ARCHIVED - Canada Health Act Annual Report 2005-2006

The Honourable Tony Clement
Minister of Health
Health Canada
December, 2006

Table of Contents

• Acknowledgements
• Introduction
• Chapter 1 - Canada Health Act Overview
• Chapter 2 - Administration and Compliance
• Chapter 3 - Provincial and Territorial Health Care Insurance Plans in 2004-2005
  • Newfoundland and Labrador
  • Prince Edward Island
  • Nova Scotia
  • New Brunswick
  • Quebec
  • Ontario
  • Manitoba
  • Saskatchewan
  • Alberta
  • British Columbia
  • Yukon
  • Northwest Territories
  • Nunavut

Acknowledgements

Health Canada would like to acknowledge the work and effort that went into producing this Annual Report. It is through the dedication and timely commitment of the following departments of health and their staff that we are able to bring you this report on the administration and operation of the Canada Health Act:

Newfoundland and Labrador Department of Health and Community Services
Prince Edward Island Health and Social Services
Nova Scotia Department of Health
New Brunswick Department of Health and Wellness
Quebec Department of Health and Social Services
Ontario Ministry of Health and Long-Term Care
Manitoba Health
Saskatchewan Health
Alberta Health and Wellness
British Columbia Ministry of Health Services
Yukon Department of Health and Social Services
Northwest Territories Department of Health and Social Services
Nunavut Department of Health and Social Services

We also greatly appreciate the extensive work effort that was put into this report by our production team: the desktop publishing unit, the translators, editors and concordance experts, and staff of Health Canada at headquarters and in the regional offices.

Introduction

Canada has a predominantly publicly financed and administered health care system. The Canadian health insurance system is achieved through 13 interlocking provincial and territorial health insurance plans, and is designed to ensure that all eligible residents of Canada have reasonable access to medically necessary hospital and physician services on a prepaid basis, without direct charges at the point of service.

The Canadian health insurance system evolved into its present form over more than five decades. Saskatchewan was the first province to establish universal, public hospital insurance in 1947 and, 10 years later, the Government of Canada passed the Hospital Insurance and Diagnostic Services Act (1957) to share in the cost of these services. By 1961, all the provinces and territories had public insurance plans that provided universal access to hospital services. Saskatchewan again pioneered in providing insurance for physician services, beginning in 1962. The Government of Canada adopted the Medical Care Act in 1966 to cost-share the provision of insured physician services with the provinces. By 1972, all provincial and territorial plans had been extended to include physician services.

In 1979, at the request of the federal government, Justice Emmett Hall undertook a review of the state of health services in Canada. In his report, he reiterated that health care services in Canada ranked among the best in the world, but warned that extra-billing by doctors and user fees levied by hospitals were creating a two-tiered system that threatened the accessibility of care. This report, and the national debate it generated, led to the enactment of the Canada Health Act in 1984.

The Canada Health Act, Canada's federal health insurance legislation, defines the national principles that govern the Canadian health insurance system, namely, public administration, comprehensiveness, universality, portability and accessibility. These principles are symbols of the underlying Canadian values of equity and solidarity.

The roles and responsibilities for Canada's health care system are shared between the federal and provincial/ territorial governments. The provincial and territorial governments have primary jurisdiction in the administration and delivery of health care services. This includes setting their own priorities, administering their health care budgets and managing their own resources. The federal government, under the Canada Health Act, sets out the criteria and conditions that must be satisfied by the provincial and territorial health insurance plans for them to qualify for their full share of the cash contribution available under the federal Canada Health Transfer.

On an annual basis, the federal Minister of Health is required to report to Parliament on the administration and operations of the Canada Health Act, as set out in section 23 of the Act. The vehicle for so doing is the Canada Health Act Annual Report. While the principal and intended audience for the report is parliamentarians, it is a readily accessible public document that offers a comprehensive report on insured services in each of the provinces and territories. The annual report is structured to address the mandated reporting requirements of the Act - its scope does not extend to commenting on the status of the Canadian health care system as a whole.

Health Canada's approach to the administration of the Act emphasizes transparency, consultation and dialogue with provincial and territorial health care ministries. The application of financial penalties through deductions under the Canada Health Transfer is considered only as a last resort when all options to resolve an issue collaboratively have been exhausted. Pursuant to the commitment made by premiers under the 1999 Social Union Framework Agreement, federal, provincial and territorial governments agreed through an exchange of letters, in April 2002, to a Canada Health Act Dispute Avoidance and Resolution (DAR) process. The DAR process was formalized in the First Ministers' 2004 Accord. Although the DAR process includes dispute resolution provisions, the federal Minister of Health retains the final authority to interpret and enforce the Canada Health Act.

For the most part, provincial and territorial health care insurance plans not only meet the criteria and conditions of the Canada Health Act, in many cases they restate the principles of the Act in provincial and territorial laws and regulations.

Currently, the most prominent concerns with respect to compliance under the Canada Health Act relate to accessibility issues, especially patient charges and queue jumping for medically necessary health services at private clinics. Health Canada has made these concerns known to the provinces that allow these charges.

Chapter 1: Canada Health Act Overview

This section describes the Canada Health Act, its requirements and key definitions under the Act. Also described are the regulations and regulatory provisions of the Act and the interpretation letters by former federal Ministers of Health Jake Epp and Diane Marleau to their provincial and territorial counterparts that are used in the interpretation and application of the Act.

What is the Canada Health Act?

The Canada Health Act is Canada's federal legislation for publicly funded health care insurance. The Act sets out the primary objective of Canadian health care policy, which is "to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers."

The Act establishes criteria and conditions related to insured health services and extended health care services that the provinces and territories must fulfill to receive the full federal cash contribution under the Canada Health Transfer (CHT).

The aim of the Act is to ensure that all eligible residents of Canada have reasonable access to medically necessary services on a prepaid basis, without direct charges at the point of service for such services.

Key Definitions Under the Canada Health Act

Insured persons are eligible residents of a province or territory. A resident of a province is defined in the Act as "a person lawfully entitled to be or to remain in Canada who makes his home and is ordinarily present in the province, but does not include a tourist, a transient or a visitor to the province."

Persons excluded under the Act include serving members of the Canadian Forces or Royal Canadian Mounted Police and inmates of federal penitentiaries.

Insured health services are medically necessary hospital, physician and surgical-dental services provided to insured persons.

Insured hospital services are defined under the Act and include medically necessary in- and out-patient services such as accommodation and meals at the standard or public ward level and preferred accommodation if medically required; nursing service; laboratory, radiological and other diagnostic procedures, together with the necessary interpretations; drugs, biologicals and related preparations when administered in the hospital; use of operating room, case room and anaesthetic facilities, including necessary equipment and supplies; medical and surgical equipment and supplies; use of radiotherapy facilities; use of physiotherapy facilities; and services provided by persons who receive remuneration therefore from the hospital, but does not include services that are excluded by the regulations.

Insured physician services are defined under the Act as "medically required services rendered by medical practitioners." Medically required physician services are generally determined by physicians in conjunction with their provincial and territorial health insurance plans.

Insured surgical-dental services are services provided by a dentist in a hospital, where a hospital setting is required to properly perform the procedure.

