Treating Health Care: How the Canadian System Works and How It Could Work Better.

Health policy analysis requires an understanding of a broad range of topics that are often taught in different disciplines spanning economics, political science, ethics, health administration, public health and healthcare. Professor Raisa Deber's Treating Health Care is essential reading for anyone interested in understanding the basic fundamentals of the healthcare system, eloquently weaving together key concepts across disciplines and background information to equip the reader with a "toolkit" for decision making in health policy analysis.

Funding Long-Term Care in Canada: Who Is Responsible for What?

As Adams and Vanin (2016) have noted, different ways of funding long-term care (LTC) have different implications. Because health is not just healthcare, and LTC is not homogeneous, determining the appropriate public-private mix is complex. We suggest that how issues are framed helps influence policy choices, including who should pay for what, and how things should be financed.

Paying for primary care: a cross-sectional analysis of cost and morbidity distributions across primary care payment models in Ontario Canada.

Policy-makers desire an optimal balance of financial incentives to improve productivity and encourage improved quality in primary care, while also avoiding issues of risk-selection inherent to capitation-based payment. In this paper we analyze risk-selection in capitation-based payment by using administrative data for patients (n = 11,600,911) who were rostered (i.e.

Accountability: the challenge for medical and nursing regulators.

Little has been written about how regulatory bodies define and demonstrate accountability. This paper describes a substudy of a research project on accountability in healthcare. The aim was to increase understanding of how regulatory bodies perceive and demonstrate accountability to their stakeholders.

Ensuring accountability through health professional regulatory bodies: the case of conflict of interest.

How do self-regulated health professions' regulatory bodies address financial conflict of interest (coi) and ensure accountability to the public? using document analysis, we examined how four ontario regulatory colleges (physicians, nurses, physiotherapists, audiologists/speech-language pathologists) defined coi and the education, guidance and enforcement they provided for coi-related issues. These colleges are upholding the mandates to define, identify and address financial coi by providing regulations or standards and guidelines to their membership; they differed in the amount of educational materials provided to their registrants and in the possible coi scenarios they presented. Although there were few disciplinary hearings pertaining to financial coi, findings for the hearings that did occur were documented and posted on the college public registers (the listing of all registered college members along with all relevant practice information), informing the public of any limitations or restrictions placed on a member as a result of the hearing.

Accountability in the City of Toronto's 10 long-term care homes.

Long-term care (LTC) residential homes provide a supportive environment for residents requiring nursing care and assistance with daily living activities. The LTC sector is highly regulated. We examine the approaches taken to ensure the delivery of quality and safe care in 10 LTC homes owned and operated by the City of Toronto, Ontario, focusing on mandatory accountability agreements with the Local Health Integration Networks (LHINs).

Accountability and primary healthcare.

This paper examines the accountability structures within primary healthcare (PHC) in Ontario; in particular, who is accountable for what and to whom, and the policy tools being used. Ontario has implemented a series of incremental reforms, using expenditure policy instruments, enforced through contractual agreements to provide a defined set of publicly financed services that are privately delivered, most often by family physicians. The findings indicate that reporting, funding, evaluation and governance accountability requirements vary across service provider models.

Hopes and realities of public health accountability policies.

Holding local boards of health accountable presents challenges related to governance and funding arrangements. These challenges result in (a) multiple accountability pressures, (b) population health outcomes whose change is measureable only over long time periods and (c) board of health activity that is often not the key immediate direct contributor to achieving desired outcomes. We examined how well these challenges are addressed in Ontario, Canada at early stages of implementation of a new accountability policy.

Accountability through regulation in Ontario's Medical Laboratory Sector.

Although the use of performance indicators for the analytical (and highly measurable) phase of the medical laboratory process has had a long and successful history, it is now recognized that the value of a laboratory test is embedded in a system of care. This case study, using both documents and interview data, examines the approaches to accountability in the Ontario Medical Laboratory Sector, noting both the challenges and benefits. This sector relies heavily on the regulation instrument, including a requirement that all medical laboratories licensed by the provincial government must follow the guidelines set out by the Quality Management Program - Laboratory Services.

Home and community care sector accountability.

This paper focuses on accountability for the home and community care (HCC) sector in Ontario. The many different service delivery approaches, funding methods and types of organizations delivering HCC services make this sector highly heterogeneous. Findings from a document analysis and environmental scan suggest that organizations delivering HCC services face multiple accountability requirements from a wide array of stakeholders.

Hospitals' internal accountability.

This study aimed to enhance understanding of the dimensions of accountability captured and not captured in acute care hospitals in Ontario, Canada. Based on an Ontario-wide survey and follow-up interviews with three acute care hospitals in the Greater Toronto Area, we found that the two dominant dimensions of hospital accountability being reported are financial and quality performance. These two dimensions drove both internal and external reporting.

Acute care hospitals' accountability to provincial funders.

Ontario's acute care hospitals are subject to a number of tools, including legislation and performance measurement for fiscal accountability and accountability for quality. Examination of accountability documents used in Ontario at the government, regional and acute care hospital levels reveals three trends: (a) the number of performance measures being used in the acute care hospital sector has increased significantly; (b) the focus of the health system has expanded from accountability for funding and service volumes to include accountability for quality and patient safety; and (c) the accountability requirements are misaligned at the different levels. These trends may affect the success of the accountability approach currently being used.

Thinking about accountability.

