Maintaining a Sustainable System
In February 2002, the Minister of Health and
Social Services released the Health and Social
1
2
† Services to people – actions to support
people in taking care of themselves and to
improve the support they receive from Health
and Social Services (HSS);
† Support to staff – actions to attract and
retain the wide range of HSS professionals
who are essential to the delivery of highquality services;
† System-wide management – actions to
improve the organizational structure and
management of the HSS System;
† Support to trustees – actions to fully
develop the leadership role and capacities of
the Boards of Trustees for HSS Authorities;
and
† System-wide accountability – actions to
clarify and increase accountability of the HSS
System to the public, and the Department and
HSS Authorities to the Minister, and with each
other.
Public status reports have been issued every six
months. Over the past two years, 39 action items
have either been completed or become part of the
ongoing work of the HSS System. Many Action
Plan accomplishments created the foundation for
delivering responsive, high-quality programming.
1.0 Public Administration
1.1 Health Care Insurance Plan and
Public Authority
The NWT Health Care Plan includes the Medical
Care Plan and the Hospital Insurance Plan. The
public authority responsible for administering the
Medical Care Plan is the Director of Medical
Insurance as appointed under the Medical Care
Act. The Minister administers the Hospital
Statistics Canada, Quarterly Population Estimates and Statistics Canada, 2001 Census.
Statistics Canada, CANSIM II, Table 051-0001, June 2003
Canada Health Act Annual Report, 2003-2004
207
Chapter 3 – Northwest Territories
Insurance Plan through Boards of Management
established under section 10 of the Hospital
Insurance and Health and Social Services
Administration Act (HIHSSA).
Legislation that enables the Plan in the NWT
includes the Medical Care Act (revised 1988) and
HIHSSA (revised 2003). In November 2003, minor
amendments were made to the HIHSSA to allow
the Minister to exempt employees of the Hay
River Board from the public services, before
reconstituting it as a Health and Social Services
Authority under that Act rather than under the
Societies Act.
The powers of the Minister are outlined in
section15 of the HIHSSA. The Minister’s mandate
is further described in the Establishment Policy for
the Department.
1.2 Reporting Relationship
In the NWT, the Minister of Health and Social
Services appoints a Director of Medical
Insurance. The Director is responsible for the
administration of the Medical Care Act and the
regulations. The Director reports to the Minister
each fiscal year respecting the operation of the
Medical Care Plan.
The Minister also appoints members to a Board of
Management for each region in the NWT. Boards
of Management are established under section 10
of the HIHSSA or under the Societies Act. The
Boards are established with the authority to
manage, control and operate health and service
facilities and, subject to the Financial
Administration Act, exercise any powers
necessary and incidental to these duties. The
Boards’ chairpersons hold office indefinitely, while
the remaining members typically hold office for a
term of three years, for a maximum of three
consecutive terms.
Pursuant to the Financial Administration Act, an
annual audit of accounts is performed at each
Board of Management. The Minister has regular
meetings with Board of Management
chairpersons. This forum allows the chairperson to
provide non-financial reporting.
208
1.3 Audit of Accounts
The Hospital Insurance Plan and the Medical Care
Plan are administered by the Department of
Heath and Social Services. The Auditor General of
Canada (AGC) has the mandate to audit the
payments made under the Medical Care Plan. As
part of the Public Accounts Audit, the AGC also
audits the Hospital Insurance Plan.
2.0 Comprehensiveness
2.1 Insured Hospital Services
Insured Hospital Services are provided under the
authority of the Hospital Insurance and Health and
Social Services Administration Act and the
Regulations. During 2003-2004, four hospitals and
28 health centres delivered insured hospital
services to both in- and out-patients.
The NWT provides a full range of insured hospital
services. Insured in-patient services include:
† accommodation and meals at the standard
ward level;
† necessary nursing services;
† laboratory, radiological and other diagnostic
procedures, together with the necessary
interpretations;
† drugs, biological and related preparations
prescribed by a physician and administered in
hospital;
† routine surgical supplies;
† use of operating room, case room and
anaesthetic facilities;
† use of radiotherapy and physiotherapy
services, where available;
† psychiatric and psychological services provided
under an approved program; services rendered
by persons who are paid by the hospital; and
† services rendered by an approved
detoxification centre.
The NWT also provides a number of out-patient
services. These include:
† laboratory tests, x-rays including
interpretations, when requested by a physician
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Northwest Territories
and performed in an out-patient facility or in an
approved hospital;
† hospital services in connection with most minor
medical and surgical procedures;
† physiotherapy, occupational therapy and
speech therapy services in an approved
hospital; and
† psychiatric and psychology services provided
under an approved hospital program.
A detailed list of insured in- and out-patient
services is contained in the Hospital Insurance
Regulations. Section 1 of the Regulations states
that “out-patient insured services” means the
following services and supplies are provided to
out-patients:
† laboratory, radiological and other diagnostic
procedures together with the necessary
interpretations for helping diagnose and treat
any injury, illness or disability, but not including
simple procedures such as examinations of
blood and urine, which ordinarily form part of a
physician’s routine office examination of a
patient;
† necessary nursing service;
† drugs, biologicals and related preparations as
provided in Schedule B, when administered in
a hospital;
† use of operating room and anaesthetic
facilities, including necessary equipment and
supplies;
† routine surgical supplies;
† services rendered by persons who receive
remuneration for those services from a
hospital;
† radiotherapy services within insured facilities;
and
† physiotherapy services within insured facilities.
The Minister may add, change or delete insured
hospital services. As such, the Minister
recommends changes to the Regulations to the
Commissioner. The Minister also determines if any
public consultation will occur before making
changes to the list of insured services.
Where insured services are not available in the
NWT, NWT residents can receive them from
hospitals in other jurisdictions. These services
Canada Health Act Annual Report, 2003-2004
must be medically necessary. The NWT provides
medical travel assistance, a supplementary health
benefit program outlined in the Medical Travel
Policy, which ensures that NWT residents have no
barriers in accessing medically necessary
services.
2.2 Insured Physician Services
The NWT Medical Care Act and the NWT Medical
Care Regulations provide for insured physician
services. All physicians and nurse practitioners
must be licensed to practice in the NWT.
A wide range of medically necessary services is
provided in the NWT. No limitation is applied if a
service has been deemed an insured service. The
Medical Care Plan insures all medically required
procedures provided by medical practitioners,
including:
† approved diagnostic and therapeutic services;
† necessary surgical services;
† complete obstetrical care;
† eye examinations; and
† visits to specialists, even when there is no
referral by a family physician.