Extended health care services as defined in the Act are certain aspects of long-term residential care (nursing home intermediate care and adult residential care services), and the health aspects of home care and ambulatory care services.

Requirements of the Canada Health Act

The Canada Health Act contains nine requirements that the provinces and territories must fulfill in order to qualify for the full amount of their cash entitlement under the CHT. They are:

• five program criteria that apply only to insured health services;
• two conditions that apply to insured health services and extended health care services; and
• extra-billing and user charges provisions that apply only to insured health services.

The Criteria

1. Public Administration (section 8)

The public administration criterion, set out in section 8 of the Canada Health Act, applies to provincial and territorial health care insurance plans. The intent of the public administration criterion is that the provincial and territorial health care insurance plans be administered and operated on a non-profit basis by a public authority, which is accountable to the provincial or territorial government for decision-making on benefit levels and services, and whose records and accounts are publicly audited.

2. Comprehensiveness (section 9)

The comprehensiveness criterion of the Act requires that the health care insurance plan of a province or territory must cover all insured health services provided by hospitals, physicians or dentists (i.e., surgical-dental services that require a hospital setting) and, where the law of the province so permits, similar or additional services rendered by other health care practitioners.

3. Universality (section 10)

Under the universality criterion, all insured residents of a province or territory must be entitled to the insured health services provided by the provincial or territorial health care insurance plan on uniform terms and conditions. Provinces and territories generally require that residents register with the plans to establish entitlement.

Newcomers to Canada, such as landed immigrants or Canadians returning from other countries to live in Canada, may be subject to a waiting period by a province or territory, not to exceed three months, before they are entitled to receive insured health services.

4. Portability (section 11)

Residents moving from one province or territory to another must continue to be covered for insured health services by the "home" jurisdiction during any waiting period imposed by the new province or territory of residence. The waiting period for eligibility to a provincial or territorial health care insurance plan must not exceed three months. After the waiting period, the new province or territory of residence assumes responsibility for health care coverage.

Residents who are temporarily absent from their home province or territory or from Canada, must continue to be covered for insured health services during their absence. This allows individuals to travel or be absent from their home province or territory, within a prescribed duration, while retaining their health insurance coverage.

The portability criterion does not entitle a person to seek services in another province, territory or country, but is intended to permit a person to receive necessary services in relation to an urgent or emergent need when absent on a temporary basis, such as on business or vacation.

If insured persons are temporarily absent in another province or territory, the portability criterion requires that insured services be paid at the host province's rate. If insured persons are temporarily out of the country, insured services are to be paid at the home province's rate.

Prior approval by the health care insurance plan in a person's home province or territory may also be required before coverage is extended for elective (non-emergency) services to a resident while temporarily absent from his/her province or territory.

5. Accessibility (section 12)

The intent of the accessibility criterion is to ensure that insured persons in a province or territory have reasonable access to insured hospital, medical and surgical-dental services on uniform terms and conditions, unprecluded or unimpeded, either directly or indirectly, by charges (user charges or extra-billing) or other means (e.g., discrimination on the basis of age, health status or financial circumstances).

In addition, the health care insurance plans of the province or territory must provide:

• reasonable compensation to physicians and dentists for all the insured health services they provide; and
• payment to hospitals to cover the cost of insured

health services. Reasonable access in terms of physical availability of medically necessary services has been interpreted under the Canada Health Act using the "where and as available" rule. Thus, residents of a province or territory are entitled to have access on uniform terms and conditions to insured health services at the setting "where" the services are provided and "as" the services are available in that setting.

The Conditions

1. Information (section 13(a))

The provincial and territorial governments shall provide information to the Minister of Health as may be reasonably required, in relation to insured health services and extended health care services, for the purposes of the Act.

2. Recognition (section 13(b))

The provincial and territorial governments shall recognize the federal financial contributions toward both insured and extended health care services.

Extra-billing and User Charges

The provisions of the Canada Health Act, which discourage extra-billing and user charges for insured health services in a province or territory, are outlined in sections 18 to 21. If it can be determined that either extra-billing or user charges exist in a province or territory, a mandatory deduction from the federal cash transfer to that province or territory is required under the Act. The amount of such a deduction for a fiscal year is determined by the federal Minister of Health based on information provided by the province or territory in accordance with the Extra-billing and User Charges Information Regulations (described below).

Extra-billing (section 18)

Under the Act, extra-billing is defined as the billing for an insured health service rendered to an insured person by a medical practitioner or a dentist (i.e., a surgical-dentist providing insured health services in a hospital setting) in an amount in addition to any amount paid or to be paid for that service by the health care insurance plan of a province or territory. For example, if a physician were to charge patients any amount for an office visit that is insured by the provincial or territorial health insurance plan, the amount charged would constitute extra-billing. Extra-billing is seen as a barrier or impediment for people seeking medical care, and is therefore contrary to the accessibility criterion.

User Charges (section 19)

The Act defines user charges as any charge for an insured health service other than extra-billing that is permitted by a provincial or territorial health care insurance plan and is not payable by the plan. For example, if patients were charged a facility fee for receiving an insured service at a hospital or clinic, that fee would be considered a user charge. User charges are not permitted under the Act because, as is extra-billing, they constitute a barrier or impediment to access.

Other Elements of the Act

Regulations (section 22)

Section 22 of the Canada Health Act enables the federal government to make regulations for administering the Act in the following areas:

• defining the services included in the Act definition of "extended health care services";
• prescribing which services to exclude from hospital services;
• prescribing the types of information that the federal Minister of Health may reasonably require, and the times at which and the manner in which that information may be provided; and
• prescribing how provinces and territories are required to recognize the CHT in their documents, advertising or promotional materials.

To date, the only regulations in force under the Act are the Extra-billing and User Charges Information Regulations. These regulations require the provinces and territories to provide estimates of extra-billing and user charges before the beginning of a fiscal year so that appropriate penalties can be levied. They must also provide financial statements showing the amounts actually charged so that reconciliations with the actual deductions can be made. (A copy of these regulations is provided in Annex A.)

Penalty Provisions of the Canada Health Act

Mandatory Penalty Provisions

Under the Act, provinces and territories that allow extra-billing and user charges are subject to mandatory dollar-for-dollar deductions from the federal transfer payments under the CHT. In plain terms, when it has been determined that a province or territory has allowed $500,000 in extra-billing by physicians, the federal cash contribution to that province or territory will be reduced by that same amount.

Discretionary Penalty Provisions

Non-compliance with one of the five criteria or two conditions of the Act is subject to a discretionary penalty. The amount of any deduction from federal transfer payments under the CHT is based on the gravity of the default.

The Canada Health Act sets out a consultation process that must be undertaken with the province or territory before discretionary penalties can be levied. To date, the discretionary penalty provisions of the Act have not been applied.

Excluded Services and Persons

Although the Canada Health Act requires that insured health services be provided to insured persons in a manner that is consistent with the criteria and conditions set out in the Act, not all Canadian residents or health services fall under the scope of the Act. There are two categories of exclusion for insured services:

• services that fall outside the definition of insured health services; and
• certain services and groups of persons are excluded from the definitions of insured services and insured persons. These exclusions are discussed below.

