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Background: Through medicare, residents in Canada are entitled to medically necessary physician services without paying out of pocket, but still many people struggle to access primary care. We conducted a survey to explore people's experience with and priorities for primary care. Methods: We conducted an online, bilingual survey of adults in Canada in fall 2022. We distributed an anonymous link through diverse channels and a closed link to 122 053 people via a national public opinion firm. We weighted completed responses to mirror Canada's population and adjusted for sociodemographic characteristics using regression models. Results: We analyzed 9279 completed surveys (5.9% response rate via closed link). More than one-fifth of respondents (21.8%) reported having no primary care clinician, and among those who did, 34.5% reported getting a same or next-day appointment for urgent issues. Of respondents, 89.4% expressed comfort seeing another team member if their doctor recommended it, but only 35.9%, 9.5%, and 12.4% reported that their practice had a nurse, social worker, or pharmacist, respectively. The primary care attribute that mattered most was having a clinician who "knows me as a person and considers all the factors that affect my health." After we adjusted for respondent characteristics, people in Quebec, the Atlantic region, and British Columbia had lower odds of reporting a primary care clinician than people in Ontario (adjusted odds ratio 0.30, 0.33, and 0.39, respectively; p < 0.001). We also observed large provincial variations in timely access, interprofessional care, and walk-in clinic use. Interpretation: More than 1 in 5 respondents did not have access to primary care, with large variation by province. Reforms should strive to expand access to relationship-based, longitudinal care in a team setting. [ABSTRACT FROM AUTHOR]

Numerous studies investigate how personality traits and individual characteristics influence vote choice. However, the effect of risk attitudes on the proclivity to cast a strategic vote has not been tested yet. This article tests whether the likelihood of defecting from one's preferred party is influenced by attitudes towards risk. I argue that the utility stemming from expressing a preference by opting for the favored party is a sure thing, whereas the utility stemming from an instrumental choice depends on some probabilities, and consequently that strategic voting is riskier than sincere voting. Using survey data from the United Kingdom and Canada, I find that risk-averse voters are less likely to vote strategically than risk-acceptant ones. [ABSTRACT FROM AUTHOR]

Access to health care based on need rather than ability to pay was the founding principle of the Canadian health-care system. Medicare was born in one province in 1947. It spread across the country through federal cost sharing, and eventually was harmonised through standards in a federal law, the Canada Health Act of 1984. The health-care system is less a true national system than a decentralised collection of provincial and territorial insurance plans covering a narrow basket of services, which are free at the point of care. Administration and service delivery are highly decentralised, although coverage is portable across the country. In the setting of geographical and population diversity, long waits for elective care demand the capacity and commitment to scale up effective and sustainable models of care delivery across the country. Profound health inequities experienced by Indigenous populations and some vulnerable groups also require coordinated action on the social determinants of health if these inequities are to be effectively addressed. Achievement of the high aspirations of Medicare's founders requires a renewal of the tripartite social contract between governments, health-care providers, and the public. Expansion of the publicly funded basket of services and coordinated effort to reduce variation in outcomes will hinge on more engaged roles for the federal government and the physician community than have existed in previous decades. Public engagement in system stewardship will also be crucial to achieve a high-quality system grounded in both evidence and the Canadian values of equity and solidarity. [ABSTRACT FROM AUTHOR]

Background: As in many health care systems, some Canadian jurisdictions have begun shifting away from global hospital budgets. Payment for episodes of care has begun to be implemented. Starting in 2012, the Province of Ontario implemented hospital funding reforms comprising three elements: Global Budgets; Health Based Allocation Method (HBAM); and Quality-Based Procedures (QBP). This evaluation focuses on implementation of QBPs, a procedure/diagnosis-specific funding approach involving a pre-set price per episode of care coupled with best practice clinical pathways. We examined whether or not there was consensus in understanding of the program theory underpinning QBPs and how this may have influenced full and effective implementation of this innovative funding model. Methods: We undertook a formative evaluation of QBP implementation. We used an embedded case study method and in-depth, one-on-one, semi-structured, telephone interviews with key informants at three levels of the health care system: Designers (those who designed the QBP policy); Adoption Supporters (organizations and individuals supporting adoption of QBPs); and Hospital Implementers (those responsible for QBP implementation in hospitals). Thematic analysis involved an inductive approach, incorporating Framework analysis to generate descriptive and explanatory themes that emerged from the data. Results: Five main findings emerged from our research: (1) Unbeknownst to most key informants, there was neither consistency nor clarity over time among QBP designers in their understanding of the original goal(s) for hospital funding reform; (2) Prior to implementation, the intended hospital funding mechanism transitioned from ABF to QBPs, but most key informants were either unaware of the transition or believe it was intentional; (3) Perception of the primary goal(s) of the policy reform continues to vary within and across all levels of key informants; (4) Four years into implementation, the QBP funding mechanism remains misunderstood; and (5) Ongoing differences in understanding of QBP goals and funding mechanism have created challenges with implementation and difficulties in measuring success. Conclusions: Policy drift and policy layering affected both the goal and the mechanism of action of hospital funding reform. Lack of early specification in both policy goals and hospital funding mechanism exposed the reform to reactive changes that did not reflect initial intentions. Several challenges further exacerbated implementation of complex hospital funding reforms, including a prolonged implementation schedule, turnover of key staff, and inconsistent messaging over time. These factors altered the trajectory of the hospital funding reforms and created confusion amongst those responsible for implementation. Enacting changes to hospital funding policy through a process that is transparent, collaborative, and intentional may increase the likelihood of achieving intended effects. [ABSTRACT FROM AUTHOR]

