How technology benefits patient care? ?What happens when technology is absent?? Does technology increase the cost of care?? Does technology increase the quality of care?

5.1 INTRODUCTION Canada’s population is 33 million people. The land area is 3,854,082 square miles (Infoplease, 2010). Eighteen percent of Canada’s population is under 15 years old (UNO, 2004), and 17% of the population is over the age of 60 (WHO, 2004). The primary languages spoken in Canada are English and French. The largest ethnic groups are British, French, and other European groups. The largest religious groups are Roman Catholic with a strong presence of Anglican and other Christian religions ( who.intl/profiles_countries ). Canada is ranked 25th out of 31 countries in the literacy rate. Because demand for health services is so high, Canadians often must wait a long time for appointments to see the doctor, especially in the province of Quebec. In the words of Frogue (2001, p. 10), “everything is free but nothing is readily available.”

5.2 HISTORICAL Dating back to 1867 Canada’s Constitution assigned most of the healthcare responsibilities to its ten provinces and three sparsely populated northern territories. These provinces vary widely by size and fiscal capacity. For example, in 2001, Prince Edward Island had a population of 135,000 while Ontario had 11.4 million.

Canada, unlike the United States, provides universal health coverage, a national health insurance program provided by the Medical Care Insurance Act of 1966. Universal coverage provides health care to all members of its society, combining mechanisms for health financing and service provision (WHO, 2008). Health care in Canada is funded through general taxes and Medicare. The National Medical Care Insurance Act operates on the basis of four principles: 1) it is comprehensive, covering all medically necessary services provided by physicians, 2) universal coverage is available to all legal and illegal residents, 3) it is publicly administrated, either directly by provincial government or by an authority directly responsible to it, and 4) it is portable.

The Canada Health Act, passed in 1984, established a fifth core principle, accessibility, which sought to force provinces to forbid extra billing and cost sharing. It called for the Canadian government to deduct the amount of such charges from its payments to any province.

During the early 1990s there were growing concerns about the perceived notion that the country was approaching physician saturation, even the potential for a surplus. This led to policy decisions such as enacting a 10% cut in first year medical school admissions, contributing to a drop in physician supply.

5.3 STRUCTURE Canada has a readily available supply of physicians, and less availability of nurses. Levels of nurses practicing in Canada are comparable to those in the United States and include registered nurses, nurse practitioners, nurse midwives, and LPNs. However, nurse practitioners and physicians assistants are relatively new to Canada and are not yet widely utilized. Other health professionals in Canada include dentists, pharmacists, medical and radiology technicians, chiropractors, and physiotherapists.

In 2004, workforce aging became a significant challenge in that health professionals were aging more rapidly than the Canadian population with the average physician being 49 and the average RN being 45. Between 1990 and 2005, the number of nurses practicing in Canada decreased from 11.1 to 10 nurses per 1,000 population, with the lowest point occurring in 2003, at 9.6 per 1,000 (OECD Health Data, 2007). Also, increasing numbers of women are entering the medical workforce.

According to OECD (2007) data, 24% of Canadians live in rural areas, yet only nine percent of the physician workforce practices in rural Canada. Although Canada has a stable supply of physicians, in 2008 approximately 14% (5 million) of Canadian adults did not have a family physician. Between 2002 and 2006, permanent migration of physicians to other countries tripled and temporary migration increased over 10%. Permanent migration of nurses increased by 40%, and temporary migration increased by 35%. In 2006, 9% of all nurses and 19% of physicians born in Canada were working in other OECD countries. Physicians also move freely among provinces, in fact 62.3% of the physicians in Canada are concentrated in the two provinces of Ontario and Quebec. Although the number of male registered nurses almost tripled from 1985 to 2006, from 5,000 to 14,000, they make up only 6% of Canada’s nursing workforce and more than half the male nurses in Canada practice in Quebec. Physicians from South Africa, and nurses from the Philippines also are part of the Canadian workforce (OECD, 2007). Many of the nurses working in the United States in the travelling nurse program were Canadians.

Canada regulates physician supply, physician and hospital budgets, and technology. The government also coordinates financing, insurance, and payment function. Unlike the American healthcare system, because the Canadian healthcare system is government run there is no need for employer involvement in health care except, of course, for supplemental catastrophic additional coverage. The role of payers is limited to the government and individuals. The role of insurers in Canada is minimal.

5.4 FINANCING

During the 1970s physicians commonly billed patients for additional costs that were already covered by the government plan. In 1984, the passing of the Canada Health Act prevented medical providers from billing patients for services if they had also billed the public insurance system. A reaffirmation of the government’s stance that they were committed to health care that was, “comprehensive, universal, portable, publically administered, and accessible,” was issued by the Prime Minister in 1999. Portable means coverage continues when patients travel or move between provinces.

