Summary and Wrap-up: Facts, Issues and Future

Summary and Wrap-up:Facts, Issues and Future Raisa Deber, PhD University of Toronto November 21, 2005

What we heard We need evidence!

Policy dilemmas • Conference clarified that there is still much we need to know • Many issues up for debate

Need to separate facts fromvalues • What is Mary’s health status? – Fact • What services will help Mary remain in the community? –Fact (once we get the data!) • What are the implications of various ways of organizing and delivering those services? – Fact (once we get the data!) • How much would those services cost? – Fact (but varies with how they are organized)

Need to separate facts fromvalues • Who should pay for those services? – Value • How much should the people who provide the services be paid? – Value (with labour economics ‘fact’ constraints)

Is health insurance immoral? • “It can also be stated that the system’s underlying egalitarianism is immoral in that it rewards that segment of the population that shows no concern for the medically deleterious consequences of its lifestyle.” Source: Jean-Luc Migué, The Fraser Institute (“Funding and Production of Health Services: Outlook and Potential Solutions.” Discussion Paper No. 10, Commission on the Future of Health Care in Canada, 2002)

Is profit immoral? “..making profits off the suffering of others is deplorable. It is is ethically and morally wrong to allow wealthy people to buy their way to the front of the line. Putting profits ahead of patients is wrong.” Source: Canada Health Coalition, For-Profit MRI/CT Clinics Reality Check. Downloaded Aug 28, 2002 from http://www.healthcoalition.ca/realitycheck4.htm

One clue we are talking about ideas • Can these statements be proven to be true or false? • What evidence (if any) might cause the individuals making them to change their minds?

Ideas are not right or wrong • You may agree or disagree with them • They are an integral part of policy making • But they should not be confused with facts

Some issues are contentious • No agreement about what we want to do • If policy is about ‘who gets what’, then it may involve redistribution of resources • It will be about ‘winners’ and ‘losers’ • E.g., competition vs. cooperation

Many policies have implications for women • As recipients of care • As providers of care • Health professionals (e.g., nursing) • Health workers (e.g., PSWs) • Volunteers • Family care givers • Various policies will have different winners and losers

Slide for Bea Levis (and my 85-year old mother-in-law)

But some issues are not contentious at all • Research may be needed about how toaccomplish particular goals • But little disagreement about the goals • I.e., Elinor Caplan’s point about BETTER care for more people, rather than just more care

Example, falls • General consensus that falls are not a goodthing • For individuals • Or for the health care systemEvidence about how best to prevent them is thus: • Valuable • Not particularly controversial (unless you market throw rugs)

Policy issue: institutional constraints • Canada Health Act requires coverage based on: • Where care delivered (in hospital) • Or by whom (physicians) • Governments can insure beyond thisBut they are not required to • Community support services do not fall under CHA Should this be changed?

For Camille

The issue of effectiveness Are various services/interventions: • effective? • cost-effective? Which services? For whom?Can we target groups most likely to be helped?

Evidence • We need the evidence! • This should not be that contentious • Although, as Pat Armstrong noted, what counts as evidence may well be!

But not always clear cut • Sliding scale of ability to benefit implies ‘boundary’ issues • Services may be cost-effective if they replace more expensive services • But also ‘add ons’ (even if often useful ones) if they are used by people who would otherwise not have been served • How do we tell the difference?

Who should pay for what? • What is the responsibility of society? • What is the responsibility of voluntary organizations (including faith-based groups)? • What is the responsibility of individuals andtheir families? • How should workers be treated (and how much should they be paid)? • Not a question of evidence, but of values

“What’s in, What’s out”: Stakeholders’ views about the boundaries of Medicare • Research team: • Raisa Deber • Earl Berger • A. Paul Williams • Brenda Gamble • Acknowledgments: M-THAC for funding • Ann Pendleton for survey mailing and data entry • Cathy Bezic for coordination and survey mailing

With the assistance of the following research partners: • Physicians: Canadian Medical Association and provincial medical associations from: Newfoundland and Labrador, PEI, Québec, Saskatchewan, Alberta, B.C. and Yukon • Medical Reform Group • Nurses: Canadian Nurses Association and provincial nursing associations from: BC, Alberta, Ontario, Québec, N.B., PEI, and Yukon • Hospitals: Canadian Healthcare Association, and Ontario Hospital Association • Canadian Home Care Association • Pharmacists: Canadian Pharmacists Association • Business:Conference Board of Canada, the Ontario Chambers of Commerce, and the Canadian Federation of Independent Business

For full results of Boundaries of Medicare Project • Results posted at: • From Medicare To Home And Community (M-THAC) Research Unit www.m-thac.org

For 48 specific items, we asked: What should coverage be? • Universal? • Full coverage, no co-pays • Subsidized? • Payment split between government and individuals (co-pays allowed) • Means tested? • Government payment only for the “poor” • Not? • No government payment

Responses given by group • Doctors (CMA) • Medical Reform group • Nurses – 3 bars • CNA, RNAO Board, RNAO members • Hospitals – 3 bars • CHA, OHA Chairs, OHA CEOs • Can. Home Care Assoc. • Pharmacists (Can. Pharm. Assoc.) • Business – 3 bars • Ont Chamber of Commerce, Small business (Can. Fed. Independent Bus.), Big Business (Conference Board)

Acute hospital care (in- patient)

Long Term Care Facilities

Nursing at Home

Medical Supplies/Equipment at Home

Personal Support at Home

Community Support

Homemaking

Respite Support for Family Caregiver

Stipend for Family Caregiver

Bottom line? • Consensus that hospital-based services should continue to be fully insured • Consensus that long-term care in institutions should involve user fees • Hypothesis: Tendency to see home care as more similar to LTC facilities than to hospitals

Result? • Little support for full universal coverage for home-based professional care • Even less support for full universal coverage for community support services • Almost no support for paying for “women’s work”

But… • Nucleus of support for believingthat they can be part of the system,with costs subsidized • Evidence thus likely to be veryimportant in clarifying which servicesare valuable, and for whom

“I think you should be more explicit here in step two.”

Policy analysis or policy advocacy • Policy analysis • balanced, objective analysis • assesses multiple positions and interests • may recommend a policy option • nPolicy advocacy • starts from a particular position • may use tools of policy analysis to justify

Role of CRNCC? • Go beyond “yea \ boo” • Try to: • Analyze what the issues are • Distinguish between “facts” and “values” • Clarify implications of ideas, institutions, and interests • Recognizing that the data can be used for more effective advocacy should you wish to do so

Summary and Wrap-up: Facts, Issues and Future