Following negotiations between the NWT Medical
Association and the Director of Medical
Insurance, additional medical services may be
considered for inclusion in the fee schedule
Regulation. It is the responsibility of the Director
of Medical Insurance to manage the process of
adding or deleting a medical service. However, it
is the Minister who makes the determination to
add or delete insured hospital services to the
Regulations, as follows:
† establishing a medical care plan that provides
insured services to insured persons by medical
practitioners that will in all respects qualify and
enable the NWT to receive payments of
contributions from the Government of Canada
under the Canada Health Act; and
† prescribing rates of fees and charges that may
be paid in respect of insured services rendered
by medical practitioners whether in or outside
the NWT, and the conditions under which the
fees and charges are payable.
209
Chapter 3 – Northwest Territories
2.3 Insured Surgical-Dental
Services
Insured services and those related to oral surgery,
injury to the jaw or disease of the mouth/jaw are
eligible. Only oral surgeons may submit claims for
billing. The NWT uses the Province of Alberta’s
Schedule of Oral and Maxillofacial Surgery
Benefits as a guide.
2.4 Uninsured Hospital, Physician
and Surgical-Dental Services
Services provided by hospitals, physicians and
dentists, but not covered by the NWT Health Care
Insurance Plan, include:
† medical-legal services;
† third-party examinations;
† services not medically required;
† group immunization;
† in-vitro fertilization;
† services provided by a doctor to his or her own
family;
† advice or prescriptions given over the
telephone;
† surgery for cosmetic purposes except where
medically required;
† dental services other than those specifically
defined for oral surgery;
† dressings, drugs, vaccines, biologicals and
related materials administered in a physician’s
office;
† eyeglasses and special appliances;
† plaster and surgical appliances or special
bandages;
† treatments in the course of chiropractics,
podiatry, naturopathy, osteopathy or any other
practice ordinarily carried out by persons who
are not medical practitioners as defined by the
Medical Care Act and Regulations;
† physiotherapy and psychology services
received from other than an insured out-patient
facility;
† services covered by the Workers’
Compensation Act or by other federal or
territorial legislation; and
210
† routine annual checkups where there is no
definable diagnosis.
In the NWT, prior approval applications must be
made to the Director of Insured Services for
uninsured medical goods or services provided in
conjunction with an insured health service. A
Medical Advisor is used to provide the Director
with recommendations regarding the
appropriateness of the request.
The NWT Medical Care Act includes Medical Care
Regulations as well as the Physician Fee
Schedule. This Act also provides for the authority
to negotiate changes or deletions to the Physician
Fee Schedule. The process was described in
section 2.2 of this report.
3.0 Universality
3.1 Eligibility
The Medical Care Act defines the eligibility of
NWT residents to the NWT Health Care Insurance
Plan.
The NWT uses the Interprovincial Agreement on
Eligibility and Portability in conjunction with the
NWT Health Care Plan Registration Guidelines to
define eligibility. There were no changes to
eligibility for the reporting period.
Ineligible individuals for NWT health care
coverage are members of the Canadian Forces,
the Royal Canadian Mounted Police (RCMP),
federal inmates and residents who have not
completed the minimum waiting period.
3.2 Registration Requirements
Registration requirements include a completed
application form and supporting documentation as
applicable; e.g., visas and immigration papers. The
applicant must be prepared to provide proof of
residency if requested. Registration should
optimally occur before the actual eligibility date of
the client. Health care cards are renewed every
two years. There is a direct link between
registration and eligibility for coverage. Claims are
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Northwest Territories
not paid for clients who do not have valid
registration.
As of August 2004, there were approximately
41,000 individuals registered with the NWT Health
Care Plan. The registered number is from the
NWT Department of Health and Social Services
Health Care Plan registration database.
No formal provisions are in place for clients to opt
out of the Health Care Insurance Plan.
3.3 Other Categories of Individual
Holders of employment visas, student visas and,
in some cases, visitor visas are covered if they
meet the provisions of the Eligibility and
Portability Agreement and guidelines for health
care plan coverage.
4.0 Portability
4.1 Minimum Waiting Period
There are waiting periods imposed on insured
persons moving to the NWT. The waiting periods
are consistent with the Interprovincial Agreement
on Eligibility and Portability. Generally the waiting
periods are the first day of the third month of
residency, for those who move permanently to the
NWT, or the first day of the thirteenth month for
those with temporary employment of less than 12
months, but who can confirm that the employment
period has been extended beyond the 12 months.
4.2 Coverage During Temporary
Absences In Canada
The Interprovincial Agreement on Eligibility and
Portability and the NWT Health Care Plan
Registration Guidelines define the portability of
health insurance during temporary absences
within Canada.
Coverage is provided to students who are
temporarily out of the NWT for full-time
attendance in a post-secondary institution, and for
up to one year for individuals who are temporarily
Canada Health Act Annual Report, 2003-2004
absent from the NWT for work, vacation, etc.
Once an individual has completed a Temporary
Absence form and been approved by the
Department as being temporarily absent from the
NWT, the full cost of insured services is paid for
all services received in other jurisdictions.
The NWT participates in both the Hospital
Reciprocal Billing Agreements and the Medical
Reciprocal Billing Agreements with other
jurisdictions.
4.3 Coverage During Temporary
Absences Outside Canada
The NWT Health Care Plan Registration
Guidelines set the criteria to define coverage for
absences outside Canada.
As per subsection 11. (1) (b) (ii) of the Canada
Health Act, insured residents may submit receipts
for costs incurred for services received outside
Canada. The NWT does provide personal
reimbursement when an NWT resident leaves
Canada for a temporary period for personal
reasons such as vacations and requires medical
attention during that time. Individuals will be
required to cover their own costs and seek
reimbursement upon their return to the NWT. The
rates are the same as those contained in the
Physician Fee Schedule and the hospital out- or
in-patient rate.
Individuals may be granted coverage for up to a
year (with prior approval), if they are outside the
country. During the reporting period, no one was
granted authorization to continue with his or her
NWT health care coverage while remaining
outside Canada for up to one year. In the
eligibility rules, NWT residents may continue their
coverage for up to one year if they are leaving
Canada, but they must provide extensive
information confirming that they are maintaining
their permanent residence in the NWT. Because
no one was covered by this clause, no payments
were required. The rates are the same as those
contained in the Fee Schedule for physicians and
the hospital out- or in-patient rate.
211
Chapter 3 – Northwest Territories
4.4 Prior Approval Requirement
5.0 Accessibility
In 2003, the Government of the Northwest
Territories followed through with the previously
announced investment of an additional $8.3 million
into human resources within the HSS System.
This investment builds on the Recruitment and
Retention Plan for NWT Allied Health
Professionals, Nurses and Social Workers
(released in November 2002) to enhance
professional development and educational
opportunities, as well as employee supports.
5.1 Access to Insured Health
Services
5.3 Access to Insured Physician and
Surgical-Dental Services
The Medical Travel Supplementary Health Benefit
Program ensures that economic barriers are
reduced for all NWT residents. As per section 14
of the Medical Care Act, extra-billing is not
allowed.
All NWT residents have access to all facilities
operated by the Government of the Northwest
Territories.
