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									      “The Health of Canadians – The Federal Role”

                         Submission to the
            Senate Standing Committee on Social Affairs,
                      Science and Technology
                               by the
                 Ontario Psychological Association




                             January 22, 2002




The Ontario Psychological Association (OPA) is the professional organization for
psychologists practising in Ontario. The Association was established in 1947
and currently has 1,400 members. The OPA is committed to advancing
psychology as an independent profession with the highest ethical standards.
1. Overview and Summary
Canadians have heard for years that their publicly funded healthcare system is "in crisis".
The cause for this "crisis" is usually identified as inadequate funding and, therefore, the
solution offered by most healthcare practitioners, hospitals and healthcare administrators
is for governments to plough substantially more money into healthcare funding. Those
who suggest that additional funding is the answer point out that Canada is consistently at
the bottom end of the ratio of public to private healthcare funding among OECD
countries.

The Ontario Psychological Association (OPA) believes that the focus on additional
funding is misplaced. In the OPA's view, our publicly-funded healthcare system is
operating at substantially below maximum--even reasonable--efficiencies because of
structural obstacles to efficiency that have been built into our system over the years. For
purposes of this Submission, the OPA aims to focus on the three structural impediments
that are of particular interest and concern to psychologists:

First, the lack of accountability in the publicly funded healthcare system that arises in
several contexts, from the separation of the "consumer" of healthcare from the "payor"
for that healthcare, to the federal government's decision in 1977 to fund healthcare
through block funding and tax points which obscured the actual federal fiscal
contribution to healthcare.

Second, that the Canada Health Act defines insured services by where and by whom they
are provided, rather than exclusively by medical necessity. This restrictive approach to
defining the boundaries of the publicly-funded healthcare system is replicated in
provincial legislation, most notably in Ontario. In a system allegedly starved for
resources it may seem counter-intuitive to liberalize this definition. However, doing so
would enhance competition among alternate regulated professions and treatment
modalities, would enhance access and consumer choice consistent with the Principal
Objective of the Canada Health Act1 and would allow the substitution of more cost-
effective treatments and regulated healthcare personnel. Given the Senate Committee’s
focus on the federal role, the OPA suggests that amending the Canada Health Act to
expand the definition of insured services to reflect the realities of modern healthcare
delivery is a necessary first step to reform.

Third, an inadequate focus on the quality of healthcare, in particular insufficient rigour by
healthcare practitioners, healthcare consumers and third-party payors in demanding
evidence-based care.

The OPA believes it self-evident that no one can know whether our publicly-funded
healthcare system requires additional funding and, even if it does, the extent of additional
funding required. We can’t make these judgements until our system is operating at

1
    Canada Health Act, Section 3, RSC.


                                             2
something close to peak efficiency. Attaining that objective requires removing the
structural impediments to increased efficiency that persist in our healthcare system.


2. A Brief Introduction to Psychology
Wilhelm Wundt is usually acknowledged as the founder of psychology and opened the
first psychology laboratory in Leipzig, Germany in 1879. Today, psychology is defined
by the profession as the study of the biological, cognitive, affective, social and cultural
aspects of behaviour. This means that psychologists are concerned with how people
think, feel and conduct themselves in particular situations and in society generally.

Research is a core value and core pursuit within the profession. Although evidence-based
practice is increasingly being adopted as the goal by other healthcare professions, it has
always been a central tenet of psychology. Psychology, alone among the healthcare
professions (including medicine), demands the completion of an approved research
project as part of the degree required for entry to practise the profession.

Laypeople being exposed to the profession of psychology for the first time often inquire
as to the differences among psychology, psychiatry and social work. Psychologists
obtain a post-graduate degree in psychology from an accredited university program and,
once registered by the regulatory body, practise as psychologists. Psychiatrists, on the
other hand, are medical doctors who have taken additional education in order to
specialize in psychiatry. Social workers graduate with a post-graduate or baccalaureate
degree.2 Figure 1 illustrates the differences in training among psychologists, psychiatrists
and social workers. One of the major practical differences between psychiatrists and
psychologists is that psychologists do not use drug therapies.

Within the profession of psychology are many areas of practice in addition to clinical
psychology, including health psychology, school psychology, clinical neuropsychology,
counselling psychology, forensic/correctional psychology, industrial/organizational
psychology and rehabilitation psychology.

Psychology has too often been overlooked or marginalized in discussions about our
healthcare delivery system. This is remarkable (and frustrating) to psychologists in light
of the costs and benefits to the healthcare system – and the economy and society
generally – of psychological health.