Single payer is used to primarily describe a system that is government funded and controlled. Canada has a single payer system, complemented by insurance and direct out-of-pocket payments. There are global budgets for hospitals and physicians, negotiated fees for services, and consumer co-payments. Hospitals and physicians must operate within a set budget with which they must strictly adhere. In order to finance Canadian health care, provincial funds are gathered from a mix of federal transfers that favor poorer provinces, general provincial revenues, employer payroll taxes, and insurance premiums.

In provinces like Alberta and British Columbia where premiums exist, there are special provisions for assistance to people with low incomes. Residents of each province receive insurance cards, which they present when being seen in a hospital or physician office. They must produce this card for care because benefits vary slightly among provinces. There is typically no general dental coverage, but most provinces provide some pediatric dentistry, and all provinces cover in-hospital oral surgery as part of hospital coverage. Many provinces provide limited optometric, chiropractic, and physical therapy coverage. Financial support for pharmaceutical expenses is included in separate programs, generally for seniors and other categories of the needy. Contraception is available to all women in Canada free of charge as birth control is also covered under the public insurance plan. Every provincial plan insures all medically necessary physician and hospital care.

Private insurance is allowed for what is referred to as non-core services. Private insurance plans are prohibited from billing patients for core services, or any service covered by the standard public insurance plan. An estimated 80% of Canada’s population has supplementary coverage for items such as private rooms, dental care, and other non-core services (Irvine, Ferguson and Cackett, 2002, p. 17). This is financed primarily through employers, and, as in the United States, is treated as a business expense for tax purposes.

5.5 INTERVENTIONAL

The social and economic conditions experienced by a people have a definite influence on their health status. Any proposed interventions must be geared toward addressing health issues within the realm of these conditions.

Despite problems with access, and language challenges that are closely related to cultures other than French, there is a high user satisfaction with health care in Canada. Canada places less reliance on technology and there is greater access to health providers in urban settings. However, there are often long waits for appointments and services. In 2005, on average, Canadians waited 12.3 weeks for an MRI, 5.5 weeks for a CT scan and 3.4 weeks for an ultrasound (Fraser Institute, 2005). Almost half of the Canadian public, when surveyed by Pollara polling in 2005, reported their willingness to pay out-of-pocket for faster access to services (Irvine et al., 2005, p. 59). Absenteeism and turnover rates for nurses are also high. For example, absenteeism rates for full time RNs was 83% higher than it was for the general labor market. The Canadian government paid 962 million C$ in absentee, overtime, and replacement wages among nurses in 2007 (Drebit, 2010).

Health care for older adults in Canada is plagued by major long-term care challenges, lengthy waits to gain admission into nursing homes, and poor quality of care.

5.6 PREVENTIVE Approaches to addressing health promotion and disease prevention in Canada are perhaps as diverse as the population. Indigenous to Canadian society are the Francophones that include the Mètis, Native American and European descendants, and the Acadians, descendants of the early French colonists. Canada, with its multiethnic, multilingual, and cultural mosaic is a melting pot of diversity (Coutu-Wakulczyk, Moreau, and Beckingham, 2003, p. 160).

Despite Canada’s nearly perfect literacy rate (approximately 99%), illiteracy is high among the Francophones and the elderly. In fact, in some communities, Canada’s high school drop-out rates exceed 40%, highest in poor and rural areas, especially for Aboriginals and Francophones, and among boys (Office of Francophone Affairs of Ontario, 2000). Another problem is obesity and obesity related hypertension especially among women. Pausova et al. (2000) believe these are attributed in great part to the TNF-α gene locus.

There has been a steep decline among Francophones in fertility rates from 4.95 children for the period 1956–1961, to 1.57 from 1991–1996 leading to the concern about long-term viability of Francophones outside Quebec especially since they have very little access to healthcare services where providers speak French (Office of Francophones Affairs of Ontario, 2001, Chung, 2009). Ansen (2000) found among Francophone women, the more educated the women the lower the

fertility rate. Edwards and Rootman (1993) reported the responses of Canadians aged 15 and older who were asked about practices for improving health. In order of importance they identified smoking cessation 81%, increased relaxation 69%, exercise 65%, income security 45%, quantity of time spent with family 45%, weight loss 42%, better dental care 27%, job changes 22%, reduced drinking 16%, moving 14%, and reduced drug use 9%.

Canada’s government-focused initiatives to address promotion of health and prevention of disease include specific programs to address obesity and the dissemination of health information via hard copy and online, keeping in mind that if the information is not disseminated in minimally English and French it will not likely be beneficial. Education always appears to be a key indicator in preventing illness.

5.7 RESOURCES Men appear to be the hallmark of the Canadian society. They are typically viewed as the moral authority, and the one responsible for providing for, and protecting the family. Women, on the other hand, are charged with responsibility for running the household, child care, and caring for family members when ill (Langelier, 1996). For childbearing women, midwives and maternity centers are commonly used.