Non-insured Health Services

In addition to the medically necessary hospital and physician services covered by the Canada Health Act, provinces and territories also provide a range of programs and services outside the scope of the Act. These are provided at provincial and territorial discretion, on their own terms and conditions, and vary from one province or territory to another. Additional services that may be provided include pharmacare, ambulance services and optometric services.

The additional services provided by provinces and territories are often targeted to specific population groups (e.g., children, seniors or social assistance recipients), and may be partially or fully covered by provincial and territorial health insurance plans.

A number of services provided by hospitals and physicians are not considered medically necessary, and thus are not insured under provincial and territorial health insurance legislation. Uninsured hospital services for which patients may be charged include preferred hospital accommodation unless prescribed by a physician, private duty nursing services and the provision of telephones and televisions. Uninsured physician services for which patients may be charged include telephone advice, the provision of medical certificates required for work, school, insurance purposes and fitness clubs, testimony in court and cosmetic services.

Excluded Persons

The Canada Health Act definition of "insured person" excludes members of the Canadian Forces, persons appointed to a position of rank within the Royal Canadian Mounted Police and persons serving a term of imprisonment within a federal penitentiary. The Government of Canada provides coverage to these groups through separate federal programs.

As well, other categories of residents such as landed immigrants and Canadians returning to live from other countries may be subject to a waiting period by a province or territory. The Act stipulates that the waiting period cannot exceed three months.

In addition, the definition of "insured health services" excludes services to persons provided under any other Act of Parliament (e.g., refugees) or under the workers' compensation legislation of a province or territory.

The exclusion of these persons from insured health service coverage predates the adoption of the Act and is not intended to constitute differences in access to publicly insured health care.

Policy Interpretation Letters

There are two key policy statements that clarify the federal position on the Canada Health Act. These statements have been made in the form of ministerial letters from former federal ministers of health to their provincial and territorial counterparts. Both letters are reproduced in Annex B of this report.

Epp Letter

In June 1985, approximately one year following the passage of the Canada Health Act in Parliament, then-federal Minister of Health and Welfare Jake Epp wrote to his provincial and territorial counterparts to set out and confirm the federal position on the interpretation and implementation of the Act.

Minister Epp's letter followed several months of consultation with his provincial and territorial counterparts. The letter sets forth statements of federal policy intent that clarify the Act's criteria, conditions and regulatory provisions. These clarifications have been used by the federal government in assessing and interpreting compliance with the Act. The Epp letter remains an important reference for interpreting the Act.

Marleau Letter - Federal Policy on Private Clinics

Between February 1994 and December 1994, a series of seven federal/provincial/ territorial meetings dealing wholly or in part with private clinics took place. At issue was the growth of private clinics providing medically necessary services funded partially by the public system and partially by patients and its impact on Canada's universal, publicly funded health care system.

At the September 1994 federal/provincial/territorial meeting of health ministers in Halifax, all ministers of health present, with the exception of Alberta's health minister, agreed to "take whatever steps are required to regulate the development of private clinics in Canada."

Diane Marleau, the federal Minister of Health at the time, wrote to all provincial and territorial ministers of health on January 6, 1995, to announce the new Federal Policy on Private Clinics. The Minister's letter provided the federal interpretation of the Canada Health Act as it relates to the issue of facility fees charged directly to patients receiving medically necessary services at private clinics. The letter stated that the definition of "hospital" contained in the Act includes any public facility that provides acute, rehabilitative or chronic care. Thus, when a provincial/ territorial health insurance plan pays the physician fee for a medically necessary service delivered at a private clinic, it must also pay the facility fee or face a deduction from federal transfer payments.

Dispute Avoidance and Resolution Process

In April 2002, then-federal Minister of Health A. Anne McLellan outlined in a letter to her provincial and territorial counterparts a Canada Health Act Dispute Avoidance and Resolution process, which was agreed to by provinces and territories, except Quebec. The process meets federal and provincial/territorial interests of avoiding disputes related to the interpretation of the principles of the Act, and when this is not possible, resolving disputes in a fair, transparent and timely manner.

The process includes the dispute avoidance activities of government-to-government information exchange; discussions and clarification of issues as they arise; active participation of governments in ad hoc federal/provincial/ territorial committees on Act-related issues; and Canada Health Act advance assessments, upon request.

Where dispute avoidance activities prove unsuccessful, dispute resolution activities may be initiated, beginning with government-to-government fact-finding and negotiations. If these are unsuccessful, either minister of health involved may refer the issues to a third-party panel to undertake fact-finding and provide advice and recommendations.

The federal Minister of Health has the final authority to interpret and enforce the Canada Health Act. In deciding whether to invoke the non-compliance provisions of the Act, the Minister will take the panel's report into consideration.

A copy of Minister McLellan's letter is included in Annex C of this report.

Chapter 2: Administration and Compliance

Administration

In administering the Canada Health Act, the federal Minister of Health is assisted by Health Canada policy, communications and information officers located in Ottawa and in the six regional offices of the Department, and by lawyers with the Department of Justice.

Health Canada works with the provinces and territories to ensure that the principles of the Act are respected. Our preference is always to work with provinces and territories to resolve issues through consultation, collaboration and cooperation.

The Canada Health Act Division

The Canada Health Act Division is part of the Intergovernmental Affairs Directorate of the Health Policy Branch at Health Canada and is responsible for administering the Act. Officers of the Division located in Ottawa and in regional Health Canada offices fulfill the following ongoing functions:

• monitoring and analysing provincial and territorial health insurance plans for compliance with the criteria, conditions and extra-billing and user charges provisions of the Act;
• working in partnership with the provinces and territories to investigate and resolve compliance issues and pursue activities that encourage compliance with the Act;
• informing the Minister of possible non-compliance and recommending appropriate action to resolve the issue;
• developing and producing the Canada Health Act Annual Report on the administration and operation of the Act;
• developing and maintaining formal and informal contacts and partnerships with health officials in provincial and territorial governments to share information;
• collecting, summarizing and analysing relevant information on provincial and territorial health care systems;
• disseminating information on the Act and on publicly funded health care insurance programs in Canada;
• responding to information requests and correspondence relating to the Act by preparing responses to inquiries about the Act and health insurance issues received by telephone, mail and the Internet, from the public, members of Parliament, government departments, stakeholder organizations and the media;
• conducting issue analysis and policy research to provide policy advice;
• collaborating with provincial and territorial health department representatives on the recommendations to the Minister concerning the interpretation of the Act; and
• collaborating with provincial and territorial health department representatives through the Interprovincial Health Insurance Agreements Coordinating Committee (see below).

Interprovincial Health Insurance Agreements Coordinating Committee (IHIACC)

The Canada Health Act Division chairs the Interprovincial Health Insurance Agreements Coordinating Committee and provides a secretariat for the Committee. The Committee was formed in 1991 to address issues affecting the interprovincial billing of hospital and medical services as well as issues related to registration and eligibility for health insurance coverage. It oversees the application of interprovincial health insurance agreements in accordance with the Canada Health Act.