Evidence now indicates that one in five people in Ontario will suffer from mental health
problems in some form and to some degree in their lifetimes.3 In the general population,


2
 Social service workers (a subset of the profession of social work) graduate with a post-secondary diploma.
3
 Canadian Mental Health Association - Ontario Division, Ontario Mental Health Statistical Sourcebook
Volume 1: An investigation into the Mental Health Supplement of the 1990 Ontario Health Survey, 1998.


                                                    3
the incidence of a major depressive episode is 17.1 percent. 4 The incidence of anxiety
disorders is approximately 25 percent.5 10.3 percent of the population can be expected to
have an incident of clinical depression once over a 12-month period. The societal and
economic burden of psychological dysfunction in Canada is calculated at a staggering
$7.8 billion annually.6 This is 1.5 times the cost of cancer. The calculation includes
indirect costs such as reduced productivity and increased absenteeism due to stress-
related factors. The Ontario Health Survey indicates that 20% of adults with mental
health difficulties missed one or more days a month of work, compared with 13% for
healthy adults.7

Physical health is also affected by psychological factors. Over 60 percent of cases
addressed by primary care physicians relate to psychological conditions. It is well
documented that many medical conditions have root causes directly associated with
behavioural/psychological issues, including smoking, heart disease, cancer, obesity and
diabetes.   The management of these physical health conditions also involves
psychological approaches to facilitate relearning and behavioural change.

In light of these circumstances, the OPA feels that the public would be far better served
by an integrated and comprehensive approach to healthcare delivery that includes
psychological health. Yet, outdated attitudes that psychological services are a "frill" and
structural flaws in current models of healthcare funding and delivery artificially confine
psychology to certain practice venues and impede access to psychological services in the
publicly funded system. The Ontario Psychological Association wants to work with
governments and other stakeholders in order to remove anachronistic and
counterproductive impediments to psychological diagnoses and treatment in the publicly
funded healthcare system.




4
  Kessler RC, Crum RM, Warner LA et al., 1994, Lifetime and 12-month prevalence of DSM-III-R
psychiatric disorders in the United States. Arch Gen Psychiatry 51(1), pp. 8-19.
5
  Well-Connected Report: Anxiety Disorders. Dec. 1998.
6
  Moore et al, Health Canada. The Economic Burden of Illness in Canada, 1993, Ottawa, 1997.
7
  Ontario Ministry of Health, Mental Health in Ontario: Selected Findings from the Mental Health
Supplement to the Ontario Health Survey, 1994.


                                                   4
Fig. 1 Training in Mental Health Diagnosis and Treatment




                                 5
Fig. 1 (cont’d) Training in Mental Health Diagnosis and Treatment




                                  6
3. Psychology in the Healthcare Continuum
Psychologists are committed to a multidisciplinary healthcare delivery system where each
regulated profession can apply its particular competencies and, in economic terms, apply
its comparative advantages.

Psychologists can play an important role in the following healthcare sectors.

In primary care. Sixty percent of conditions presented to primary care physicians are
psychological, have a psychological component or are influenced by psychological
factors. Early diagnosis and intervention using appropriate treatment modalities are key
to reducing suffering and downstream costs generated by the psychological components
of illness and injury. Yet, psychological conditions are often misdiagnosed or overlooked
entirely in primary care. For example, research indicates that primary care physicians
diagnosed depression with a sensitivity of only 36 percent. 8 Even after specialized
education and the development of new practice guidelines, primary care physicians
managed to improve the sensitivity rate to only 39 percent. 9 Other studies show that 40
percent of primary care patients who are heavy users of medical services actually have a
treatable depressive illness10 and 59 percent of depressed patients in primary care receive
no treatment whatsoever for depression.11 In primary care venues, health psychologists
can also treat patients with a range of medical diseases or disorders, such as chronic pain,
diabetes, cancer, high-risk pregnancies, sleep disorders, HIV/AIDS and respiratory
problems.12 Psychologists also counsel individuals who are in the early stages of
developing mental health problems. Treating such people early may prevent the
development of serious mental illnesses later on.13

In acute care hospitals. Psychologists in acute care hospitals work with both inpatients
and outpatients in three general areas. First, psychologists work with individuals for
whom mental health issues, such as major depressive disorder or panic disorder, are their
primary problem. Second, they work with patients from a variety of medical services
(e.g., Cardiology, Oncology) where psychological factors have a significant impact on
the effectiveness of medical treatment. For example, an HIV-positive patient where a
depressive reaction to the diagnosis makes it difficult to follow the necessary treatment
regimen. Third, psychologists who specialize in the relationship of brain and behaviour
8
  Thompson, C. et al. (2000) Effects of a clinical-practice guideline and practice-based education on
determining outcome of depression in primary care: Hampshire Depression Project Randomized controlled
trial. Lancet, 355, 185-191.
9
  Ibid.
10
   Online Coverage from the 9th annual U.S. Psychiatric & Mental Health Congress, November 14-17,
1996, Depression in the Medically Ill. Medscape, 1996.
11
   Ibid.
12
   By way of illustration, psychologists treat patients with cardiovascular disease by modifying patients'
behaviour in favour of healthier and less stressful lifestyles and by mitigating other risk factors that are
present.
13
   For a more extensive discussion, see Dr. Pierre J. Ritchie, “Psychological Services in Primary Care,”
March 1997.