In some segments of Canada’s population, family, extended family, and clergy are particularly supportive in the care of persons at or nearing the end-of-life. For example, African Canadians account for more than half (52%) of Nova Scotia’s visible minorities (Statistics Canada, 2003). According to Clairmont and Magill (1970), years of poor living conditions, racism, hostile treatment, and a widespread lack of acceptance and integration into Nova Scotia society has led to the creation of a Black community that has been oppressed. Rather than seeking help from the healthcare system, many persons of African descent draw heavily on each other for support when challenged by an illness. Crawley et al. (2000) describe the rich religious tradition among African Americans in explaining some of the behaviors of African Canadians. The authors explain that in considering the omnipotence of God, if they do not receive a healing miracle, they often welcome death as a “home going.”

5.8 MAJOR HEALTH ISSUES Canadians are plagued by troubling diseases that often result in death, with cancer leading the way. Although the incidence of smoking is trending down, lung cancer is still the leading cancer killer in Canada for men and women (The Canadian Cancer Society, 2007). Heart disease and stroke rank

as the second and third leading causes of death in Canada. The WHO (2010) record of the top ten diseases causing death in Canada are as listed in Table 5-1 .

5.9 DISPARITIES The top three diseases, cancer, heart disease, and stroke, in Canada are treated similarly to the United States. There are many similarities and differences in treatment approaches among Canadian provinces. Whether health outcomes are positive or negative they are influenced by social determinants such as population, poverty, age, race/ethnicity, and gender.

Table 5-1 Top 10 causes of death (all ages) in Canada, 2002, with the number and percent of years of life lost by disease.

Source: Death and DALY estimates by cause, 2002.

http://www.who.int/entity/healthinfo/statistics/bodgbddeathdalyestimates.xls

SUMMARY There are many more strengths in the urban healthcare area than rural among Canadian provinces. It is important for Canada to build a workforce that is more sustainable and effective at meeting the needs of its residents both rural and urban. Recruitment and retention incentives may be effective ways to address these two important workforce issues.

4.1 INTRODUCTION The United States of America (USA) covers 3,717,727 square miles and is made up of 50 states (Infoplease, 2010). The USA’s population in 2004 was 293,027,571 (U.S. Census, 2004). In 2010 the population reached over 307 million. The proportion of the population that is under 15 years old in the United States (U.S.) is 21%, and the over-60 population proportion is 16% (UNO, 2004). Slightly more than 12.4% of the population were 65 years and older of which 1,557,800 (4.5%) were living in nursing homes (U.S. Census, 2010). The primary languages spoken in the United States are English and Spanish. The largest ethnic groups are European American (75%). African American and Latino groups each constitute approximately one-eighth of the population. The largest religious groups are Protestant (over 50%) and Roman Catholic (25%).

The United States is the largest, most powerful nation in the industrialized (developed) world, and it has a high literacy rate. However, in 2006, while it led the world in healthcare spending per capita, it ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th in life expectancy, earning an overall ranking of 37th in the industrialized world in healthcare performance (Murray & Frenk, 2010, p. 1). Life expectancy in the United States is 80 years of age for European American women, 75.9 for African American women, 75.3 for European American men, and 68.9 for African American men. The life expectancy rate for the United States is among the lowest for the industrialized world, and infant mortality is among the highest. Americans consider quality, affordable health care a birthright, an expectation. Yet, unlike other world powers, the U.S. government plays a small role in ensuring that everyone has equal access to quality health care and services.

Although the United States is envied for its wealth, high technological capabilities, and research savvy, historically it has not kept pace with other industrialized nations in the area of healthcare delivery. This is reflected by its poor outcomes in infant mortality and life expectancy. The healthcare system is also overwhelmed by disparities and inequities in care and lack of access (except for the most affluent and informed), and cost that has outpaced care. Despite an international reputation as an advocator for human rights, a nation which has openly shown intolerance of non-Western countries charged with violating the human rights of their citizenry, the United States is a system plagued with its own injustices. Though a commodity to some, many believe health care is a birthright. Primary care is of major importance to maximizing health outcomes. The Institute of Medicine (Starfield, 1994) describes primary care as care on first contact, comprehensive care, coordinated or integrated care, and care that is longitudinal rather than episodic.

Three decades ago many in the United States overutilized emergency departments for routine, non-acute care. To reverse this trend, the healthcare system began focusing more on primary care and prevention. By allowing patients to see the same provider on each wellness and illness visit, many individuals stopped seeking routine care in emergency rooms. Rather, they began utilizing physician’s offices and community and migrant health centers (C/MHCs) where the focus was, and still is, on maintaining health and wellness. Health providers enrolled patients to their maximum capacity in these centers and private offices. Years later, as providers stopped taking new patients and began denying services to those on Medicaid (a government funded insurance plan for the poor and disabled funded under Title XIX of the Social Security Act), there was a cyclical trend of consumers migrating back to emergency departments for primary care, in numbers not seen for more than thirty years. Many attribute this to the downturn in the U.S. economy resulting in a historically high unemployment rate. Today the only primary care (preventive and illness care provided by the same health provider) that many people receive is in the emergency departments.