The within-Canada portability provisions of the Act are implemented through a series of bilateral reciprocal billing agreements between provinces and territories for hospital and physician services. This generally means that a patient's health card will be accepted, in lieu of payment, when the patient receives hospital or physician services in another province or territory. The province or territory providing the service will then directly bill the patient's home province. All provinces and territories participate in reciprocal hospital agreements and all, with the exception of Quebec, participate in reciprocal medical agreements. The intent of these agreements is to ensure that Canadian residents do not face point-of-service charges for medically required hospital and physician services when they travel in Canada. However, these agreements are interprovincial/territorial and signing them is not a requirement of the Act.

Compliance

As mentioned in Chapter 1, the provinces and territories must comply with the criteria and conditions of the Canada Health Act to receive the full amount of the Canada Health Transfer (CHT) cash contribution (previous to April 1, 2004, the cash contribution was payable under the Canada Health and Social Transfer). The following section outlines how Health Canada determines provincial/territorial compliance.

Health Canada's approach to resolving possible compliance issues emphasizes transparency, consultation and dialogue with provincial and territorial health ministry officials. In most instances, issues are successfully resolved through consultation and discussion based on a thorough examination of the facts. Deductions have only been applied when all options to resolve the issue have been exhausted. To date, most disputes and issues related to administering and interpreting the Canada Health Act have been addressed and resolved without resorting to deductions.

Health Canada officials routinely liaise with provincial and territorial health ministry representatives and health insurance plan administrators to help resolve common problems experienced by Canadians related to eligibility for health insurance coverage and portability of health services within and outside Canada.

The Canada Health Act Division and regional office staff monitor the operations of provincial and territorial health care insurance plans in order to provide advice to the Minister on possible non-compliance with the Act. Sources for this information include: provincial and territorial government officials and publications; media reports; and correspondence received from the public and other non-government organizations. Staff in the Compliance and Interpretation Unit, Canada Health Act Division, assess issues of concern and complaints on a case-by-case basis. The assessment process involves compiling all facts and information related to the issue and taking appropriate action. Verifying the facts with provincial and territorial health officials may reveal issues that are not directly related to the Act, while others may pertain to the Act but are a result of misunderstanding or miscommunication, and are resolved quickly with provincial assistance. In instances where a Canada Health Act issue has been identified and remains after initial enquiries, Division officials then ask the jurisdiction in question to investigate the matter and report back. Division staff then discuss the issue and its possible resolution with provincial officials. Only if the issue is not resolved to the satisfaction of the Division after following the aforementioned steps, is it brought to the attention of the federal Minister of Health.

Compliance Issues

For the most part, provincial and territorial health care insurance plans meet the criteria and conditions of the Canada Health Act. However, some issues and concerns remain. The most prominent of these relate to accessibility issues, especially patient charges and queue jumping for medically necessary health services at private clinics.

The Act requires that all medically necessary physician and hospital services be covered by the provincial and territorial health insurance plans, whether the services are provided in a hospital or in a facility providing hospital care. There are concerns about queue jumping and charges to insured persons at private surgical clinics in Quebec and British Columbia, for services that are covered under their respective provincial health insurance plans. Patient charges and queue jumping at private diagnostic clinics also remains an issue in five provinces (British Columbia, Alberta, Manitoba, Quebec and Nova Scotia). where private clinics are charging patients and allowing them to jump the queue for insured health services.

During 2005-2006, Health Canada was successful in reaching an agreement with Manitoba to address patient charges for medical surgical supplies, known as "tray fees."

Also during 2005-2006, the federal Health Minister notified his counterpart in New Brunswick of his intent to refer the province's refusal to provide coverage for medically necessary abortion services performed in clinics to a panel review under the Canada Health Act Dispute Avoidance and Resolution process.

Canada Health Transfer Deductions in 2005-2006

Deductions were taken from the March 2006 Canada Health Transfer (CHT) payments to British Columbia in respect of extra-billing and user charges at surgical clinics that occurred during fiscal year 2003-2004, in the amount of $29,019, on the basis of charges reported by the province to Health Canada.

A one-time positive adjustment in the amount of $8,121 was made to Nova Scotia's March 2006 CHT to reconcile amounts actually charged in respect of extra-billing and user charges at a private clinic with the penalties that had already been levied, based on provincial estimates reported for fiscal 2003-2004.

History of Deductions and Refunds Under the Canada Health Act

The Canada Health Act, which came into force April 1, 1984, reaffirmed the national commitment to the original principles of the Canadian health care system, as embodied in the previous legislation, the Medical Care Act and the Hospital Insurance and Diagnostic Services Act. By putting into place mandatory dollar-for-dollar penalties for extra-billing and user charges, the federal government took steps to eliminate the proliferation of direct charges for hospital and physician services, judged to be restricting the access of many Canadians to health care services due to financial considerations.

During the period 1984 to 1987, subsection 20(5) of the Act provided for deductions in respect of these charges to be refunded to the province if the charges were eliminated before April 1, 1987. By March 31, 1987, it was determined that all provinces, which had extra-billing and user charges, had taken appropriate steps to eliminate them. Accordingly, by June 1987, a total of $244.732 million in deductions were refunded to New Brunswick ($6.886 million), Quebec ($14.032 million), Ontario ($106.656 million), Manitoba ($1.270 million), Saskatchewan ($2.107 million), Alberta ($29.032 million) and British Columbia ($84.749 million).

Following the Canada Health Act's initial three-year transition period, under which refunds to provinces and territories for deductions were possible, penalties under the Act did not reoccur until fiscal year 1994-1995. As a result of a dispute between the British Columbia Medical Association and the British Columbia government over compensation, several doctors opted out of

the provincial health insurance plan and began billing their patients directly. Some of these doctors billed their patients at a rate greater than the amount the patients could recover from the provincial health insurance plan. This higher amount constituted extra-billing under the Act. Including deduction adjustments for prior years, dating back to fiscal year 1992-1993, deductions began in May 1994 until extra-billing by physicians was banned when changes to British Columbia's Medicare Protection Act came into effect in September 1995. In total, $2.025 million was deducted from British Columbia's cash contribution for extra-billing that occurred in the province between 1992-1993 and 1995-1996. These deductions and all subsequent deductions are non-refundable.

In January 1995, the federal Minister of Health, Diane Marleau, expressed concerns to her provincial and territorial colleagues about the development of two-tiered health care and the emergence of private clinics charging facility fees for medically necessary services. As part of her communication with the provinces and territories, Minister Marleau announced that the provinces and territories would be given more than nine months to eliminate these user charges, but that any province that did not, would face financial penalties under the Canada Health Act. Accordingly, beginning in November 1995, deductions were applied to the cash contributions to Alberta, Manitoba, Nova Scotia and Newfoundland and Labrador for noncompliance with the Federal Policy on Private Clinics.

From November 1995 to June 1996, total deductions of $3.585 million were made to Alberta's cash contribution in respect of facility fees charged at clinics providing surgical, ophthalmological and abortion services. On October 1, 1996, Alberta prohibited private surgical clinics from charging patients a facility fee for medically necessary services for which the physician fee was billed to the provincial health insurance plan.

