Medicare (Canada) - Delivery

Delivery

Canada uses a mix of public and private organizations to deliver health care; in turn, these organizations bill the provincial health authorities, with few exceptions. Hospitals are largely non-profit organizations, historically often linked to religious or charitable organizations. In some provinces, individual hospital boards have been eliminated and combined into quasi-private regional health authorities, subject to varying degrees of provincial control. Laboratory services are often delivered by for-profit investor-owned corporations.

With rare exceptions, medical doctors are small for-profit independent businesses. Historically, they have practiced in small solo or group practices and billed the medicare system on a fee for service basis. Unlike the practice in some other countries, hospital-based physicians were rarely hospital employees, and also billed the provincial insurance plans on a fee-for-service basis. Since 2000, physicians have been allowed to incorporate for tax reasons (dates of authorization vary province to province). However, efforts to achieve primary health care reform have increasingly encouraged physicians to work in multidisciplinary teams, and be paid through blended funding models, including elements of capitation and other 'alternative funding formulas'. Similarly, some hospitals (particularly teaching hospitals and rural/remote hospitals) have also experimented with alternatives to fee-for-service.

In summary, the system is known as a "public system" due to its public financing, but is not a nationalized system such as the UK's NHS; most medicare services are provided privately.

An additional complexity is that, because health care is deemed to be under provincial jurisdiction, there is not a "Canadian health care system". Most providers are private, and may or may not coordinate their care. Publicly funded insurance is organized at the level of the province/territory; each manages its own insurance system, including issuing its own healthcare identification cards (a list of the provincial medical care insurance programs is given at the end of this entry). Once care moves beyond the services required by the Canada Health Act — for which universal comprehensive coverage applies — there is inconsistency from province to province in the extent of publicly funded coverage, particularly for such items as outpatient drug coverage and rehabilitation, as well as vision care, mental health, and long-term care, with a substantial portion of such services being paid for privately, either through private insurance, or out-of-pocket. Eligibility for these additional programs may be based on various combinations of such factors as age (e.g., children, seniors), income, enrollment in a home care program, or diagnosis (e.g., HIV/AIDS, cancer, cystic fibrosis).

The Canada Health Act requires coverage for all medically necessary care provided in hospitals or by physicians; this explicitly includes diagnostic, treatment and preventive services. Coverage is universal for qualifying Canadian residents, regardless of income level. Services of non-physicians working within hospitals are covered; but provinces can, but are not forced to, cover services by non-physicians if provided outside hospitals. Changing the site of treatment may thus change coverage. For example, pharmaceuticals, nursing care, and physical therapy must be covered for inpatients, but there is considerable variation from province to province in the extent to which they are covered for patients discharged to the community (e.g., after day surgery). The need to modernize coverage was pointed out in 2002 by both the Romanow Commission and by the Kirby committee of the Canadian Senate (see External links below). Similarly, the extent to which non-physician providers of primary care are funded varies; Quebec offers primary health care teams through its CLSC system).