Health policy

Intro to health policy and health systems  

What is health policy ?

• decisions plans and actions that are undertaken to achieve specific health care goals within a society 

• Policy as a process in time and place 

Who

• Political actors 

• Public sector (governments)

• Private sector (industry)

What

• Decisions, plans, actions 

• Non-decisions, No plans, inaction 

Where 

• Within society 

• Health care system institutions, organizations

• External to the health care system (food, transportation, tobacco..)

Why 

• Achieve health and health care goals 

• **Health policy is always political - it is always a question of values

What are health systems?

• set of institutions and rules to regulate, finance, and pay for personal services called health care 

Health policies are aimed at particular features of health systems and health systems make some health policy issues more relevant/ visible 

Policy objectives 

What are we trying to accomplish??

• trade-offs — often more than one objective 

• objectives not always compatible 

security - minimum human needs (food, shelter) 

liberty - freedom to do what you want, without harming others 

equity - “treating likes alike” 

efficiency - getting most for money spent 

Policy instruments 

1. Status quo - do nothing, people should be free to eat what they want and decide not to act on obesity 

2. Encourage activities without forcing it - developing public education programs to encourage people to eat healthy foods and exercise 

3. Spending money - Subsidize healthy school lunches 

4. Tax policy to encourage/discourage activities - tax deductions for people who enroll their children in physical activity programs 

5. Rules to encourage or penalize activities - government ban on certain types of foods deemed to be unhealthy 

6. Government-run activities - city-run public skating rink to encourage people to exercise

Lalonde report (1974) 

• health of populations affected by four types of factors: 

Human biology

• Biological causes of disease, genetic inheritance  

Environment 

• Physical and social 

• Not under individual control ex. water, air

Lifestyle 

• Personal decisions ex. smoking, drinking, eating, exercise 

Health care organizations 

• Clinical services 

Social determinants of health 

• Income and social status

• Social support networks

• Education and literacy

• Employment/ working conditions

• Social environments

• Physical environments

• Personal health practices and coping skills

• Healthy child development

• Biology and genetic endowment

• Health services

• Gender

• Culture

Who is responsible for Social determinants of Health? 

Principal-agent relationship ?

• Patient = principal 

Health care provider (HCP) = agent 

Types of services 

• Tertiary care - 

• Secondary care 

• primary care 

Primary care 

• first point of entry in health care system; coordinates and oversees care 

• Focuses on services to prevent, diagnose, treat and manage diseases 

Specialized care 

Secondary care 

• Ambulatory care (outpatient services provided outside of hospital ex. office)

• It includes treatment by specialists in hospitals or clinics for conditions that require more expertise than primary care can offer. 

Tertiary care

• hospitals 

• Highly specialized, complex 

• May include research and teaching 

Emergency services 

• Potentially life-threatening situations 

• Ambulance services 

• Transport to hospital 

• may treat directly in community or en route 

Long term care (LTC) 

• set of health, personal care, and social services required on a sustained basis 

• LTC institutions 

Specialized facility (nursing home, home for the aged)

How is a Profession defined? - Work relies on a systematic body of knowledge that must be learned and taught in a recognized educational institution 

asymmetry of information - recipients cannot judge effectiveness or appropriateness of services 

Skilled trades 

• Personal support workers (PSWs)

• Assist with activities of daily living 

• Work in multiple settings (institutions, homes, hospitals)

Informal caregivers

• Often family members (often women)

• Financial implications 

• Avoid LTC institutions, stay in your own home?

• Cheaper for health care system 

Health Human Resources (HHR)

• Stickiness — probability that someone working in a job will stay there the next year 

• Hospitals — highly sticky 

• Home care — not sticky 

Health policy is always political — it is always a question of values 

Practice Questions about this lecture…

1. The _______ problem arises in health care when insured patients heavily utilize available resources, resulting in an increased cost of insurance for everyone involved.

•   Socialist medicine 

•   Single-payer 

•   Inequitable resourcing 

•   Moral hazard 

  Capitation ethics 

2. Which of the following is NOT true about the design of the Canada Health Act?

•  It amalgamated existing federal cost-sharing legislation

•  It embodied principles crucial to the NDP government’s vision of federalism and national unity

•  It aimed to give the federal government a fiscal lever to enforce conditions on the money it allocated to the provinces for health care

•  It became part of a larger perception of the moral leadership that the federal government sought to develop

•  It aimed to carve out a visible and powerful space for the federal government in health care, over and above the fiscal measures at its disposal

3.  Most physicians in Canada are paid based on:

•   Their impact on patient health outcomes 

•   The quality of care provided 

•   The number and type of services provided 

•   The number of hours spent working 

•   The geographic location of their practice 

4. Kevin was born and raised in Ontario and moved to British Columbia to attend university. He sprained his ankle on the first day of classes but hesitated to seek medical care because his roommate said that OHIP cards aren’t valid in BC. What principle of the Canada Health Act does this scenario best align with?