                                                     7
(neuropsychologists) assess the impact on a patient's functioning after brain damage.
Such brain damage can be direct (for example, as a result of a head injury following a
fall), or indirect (for example, as a result of anoxia during an extended cardiac arrest). In
all of these situations psychologists work either as members of interdisciplinary care
teams, or as consultants to those health care teams.

In rehabilitation after serious illness or injury. Psychological factors often play a pivotal
role in facilitating recovery from an accident, surgery or serious disease. Psychologists
work with patients and with people in their support networks to expedite return to
maximum physical functioning and to prevent relapse. Psychologists are one of the six
healthcare professions authorized to certify a treatment plan for motor vehicle accident
victims under the (Ontario) Automobile Insurance Rate Stability Act.

In health promotion and disease prevention. Quality of life is enhanced and healthcare
and economic costs are reduced whenever illness or injury can be prevented.
Psychologists engage in health promotion and disease prevention by educating and
influencing the behaviour of individuals and groups. More specifically, psychologists
help patients in stress and anger management, parenting and caregiver skills,
management of chronic disease and in smoking cessation.

In long-term care, chronic care and home care. Psychologists help ease patients’ (and
their families’) transition from independent living and to deal with issues relating to
declining mental and physical health and mobility. Psychologists assess patients’
cognitive competence and emotional well-being and help staff address long-term care
patients’ behavioural problems. Because of the aging population, psychologists play an
increasingly important role in the multidisciplinary team that provides assessment,
consultation and treatment services to assist the elderly and chronic care patients living in
the community or in various care venues.

In all healthcare sectors, psychologists help with patients’ acceptance of and adherence to
their courses of treatment.

In Ontario, psychological diagnoses and treatments may be obtained in the following
delivery streams, in addition to private practice:

      In public hospitals, which is one of the very few venues in which the general
       public can currently access publicly funded psychological services.
       Unfortunately, funding constraints have substantially reduced the number of
       psychologists available in public hospitals and a physician’s referral is necessary
       in order for patients to consult a psychologist in public hospitals.




                                             8
          By claimants under the (Ontario) Workplace Safety and Insurance Act. The
           Workplace Safety and Insurance Board has in place a fee for service schedule
           covering treatments by registered psychologists. WSIB claimants require a
           physician's referral to consult a psychologist.

          By persons injured in motor vehicle accidents who are insured by one of the
           companies regulated under the (Ontario) Automobile Rate Stability Act.
           Psychologists are paid up to a maximum fee as prescribed by regulation under
           that Act.

          In the criminal justice system and in federal and provincial correctional facilities,
           where psychologists are salaried employees or contractors.

          In industry, where psychologists are contracted on a part-time basis, or are
           salaried employees.

          In provincial psychiatric hospitals where psychologists are available as salaried or
           contracted personnel.

          In the provincial education system, where psychologists are available as salaried
           or contracted professionals.

          On First Nations Reserves, where psychological services are made available
           through federal funding.


4. Efficacy of Psychological Intervention
Research demonstrates that psychological treatment is a powerful treatment tool, either
on its own or in conjunction with others. Furthermore, psychotherapy is highly cost-
effective in that it gives patients skills that they can use throughout their lives to prevent,
reduce or delay relapses and does not involve expensive drug therapies.

Support for the efficacy of psychological intervention is well documented. For example:

           In a meta-analysis of studies published between 1974 and 1994,
           researchers compared controlled trials of cognitive-behavioural therapy
           and pharmacological treatment for patients with panic disorder. While
           both treatments worked in the short run, the results were more positive
           and longer lasting for cognitive-behavioural therapy.14




14
     Clinical Psychology Review, 1995, Vol. 15, p. 819-844.


                                                      9
Furthermore, there is an increasing preference for psychological treatment over
treatments that involve drug therapies, due to the number of harmful side effects patients
exhibit as a result of the medication used. The American Psychological Association has
found that alternatives to drug therapies are valuable to elderly populations, who are often
suffering from overmedication and numerous side effects of various drug and drug
interactions.15 In addition, psychotherapy is more cost-effective than drug therapies,
since patients are normally treated with psychotherapy within a finite number of sessions.
With medication, patients often rely on expensive drugs for a lifetime.