Accountability is a key component of healthcare reforms, in Canada and internationally, but there is increasing recognition that one size does not fit all. A more nuanced understanding begins with clarifying what is meant by accountability, including specifying for what, by whom, to whom and how. These papers arise from a Partnership for Health System Improvement (PHSI), funded by the Canadian Institutes of Health Research (CIHR), on approaches to accountability that examined accountability across multiple healthcare subsectors in Ontario.

The distribution of physiotherapists in ontario: understanding the market drivers.

Purpose: To understand the factors that affect the distribution of physiotherapists in Ontario by examining three potential influences in the multi-payer physiotherapy (PT) market: population need, critical mass (related to academic health science centres [AHSCs]), and market forces.

Methods: Physiotherapist density and distribution were calculated from 2003 and 2005 College of Physiotherapists of Ontario registration data. Physiotherapists' workplaces were classified as not-for-profit (NFP) hospitals, other NFP, or for-profit (FP), and their locations were classified by census division (CD) types (cities and counties).

Barriers and facilitators to care for the terminally ill: a cross-country case comparison study of Canada, England, Germany, and the United States.

Background: Why do many patients not die at their preferred location?

Aim: Analyze system-level characteristics influencing the ability to implement best practices in delivering care for terminally ill adults (barriers and facilitators).

Design: Cross-country comparison study from a "most similar-most different" perspective, triangulating evidence from a scoping review of the literature, document analyses, and semi-structured key informant interviews.

Setting: Case study of Canada, England, Germany, and the United States.

Attractiveness of employment sectors for physical therapists in Ontario, Canada (1999-2007): implication for the long term care sector.

Background: Recruiting and retaining health professions remains a high priority for health system planners. Different employment sectors may vary in their appeal to providers. We used the concepts of inflow and stickiness to assess the relative attractiveness of sectors for physical therapists (PTs) in Ontario, Canada.

Resource utilization and cost analyses of home-based palliative care service provision: the Niagara West End-of-Life Shared-Care Project.

Background: Increasing emphasis is being placed on the economics of health care service delivery - including home-based palliative care.

Aim: This paper analyzes resource utilization and costs of a shared-care demonstration project in rural Ontario (Canada) from the public health care system's perspective.

Design: To provide enhanced end-of-life care, the shared-care approach ensured exchange of expertise and knowledge and coordination of services in line with the understood goals of care.

Another look at the human papillomavirus vaccine experience in Canada.

Policy debates about immunization frequently focus on classic trade-offs between individual versus collective well-being. Publicly funded immunization programs are usually justified on the basis of widespread public benefit with minimal individual risk. We discuss the example of the policy process surrounding the adoption of the human papillomavirus (HPV) vaccine in Canada to consider whether public good arguments continue to dominate immunization policymaking.

Compulsory school-entry vaccination laws and exemptions: who is opting out in ontario and why does it matter?

School-entry vaccination regulations are a policy instrument that has been widely used in some jurisdictions as a mechanism to ensure high immunization coverage rates. Exemptions to school-entry vaccination, which can be allowed on medical or non-medical grounds, present a number of ethical and policy challenges. In this paper, we consider the situation in Canada, where school-entry vaccination laws are rare.

Strategic responses to fiscal constraints: a health policy analysis of hospital-based ambulatory physical therapy services in the Greater Toronto Area (GTA).

Purpose: Ambulatory physical therapy (PT) services in Canada are required to be insured under the Canada Health Act, but only if delivered within hospitals. The present study analyzed strategic responses used by hospitals in the Greater Toronto Area (GTA) to deliver PT services in an environment of fiscal constraint.

Methods: Key informant interviews (n = 47) were conducted with participants from all hospitals located within the GTA.

Building community and public health nursing capacity: a synthesis report of the National Community Health Nursing Study.

Objectives: 1) To describe the community health nursing workforce in Canada; 2) To compare, across political jurisdictions and community health sectors, what helps and hinders community nurses to work effectively; 3) To identify organizational attributes that support one community subsector--public health nurses--to practise the full scope of their competencies.

Methods: Our study included an analysis of the Canadian Institute for Health Information nursing databases (1996-2007), a survey of over 13,000 community health nurses across Canada and 23 focus groups of public health policy-makers and front-line public health nurses.

Results: Over 53,000 registered and licensed practical nurses worked in community health in Canada in 2007, about 16% of the nursing workforce.

Telehealth as gatekeeper: policy implications for geography and scope of services.

Why, despite enthusiasm, is telehealth still a relatively minor part of healthcare delivery in many health systems? We examined two less-considered policy issues: (1) the scope of services being offered by telehealth and how this matches existing arrangements for insured services; and (2) how the ability of telehealth services to minimize barriers associated with geography is dealt with in a system organized and financed on geographical boundaries. Fifty-three semistructured interviews with key stakeholders involved in the management of 43 Canadian telehealth programs were conducted. In addition, quantitative activity data were analyzed from 33 telehealth programs.

Access without Appropriateness: Chicken Little in Charge?

Health policy makers in Canada have swung between the twin poles of ensuring access and controlling costs. Recently, access has dominated. Reconciling these opposing ideals, rather than alternating between them, requires adding the concept of appropriateness, and recognizing that rapid access to unneeded care may do more harm than good.

Variations in Lifetime Healthcare Costs across a Population.

The mean costs of providing healthcare increase with age, but within every age/sex cohort there is substantial variation. Moreover, this variation does not disappear over the users' lifetime. This study applies Markov modelling to administrative data to examine the variability of healthcare costs currently covered under the Canada Health Act across a population and over the lifespan.