The NWT requires prior approval if coverage is to
be considered for elective services in other
provinces, territories and outside the country.
Prior approval is also required if insured services
are to be obtained from private facilities.
5.2 Access to Insured Hospital
Services
Beds were available during the reporting period. If
a bed shortage were to arise, the resident would
be transported to another facility where
appropriate beds exist. NWT hospitals and health
centres continued to face some short-term
staffing difficulties that had negative effects on
their operations. However, through the use of
medical travel arrangements, access to services
was maintained throughout 2003-2004.
Facilities in the NWT do offer a range of medical,
surgical, rehabilitative and diagnostic services.
The NWT medical travel program ensures that
residents will have access to necessary services
not available in NWT facilities.
In order to improve access to insured hospital
services, the NWT continued to expand the
Telehealth program through technical upgrades to
existing sites in 2003-2004. A number of steps
were taken to ensure that installing equipment
and upgrading the three existing WestNet sites
(Inuvik, Fort Smith and Yellowknife) and adding
four communities (Deline, Fort Simpson, Hay
River and Holman) were completed.
212
The medical travel program provides access to
physicians for residents and the Telehealth
program expands the specialist services available
to residents in isolated communities.
5.4 Physician Compensation
The Medical Care Act and the Medical Care
Regulations are used in the NWT to govern
payments to physicians. To compensate
physicians, the NWT uses two models: fee-forservice and employee contracts. The majority of
family physicians are employed through a
contractual arrangement with the NWT. The
remainder provide services through a fee-forservice arrangement.
Physician compensation is determined for
physician contracts and fees-for-service scheduled
through negotiations between the NWT Medical
Association and the Department. The Director of
Medical Insurance and his or her designates
negotiate on behalf of the Department. The NWT
Medical Association chooses a negotiation team
from within their membership. In March 2004, the
NWT Fee Schedule was renewed along with new
four-year General Practitioner and specialist
contracts for the Stanton Territorial Heath
Authority.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Northwest Territories
5.5 Payments to Hospitals
Payments made to hospitals are based on
contribution agreements between the Boards of
Management and the Department. Amounts
allocated in the agreements are based on the
resources available in the total government
budget and level of services provided by the
hospital.
Payments to facilities providing insured hospital
services are governed under the HIHSSA and the
Financial Administration Act. No amendments
were implemented in 2003-2004 to provisions
involving payments to facilities. A comprehensive
budget is used to fund hospitals in the NWT.
6.0 Recognition Given to
Federal Transfers
Federal funding received through the Canada
Health and Social Transfer (CHST) has been
recognized and reported by the Government of
the Northwest Territories through press releases
and various other documents. For fiscal year
2003-2004, these documents included:
† 2003-2004 Budget Address;
† 2003-2004 Main Estimates;
† 2002-2003 Public Accounts; and
† 2003-2006 Business Plan for the Department
of Finance.
The Estimates noted above represent the
government's financial plan and are presented
each year by the Government to the Legislative
Assembly.
Canada Health Act Annual Report, 2003-2004
7.0 Extended Health Care
Services
Continuing Care programs and services offered in
NWT communities may include: supported living,
adult group homes, long-term care facilities and
extended care facilities. These programs and
services operate where applicable according to
the Department of Health and Social Services
Establishment Policy, the HIHSSA and the
Hospital Standards Regulations.
Supported living services provide a home-like
environment with increased assistance and a
degree of supervision unavailable through home
care services. Current services in this area include
supported living arrangements in family homes,
apartments and group-living homes, where clients
live as independently as possible. Group homes,
long-term care facilities and extended care
facilities provide more complex medical, physical
and/or mental supports on a 24-hour basis.
The NWT Home Care Program is a territorial-wide
program established to provide effective, reliable
and responsive community health care services to
support independent living; to develop appropriate
care options to support continued community
living; and to facilitate admission to institutional
care when community living is no longer a viable
alternative. Home care services are delivered
through the Regional Health and Social Services
Authorities and include a broad range of services
based on a multi-disciplinary assessment of
individual needs. The Home Care Program
provides services to the six regions of Yellowknife,
Hay River, Fort Smith, Inuvik (inclusive of the
Beaufort Delta and the Sahtu Region), Deh Cho
and Dogrib.
213
Chapter 3 – Northwest Territories
Registered Persons
1. Number as of March 31st (#).
1999-2000
2000-2001
41,000
41,673
2001-2002
2002-2003
42,886 1
40,399 1
2003-2004
43,202 1
Insured Hospital Services Within Own Province or Territory
Public Facilities
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
2. Number (#):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
4
not applicable 2
not applicable 2
28 3
32
4
not applicable 2
not applicable 2
28 3
32
4
not applicable 2
not applicable 2
28 3
32
4
not applicable 2
not applicable 2
28 3
32
4
not applicable 2
not applicable 2
28 3
32
3. Payments ($):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
not available
not applicable 2
not applicable 2
not available
36,215,847
not available
not applicable 2
not applicable 2
not available
40,282,046
not available
not applicable 2
not applicable 2
not available
44,268,039
not available
not applicable 2
not applicable 2
not available
48,451,358
not available
not applicable 2
not applicable 2
not available
50,962,729
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5. Number of insured hospital services
provided (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
6. Payments ($):
a. surgical facilities
b. diagnostic imaging facilities
c. total
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
not applicable
Private For-Profit Facilities
4. Number (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
214
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Northwest Territories
Insured Physician Services Within Own Province or Territory
1999-2000
7. Number of participating physicians (#):
a. general practitioners
b. specialists
c. other
d. total
2000-2001
2001-2002
2002-2003
2003-2004
35 4
18 4
106 5
159 6
29 4
18 4
151 5
198 6
24 4
13 4
175 5
212 6
37 4
16 4
155 5
208 6
44 4
15 4
169 5
228 6
8. Number of opted-out physicians (#):
a. general practitioners
b. specialists
c. other
d. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
9. Number of not participating
physicians (#):
a. general practitioners
b. specialists
c. other
d. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
10. Number of services provided through
fee for service (#):
a. general practitioners
b. specialists
c. other
d. total
142,004
9,487
not available
151,491
81,921
5,466
not available
87,387
32,339
5,618
not available
37,957
18,493
5,524
not available
24,017
20,671
5,240
not available
25,911
11. Total payments to physicians paid
through fee for service ($):
a. general practitioners
b. specialists
c. other
d. total
5,589,151
650,639
not available
6,239,790
3,357,203
599,167
not available
3,956,370
1,226,502
616,393
not available
1,842,895
824,503
617,448
not available
1,441,951
813,758
673,494
not available
1,487,252
12. Average payment per fee for service
service ($):
a. general practitioners
b. specialists
c. other
d. all services
39.4
68.6
not available
41.19
41.0
109.6
not available
45.27
37.9
109.7
not available
48.55
44.6
111.8
not available
60.04
39.4
128.5
not available
57.40
13. Number of services provided through
all payment methods (#):
a. medical
b. surgical
c. diagnostic
d. other
e. total
not available
not available
not available
not available
213,665
not available
not available
not available
not available
200,198
not available
not available
not available
not available
199,751
not available
not available
not available
not available
195,508
not available
not available
not available
not available
197,543
14. Total payments to physicians paid
through all payment methods ($):
a. medical
b. surgical
c. diagnostic
d. other
e. total
not available
not available
not available
not available
10,546,580
not available
not available
not available
not available
16,278,000
not available
not available
not available
not available
19,081,000
not available
not available
not available
not available
19,813,000
not available
not available
not available
not available
27,352,000
15. Average payment per service, all
payment methods ($):