Finally, psychotherapy is cost-effective in that it reduces hospitalization, psychiatric
inpatient services and emergency room care. These decrease overall medical expenses
and work disability, which ultimately drive further reductions in the costs involved in
treating a mental illnesses including, for example, cardiac care, oncology and recovery
from surgery. Savings have been calculated at $10,000 per patient per year.
Psychologist Steven D. Hollon, Ph.D. at Vanderbilt University, stated:

        “If you can get with four months of psychotherapy the same benefits you
        get from a year and a half to two years of continuous medication, you
        begin to break even after about a year's time even though it's more
        expensive upfront to provide psychotherapy. If the benefits extend over a
        half-decade, your savings really start piling up.”16

Due to the aging population and increasing levels of stress in everyday living, the
demand for psychotherapy in the treatment of mental illness will likely increase in the
foreseeable future.


5. The Regulation of Psychology in Ontario
In Ontario, psychology has been a statutory, self-governing profession since 1960.17

There are 2,754 psychologists and psychological associates currently registered with the
College of Psychologists of Ontario, compared to 12,456 registered psychologists in
Canada as a whole. Over the past decade, the profession in Ontario has grown by 47
percent (see Fig. 2).18




15
   American Psychological Association, Government Relations Practice Directorate. “Psychology:
Promoting Health and Well-Being through High Quality, Cost-Effective Treatment”, Feb. 2001.
16
   Clay, Rebecca A. “Psychotherapy is cost-effective”. Monitor on Psychology. Vol. 31, No. 1, Jan. 2000.
17
   When the (Ontario) Psychologist Registration Act came into force and effect.
18
   College of Psychologists of Ontario, Nov. 8, 2001.


                                                  10
              Fig. 2 Total Number of Registered Psychologists in Ontario, 1990-2000


  3000

  2500

  2000

  1500

  1000

   500

       0
             1990   1991   1992   1993    1994    1995   1996   1997   1998   1999    2000


Ontario psychologists are now regulated in Ontario as a statutory, self-governing
profession under the Regulated Health Professions Act, 1991 (RHPA) and the
Psychology Act, 1991.

The Ontario Psychology Act, 1991 defines the practice of psychology as:

           "the assessment of behavioural and mental conditions, the diagnosis of
           neuropsychological disorders and dysfunctions and psychotic, neurotic
           and personality disorders and dysfunctions and the prevention and
           treatment of behavioural and mental disorders and dysfunctions and the
           maintenance and enhancement of physical, intellectual, emotional, social
           and interpersonal functioning."

In Ontario, there are two protected titles respecting the practice of psychology reserved
for members in good standing of the College of Psychology:

          Psychologist - which requires a doctoral degree in psychology
          Psychological Associate - which requires a masters degree in psychology and at
           least four years of relevant, post-degree experience

Psychologists are one of only six professions regulated under the RHPA authorized to
communicate a diagnosis as defined by section 26 of the RHPA. A psychologist may
communicate a diagnosis “identifying, as the cause of a person's symptoms, a
neuropsychological disorder or a psychologically based psychotic, neurotic or personality
disorder.”

In addition, the Psychology Act, 1991 prohibits anyone who is not a member of the
College of Psychologists of Ontario from using the terms "psychology" or


                                                 11
"psychological", abbreviations or equivalents in another language or in any description of
services offered or provided. Such a restriction is unique within Ontario's regulatory
framework for healthcare professionals.19

Finally, registered psychologists are also one of only five regulated professions
authorized to use the "doctor" title, a variation or abbreviation thereof or an equivalent in
another language. Psychologists are also only one of five regulated professions
authorized to use the “doctor” title when providing, or offering to provide, healthcare
services.


6. Addressing the Structural Impediments to Efficiency in the
Publicly-Funded Healthcare System
A. Lack of Accountability and Transparency: Increased accountability and transparency
in our healthcare system are preconditions to increased efficiency. Perhaps the largest
structural flaw, in this regard, is the way in which the healthcare system (in both publicly
funded and privately funded sectors) separates the healthcare consumer from the payor.
This separation nullifies the consumer’s incentive to demand the most cost-effective care;
it encourages excessive utilization of healthcare services (such as "doctor shopping") and
erodes the checks and balances that would otherwise guard against over-billing and other
fraudulent billing practices.

Various funding models have been studied by the Senate Standing Committee that are
designed to resolve the fundamental conundrum of how to reconnect the healthcare
consumer with the healthcare payor, without actually requiring individuals to pay for
medically necessary services out of their own pockets. Whether called Universal
Medical Savings Accounts (USMSA's), or some variation thereof, they aim to retain
universality, while restoring service levels, controlling costs and improving transparency
and accountability in the publicly funded healthcare system. Too frequently such models
have been rejected out-of-hand as somehow penalizing the chronically ill. To be
acceptable, any such model must not compromise the principle of universality entrenched
in the Canada Health Act and will have to make provision for health emergencies and
catastrophic situations so that no person is denied publicly-funded healthcare whenever it
is medically required.