•   Comprehensiveness 

•   Portability 

•   Public Administration 

•   Universality 

•   Accessibility 

5. Which of the following is NOT true about formal and informal health care?

•  The criteria for formal health care varies across societies and time periods

•  The criteria for informal health care varies across societies and time periods

•  Care delivered within pre-established relationships is considered informal health care

•  Formal health care requires an explicit contract that identifies the duties of the agent toward the principal

•  Informal health care requires a contract that identifies the carer and patient

Canadian health care systems week 3part 1

Federation

• national government (federal government)

• sub-national jurisdictions (provinces and territories) 

Canadian medicare History

• 1947 -  Saskatchewan Hospital Services Plan

• 1957 -  Hospital Insurance and Diagnostic Services Act 

• July 1 1962 - Saskatchewan Medical Insurance Act 

• 1965 - Medical Care Insurance Act 

• 1984 - Canada Health act 

Canada Health Act 

CHA  Public administration

• Managed on non-profit basis

• Management of insurance plan

CHA Comprehensiveness

• Must cover all insured health services provided by hospitals, physicians or dentals 

• Insured person = resident

• Insured health service = medically necessary

CHA  Universality 

• All insured residents must be entitled to the insured health services on uniform terms and conditions

• Health should be available to all residents equally 

CHA Portability 

• Transferable between provinces

• Allow residents to move freely within country without losing coverage

Accessibility 

• Remove financial barriers to access to care 

Insured health services

Hospital services - accommodation to meals, nursing, diagnostics, drugs, operating, and physiotherapy 

Physician services - medical doctors and surgeons 

Surgical-dental services (performed in hospital)

Extended health care services 

1. Nursing home intermediate care service

2. Adult residential care service 

3. Home care service

4. Ambulatory health service 

5. Not subject to CHA

POLICIES OF CHA INCLUDE:

• Prioritizes hospital and physician care 

• Ensures coverage for citizens and residents

• Prohibits private pay for insured health services 

Canadian health care systems week 4 part 2

Cash grants - direct transfers from one level of government to another 

• Can be tied to terms and conditions, withheld if in violation 

Tax room - senior level of government decreases its tax rate, leaving room for sub-national units to increase their tax rates, without increasing total tax burden on taxpayer 

User Fees 

• Co-payment: those who receive care pay a fixed amount

• Co-insurance: amount paid is a percentage of the bill

• Deductible: insurance begins after user has paid a certain sum

Public vs Private

• Financing (how services are paid for) vs delivery (how services are provided)

Public 

• Government (national, provincial/ territorial, regional, local)

• Money has come from general revenues or special taxes designated for health care

• Public health, public schools

• Health spending is 40% of total provincial budget

Private

• Corporate for-profit (maximize return)

• For-profit small business (health care professional practices)

• Not-for-profit (hospitals, community agencies)

Public/ private split – Canada

• Approximately 30% of total health spending is spent outside the public system

• 70% is spent in the public system 

Allocation

• How resources flow from payers to providers and the different incentives that go with different payment models 

• Actual costs (e.g., pharmaceutical)

• Time spent (e.g., wages)

• Service provided (e.g., fee-for-service or activity-based funding)

• Capitation (fixed payment each patient, potentially adjusted for population)

• Bonus payment (e.g., pay for performance) 

• Global budgets (e.g., hospital funding)

Incentives  - Payment models that influence what providers and organizations have incentive to do (or not)

• Global budgets → do as little as possible, ensure budget is not exceeded

• Fee-for-service → deliver more services to increase revenues 

• Capitation → select lowest cost clients

**important notes from this lec

• Canada doesn’t have a universal health care system:

• Public pay, private delivery 

• Hospital and physician services only 

• Different allocation models will (dis)incentivize kinds of care

Politics of health policy week 5 

Canada has seen increasing privatization bc…

Key pressures:

• Economic 

• Political

• Ideological shifts 

Privatization 

• Process of increasing private-sector involvement in ownership, financing, or delivery of services that were previously provided by public sector

In healthcare:

• Reliance on private insurance 

Factors contributing to privatization: 

Government cost cutting, technological advance, wait times 

Health policy is always political, always a question of values

• Despite canada's leadership in theory, policy implementation is weak bc of nature and how it distributes economic and social security through governmental/ state intervention

Welfare state 

• How a nation provides economic and social security through governmental / state intervention

• Public programs and services are an entitlement of citizenship 

Decommodification  - certain programs and services are not subject to purchase on open market 

Politics

• Welfare states reflect how a society views what it owes to its members by virtue of citizenship (or residence)

•  Form of welfare state is shaped by politics: who gets what, when, how 

Forms of welfare state:

• Social democratic

• Conservative

• Liberal 

Neoliberalism

• Emerged in the 1930s, and was a response to increasing state control of markets after the great depression

• Favours the market/ economy and material gain

Markets are the best and most efficient producers and allocators of resources

Societies are composed of autonomous (rational) individuals (producers and consumers) motivated 

chiefly or entirely by material or economic interests

Competition is the major market vehicles for innovation

Welfare state - conservative 

• Offer generous benefits provided through social 

• insurance plans associated with employment 

• Emphasis on male wage earners

Welfare state - liberal 

• Key feature is means-tested benefits

• Target only the least well off and only intended to meet immediate needs

• Least developed in providing economic and social security

Welfare state - social democratic 

• Emphasizes universal welfare rights

• Provides generous entitlements and benefits

Income inequality

• Perfect equality = 0.00

• Complete inequality = 1.00

Poverty rates

International comparisons week 6

What is Medicare?

Medicare is broken into four components:

•(1965) Medicare Part A: Hospital benefits paid directly by the federal government and financed from compulsory payroll contributions.

•(1965) Medicare Part B: A supplementary medical insurance for physician care, financed through monthly premiums and subsidized by Medicare as a whole.

•(2003) Medicare Part C: Allowing Medicare beneficiaries to enrol in privately managed plans.

•(2003) Medicare Part D: Allowing enrollment into private drug plans for outpatient prescriptions.

Two Models of Healthcare:

Bismarck Model

Characterized by social insurance, with healthcare insurance coverage compulsory for all workers in the country. Everyone must contribute into a designated fund, usually according to their income, with the government supplementing those not in the labour market. (Examples: Germany, France, the Netherlands, also the basis for Medicare in the US).

Beveridge Model

Developed after WW2, based on universal coverage and public financing, with general state revenues used to fund centralized health care systems (Examples: UK, Sweden, Italy).