a. medical
b. surgical
c. diagnostic
d. other
e. all services
not available
not available
not available
not available
49.36
not available
not available
not available
not available
81.31
not available
not available
not available
not available
95.52
not available
not available
not available
not available
101.34
not available
not available
not available
not available
138.46
Canada Health Act Annual Report, 2003-2004
215
Chapter 3 – Northwest Territories
Insured Services Provided to Residents in Another Province or Territory
Hospitals
16. Total number of claims, in-patient (#).
17. Total number of claims,
out-patient (#).
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
1,076
952
992
1,233
1,015
7,828
8,106
8,369
9,167
8,429
18. Total payments, in-patient ($).
7,124,045
5,235,249
5,688,458
8,606,767
6,100,096
19. Total payments, out-patient ($).
1,153,525
1,378,612
1,406,932
1,831,343
1,839,081
20. Average payment, in-patient ($).
6,620.86
5,499.21
5,734.33
6,980.35
6,009.95
147.36
170.07
168.11
199.78
218.18
Physicians
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
22. Number of services (#).
44,476
40,095
42,395
43,862
40,945
2,340,523
2,140,669
2,264,235
2,794,590
2,937,334
52.62
53.39
53.41
63.71
71.74
21. Average payment, out-patient ($).
23. Total payments ($).
24. Average payment per service ($).
Insured Services Provided Outside Canada
Hospitals
25. Total number of claims, in-patient (#).
26. Total number of claims,
out-patient (#).
27. Total payments, in-patient ($).
28. Total payments, out-patient ($).
29. Average payment, in-patient ($).
30. Average payment, out-patient ($).
Physicians
31. Number of services (#).
32. Total payments ($).
33. Average payment per service ($).
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
6
5
3
1
1
12
16
15
51
18
10,190
2,908
10,535
1,194
1,283
2,270
1,713
2,181
99,009
16,763
1,698.39
581.52
3,511.52
1,193.53
1,283.00
189.20
107.04
145.39
1941.35
931.26
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
212
186
101
138
47
18,197
13,989
9,979
9,482
2,424
85.83
75.21
98.80
68.71
51.57
Insured Surgical-Dental Services Within Own Province or Territory
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
34. Number of particpating dentists (#).
not available
not available
not available
not available
not available
35. Number of services provided (#).
not available
not available
not available
not available
not available
36. Total payments ($).
not available
not available
not available
not available
not available
37. Average payment per service ($).
not available
not available
not available
not available
not available
216
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Northwest Territories
Endnotes
1. 2001-02 figure is as of September 18, 2002, 2002-03 figure is as of September 2, 2003, and the 2003-2004 figures is as of
August 25, 2004.
2. Northwest Territories does not have facilities that provide these services as their primary type of care. Instead, the 4 hospital
acute care facilities provide long term care, extended care, day surgery, out-patient services, diagnostic services and
rehabilitative care.
3. Includes Health Centres and Public Health Units.
4. 1999/00 to 2001/02 numbers from Counts from Canadian Institute for Health Information, Southam Medical Database; and
2002/03 and 2003/04 numbers are estimates from NWT Department of Health and Social Services.
5. This is an estimate of the number of locum physicians. For measures 10 through 15, locum physicians are captured within the
general practitioners and specialists categories.
6. Estimate based on total active physicians for each fiscal year.
Canada Health Act Annual Report, 2003-2004
217
Chapter 3 – Nunavut
development, service design and delivery, is an
expectation placed on all departments.
Nunavut
Introduction
Nunavut was formed as a Territory on
April 1,1999. The Territory covers one-fifth of
Canada’s total landmass. There are twenty-six
communities situated across three time zones.
The Territory is divided into three regions: the
Qikiqtaaluk, which consists of 13 communities;
the Kivalliq, which consists of eight communities;
and the Kitikmeot, which consists of five
communities. According to recent statistics, the
population of Nunavut is 29,644. Approximately
40 percent of the population is under the age of
25. Inuit make up the majority at about 85 percent
of the residents. There is a small French-speaking
population of about four to six percent residing on
Baffin Island, predominantly in the capital city of
Iqaluit. Nunavut has a highly transient workforce,
in particular skilled labourers and other seasonal
workers from other provinces and territories.
Legislation governing the administration of health
and social services in Nunavut was carried over
from the Northwest Territories as Nunavut
statutes pursuant to Nunavut Act (1999). Over
the coming years, the Department of Health and
Social Services plans to review all existing
legislation to ensure its relevancy and
appropriateness for the Government of Nunavut
as set out in the objectives of The Bathurst
Mandate Pinasuaqtavut. Pinasuaqtavut outlines
the Government’s agenda to achieve healthy
communities, simplicity and unity, self-reliance and
continuous learning. The incorporation of
traditional Inuit values, known as Inuit
Qaujimajatuqangit, in program policy
Canada Health Act Annual Report, 2003-2004
The delivery of health services in Nunavut is
based on a primary health care model. There is a
local health centre in each of the 25 communities
across Nunavut, as well as one regional hospital in
Iqaluit. The primary health care providers are
nurses with expanded scopes, with the exception
of 17 full-time family physicians; 11 in the
Qikiqtaaluk region; four in the Kivalliq region; two
in the Kitikmeot region. Nunavut relies heavily on
the Northern Medical Unit of the University of
Manitoba, Ottawa Health Services Network Inc.
and Stanton Regional Hospital in Yellowknife for
the majority of its physician and specialist
services.
The management and delivery of health services
in Nunavut were integrated into the overall
operations of the Department on March 31, 2000,
when the former boards (Qikiqtaaluk, Kitikmeot
and Kivalliq) were dissolved. Former board staff
became employees of the Department at that
time. The Department has a regional office in
each of the three regions which manages the
delivery of health services at a regional level. A
continued emphasis on support to front-line
service delivery has remained an integral part of
this amalgamation.
The Territorial budget for health care and social
services in 2003-2004 was $182,244,000 including
approximately $28.8 million allocated for capital.
Nunavut’s new Nursing Act (January 2004) allows
for hiring nurse practitioners and over the next
year amendments will be made to other legislation
to outline the scope of the expanded
responsibilities of these health care professionals.