Inadequate accountability and transparency persists at the level of federal-provincial
transfer payments for healthcare, as well. In 1977, the federal Department of Finance

19
  The OPA has urged the Ontario government to restrict use of the terms "psychotherapy" as well since
psychotherapy can be harmful if not provided by an appropriately-trained, regulated professional. In its
March 2001 Report to the Minister of Health and Long Term Care, the Health Professions Regulatory
Advisory Council recommended that the so-called "harm clause" of the RHPA be amended to add
"psychological harm." HPRAC invited a referral from appropriate RHPA-regulated professionals as to
amending the RHPA to list “psychotherapy” as a controlled act.


                                                    12
decided to integrate three cost-sharing programs into one block funding program,
Established Programs Financing (EPF), in recognition of provincial constitutional
responsibility for delivery of hospital insurance, medical insurance and postsecondary
education. In addition, the federal government decided to "finance" EPF in part through
the transfer of tax points to the provinces. During the fiscal restraint period of the 1990s,
Ottawa made unilateral changes to the indexing formula that resulted in an increasing
proportion of federal transfers taking the form of tax points. In 1996 the federal
government added another federal-provincial cost sharing program, the Canada
Assistance Plan, and launched the new Canada Health and Social Transfer (CHST).
Coincidentally the federal government also reduced total federal cash payments. The
block transfers were "untied" and therefore simply became part of provincial revenues to
allocate as the provinces saw fit. The transfer of tax points was rarely included, by the
provinces at least, in the calculation of federal transfers. In the case of some provinces,
such as Ontario, some of the tax room provided by the federal government to support
health and social programs was actually given away as part of the provincial
government's tax reduction strategy. As such, those tax points are "gone" and cannot be
retrieved by the federal government, or by the provincial government, without increasing
taxes.

The experiment in block transfer funding, therefore, has had several unfortunate results.
It has meant that the federal government does not receive the credit that it is due for
healthcare funding. It has set up the unfortunate finger-pointing between the two levels
of government as to which has not lived up to its healthcare funding promises.
Lamentably, as the Auditor General of Canada has noted, Canadians are no longer able to
identify the federal government's fiscal contribution to healthcare with any precision,
which is a horrendous commentary on the block funding/tax points transfer model.
Finally, it has reduced the federal government's leverage over the healthcare sector in the
establishment and maintenance of national standards and the five principles of the
Canada Health Act.

The OPA suggests that the federal government revisit its approach to federal transfers for
healthcare funding and seriously consider returning to specifically-identified transfers for
healthcare.

B. The Canada Health Act: The Canada Health Act applies a very restrictive definition
to the healthcare services that are insured under the Act:

           "Insured health services,” means hospital services, physician services and
           surgical-dental services provided to ensure persons..."20

This means that the publicly funded system under the Canada Health Act consists of
medically-necessary services that are provided in hospitals and by physicians. The
corollary is that the Canada Health Act does not cover the wide range and growing

20
     Subsection 2 “insured health services”


                                              13
number of community-based services and non-hospital long-term care services that are
medically-necessary and are a critical factor in overall population health. This approach
to defining insured services represents a linear progression from the 1957 (federal)
Hospital Insurance and Diagnostic Services Act, by which the federal and provincial
governments shared the cost of provincial hospital insurance plans and the 1966 (federal)
Medical Care Act, by which the federal government shared the cost of covering physician
services with the provinces. In effect, the Canada Health Act (1984) simply combined
the coverage instituted by the two previous acts.

In 1957, or in 1966, hospitals were arguably at the centre of the healthcare system,
because most people who were sick would be treated in hospitals. Since then, however,
advances in technology, changes in the regulatory structure for "allied" healthcare
practitioners and the growing demand for treatments at home or in the community should
have allowed the increasing demand for healthcare services to be spread across the
spectrum of delivery mechanisms and regulated professions. Instead, the Canada Health
Act persists as an anachronism, out of sync with the evolution of healthcare.

In fact, the Canada Health Act formulation acts as a significant obstacle to the
achievement of efficiencies by locking a large number of regulated healthcare
professionals and cost-effective treatment modalities out of the publicly-funded system,
by restricting competition amongst those professionals and modalities, by militating
against the development of inter professional models of healthcare delivery and by
depriving healthcare consumers of their right to choose among those professionals and
modalities. As such, the Act's definition appears to be in direct conflict with the Principal
Objective of Canadian Health Care Policy set out in the Act, namely

           "to promote and restore physical and mental well-being of residents of
           Canada (and)... to facilitate reasonable access to health services without
           financial or other barriers."21

Despite the Act's ostensible commitment to mental well-being, psychologists and the
services that they provide are not covered under the Act and the Act's restrictive
definition actually creates a barrier to access to needed health services.