Similarly, due to facility fees allowed at an abortion clinic, a total of $284,430 was deducted from Newfoundland and Labrador's cash contribution before these fees were eliminated, effective January 1, 1998.

From November 1995 to December 1998, deductions from Manitoba's CHST cash contribution amounted to $2,055,000, ending with the confirmed elimination of user charges at surgical and ophthalmology clinics, effective January 1, 1999. However, during fiscal year 2001-2002, a monthly deduction (from October 2001 to March 2002 inclusive) in the amount of $50,033 was levied against Manitoba's CHST cash contribution on the basis of a financial statement provided by the province showing that actual amounts charged with respect to user charges for insured services in fiscal years 1997-1998 and 1998-1999 were greater than the deductions levied on the basis of estimates. This brought total deductions levied against Manitoba to $2,355,201.

With the closure of its abortion clinic in Halifax effective November 27, 2003, Nova Scotia was deemed to be in compliance with the Federal Policy on Private Clinics. Before it closed, a total deduction of $372,135 was made from Nova Scotia's CHST cash contribution for its failure to cover facility charges to patients while paying the physician fee.

In January 2003, British Columbia provided a financial statement in accordance with the Canada Health Act Extra-billing and User Charges Information Regulations, indicating aggregate amounts actually charged with respect to extra-billing and user charges during fiscal year 2000-2001, totalling $4,610. Accordingly, a deduction of $4,610 was made to the March 2003 CHST cash contribution.

In 2004, British Columbia did not report to Health Canada the amounts of extra-billing and user charges actually charged during fiscal year 2001-2002, in accordance with the requirements of the Extra-billing and User Charges Information Regulations. As a result of reports that British Columbia was investigating cases of user charges, a $126,775 deduction was taken from British Columbia's March 2004 CHST payment, based on the amount Health Canada estimated to have been charged during fiscal year 2001-2002.

Deductions were taken from the March 2005 CHT payments to three provinces as a result of charges to patients which occurred during 2002-2003. A deduction of $72,464 was made to British Columbia on the basis of charges reported by the province for extra-billing and patient charges at surgical clinics. A deduction of $1,100 was made to Newfoundland and Labrador as a result of patient charges for a Magnetic Resonance Imaging scan in a hospital, and a deduction of $5,463 was made to Nova Scotia as a reconciliation for deductions that had already been made to Nova Scotia for patient charges at a private clinic.

Deductions were taken from the March 2006 CHT payments to British Columbia in respect of extra-billing and user charges at surgical clinics that occurred during fiscal year 2003-2004, in the amount of $29,019, on the basis of charges reported by the province to Health Canada.

A one-time positive adjustment in the amount of $8,121 was made to Nova Scotia's March 2006 CHT to reconcile amounts actually charged in respect of extra-billing and user charges at a private clinic with the penalties that had already been levied, based on provincial estimates reported for fiscal 2003-2004.

Since the enactment of the Canada Health Act, from April 1984 to March 2006, deductions totalling $8,853,076 have been applied against provincial cash contributions in respect of the extra-billing and user charges provisions of the Act. This amount excludes deductions totalling $244,732,000 that were made between 1984 and 1987 and subsequently refunded to the provinces when extra-billing and user charges were eliminated.

Chapter 3: Provincial and Territorial Health Care Insurance Plans in 2005-2006

The following chapter presents the 13 provincial and terri torial health insurance plans that make up the Canadian publicly funded health insurance system. The purpose of this chapter is to demonstrate clearly and consistently the extent to which provincial and territorial plans fulfilled the requirements of the Canada Health Act program criteria and conditions in 2005-2006.

Officials in the provincial, territorial and federal governments have collaborated to produce the detailed plan overviews contained in Chapter 3. While all provinces and territories have submitted detailed descriptive infor mation on their health insurance plans, New Brunswick and Quebec have chosen not to submit supplemental statistical information which is contained in the tables in this year's report. The information that Health Canada requested from the territorial departments of health for the report consists of two components:

• a narrative description of the provincial or territorial health care system relating to the five criteria and the first condition (that of providing the Minister of Health with information in relation to insured health services and extended health care services) of the Act, which can be found following this chapter; and
• statistical information related to insured health services.

The narrative component is used to help with the moni toring and compliance of provincial and territorial health care plans with respect to the requirements of the Canada Health Act, while statistics help to identify current and future trends in the Canadian health care system.

To help provinces and territories prepare their submissions to the annual report, Health Canada provided them with the document Canada Health Act Annual Report 2005-2006: A Guide for Updating Submissions (User's Guide). This guide was developed through discussion with provincial and territorial officials and is designed to help provinces and territories meet the reporting requirements of Health Canada. Annual revisions to the guide are based on Health Canada's analysis of health plan descriptions from previous annual reports and its assessment of emerging issues relating to insured health services.

The process for the 2005-2006 Canada Health Act Annual Report was launched late spring 2006 when letters were sent to all provinces and territories confirming the time table for this year's annual report. An updated User's Guide was also sent to the provinces and territories at that time. Additionally, bilateral meetings were held this year with provincial and territorial officials from Ontario and Prince Edward Island to review the process and reporting requirements.

Insurance Plan Descriptions

For the following chapter, provincial and territorial officials were asked to provide a narrative description of their health insurance plan. The descriptions follow the program criteria areas of the Canada Health Act in order to illustrate how the plans satisfy these criteria. This narrative description also includes information on how each jurisdiction met the Canada Health Act requirement for recognition of federal contributions that support insured and extended health care services and a section outlining the range of extended health care services in their jurisdiction.

Provincial and Territorial Health Care Insurance Plan Statistics

In 2003-2004, the section of the annual report containing the statistical information submitted from the provinces and territories was simplified and streamlined following feedback received from provincial and territorial officials, and based on a review of data quality and availability.

The format remains the same for the 2005-2006 report. The supplemental statistical information can be found at the end of each provincial or territorial narrative, except for New Brunswick and Quebec.

The purpose of the statistical tables is to place the administration and operation of the Canada Health Act in context and to provide a national perspective on trends in the delivery and funding of insured health services in Canada that are within the scope of the federal Act.

The statistical tables contain resource and cost data for insured hospital, physician and surgical-dental by province and territory for five consecutive years ending on March 31, 2006. All information was provided by provincial and territorial officials.

Although efforts are made to capture data on a consistent basis, differences exist in the reporting on health care programs and services between provincial and territorial governments. Therefore, comparisons between jurisdictions are not made. Provincial and territorial governments are responsible for the quality and completeness of the data they provide.

Organization of the Information

Information in the tables is grouped according to the nine subcategories described below.

Registered Persons: Registered persons are the number of residents registered with the health care insurance plans of each province or territory.

Public Facilities: Statistics on facilities providing insured hospital services, excluding psychiatric hospitals and nursing homes (which are not covered under the CHA), are provided in fields two and three.

Private-for-Profit Facilities: Measures four through six capture statistics on private-for-profit health care facilities that provide insured hospital services. These measures have been broken down into two sub-categories based on the services provided under the definition of insured hospital services in the CHA.

Insured Physician Services Within Own Province or Territory: Statistics in this sub-section relate to the provision of insured physician services to residents in each province or territory, as well as to visitors from other regions of Canada.