In 2003-2004, Nunavut had 15 communities
across the Territory connected to the Telehealth
network. The Department of Health and Social
Services received an additional $2.7 million from
the Primary Health Care Transition Fund to allow
for the addition of seven communities to the
Telehealth network, to bring the total to 22
communities. These communities receive a broad
range of services: specialist consultation services
such as dermatology, psychiatry and internal
219
Chapter 3 – Nunavut
medicine; rehabilitation services; regularly
scheduled counseling sessions; family visitation;
and continuing medical education.
Nunavut has many unique needs and challenges
with respect to the health and well-being of its
residents. Approximately one-fifth of the
Department’s budget is spent on medical travel.
Due to the very low population density in this vast
territory and limited health infrastructure
(equipment and health human resources), access
to a range of hospital and specialist services often
requires that residents be sent out of the Territory.
A new regional hospital in Iqaluit and new regional
health facilities in Rankin Inlet and Cambridge Bay
that will be built over the next two years will
enable Nunavut to build internal capacity and
enhance the range of services that can be
provided within the Territory. Nunavut continues to
be challenged by the acute shortage of nurses,
despite aggressive national and international
recruitment and retention activities. Recruitment
and retention of other health care professionals
such as social workers, physicians and
physiotherapists is also a challenge.
Nunavut received approximately $209,000 in
2003-2004 as part of a three year allotment of
$4.4 million from the Primary Health Care
Transition Fund Provincial/Territorial Envelope.
These funds are designated to support the
transitional costs of implementing sustainable,
large-scale primary health care renewal initiatives.
The Government of Nunavut has hired a Primary
Health Care Renewal Implementation Coordinator
and has plans for improvements to information
technology, mental health training, health
promotion, service provider training, Inuit staff
capacity building, and population health
programming.
Health promotion and prevention activities are
high on the Department’s list of service priorities.
This includes strategies to reduce tobacco use,
public education for healthy lifestyle choices,
FASD awareness, importance of traditional foods,
and pre-natal nutrition, and our Northern
Contaminants Program.
220
1.0 Public Administration
1.1 Health Care Insurance Plan and
Public Authority
The health care insurance plans of Nunavut,
including physician and hospital services, are
administered by the Department of Health and
Social Services on a non-profit basis.
The Medical Care Act (NWT, 1988 and as
duplicated for Nunavut by section 29 of the
Nunavut Act, 1999) governs the entitlement to
and payment of benefits for insured medical
services. The Hospital Insurance and Health and
Social Services Administration Act (NWT, 1988
and as duplicated for Nunavut by section 29 of
the Nunavut Act, 1999) enables the establishment
of hospital and other health services.
Through the Dissolution Act (Nunavut, 1999), the
three former Health and Social Services Boards of
Baffin, Kitikmeot and Kivalliq were dissolved and
their operations were integrated into the
Department of Health and Social Services
effective April 1, 2000. Regional sites were
maintained to support front-line workers and
community-based delivery of a wide range of
health and social services.
There have been no legislative amendments for
the fiscal year 2003-2004.
1.2 Reporting Relationship
A Director of Medical Care is appointed under the
Medical Care Act and is responsible for the
administration of the Territory’s medical care
insurance plan. The Director reports to the
Minister of Health and Social Services and is
required to submit an annual report on the
operations of the medical insurance plan. Our
annual submissions to the Canada Health Act
Annual Report serve as the basis for these
reports under the Medical Care Act.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Nunavut
1.3 Audit of Accounts
The Auditor General of Canada is the auditor of
the Government of Nunavut in accordance with
section 30.1 of the Financial Administration Act
(Nunavut, 1999). The Auditor General has the
mandate to audit the activities of the Department
of Health and Social Services.
The Auditor General is required to conduct an
annual audit of the transactions and consolidated
financial statements of the Government; however,
the annual report was not tabled in the Legislature
during 2003-2004.
2.0 Comprehensiveness
2.1 Insured Hospital Services
Insured Hospital Services are provided in Nunavut
under the authority of the Hospital Insurance and
Health and Social Services Administration Act and
Regulations, sections 2 to 4. No amendments
were made to legislation or Regulations in 20032004.
In 2003-2004, insured hospital services were
delivered in 26 facilities throughout Nunavut,
including a general hospital located in Iqaluit and
25 community health centres. The Baffin Regional
Hospital in Iqaluit is the only acute care facility in
Nunavut providing a range of in-patient and outpatient hospital services as defined by the
Canada Health Act. Community health centres
provide public health, out-patient services,
emergency room services and some overnight
services (observations). There are also a limited
number of birthing beds at the Rankin Inlet
Birthing Centre. Public health services are
provided at a Public Health Clinic in Rankin Inlet
and Iqaluit.
The Department is responsible for authorizing,
licensing, inspecting and supervising all health
facilities and social services facilities in the
Territory.
Insured in-patient hospital services include:
Canada Health Act Annual Report, 2003-2004
† accommodation and meals at the standard
ward level;
† necessary nursing services;
† laboratory, radiological and other diagnostic
procedures, together with the necessary
interpretations;
† drugs, biological and related preparations
prescribed by a physician and administered in
hospital;
† routine surgical supplies;
† use of operating room, case-room and
anaesthetic facilities;
† use of radiotherapy and physiotherapy
services, where available;
† psychiatric and psychological services provided
under an approved program;
† services rendered by persons who are paid by
the hospital; and
† services rendered by an approved
detoxification centre.
Out-patient services include:
† laboratory tests and x-rays, including
interpretations, when requested by a physician
and performed in an out-patient facility or in an
approved hospital;
† hospital services in connection with most minor
medical and surgical procedures;
† physiotherapy, occupational therapy, audiology
and speech therapy services in an out-patient
facility or in an approved hospital; and
† psychiatric and psychology services provided
under an approved hospital program. The
Department of Health and Social Services
makes the determination to add insured
services in its facilities based on the
availability of appropriate resources, equipment
and overall feasibility in accordance with
financial guidelines set by the Department and
with the approval of the Nunavut Financial
Management Board.
No new services were added in 2003-2004 to the
list of insured hospital services.
2.2 Insured Physician Services
The Medical Care Act, section 3(1), and Medical
Care Regulations, section 3, provide for insured
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Chapter 3 – Nunavut
physician services in Nunavut. No amendments
were made to legislation or Regulations in 20032004.
2.3 Insured Surgical-Dental
Services
Although the Nursing Act (2004) allows for
licensure of nurse practitioners in Nunavut, only
medical doctors are permitted to deliver insured
physician services in Nunavut at this time. The
physician must be in good standing with a College
of Physicians and Surgeons and be licensed to
practice in Nunavut. The Government of
Nunavut’s Medical Registration Committee
currently manages this process for Nunavut
physicians. There are a total of 17 full-time family
physicians in Nunavut (11 in the Qikiqtaaluk
region; four in the Kivalliq region; two in the
Kitikmeot region), as well as one surgeon at the
Baffin Regional Hospital, providing services to
Nunavummiut. Visiting specialists, general
practitioners and locums, through arrangements
made by each of the Department’s three regions,
also provide insured physician services. As of
March 31, 2004, Nunavut had 139 physicians
participating in the health insurance plan.