Another unintended consequence of the Canada Health Act formulation is to force, or at
least encourage, privatization by stealth. As cost-cutting and the natural evolution of
healthcare moves more and more services out of hospitals, those services become part of
the privately-funded system. Provincial governments who wish to relieve the fiscal
pressures on the publicly-financed system need only apply funding constraints to
hospitals and then turn a blind eye as hospital-based services are transferred to other
delivery streams. This "privatization by stealth" appears to be in conflict with at least the
spirit of the "comprehensiveness" principle of the Act.


21
     Canada Health Act, Section 3


                                              14
The Canada Health Act formulation has frequently been replicated in provincial
legislation defining the scope of "extended healthcare services". For example, in
Ontario, the Ontario Health Insurance Plan covers services only when provided by
designated professions (physiotherapists, podiatrists, optometrists, audiologists and
chiropractors). Similarly, the (Ontario) Long-Term Care Act defines mandatory services
as those provided by certain named professionals. Under the (Ontario) Public Hospitals
Act and regulations there under, only physicians and dentists may admit patients to public
hospitals. Pursuant to the regulations under the (Ontario) Workplace Safety and
Insurance Act, injured workers wishing to access the services provided by psychologists
and other "allied" health care practitioners must first obtain a referral from a physician.

These obstacles to access in the publicly-funded system have a ripple effect in other
components of healthcare and in the future development of healthcare delivery systems.
In Ontario, new models of primary care delivery involve only physicians. Psychologists
have not been part of any "Primary Care Network" pilot projects launched in Ontario to
date, nor any pilot projects funded by the federal government, despite psychologists being
primary care practitioners and also despite the importance of accurate diagnoses of an
appropriate treatment for mental problems in primary care. Furthermore, only
Telepsychiatry provided by psychiatrists has been made available by the Telehealth pilot
projects currently underway in Canada.

A substantial portion of people who require psychotherapy are economically
disadvantaged such as single parents, the working poor, seniors, students and the
homeless. Private insurance plans rarely provide adequate coverage for treatment by
psychologists. In any event, very few of these people would have extended health
benefits anyway, or any other form of third-party insurance that would cover
psychotherapy. Their inability to access medically-necessary psychotherapy in the
publicly-funded system, therefore, represents a serious--perhaps life-threatening--
impediment to their physical and psychological well-being and to their ability to function
as productive members of society. Lack of access to publicly-funded psychotherapy also
generates additional costs for the healthcare system.

C. Quality in Healthcare Delivery: Perhaps because of the separation between consumer
and payor, or perhaps because of the diffusion of accountability and responsibility in
publicly-funded healthcare, the system is too frequently indifferent to quality. As a
consequence, scarce health resources are often spent on cost-ineffective treatments. Of
particular concern to healthcare policymakers and of equal concern to psychologists are
the quality considerations relating to drug therapies. As indicated previously in this
Submission drugs represent the fastest growing component of healthcare costs, 22 leading
to demands from some that drug prescriptions be encompassed within the publicly-

22
  According to CIHI data, spending on drugs in Canada has risen continually over the past quarter Century,
from $1.1 billion in 1975 to $14.7 billion in 2000. In 1975, drugs accounted for 9% of total healthcare
expenditures, forecast to hit 16% by 2000. Drug expenditures increased per capita by 93% during that
period, more than any other expenditure category and twice the average for all healthcare expenditures.
Prescription drugs account for 77% of all spending on drugs, up from 72% in 1975.


                                                   15
funded system. This, in turn, generates the legitimate concern that were this to happen,
drug prescription costs could quickly become the largest component of healthcare, if not
bankrupt the system outright.

Yet, because the healthcare system does not focus on quality and does not insist on
evidence-based care, drugs are routinely over prescribed, particularly for mental
conditions and particularly for the elderly. This over prescription generates substantial
unnecessary costs for the healthcare system, not only in the costs of the drugs prescribed,
but also in avoidable remedial treatments, such as admissions to hospitals. Too
frequently, worthwhile drugs are prescribed without a parallel process for convincing
patients of their utility and the need to take them as prescribed. Finally, the over
prescription or incorrect prescription of drugs probably results in the needless deaths of
tens of thousands of Canadians annually.23

The actuality of quality, or evidence-based, care in the healthcare system compares
unfavourably with the rhetoric. Major efficiencies can be realized in healthcare delivery
with a true commitment to quality care and evidence-based treatments.