Insured Services Provided to Residents in Another Province or Territory - Hospitals: This sub-section presents out-of-province or out-of-territory insured hospital services that are paid for by a person's home jurisdiction when they travel to other parts of Canada.

Insured Services Provided to Residents in Another Province or Territory - Physicians: This sub-section reports on physician services that are paid by a jurisdiction to other provinces or territories for their visiting residents.

Insured Services Provided Outside Canada - Hospitals: Hospital services provided out of country represent a person's hospital costs incurred while travel ling outside of Canada that are paid for by their home province or territory.

Insured Services Provided Outside Canada - Physicians: Physician services provided out of country represent a person's medical costs incurred while travelling outside of Canada that are paid by their home province or territory.

Insured Surgical-Dental Services Within Own Province or Territory: The information in this subsection describes insured surgical-dental services provided in each province or territory.

Newfoundland and Labrador

Introduction

The reorganization of the province's 14 health boards into four new regional health authorities occurred in 2005-2006. The new structure will achieve greater integration of services on a regional basis. The four new regional authorities will focus on the full continuum of care including public health, community services and acute and long-term care services. By the end of fiscal year 2005-2006, new Boards of Trustees and senior executive teams were in place and restructuring of administrative and support services were underway.

The provincial government appoints Boards of Trustees who serve as volunteers. These boards are responsible for delivering health and community services to their regions and, in some cases, to the province as a whole, interact. Regional authorities interact with the public and stakeholders to determine health needs. The boards receive their funding from the provincial government, to which they are accountable. The Department of Health and Community Services provides the boards with policy direction and monitors programs and services.

In March 2006 the department released the Provincial Wellness Plan. The first phase of the plan will be implemented over the next three years and will focus on key areas including healthy eating, physical activity, tobacco control and injury prevention.

Other key initiatives during the year included:

• The appointment of the province's first Chief Nurse.
• A new Medical Act which will increase accountability and public protection. Under this legislation, the Newfoundland Medical Board is renamed the College of Physicians and Surgeons of Newfoundland and Labrador.
• Working Together for Mental Health, a new provincial policy for mental health and addictions services, was released.
• The Province reached a new four-year Memorandum of Agreement with physicians.
• Design and some site work began on new long-term care sites in the Eastern and Western regions.
• Budget 2005 continued Government's development of an Electronic Health Record through an investment of $4 million to expand and enhance the Picture Archiving and Communications System (PACS). This allows diagnostic images including X-rays and CT scans to be digitally captured, viewed, stored and transmitted electronically from one facility to another. By 2007 there will be 27 PACS sites in Newfoundland and Labrador making it the first province in Canada to have a province-wide system.
• A Provincial Wait Time Coordinator was hired in September 2005 to coordinate improved monitoring and reporting of wait times for select health services. Regional Wait Times coordinators were put in place to assist with this initiative. In December 2005, Government announced the implementation of pan-Canadian wait times for five select procedures and committed to quarterly reporting.
• Budget 2005 allocated $2.6 million to implement another three primary health care teams (Port aux Basques, Deer Lake/White Bay, Springdale/Green Bay) and expand some of the existing networks, with funding provided to four more areas (Grand Falls-Windsor/Botwood, New-Wes-Valley, St. John's downtown and Burin Peninsula) to develop proposals for PHC changes in their areas.
• In spring 2005, a Chronic Disease Prevention and Management Collaborative program, with diabetes as the first collaborative, was funded provincially and initiated in eight PHC team areas.
• In winter 2005, funding was provided to develop a provincial Telehealth Plan.

The Department continues to address the challenges of delivering quality health and community services to the people of the province while recognizing the challenges of an aging population, fiscal resource constraints, diverse geography and human resource issues.

In Newfoundland and Labrador, almost 19,000 health care providers and administrators provided health services to 510,000 residents.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

Health care insurance plans managed by the Department include the Hospital Insurance Plan and the Medical Care Plan. Both plans are non-profit and publicly administered.

The Hospital Insurance Agreement Act, amended in 1994, is the legislation that enables the Hospital Insurance Plan. The Act gives the Minister of Health and Community Services the authority to make regulations for providing insured services on uniform terms and conditions to residents of the province under the conditions specified in the Canada Health Act and Regulations.

The Medical Care Insurance Act (1999) which came into force on April 1, 2000, empowers the Minister to administer a plan of medical care insurance for residents of the province. It allows for developing regulations to ensure that the provisions of the statute meet the requirements of the Canada Health Act as it relates to administering the Medical Care Plan.

The Medical Care Plan facilitates the delivery of comprehensive medical care to all residents of the province by implementing policies, procedures and systems that permit appropriate compensation to providers for rendering insured professional services. The Medical Care Plan operates in accordance with the provisions of the Medical Care Insurance Act (1999) and Regulations, and in compliance with the Canada Health Act.

There were no legislative amendments to the Medical Care Insurance Act (1999) or the Hospital Insurance Agreement Act in 2005-2006.

1.2 Reporting Relationship

The Department is mandated with administering the Hospital Insurance and Medical Care Plans. The Department reports on these plans through the regular legislative processes, e.g. Public Accounts and the Estimates Committee of the House of Assembly.

The Department will be tabling its 2005-2006 Annual Report in the House of Assembly in fall 2006. The four regional health authorities, on behalf of predecessor boards, and some health agencies will also table their reports.

The Department's Annual Report highlights the accomplishments of 2005-2006 and provides an overview of the initiatives and programs that will continue to be developed in 2006-2007. The report is a public document and is circulated to stakeholders. It will be posted on the Department's website at: www.health.gov.nl.ca/health.

1.3 Audit of Accounts

Each year the Province's Auditor General independently examines provincial public accounts. The expenditures are now considered a part of the public accounts. The Auditor General has full and unrestricted access to MCP records.

The four regional health authorities are subject to Financial Statement Audits, Reviews and Compliance Audits. Financial Statement Audits were performed by independent auditing firms that are selected by the health authorities under the terms of the Public Tendering Act. Review engagements, compliance audits and physician audits were carried out by personnel from the Department under the authority of the Newfoundland Medical Care Insurance Act (1999). Physician records and professional medical corporation records were reviewed to ensure that the records supported the services billed and that the services are insured under the Medical Care Plan.

Beneficiary audits were performed by personnel from the Department under the Medical Care Insurance Act (1999). Individual providers are randomly selected on a bi-weekly basis for audit.

2.0 Comprehensiveness

2.1 Insured Hospital Services

The Hospital Insurance Agreement Act (as amended) and the Hospital Insurance Regulations 742/96 (1996) provide for insured hospital services in Newfoundland and Labrador.

Insured hospital services are provided for in- and outpatients in 36 facilities (14 hospitals and 22 community health centres) and 14 nursing stations. Insured services include: accommodation and meals at the standard ward level; nursing services; laboratory, radiology and other diagnostic procedures; drugs, biologicals and related preparations; medical and surgical supplies, operating room, case room and anaesthetic facilities; rehabilitative services (e.g. physiotherapy, occupational therapy, speech language pathology and audiology); out-patient and emergency visits; and day surgery.