Dentists providing insured surgical-dental services
under the Medical Care Insurance Plan of the
Territory must be licensed pursuant to the Dental
Professions Act (NWT, 1988 and as duplicated for
Nunavut by section 29 of the Nunavut Act, 1999).
Billing numbers are provided for the purpose of
billing the Plan for the provision of insured dental
services. In 2003-2004, five oral surgeons were
permitted to bill the Nunavut Medical Care
Insurance Plan for insured dental services.
Physicians can make an election to collect fees
other than those under the Medical Care Plan in
accordance with section 12 (2)(a) or (b) of the
Medical Care Act by notifying the Director in
writing. An election can be revoked the first day
of the following month after a letter to that effect
is delivered to the Director. In 2003-2004, no
physicians provided written notice of this election.
Insured physician services refers to all services
rendered by medical practitioners that are
medically required. Where the insured service is
unavailable in Nunavut, the patient is referred to
another jurisdiction to obtain the insured service.
The addition or deletion of insured physician
services requires government approval. For this,
the Director of Medical Insurance would become
involved in negotiations with a collective group of
physicians to discuss the service then the decision
of the group would be presented to Cabinet for
approval. No additions or deletions were added in
2003-2004.
222
Insured dental services are limited to those
dental-surgical procedures scheduled in the
Regulations, requiring the unique capabilities of a
hospital for their performance, for example, of
orthognathic surgery. Oral surgeons are brought
to Nunavut on a regular basis but on rare
occasions, for medically complicated situations,
patients are flown out of Territory to more
sophisticated centres.
The addition of new surgical-dental services to the
list of insured services requires government
approval; no new services were added to the list
in 2003-2004.
2.4 Uninsured Hospital, Physician
and Surgical-Dental Services
Services provided for under the Workers
Compensation Act (NWT, 1988 and as duplicated
for Nunavut by section 29 of the Nunavut Act,
1999) or other Acts of Canada, except the
Canada Health Act, are excluded.
Services provided by physicians that are not
insured include:
† yearly physicals;
† cosmetic surgery;
† services that are considered experimental;
† prescription drugs;
† physical examinations done at the request of a
third party;
† optometric services;
† dental services other than specific procedures
related to jaw injury or disease;
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Nunavut
† the services of chiropractors, naturopaths,
podiatrists, osteopaths and acupuncture
treatments; and
† physiotherapy, speech therapy and psychology
services, received in a facility that is not an
insured out-patient facility (hospital).
Services not covered in a hospital include:
† hospital charges above the standard ward rate
for private or semi-private accommodation;
† services that are not medically required, such
as cosmetic surgery;
† services that are considered experimental;
† ambulance charges (except inter-hospital
transfers);
† dental services, other than specific procedures
related to jaw injury or disease; and
† alcohol and drug rehabilitation, unless with
prior approval.
The Baffin Regional Hospital charges $2,180.25
per diem for services provided for non-Canadian
resident stays.
When residents are sent out of the Territory for
services, the Department relies on the policies
and procedures guiding that particular jurisdiction
when they provide services to Nunavut residents
that could result in additional costs, only to the
extent that these costs are covered by Nunavut’s
Medical Insurance Plan (see section 4.2 under
Portability). Any query or complaint is handled on
an individual basis with the jurisdiction involved.
The Department also administers the Non-Insured
Health Benefits (NIHB) Program on behalf of
Health Canada for Inuit and First Nations
residents in Nunavut. NIHB covers a co-payment
for medical travel, accommodations and meals at
boarding homes (in Ottawa, Winnipeg, Churchill,
Edmonton and Yellowknife), prescription drugs,
dental treatment, vision care, medical supplies
and prostheses, and a number of other incidental
services for Inuit and First Nations.
3.0 Universality
3.1 Eligibility
Eligibility for the Nunavut Health Care Plan is
briefly defined under section 3(1)(2)(3) of the
Medical Care Act. The Department also adheres
to the Inter-Provincial/Territorial Agreement on
Eligibility and Portability as well as internal
guidelines. No amendments were made to the
legislation or Regulations in 2003-2004.
Subject to these provisions, every Nunavut
resident is eligible for and entitled to insured
health services on uniform terms and conditions.
A resident means a person lawfully entitled to be
or to remain in Canada, who makes his or her
home and is ordinarily present in the Territory, but
does not include a tourist, transient or visitor to
the Territory. Applications are accepted for health
coverage and supporting documentation is
required to confirm residency. Eligible residents
receive a health card with a unique health care
number.
Coverage generally begins the first day of the
third month after arrival in the Territory, but firstday coverage is provided under a number of
circumstances, e.g. newborns whose mothers or
fathers are eligible for coverage. As well,
permanent residents (landed immigrants),
returning Canadians, repatriated Canadians,
returning permanent residents and a nonCanadian who has been issued an employment
visa for a period of 12 months or more are also
granted first-day coverage.
Members of the Canadian Armed Forces, the
Royal Canadian Mounted Police and inmates of a
federal penitentiary are not eligible for
registration. These groups are granted first-day
coverage under the Nunavut Health Care Plan
upon discharge.
Pursuant to section 7 of the InterProvincial/Territorial Agreement on Eligibility and
Portability, persons in Nunavut who are
temporarily absent from their home
province/territory and who are not establishing
Canada Health Act Annual Report, 2003-2004
223
Chapter 3 – Nunavut
residency in Nunavut remain covered by their
home provincial or territorial health insurance
plans for up to one year.
3.2 Registration Requirements
Registration requirements include a completed
application form and supporting documentation. A
health care card is issued to each resident.
Nunavut will be going to a staggered renewal
process in 2004-2005 as a new health claims
system has been put into place in 2003-2004. No
premiums exist. Coverage under the Nunavut
Medical Insurance Plan is linked to verification of
registration, although every effort is made to
ensure registration occurs when a coverage issue
arises for an eligible resident. For non-residents, a
valid health care card from their home
province/territory is required.
As of March 31, 2004, 31,660 residents were
registered with the Nunavut Health Care Plan.
Nunavut’s population statistics are published by
Statistics Canada and include a number of
temporary residents who are not eligible for
coverage under the Territory’s health plan. There
are no formal provisions for Nunavut residents to
opt out of the health care insurance plan.
3.3 Other Categories of Individual
Non-Canadian holders of employment visas of
less than 12 months, foreign students with visas
of less than 12 months, transient workers and
individuals holding a Minister’s Permit (with one
exception) are not eligible for coverage. When
unique circumstances occur, assessment is done
on an individual basis. This is consistent with
section 15 of the NWT’s Guidelines for Health
Care Plan Registration, which were adopted by
Nunavut in 1999.