7. Funding and Delivery Models
Approximately 30% of total healthcare expenditures in Ontario are privately funded.
Even at that, the private component of healthcare funding is underestimated because
calculations do not reflect private sector, charitable, religious and municipal government
expenditures in long term care (e.g. nursing and retirement homes), or the costs of care
provided by volunteers and family members. The OPA acknowledges that fiscal and
economic realities in Canada dictate the confirmation of a sizeable, privately-funded
system. Accordingly, the OPA supports balanced, sustainable, publicly-funded and
privately-funded systems.       In the current and foreseeable economic and fiscal
environment, coupled with Canada's aging demographics, it is unrealistic to expect the
publicly-funded system to cover 100% of medically-necessary services at acceptable
levels of quality and patient access.

The OPA does not purport to know the appropriate balance between the publicly-funded
and privately-funded systems. Clearly, a publicly-funded and publicly-administered
system has advantages over a private system. A publicly-funded system can use its
quasi-monopoly and governmental powers to control costs in ways that a private and
fragmented private system cannot. A publicly-funded system allows wealthy Canadians
to subsidize healthcare delivery for the less fortunate through the tax and federal-
provincial equalization systems so that no Canadian need go without necessary healthcare
because of an inability to pay. On the other hand, the major defect of the publicly-funded
system is that it separates the healthcare consumer from the healthcare provider in terms

23
   Extrapolated from U.S. Institute of Medicine Study, 2000 on the incidence of medical misadventures
attributed to drug prescriptions.


                                                   16
of payment, which in turn has negative consequences for accountability, rewarding
efficiency and best practices and interferes with competition and choice among alternate
healthcare providers.

In choosing the appropriate balance between the public and private systems, the publicly-
funded system must be of sufficient size and scope to maximize economies of scale and
to ensure that no Canadian is deprived of medically necessary care of reasonable quality
because of geographic location in Canada, or an inability to pay. If this objective is
achieved, the relative size of the public and private sectors becomes less relevant because
the linkage between privately-funded healthcare and “two-tier healthcare” is broken.

The Ontario Psychological Association has examined alternate funding and delivery
models that have been put forward by others. Each model has advantages and
disadvantages relative to the other models. Some models are applicable in certain
instances, but not in others; and all models would have to be tested in order to evaluate
their feasibility and efficacy.

Accordingly, the Ontario Psychological Association does not wish to state a preference
for one model over another. Instead, the OPA has developed a list of 11 principles that it
believes should be incorporated into the development and evaluation of any funding and
delivery models in the publicly-funded sector:

1. Universal Accessibility: Quality health care that is medically-necessary must be
reasonably accessible to any legal resident of Canada who needs it, when it’s needed and
without discrimination. This principle has become entrenched as part of the Canadian
value system and, therefore, must be reflected in any reforms.

2. Fiscal Sustainability: A persistent question is whether Canada has or is likely to have
the fiscal resources necessary to sustain universal accessibility to quality health care. At
this point in time, the question is unanswerable because of structural flaws in the funding
models and delivery systems that inhibit delivery of the most cost-effective, evidence-
based care at the appropriate time. These flaws also inhibit making the appropriate
emphasis on health promotion, disease and injury prevention in order to reduce long-term
costs. Notwithstanding, our members acknowledge that the fiscal resources available for
healthcare are not infinite and healthcare expenditures cannot be allowed to grow to the
extent that they prejudice sound fiscal policy and economic development.

3. Reconnecting the Consumer and the Payor: Any funding model should try to
replicate the normal market forces brought to bear in the relationship between buyers and
sellers of services by disciplining the healthcare consumer to use healthcare resources
wisely.

4. Evidence-Based Care: Treatments should be publicly-funded only when the efficacy
of those treatments has been demonstrated by the best objective, scientific evidence
available. Outcomes should be continually measured and evaluated in order to make


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necessary improvements to treatments and in order to maintain eligibility for public
funding.

5. Consumer Choice: The funding and delivery models should place no artificial
restrictions on patients’ access to treatment modalities and regulated healthcare
practitioners of their choice. In order to increase competition as well as clinical and fiscal
accountability in the healthcare system, healthcare consumers should have the widest
possible choice among alternate treatments that are safe and proven and among the
regulated, primary care health professionals who provide them. The traditional
orthodoxy is that healthcare choices are too complex and important to be left to
consumers to decide. This attitude is excessively paternalistic and underestimates the
potential of healthcare consumers to make intelligent choices, especially in an
environment of evidence-based care. It also underestimates the contribution of the
Internet, health information centres and other advances in helping consumers make
informed choices.