Background: With the exception of Canada, all countries with universal health insurance systems provide universal coverage of prescription drugs. Progress toward universal public drug coverage in Canada has been slow, in part because of concerns about the potential costs. We sought to estimate the cost of implementing universal public coverage of prescription drugs in Canada. Methods: We used published data on prescribing patterns and costs by drug type, as well as source of funding (i.e., private drug plans, public drug plans and out-of-pocket expenses), in each province to estimate the cost of universal public coverage of prescription drugs from the perspectives of government, private payers and society as a whole. We estimated the cost of universal public drug coverage based on its anticipated effects on the volume of prescriptions filled, products selected and prices paid. We selected these parameters based on current policies and practices seen either in a Canadian province or in an international comparator. Results: Universal public drug coverage would reduce total spending on prescription drugs in Canada by $7.3 billion (worst-case scenario $4.2 billion, best-case scenario $9.4 billion). The private sector would save $8.2 billion (worst-case scenario $6.6 billion, best-case scenario $9.6 billion), whereas costs to government would increase by about $1.0 billion (worst-case scenario $5.4 billion net increase, best-case scenario $2.9 billion net savings). Most of the projected increase in government costs would arise from a small number of drug classes. Interpretation: The long-term barrier to the implementation of universal pharmacare owing to its perceived costs appears to be unjustified. Universal public drug coverage would likely yield substantial savings to the private sector with comparatively little increase in costs to government. [ABSTRACT FROM AUTHOR]

Background: A novel and comprehensive two-year health policy curriculum was developed and implemented for family medicine residents at two University of Toronto-affiliated teaching sites. Aim: To evaluate the impact of the curriculum on residents' knowledge of health policy issues, and its usefulness to their learning. Method: The evaluation included a pre-post delivery assessment of residents' content-based knowledge of issues in the Canadian healthcare system. Residents were also asked to evaluate the content, process and usefulness of the health policy curriculum. Results: At the end, more than two-thirds of residents had a better understanding of the Canadian healthcare system. The overall pre-post scores showed that residents retained content-based facts in some detail. However, more importantly, residents' positive evaluations of the curriculum indicated they were engaged, enthusiastic and recognized its importance for their learning. Conclusion: Despite residents' positive evaluations, questions remain as to how best to assess the success of health policy curricula. Moving beyond the popular pre-post test, less traditional approaches might complement standard program evaluation methods in future. As educators increasingly develop curricula aimed at non-biomedical expertise, we must consider how we can most meaningfully evaluate long-term impact on graduates' approach to clinical practice and their engagement in health system advocacy. [ABSTRACT FROM AUTHOR]

The author discusses the implementation of the national pharmacare in Canada which provides numerals and percentages of Canadians using public drug plans, employers and unions spending for employees' private drug plans, and physicians engagement in health advocacy.