Some of the barriers that limit access to care are financial, structural, and personal. Financial barriers include not having health insurance, not having enough health insurance to cover needed services, or not having the financial capacity to cover services not paid for by a specific health plan or insurance. Structural barriers include the lack of primary care providers, medical specialists, or other healthcare professionals to meet special needs, or the lack of healthcare facilities (USDHHS, Healthy People 2010).

4.2 HISTORICAL The first operation performed in the United States was an excision of a tumor from a patient’s neck. During an address before the American Medical Association, John Collins Warren confirmed that he performed the world’s first surgical procedure on October 16, 1846 in a Boston, Massachusetts hospital, using sulphuric ether anesthesia (Cincinnati, Ohio, May 8, 1850). Over 20 years later, the United States is the only country in the industrialized world that does not have a National Health Care program. In the decades leading up to the seventies, health care was provided almost exclusively in outpatient clinics or general practice/family practice offices. The 1970s witnessed the emergence of primary care as we know it.

Approximately 30 years ago the United States healthcare system was medically dominated. Physicians ruled. The diagnostic tests, procedures, and referrals made, and length of hospital stays of patients were based on physician’s unscrutinized decisions. During the past twenty-five years the United States has moved from physician dominance, where physicians were autonomous decision-makers, to insurance companies and business dominance. Other systems, such as the United Kingdom and Ghana, still place physicians in powerful autonomous roles.

In the early 1990s, President Clinton proposed healthcare reform to provide universal coverage but this effort failed and the current system, though widely criticized, prevails. In 2009, President Barack Obama proposed an “Insurance Mandate Plan,” called the Affordable Care Act , designed to ensure that everyone with the ability to do so, purchases insurance coverage.

The Affordable Care Act The status of health care in the United States has posed critical problems for individuals, families, older adults, state budgets, and the U.S. economy. Prior attempts at healthcare reform in the United States have failed.

In 2007, the United States spent approximately $2.2 trillion ($7,421 per person) or 16.2% of the GDP on health care (Office of the Actuary, 2007). By 2009, healthcare spending escalated to $2.5 trillion (an increase of $134 million) and reached a record estimate of 17.3% of the U.S. economy (OECD, 2008; Orszag, 2008). Long-term projections suggest that aging will play a critical role in healthcare spending with Medicare and Medicaid taking up a significant proportion of the healthcare budget. If the projections hold true, healthcare spending could rise to 25% of the federal budget by 2025 and, more ominously, to nearly half (49%) of the budget by 2082 (Orszag, 2008). In the wake of the economic crisis of 2007, increasing numbers of Americans are uninsured or they have inadequate health coverage.

According to the U.S. Census Bureau, the number of uninsured increased from 46.3 million in 2008 to 50.7 million in 2009 (DeNovas-Walt, Proctor, & Smith, 2010). “Because uninsured persons often postpone seeking care, have difficulty obtaining care when they ultimately seek it, and must bear the full brunt of healthcare costs, prolonged periods of uninsurance (no insurance coverage for over a year) can have a particularly serious impact on a person’s health and stability. Over time, the cumulative consequences of being uninsured compound, resulting in a population at particular risk for suboptimal health care and health status” (Agency for Healthcare Research and Quality (AHRQ), 2007, p. 118).

The 2008 National Scorecard on U.S. Health System Performance observed that the quality of health care in the United States is “uneven” and falls short of what is expected given its resources. Across 37 indicators, the United States achieved an overall score of 65 out of a possible 100. “Performance measures of health system efficiency remain especially low, with the United States scoring 53 out of 100 on measures gauging inappropriate, wasteful, or fragmented care; avoidable hospitalizations; variation in quality and costs; administrative costs; and use of information technology. Lowering administrative costs alone could save up to $100 billion a year at the lowest country rates” (The Commonwealth Fund Commission, 2008, p. 10). Eight in ten Americans are

dissatisfied with the prohibitive costs of health care (Gallup Poll, 2007); and many are likely to forgo healthcare services altogether ( Healthreform.gov , 2011).

Ideas and strategies to improve health care in the United States have been enmeshed in heated political debates for over two decades. However, the country has taken more definitive steps to build a comprehensive healthcare plan. On March 23, 2010, the Patient Protection and Affordable Care Act (PPAC), more commonly referred to as the Affordable Care Act, was signed into law by President Barack Obama. The new health reform intends to ensure that all Americans have access to quality, affordable health care. “A major goal of the Af

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