The coverage policy for insured hospital services is linked to the coverage policy for insured physician services. The Department of Health and Community Services manages the process of adding or delisting a hospital service from the list of insured services based on direction from the Minister. There were no services added or de-listed in 2005-2006.

2.2 Insured Physician Services

The enabling legislation for insured physician services is the Medical Care Insurance Act (1999).

Other governing legislation under the Medical Care Insurance Act includes:

• the Medical Care Insurance Insured Services Regulations;
• the Medical Care Insurance Beneficiaries and Inquiries Regulations; and
• the Medical Care Insurance Physician and Fees Regulations.

Licensed medical practitioners are allowed to provide insured physician services under the insurance plan. A physician must be licensed by the Newfoundland Medical Board (now named the College of Physicians and Surgeons of Newfoundland and Labrador) to practice in the province.

An insured service is defined as one that is: listed in section 3 of the Medical Care Insurance Insured Services Regulations; medically necessary; and/or recommended by the Department of Health and Community Services. There are no limitations on the services covered, subject to these criteria.

For purposes of the Act, the following services are covered:

• all services properly and adequately provided by physicians to beneficiaries suffering from an illness requiring medical treatment or advice;
• group immunizations or inoculations carried out by physicians at the request of the appropriate authority; and
• diagnostic and therapeutic x-ray and laboratory services in facilities approved by the appropriate authority that are not provided under the Hospital Insurance Agreement Act and Regulations made under the Act.

Physicians can choose not to participate in the health care insurance plan as outlined in subsection 12(1) of the Medical Care Insurance Act (1999), namely:

1. Where a physician providing insured services is not a participating physician, and the physician provides an insured service to a beneficiary, the physician is not subject to this Act or the regulations relating to the provision of insured services to beneficiaries or the payment to be made for the services except that he or she shall:
   1. before providing the insured service, if he or she wishes to reserve the right to charge the beneficiary for the service an amount in excess of that payable by the Minister under this Act, inform the beneficiary that he or she is not a participating physician and that the physician may so charge the beneficiary; and
   2. provide the beneficiary to whom the physician has provided the insured service with the information required by the minister to enable payment to be made under this Act to the beneficiary in respect of the insured service.
2. Where a physician who is not a participating physician provides insured services through a professional medical corporation, the professional medical corporation is not, in relation to those services, subject to this Act or the regulations relating to the provision of insured services to beneficiaries or the payment to be made for the services and the professional medical corporation and the physician providing the insured services shall comply with subsection (1).

As of March 31, 2006, there were no physicians who had opted out of the Medical Care Plan.

Ministerial direction is required to add to or to de-insure a physician service from the list of insured services. This process is managed by the Department in consultation with various stakeholders, including the provincial medical association and the public. There were no services added or deleted during the 2005-2006 fiscal year to the list of insured physician services.

2.3 Insured Surgical-Dental Services

The provincial Surgical-Dental Program is a component of the Medical Care Plan. Surgical-dental treatments provided to a beneficiary and carried out in a hospital by a dentist are covered by Medical Care Plan if the treatment is specified in the Surgical-Dental Services Schedule.

All dentists licensed to practice in Newfoundland and Labrador and who have hospital privileges are allowed to provide surgical-dental services. The dentist's license is issued by the Newfoundland Dental Licensing Board.

Dentists may opt out of the Medical Care Plan. These dentists must advise the patient of their opted-out status, stating the fees expected, and provide the patient with a written record of services and fees charged. One dentist is currently in the opted-out category.

Because the Surgical-Dental Program is a component of the Medical Care Plan, management of the Program is linked to the Plan process regarding changes to the list of insured services.

Addition of a surgical-dental service to the list of insured services must be approved by the Department.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Hospital services not covered by the Plan include: preferred accommodation at the patient's request; cosmetic surgery and other services deemed to be medically unnecessary; ambulance or other patient transportation before admission or upon discharge; private duty nursing arranged by the patient; non-medically required x-rays or other services for employment or insurance purposes; drugs (except antirejection and AZT drugs) and appliances issued for use after discharge from hospital; bedside telephones, radios or television sets for personal, non-teaching use; fibreglass splints; services covered by Workers' Compensation legislation or by other federal or provincial legislation; and services relating to therapeutic abortions performed in non-accredited facilities or facilities not approved by the Newfoundland Medical Board.

The use of the hospital setting for any services deemed not insured by the Medical Care Plan are also uninsured under the Hospital Insurance Plan.

For purposes of the Medical Care Insurance Act (1999), the following is a list of non-insured physician services:

• any advice given by a physician to a beneficiary by telephone;
• the dispensing by a physician of medicines, drugs or medical appliances and the giving or writing of medical prescriptions;
• the preparation by a physician of records, reports or certificates for, or on behalf of, or any communication to, or relating to, a beneficiary;
• any services rendered by a physician to the spouse and children of the physician;
• any service to which a beneficiary is entitled under an Act of the Parliament of Canada, an Act of the Province of Newfoundland and Labrador, an Act of the legislature of any province of Canada, or any law of a country or part of a country;
• the time taken or expenses incurred in travelling to consult a beneficiary;
• ambulance service and other forms of patient transportation;
• acupuncture and all procedures and services related to acupuncture, excluding an initial assessment specifically related to diagnosing the illness proposed to be treated by acupuncture;
• examinations not necessitated by illness or at the request of a third party except as specified by the appropriate authority;
• plastic or other surgery for purely cosmetic purposes, unless medically indicated;
• testimony in a court;
• visits to optometrists, general practitioners and ophthalmologists solely for determining whether new or replacement glasses or contact lenses are required;
• the fees of a dentist, oral surgeon or general practitioner for routine dental extractions performed in hospital;
• fluoride dental treatment for children under four years of age; excision of xanthelasma;
• circumcision of newborns;
• hypnotherapy;
• medical examination for drivers;
• alcohol/drug treatment outside Canada;
• consultation required by hospital regulation;
• therapeutic abortions performed in the province at a facility not approved by the Newfoundland Medical Board;
• sex reassignment surgery, when not recommended by the Clarke Institute of Psychiatry;
• in vitro fertilization and ovarian stimulation and sperm transfer (OSST); reversal of previous sterilization procedure;
• surgical, diagnostic or therapeutic procedures not provided in facilities other than those listed in the Schedule to the Hospitals Act or approved by the appropriate authority under paragraph 3(d); and
• other services not within the ambit of section 3 of the Act.

The majority of diagnostic services, e.g. laboratory services and x-ray are performed within public facilities in the province. Hospital policy concerning access ensures that third parties are not given priority access.

Medical goods and services that are implanted and associated with an insured service are provided free of charge to the patient and are consistent with national standards of practice. Patients retain the right to financially upgrade the standard medical goods or services. Standards for medical goods are developed by the hospitals providing those services in consultation with service providers.

Surgical-dental and other services not covered by the Surgical-Dental Program include the dentist's fee and the oral surgeon's or general practitioner's fees for routine dental extractions in a hospital.

3.0 Universality

3.1 Eligibility

Residents of Newfoundland and Labrador are eligible for coverage under the Medical Care Insurance Act (1999) and the Hospital Insurance Agreement Act (as amended).