Background: Since 2011, the Government of Ontario, Canada, has phased in hospital funding reforms hoping to encourage standardised, evidence-based clinical care processes to both improve patient outcomes and reduce system costs. One aspect of the reform - quality-based procedures (QBPs) - replaced some of each hospital's global budget with a pre-set price per episode of care for patients with specific diagnoses or procedures. The QBP initiative included publication and dissemination of a handbook for each of these diagnoses or procedures, developed by an expert technical group. Each handbook was intended to guide hospitals in reducing inappropriate variation in patient care and cost by specifying an evidence-based episode of care pathway. We explored whether, how and why hospitals implemented these episode of care pathways in response to this initiative.Methods: We interviewed key informants at three levels in the healthcare system, namely individuals who conceived and designed the QBP policy, individuals and organisations supporting QBP adoption, and leaders in five case-study hospitals responsible for QBP implementation. Analysis involved an inductive approach, incorporating framework analysis to generate descriptive and explanatory themes from data.Results: The 46 key informants described variable implementation of best practice episode of care pathways across QBPs and across hospitals. Handbooks outlining evidence-based clinical pathways did not address specific barriers to change for different QBPs nor differences in hospitals' capacity to manage change. Hospitals sometimes found it easier to focus on containing and standardising costs of care than on implementing standardised care processes that adhered to best clinical practices.Conclusion: Implementation of QBPs in Ontario's hospitals depended on the interplay between three factors, namely complexity of changes required, internal capacity for organisational change, and availability and appropriateness of targeted external facilitators and supports to manage change. Variation in these factors across QBPs and hospitals suggests the need for more tailored and flexible implementation supports designed to fit all elements of the policy, rather than one-size-fits-all handbooks alone. Without such supports, hospitals may enact quick fixes aimed mainly at preserving budgets, rather than pursue evidence- and value-based changes in care management. Overestimating hospitals' change management capacity increases the risk of implementation failure. [ABSTRACT FROM AUTHOR]

The article focuses on vertical integration of health care reforms in Canada. It states that the integration would help in the proper coordination and cooperation of health care providers for better health outcomes and patient experience. It mentions several benefits of the integration including avoidable hospital admissions, shorter emergency department wait times and leveling off of health care spending. It also highlights challenges related to the integration of health reforms.

Background: Through medicare, residents in Canada are entitled to medically necessary physician services without paying out of pocket, but still many people struggle to access primary care. We conducted a survey to explore people's experience with and priorities for primary care., Methods: We conducted an online, bilingual survey of adults in Canada in fall 2022. We distributed an anonymous link through diverse channels and a closed link to 122 053 people via a national public opinion firm. We weighted completed responses to mirror Canada's population and adjusted for sociodemographic characteristics using regression models., Results: We analyzed 9279 completed surveys (5.9% response rate via closed link). More than one-fifth of respondents (21.8%) reported having no primary care clinician, and among those who did, 34.5% reported getting a same or next-day appointment for urgent issues. Of respondents, 89.4% expressed comfort seeing another team member if their doctor recommended it, but only 35.9%, 9.5%, and 12.4% reported that their practice had a nurse, social worker, or pharmacist, respectively. The primary care attribute that mattered most was having a clinician who "knows me as a person and considers all the factors that affect my health." After we adjusted for respondent characteristics, people in Quebec, the Atlantic region, and British Columbia had lower odds of reporting a primary care clinician than people in Ontario (adjusted odds ratio 0.30, 0.33, and 0.39, respectively; p < 0.001). We also observed large provincial variations in timely access, interprofessional care, and walk-in clinic use., Interpretation: More than 1 in 5 respondents did not have access to primary care, with large variation by province. Reforms should strive to expand access to relationship-based, longitudinal care in a team setting., Competing Interests: Competing interests:: Tara Kiran reports receiving support for the present manuscript from Health Canada, Staples Canada, the Max Bell Foundation, and the FDC Foundation. Dr. Kiran has also received grants or contracts from the Ministry of Health and Long-Term Care and the St. Michael’s Hospital Foundation, and grants and consulting fees from Ontario Health. Dr. Kiran has received payment or honoraria from the Canadian Medical Association, the College of Family Physicians of Canada (CFPC), the Association of Family Health Teams of Ontario, the Ontario Medical Association, and the Ontario College of Family Physicians. Dr. Kiran is the Fidani Chair in Improvement and Innovation at the University of Toronto and is also supported as a clinician scientist by the Department of Family and Community Medicine at the University of Toronto and at St. Michael’s Hospital. Amanda Condon reports receiving honoraria as the Manitoba co-lead for OurCare, in support of the present manuscript. Dr. Condon is also the Manitoba co-lead for Health Canada and the Canadian Institutes of Health Research CanTreatCOVID adaptive platform trial, and reports receiving funding for travel related to this trial. Dr. Condon is a director of the board of the CFPC. Michael Green is president and board chair of the CFPC, and board member and chair of the Fellowship Committee of AMS Healthcare Inc. Alan Katz reports receiving support for the current manuscript from the University of Manitoba. Maggie Keresteci reports receiving a grant from the Canadian Association for Health Services and Policy Research, consulting fees from Healthcare Excellence Canada and the Canadian Agency for Drugs and Technologies in Health (CADTH), and payment or honoraria from Healthcare Excellence Canada, CADTH, the Ontario College of Family Physicians, and the University of Ottawa. Dr. Keresteci also reports holding a leadership role with Emily’s House Children’s Hospice. Sarah Newbery reports receiving travel support from the PSI Foundation for attending a meeting, and from the Northern Ontario School of Medicine University for attending the CFPC’s Family Medicine Forum. Dr. Newbery is also a member of the CMAJ Editorial Advisory Board. Goldis Mitra reports holding roles with BC Family Doctors (Executive Treasurer), the Statutory Negotiations Committee of Doctors of BC, and OurCare (BC Physician Lead). Katherine Stringer reports receiving an honorarium as the Nova Scotia co-lead for the OurCare initative (paid to Dalhousie Department of Family Medicine) and support from the CFPC and Dalhousie University to travel to and attend meetings or conferences. Dr. Stringer reports holding the roles of chair of the CFPC Family Medicine Specialty Committee and chair of the Association of Academic Chairs of Family Medicine (both unpaid). No other competing interests were declared., (© 2024 CMA Impact Inc. or its licensors.)