6. Regulated Healthcare Practitioners: Only those treatments provided by healthcare
practitioners who are statutorily regulated by a province should be publicly funded. The
regulatory structure protects the public interest and provides healthcare consumers who
have experienced a misadventure, or who otherwise have been aggrieved by a
practitioner, with effective means of recourse and redress. The unregulated sector does
not have these protections, or at least does not have them uniformly.

7. Maximum Integration: Inter-professional delivery models should be the norm across
the continuum of the healthcare system. The mix of professions involved should be
driven, on a case-by-case basis, by the circumstances and requirements of the needs of
the population being served. Funding and delivery models should also act as a catalyst to
break down the "silos" in health care and to drive a more seamless system of healthcare
delivery from primary care through acute care, long-term and home care to palliative
care.

8. Non-Discrimination: Funding or delivery models should not discriminate among
healthcare professions. Professional protectionism should not be tolerated in the
publicly-funded system. Treatments should be funded regardless of which regulated
healthcare professional provides them and regardless of the venue (e.g. whether hospital,
home, clinic, long-term care facility) in which treatments are provided.

9. Drugless Therapies: Rising pharmaceutical costs account for the largest growth in
healthcare expenditures in Canada. Current trends in healthcare suggest an increase in
the use of very expensive pharmacotherapeutic and technological interventions, often
without reliable evidence of efficacy and often for small or limited groups of patients.
This high ratio of expense to population health returns absorbs disproportionate resources
relative to more broadly-based, basic and preventive interventions. Funding and delivery
models should promote effective alternatives to expensive pharmacotherapeutic and
technological treatments.


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10. Direct Access: Our healthcare system still tends to be physician-centric and
physicians still position themselves, or are positioned by others, as de facto "gatekeepers"
to healthcare. This, in turn, creates a bottleneck in the healthcare delivery system, often
duplicates the cost of care and delays referrals to other practitioners, even when early
intervention is required or is the most appropriate response. Health legislation and
funding models should not impose gatekeepers to care provided by regulated primary
care professionals. Patients should have direct access to the regulated, primary care
practitioner of choice.

11. Community-Based Care: Our healthcare system also tends to be hospital-centric and
hospitals account for the largest single expenditures in healthcare. 24 Funding and
delivery models should also promote community and home-based care in order to relieve
some of the pressures on hospitals and also to provide care in venues where it is most
cost-effective and convenient for and accessible to the patient.


Conclusions
Canada needs to restructure and revitalize its healthcare system. As respected historian
and commentator Michael Bliss has stated:

        “Canadian social policies are no longer pioneering, innovative or of
        much interest to anyone outside of Canada. Instead of being copied by
        others as it once was, our healthcare system is out of step with
        international practices, and in desperate need of reform.”25

In the OPA’s view, current debates around private healthcare funding too often deflect
discussions from what should be the real objective: improving cost-effectiveness. At
least one-third of healthcare expenditures are privately-funded in Canada already and
reducing the relative size of private funding is not a practical alternative. Furthermore,
private funding is frequently equated with two-tier healthcare. The two are not
necessarily synonymous. Any Canadian who needs quality healthcare should be able to
access it through a publicly-funded system that co-exists with a privately-funded one.
The objective should be to find a balance between the publicly-funded and privately-
funded systems so that the publicly-funded system has the scope to maximize economies
of scale and also to ensure access to quality care by every Canadian who requires it.

Psychologists are fully aware of the current economic situation and its impact on
government revenues. Even without the economic downturn, continuing the recent trend
in publicly-funded healthcare expenditures is not fiscally prudent.


24
   Standing Senate Committee on Social Affairs, Science and Technology. The Health of Canadians – The
Federal Role, Interim Report, Vol.4, and p.19: Sept. 2001.
25
   Michael Bliss, “Is Canada a country in decline?” National Post, November 30, 2001.


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However, a quality, publicly-funded healthcare system that is universally accessible
contributes substantially to Canadians’ quality of life, a healthier population and also
lowers the cost of doing business in Canada. All these are factors in reversing the
Canadian “brain drain” and in making the Canadian economy more competitive in an
increasingly globalized and liberalized marketplace.

With these imperatives in mind, the Ontario Psychological Association is convinced that
our publicly-funded healthcare system would be substantially more cost-effective if it
were restructured to reflect the 11 principles set out in this Submission. In particular, any
new funding and delivery models must:

      reconnect the consumer with the payor;
      reflect a commitment to evidence-based practice;
      allow healthcare consumers to access care provided by regulated healthcare
       practitioners within their statutory scopes of practice, regardless of where the care
       is delivered, or which regulated professional provides it; and
      allow healthcare consumers to access their primary healthcare practitioner of
       choice directly.




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