4.0 Portability
4.1 Minimum Waiting Period
Consistent with section 3 of the InterProvincial/Territorial Agreement on Eligibility and
Portability, the waiting period before coverage
begins for individuals moving within Canada is
three months or the first day of the third month
following the establishment of residency in a new
province or territory or the first day of the third
month when an individual, who has been
temporarily absent from his or her home province,
decides to take up permanent residency in
Nunavut.
4.2 Coverage During Temporary
Absences In Canada
The Medical Care Act, section 4(2), prescribes
the benefits payable where insured medical
services are provided outside Nunavut but within
Canada. The Hospital Insurance and Health and
Social Services Administration Act, sections 5(d)
and 28(1)(j)(o), provide the authority for the
Minister to enter into agreements with other
jurisdictions to provide health services to Nunavut
residents and the terms and conditions of
payment. No legislative or regulatory changes
were made in 2003-2004 with respect to coverage
outside Nunavut.
Students studying outside Nunavut must notify
the Department and provide proof of enrolment to
ensure coverage continues. Requests for
extensions must be renewed yearly and are
subject to approval by the Director. Temporary
absences for work, vacation or other reasons for
up to one year are approved by the Director upon
receipt of a written request from the insured
person. The Director may approve absences in
excess of 12 continuous months upon receipt of a
written request from the insured person.
The provisions regarding coverage during
temporary absences in Canada fully comply with
the terms and conditions of the Inter-
224
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Nunavut
Provincial/Territorial Agreement on Eligibility and
Portability, as of January 1, 2001.
Nunavut participates in Physician and Hospital
Reciprocal Billing. Agreements are in place with
other provinces and territories (Ontario,
Manitoba, Alberta and the Northwest Territories).
The Hospital Reciprocal Billing Agreements
provide payment of in-patient and out-patient
hospital services to eligible Nunavut residents
receiving insured services outside the Territory.
High-cost procedure rates, newborn rates and
out-patient rates are based on those established
by the Coordinating Committee on Reciprocal
Billing. A special agreement exists between the
Northwest Territories and Nunavut Territory which,
based on a block-funding approach, enables the
Stanton Hospital in Yellowknife to provide services
to Nunavut residents in the hospital and through
visiting specialist services in the Kitikmeot area
(Western Arctic).
The Physician Reciprocal Billing Agreements
provide payment of insured physician services on
behalf of eligible Nunavut residents receiving
insured services outside the territory. Payment is
made to the host province at the rates established
by that province.
Out-of-territory hospitals were paid $18,755,064
in the fiscal year 2003-2004.
4.3 Coverage During Temporary
Absences Outside Canada
The Medical Care Act, section 4(3), prescribes
the benefits payable where insured medical
services are provided outside Canada. The
Hospital Insurance and Health and Social Services
Administration Act, section 28(1)(j)(o), provides
the authority for the Minister to set the terms and
conditions of payment for services provided to
Nunavut residents outside Canada. Individuals are
granted coverage for up to one year if they are
temporarily out of the country for any reason,
although they must give prior notice in writing. For
services provided to residents who have been
referred out of the country for highly specialized
procedures unavailable in Nunavut and Canada,
Canada Health Act Annual Report, 2003-2004
Nunavut will pay the full cost. For non-referred or
non-emergency services, the payment for hospital
services is $1,396 per diem and $110 for outpatient care. No changes were made to these
rates in 2003-2004.
In 2003-2004, Nunavut paid a total of $6,700 for
insured emergency in-patient and out-patient
health services to eligible residents temporarily
outside Canada.
Insured physician services provided to eligible
residents temporarily outside the country are paid
at rates equivalent to those paid had that service
been provided in the Territory. Reimbursement is
made to the insured person or directly to the
provider of the insured service.
4.4 Prior Approval Requirement
Prior approval is required for elective services
provided in private facilities in Canada or in any
facility outside the country.
5.0 Accessibility
5.1 Access to Insured Health
Services
The Medical Care Act, section 14, prohibits extra
billing by physicians unless the medical
practitioner has made an election that is still in
effect. Access to insured services is provided on
uniform terms and conditions. To break down the
barrier posed by distance and cost of travel, the
Government of Nunavut provides medical travel
assistance. Interpretation services are also
provided to patients in any health care setting.
5.2 Access to Insured Hospital
Services
The Baffin Regional Hospital, located in Iqaluit, is
the one acute care hospital facility in Nunavut.
The hospital has 25 beds available for acute,
rehabilitative, palliative and chronic care services.
The hospital has a staff of 87, including 34 nurses
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Chapter 3 – Nunavut
and ten physicians. The facility provides inpatient, out-patient, and 24-hour emergency
services. Local physicians provide emergency
services on rotation. Medical services provided
include an ambulatory care/out-patient clinic,
intensive care services, respiratory services,
cardiovascular care, maternity, palliative care,
gastrointestinal bleeds and hypertension
treatment. Surgical services provided include
minor orthopaedics, gynaecology, paediatrics,
general abdominal, emergency trauma and
ENT/otolaryngology. Patients requiring
specialized surgeries are sent to other
jurisdictions. Diagnostic services include
radiology, laboratory and electrocardiogram.
Rehabilitative services are limited to Iqaluit.
Nunavut has special arrangements with facilities
in Ottawa, Toronto, Churchill, Winnipeg, Edmonton
and Yellowknife to provide insured services to
referred patients.
Outside the Baffin Regional Hospital, out-patient
and 24-hour emergency services are provided by
all 25 health centres located in the communities.
Although nursing and other health professionals
were not at the desired levels of staffing, all basic
services were provided in 2003-2004. Nunavut is
seeking to increase resources in all areas.
The use of Telehealth services has been a
significant step in improving access to hospital,
medical and other health and social services in
Nunavut. Telehealth facilities are active in 15
communities with a goal of expanding to all other
communities in 2004-2005. The long-term goal is
to integrate Telehealth into the primary care
delivery system, enabling residents of Nunavut
greater access to a broader range of service
options and allowing service providers and
communities to use existing resources more
effectively.
5.3 Access to Insured Physician and
Surgical-Dental Services
In addition to the medical travel assistance and
Telehealth initiatives, Nunavut has agreements
with a number of health regions or facilities to
226
provide medical and visiting specialists and other
visiting health practitioner services. For services
and equipment unavailable in Nunavut, patients
are referred to other jurisdictions. The Telehealth
network, linking 15 communities, allows for the
delivery of a broad range of services: specialist
consultation services such as dermatology,
psychiatry and internal medicine; rehabilitation
services; regularly scheduled counselling sessions;
family visitation; and continuing medical
education. In 2003-2004, Nunavut had 139
physicians registered.