Background: Virtual care for patients with coronavirus disease 2019 (COVID-19) allows providers to monitor COVID-19-positive patients with variable trajectories while reducing the risk of transmission to others and ensuring health care capacity in acute care facilities. The objective of this descriptive analysis was to assess the initial adoption, feasibility and safety of a family medicine-led remote monitoring program, COVIDCare@Home, to manage the care of patients with COVID-19 in the community., Methods: COVIDCare@Home is a multifaceted, interprofessional team-based remote monitoring program developed at an ambulatory academic centre, the Women's College Hospital in Toronto. A descriptive analysis of the first cohort of patients admitted from Apr. 8 to May 11, 2020, was conducted. Lessons from the implementation of the program are described, focusing on measure of adoption (number of visits per patient total, with a physician or with a nurse; length of follow-up), feasibility (received an oximeter or thermometer; consultation with general internal medicine, social work or mental health, pharmacy or acute ambulatory care unit) and safety (hospitalizations, mortality and emergency department visits)., Results: The COVIDCare@Home program cared for a first cohort of 97 patients (median age 41 yr, 67% female) with 415 recorded virtual visits. Patients had a median time from positive testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to first appointment of 3 (interquartile range [IQR] 2-4) days, with a median virtual follow-up time of 8 (IQR 5-10) days. A total of 4 (4%) had an emergency department visit, with no patients requiring hospitalization and no deaths; 16 (16%) of patients required support with mental and social health needs., Interpretation: A family medicine-led, team-based remote monitoring program can safely manage the care of outpatients diagnosed with COVID-19. Virtual care approaches, particularly those that support patients with more complex health and social needs, may be an important part of ongoing health system efforts to manage subsequent waves of COVID-19 and other diseases., Competing Interests: Competing interests: None declared., (© 2021 Joule Inc. or its licensors.)

Competing Interests: Competing interests: Danielle Martin is employed as an administrator at Women’s College Hospital, Toronto, Ont. No other competing interests were declared.

Objective: To compare primary care in Canada and Brazil and how both countries have embraced the Starfield principles in the design of their health care systems., Composition of the Committee: A subgroup of the Besrour Centre of the College of Family Physicians of Canada developed connections with colleagues in Brazil and collaborated to undertake a between-country comparison, comparing and contrasting various elements of both countries' efforts to strengthen primary care over the past few decades., Methods: Following a literature review, the authors collectively reflected on their experiences in an attempt to explore the past and current state of family medicine in Canada and Brazil., Report: The Brazilian and Canadian primary care systems have both adopted and advanced the Starfield principles in various ways, with both countries showing an increasing trend toward adopting interprofessional team-based care. Access to primary care remains a challenge in rural areas in both countries, and longitudinal relationships between providers and patients appear to be more common in Canada. With the advent of technology, increasing patient engagement and expectations, the decline of paternalistic medicine, and the sheer mass of readily available information (and misinformation), to be successful, primary care systems must also be constructed to engender trust at both the local and the system levels. Both countries face challenges to maintaining trust in the context of the increasing prevalence of team-based care, and a lack of trust at the system level can be seen in patients' perceptions about the difficulty of finding a family doctor and in high rates of emergency department and urgent care centre use in both countries. Primary care reform must be implemented with the public's trust in mind., Conclusion: Trust is a crucial ingredient to the success of primary care and must be protected at both local and system levels. If designed with trust in mind, primary care in Canada and Brazil has the potential to meet the challenges set out by the Starfield principles., (Copyright© the College of Family Physicians of Canada.)