All questions

Overview

Canada is a federated country comprising 10 provinces and three territories,2 populated by over 38 million people.3 Under a 'separation of powers' concept, Canada's Constitution allocates responsibility for various matters between the federal government of Canada and the provincial governments. Canada has a publicly funded universal healthcare system, accessible by all Canadians, as described in more detail below; there is also a significant market for private healthcare services outside of the medically necessary services provided by the universal system.

While the federal government is responsible for the delivery of healthcare to a subset of Canada's population,4 generally, the regulation of healthcare is within the provincial jurisdiction and is a significant function of the provincial governments. The delivery of healthcare is, year in and year out, among the issues of greatest import to Canada's populace. Provincial legislatures pass laws relating to issues including: healthcare delivery; health protection and promotion; the governance and operation of facilities in which healthcare is delivered; the regulation of healthcare professionals; healthcare privacy, procurement, accountability and transparency; and the means by which physicians may be compensated for the provision of their services. Individual health professions are self-regulated and each health profession has its own provincial regulatory college, which can add a further layer of complexity to the regulation of healthcare services in Canada.

The healthcare economy

i General

The Canada Health Act, a federal statute, helps define how healthcare is delivered in Canada. Its goal is to ensure that all eligible Canadian residents have reasonable access to a publicly funded universal healthcare system for medically necessary services.5 Although the federal government does not have the constitutional authority to regulate healthcare, the Canada Health Act shapes the provision of healthcare because the federal government provides significant funding for healthcare. The statute sets out criteria and conditions that provinces must meet in order to receive funding.6

ii The role of health insurance

To receive federal funding under the Canada Health Act, each province must have a health insurance plan in effect which satisfies the following five programme criteria:

  1. Public administration: the plan must be administered and operated on a non-profit basis by a public authority which is accountable to the provincial government.
  2. Comprehensiveness: the plan must cover all insured health services provided by hospitals, physicians or dentists.
  3. Universality: the plan must cover all insured persons of the province on uniform terms and conditions.
  4. Portability: the plan must not impose minimum waiting periods or residency requirements of more than three months before residents are eligible for coverage and must cover insured persons when they are temporarily absent from their home province.
  5. Accessibility: the plan must provide all insured persons with reasonable access to insured services, which is not to be impeded or precluded by financial or other means (e.g., discrimination on the basis of health status).

The healthcare services that a province funds are determined by each provincial government on the basis of 'medical necessity', which is not clearly defined in the Canada Health Act or in provincial health insurance statutes.

The result of the Canada Health Act is that each province has its own government-operated health insurance plan that pays for medically necessary healthcare services provided to eligible residents. In fact, all persons other than the provincial health insurance plans – including hospitals and healthcare providers – are prohibited by law in most provinces from charging Canadians for medically necessary healthcare. Canada is one of the few countries in the world where the sale of supplemental or private healthcare insurance for medically necessary healthcare services is generally prohibited (although this prohibition varies by province).

iii Funding and payment for specific services

Although most provinces prohibit private insurance companies from selling insurance for medically necessary healthcare services delivered to Canadians, a private insurance market exists for healthcare services that are not covered by provincial plans, including the following:

  1. most dental services;
  2. most prescription drugs; and
  3. non-medically necessary services (e.g., most physiotherapy, chiropractic services and home care).

These services and the healthcare providers are largely regulated provincially, but the pricing of these private services is not typically publicly determined.

Primary/family medicine, hospitals and social care

Healthcare is delivered in various settings including hospitals, physicians' offices, private clinics, surgical clinics, and community health centres. Because not all healthcare services are medically necessary and thus, not insured services under provincial health insurance plans, certain services in the above settings may be paid for privately, including by the patients receiving such services and their private insurers.

Typically, patients access medically necessary healthcare through a general practitioner or family physician, if one is available, and otherwise through clinics or emergency departments. Nearly all other practising physicians in Canada are specialists and are accessed via referral from a family physician. While there is no specific legal framework requiring a referral, most specialists do not accept direct patient contact.

To reduce the number of patients seeking care at clinics or emergency departments, a growing number of hospital-sponsored urgent care centres and telemedicine solutions have emerged to meet patient demands stemming from, among other things, the inaccessibility of their family physician.

The scope of healthcare services that may be provided in these settings is often restricted by legislation. In some provinces, legislated licensing regimes regulate the settings in which services can be performed. The provinces of Ontario and Saskatchewan, for example, require facilities in which specified diagnostic or laboratory services are performed to possess licences. Most provinces also empower the provincial body responsible for regulating physicians in that province to establish and institute criteria for facilities where specified healthcare services are provided, such as surgical clinics.

To respond to increased demands placed on healthcare systems, provinces have begun to adopt patient-centred approaches to the delivery of healthcare. Ontario, for example, has made a number of changes to its healthcare structures in an effort to improve patient care coordination. One of these changes has been the introduction of Ontario Health Teams, through which patients within a specified geography receive integrated care, including, for example, primary care, hospital services, mental health and addictions services, long-term care and community care from healthcare providers who are part of the same Ontario Health Team. Another change has been to centralise a number of pre-existing healthcare agencies into one entity, Ontario Health. The new Ontario Health agency has a mandate to connect and coordinate the province's healthcare system under one centralised system with an aim of reducing prior inefficiencies while overseeing healthcare delivery across the province.

Canada does not yet have a national electronic health record (EHR) system, although most healthcare practitioners use electronic records in their own practices.

i Services to support seniors

As Canada's population continues to age, services and programmes to support the health needs and social well-being of seniors continue to be necessary components along the continuum of care. The majority of provincial governments offer or provide services and programmes to benefit the health and social needs of seniors. For example, home care services and community support services are generally funded, at least in part, by the provinces and aim to keep seniors living within their residences for as long as possible, thereby reducing unnecessary hospital admissions and lengthy hospital stays. Many of the services offered by provincial governments are provided for or coordinated in partnership with community agencies.