The following specialist services were provided
under the visiting specialists program:
ophthalmology, orthopaedics, internal medicine,
otolaryngology, neurology, rheumatology,
dermatology, paediatrics, obstetrics,
physiotherapy, occupational therapy, psychiatry
and dental surgery. Visiting specialist clinics are
held depending on demand and availability of
specialists.
5.4 Physician Compensation
There is one fee-for-service physician residing in
Nunavut. Because fee-for-service physicians pay
the expenses of running a practice in an isolated
community, they are paid a rate 20 percent
greater than the amounts set out in the schedule
(per the Medical Care Act, section 4). The fees
are negotiated between the Department of Health
and Social Services and the physician, and are
based on the NWT standards. The remaining
physicians are on contract at a per-diem rate or
are on salary. Visiting specialists are paid on a per
diem basis under the terms of their contracts.
5.5 Payments to Hospitals
Funding for the Baffin Regional Hospital and the
25 community health centres are part of the
Department's budget as represented in the
budgets for regional operations. No payments are
made directly to hospitals or community health
centres.
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Nunavut
6.0 Recognition Given to
Federal Transfers
Recognition will be given this year when the
Director of Medical Care presents the 2002-2003
and 2003-2004 annual reports to the Minister.
7.0 Extended Health Care
Services
The Home Care Program assists Nunavut
residents who are not fully able to care for
themselves at home. A community-based visiting
service encourages self-sufficiency and supports
family members and community involvement to
enable individuals to remain safely in their own
Canada Health Act Annual Report, 2003-2004
homes. Services include basic housekeeping
support, meal preparation and assistance with
daily living.
Intermediate care is available at St. Theresa's
Home in Chesterfield Inlet. The facility provides
24-hour care and is fully staffed with professional
and para-professional personnel. Nursing services
are available between 7 a.m. and 7 p.m. Afterhours services are for personal care only. The
community health centre provides after-hours
medical attention.
Nursing home services are available at the Iqaluit
and Arviat's Elders Homes. These facilities provide
the highest level of long-term care in Nunavut;
that is, extensive chronic care services up to the
point of acute care (levels 4 and 5) services.
Acute care cases are transferred to the closest
hospital.
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Chapter 3 – Nunavut
Registered Persons
1. Number as of March 31st (#).
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
not available
26,829
28,630
29,478
31,660
Insured Hospital Services Within Own Province or Territory
Public Facilities
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
2. Number (#):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
1
not available
not available
25 1
not available
1
not available
not available
25 1
not available
1
not available
not available
25 1
not available
1
not available
not available
25 1
not available
1
not available
not available
25 1
not available
3. Payments ($):
a. acute care
b. chronic care
c. rehabilitative care
d. other
e. total
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
4. Number (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5. Number of insured hospital services
provided (#):
a. surgical facilities
b. diagnostic imaging facilities
c. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
6. Payments ($):
a. surgical facilities
b. diagnostic imaging facilities
c. total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Private For-Profit Facilities
1. Health Centres.
228
Canada Health Act Annual Report, 2003-2004
Chapter 3 – Nunavut
Insured Physician Services Within Own Province or Territory
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
85
79
0
164
59
55
0
114
81
67
0
148
106
80
0
186
75
64
0
139
8. Number of opted-out physicians (#):
a. general practitioners
b. specialists
c. other
d. total
not available
not available
not available
not available
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
9. Number of not participating
physicians (#):
a. general practitioners
b. specialists
c. other
d. total
not available
not available
not available
not available
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
10. Number of services provided through
fee for service (#):
a. general practitioners
b. specialists
c. other
d. total
not available
not available
not available
not available
61,074
29,485
0
90,559
39,035
19,733
0
58,768
44,876
20,656
0
65,532
43,142
17,419
0
60,561
2,323,234
1,146,522
3,469,756
2,494,221
1,229,811
0
3,724,032
1,943,399
1,042,366
0
2,985,765
2,137,218
1,199,648
0
3,336,866
2,023,584
1,524,873
0
3,548,457
12. Average payment per fee for service
service ($):
a. general practitioners
b. specialists
c. other
d. all services
not available
not available
not available
not available
40.83
41.00
0.00
40.92
49.79
52.82
0.00
50.81
47.62
58.08
0.00
50.92
48.16
62.13
0
53.31
13. Number of services provided through
all payment methods (#):
a. medical
b. surgical
c. diagnostic
d. other
e. total
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
14. Total payments to physicians paid
through all payment methods ($):
a. medical
b. surgical
c. diagnostic
d. other
e. total
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
15. Average payment per service, all
payment methods ($):
a. medical
b. surgical
c. diagnostic
d. other
e. all services
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
not available
7. Number of participating physicians (#):
a. general practitioners
b. specialists
c. other
d. total
11. Total payments to physicians paid
through fee for service ($):
a. general practitioners
b. specialists
c. other
d. total
Canada Health Act Annual Report, 2003-2004
229
Chapter 3 – Nunavut
Insured Services Provided to Residents in Another Province or Territory
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
16. Total number of claims, in-patient (#).
1,842
1,549
1,782
2,524
2,526
17. Total number of claims,
out-patient (#).
9,656
8,682
9,155
10,677
12,112
18. Total payments, in-patient ($).
8,546,013
7,612,791
7,681,154
18,640,982
17,202,646
19. Total payments, out-patient ($).
1,470,018
1,352,594
1,525,710
1,740,038
1,552,418
20. Average payment, in-patient ($).
4,639.00
4,915.00
4,310.41
7,385.49
6,981.59
152.00
156.00
166.65
162.00
138.47
Physicians
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
22. Number of services (#).
not available
55,389
39,438
43,064
51,050
23. Total payments ($).
not available
3,232,940
2,335,998
2,674,445
2,955,996
24. Average payment per service ($).
not available
58.00
59.23
62.10
58.61
21. Average payment, out-patient ($).
Insured Services Provided Outside Canada
Hospitals
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
14
0
0
0
2
5
1
53
3
2
12,010
0
0
0
6,300
28. Total payments, out-patient ($).
1,130
110
128,398
982
400
29. Average payment, in-patient ($).
857.00
0.00
0.00
0.00
3,150.00
25. Total number of claims, in-patient (#).
26. Total number of claims,
out-patient (#).
27. Total payments, in-patient ($).
30. Average payment, out-patient ($).
226.00
110.00
2,422.60
327.28
200.00
Physicians
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
31. Number of services (#).
0
0
12
1
19
32. Total payments ($).
0
0
14,835
8
1,519
0.00
0.00
1,236.25
7.61
151.91
33. Average payment per service ($).
Insured Surgical-Dental Services Within Own Province or Territory
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
27
21
not available
not available
not available
35. Number of services provided (#).
not available
not available
not available
not available
not available
36. Total payments ($).
not available
not available
not available
not available
not available
37. Average payment per service ($).
not available
not available
not available
not available
not available
34. Number of particpating dentists (#).
230
Canada Health Act Annual Report, 2003-2004
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