The Medical Care Insurance Act (1999) defines a "resident" as a person lawfully entitled to be or to remain in Canada, who makes his or her home and is ordinarily present in the province, but does not include tourists, transients or visitors to the province.

The Medical Care Insurance Beneficiaries and Inquiries Regulations (Regulation 20/96) identify those residents eligible to receive coverage under the plans. The Medical Care Plan has established rules to ensure that the Regulations are applied consistently and fairly in processing applications for coverage.

Persons not eligible for coverage under the plans include: students and their dependants already covered by another province or territory; dependants of residents if covered by another province or territory; certified refugees and refugee claimants and their dependants; foreign workers with Employment Authorizations and their dependants who do not meet the established criteria; foreign students and their dependants; tourists, transients, visitors and their dependants; Canadian Forces and Royal Canadian Mounted Police (RCMP) personnel; inmates of federal prisons; and armed forces personnel from other countries who are stationed in the province.

3.2 Registration Requirements

Registration under the Medical Care Plan and possession of a valid Medical Care Plan card are required to access insured services. New residents are advised to apply for coverage as soon as possible on arriving in Newfoundland and Labrador.

It is the parent's responsibility to register a newborn or adopted child. The parents of a newborn child will be given a registration application upon discharge from hospital. Applications for newborn coverage will require, in most instances, a parent's valid Medical Care Plan number. A birth or baptismal certificate will be required where the child's surname differs from either parent's surname.

Applications for coverage of an adopted child require a copy of the official adoption documents, the birth certificate of the child, or a Notice of Adoption Placement from the Department. Applications for coverage of a child adopted outside Canada require Permanent Resident documents for the child.

3.3 Other Categories of Individual

Foreign workers, clergy and dependants of North Atlantic Treaty Organization (NATO) personnel are eligible for benefits. Holders of Minister's permits are also eligible, subject to MCP approval. There are approximately 500 beneficiaries covered under a work permit, only one under a Minister's permit and approximately 15 dependents of NATO personnel. Clergy are included under the work permit or other category and numbers are not readily available.

4.0 Portability

4.1 Minimum Waiting Period

Insured persons moving to Newfoundland and Labrador from other provinces or territories are entitled to coverage on the first day of the third month following the month of arrival.

Persons arriving from outside Canada to establish residence are entitled to coverage on the day of arrival. The same applies to discharged members of the Canadian Forces, the RCMP and released inmates of federal penitentiaries. For coverage to be effective, however, registration is required under the Medical Care Plan. Immediate coverage is provided to persons from outside Canada authorized to work in the province for one year or more.

4.2 Coverage During Temporary Absences in Canada

Newfoundland and Labrador is a party to the Agreement on Eligibility and Portability regarding matters pertaining to portability of insured services in Canada.

Sections 12 and 13 of the Hospital Insurance Regulations (1996) define portability of hospital coverage during temporary absences both within and outside Canada. Portability of medical coverage during temporary absences both within and outside Canada is defined in departmental policy.

Eligibility policy for insured hospital services is linked to the eligibility policy for insured physician services, although there is no formalized process.

Coverage is provided to residents during temporary absences within Canada. The Government has entered into formal agreements (i.e. the Hospital Reciprocal Billing Agreement) with other provinces and territories for the reciprocal billing of insured hospital services. In-patient costs are paid at standard rates approved by the host province or territory. In-patient, high-cost procedures and out-patient services are payable based on national rates agreed to by provincial and territorial health plans through the Interprovincial Health Insurance Agreements Coordinating Committee (IHIACC).

Except for Quebec, medical services incurred in all provinces or territories are paid through the Medical Reciprocal Billing Agreement at host province or territory rates. Claims for medical services received in Quebec are submitted by the patient to the Medical Care Plan for payment at host province rates.

In order to qualify for out-of-province coverage, a beneficiary must comply with the legislation and Medical Care Plan rules regarding residency in Newfoundland and Labrador. A resident must reside in the province at least four consecutive months in each 12-month period to qualify as a beneficiary. Generally, the rules regarding medical and hospital care coverage during absences include:

• Before leaving the province for extended periods, a resident must contact the Medical Care Plan to obtain an out-of-province coverage certificate.
• Beneficiaries leaving for vacation purposes may receive an initial out-of-province coverage certificate of up to 12 months. Upon return, beneficiaries are required to reside in the province for a minimum of four consecutive months. Thereafter, certificates will only be issued for up to eight months of coverage;
• Students leaving the province may receive a certificate, renewable each year, provided they submit proof of full-time enrolment in a recognized school located outside the province;
• Persons leaving the province for employment purposes may receive a certificate for coverage up to 12 months. Verification of employment may be required;
• Persons must not establish residence in another province, territory or country while maintaining coverage under the Newfoundland MCP;
• For out-of-province trips of 30 days or less, an outof- province coverage certificate is not required, but will be issued upon request;
• For out-of-province trips lasting more than 30 days, a certificate is required as proof of a resident's ability to pay for services while outside the province.

Failure to request out-of-province coverage or failure to abide by the residency rules may result in the resident having to pay the entire cost of any medical or hospital bills incurred outside the province.

Insured residents moving permanently to other parts of Canada are covered up to and including the last day of the second month following the month of departure.

Coverage is immediately discontinued when residents move permanently to other countries.

4.3 Coverage During Temporary Absences Outside Canada

The Province provides coverage to residents during temporary absences outside Canada. Out-of-country insured hospital in- and out-patient services are covered for emergency, sudden illness and elective procedures at established rates. Hospital services are considered under the Plan when the insured services are provided by a recognized facility (licensed or approved by the appropriate authority within the state or country in which the facility is located) outside Canada. The maximum amount payable by the Government's hospitalization plan for out-of-country in-patient hospital care is $350 per day, if the insured services are provided by a community or regional hospital. Where insured services are provided by a tertiary care hospital (a highly specialized facility), the approved rate is $465 per day. The approved rate for out-patient services is $62 per visit and hæmodialysis is $220 per treatment. The approved rates are paid in Canadian funds.

Physician services are covered for emergencies or sudden illness and are also insured for elective services not available in the province or within Canada. Physician services are paid at the same rate as would be paid in Newfoundland and Labrador for the same service. If the services are not available in Newfoundland and Labrador, they are usually paid at Ontario rates, or at rates that apply in the province where they are available.

4.4 Prior Approval Requirement

Prior approval is not required for medically necessary insured services provided by accredited hospitals or licensed physicians in the other provinces and territories.

If a resident of the province has to seek specialized hospital care outside the country because the insured service is not available in Canada, the provincial health insurance plan will pay the costs of services necessary for the patient's care. However, it is necessary in these circumstances for such referrals to receive prior approval from the Department. The referring physicians must contact the Department or the Medical Care Plan for prior approval.

Prior approval is not required for physician services; however, it is suggested that physicians obtain prior approval from the Medical Care Plan so that patients may be made aware of any financial implications. General practitioners and specialists may request prior approval on behalf of their patients. Prior approval is not granted for out-of-country treatment of elective services if the service is available in the province or elsewhere within Canada.

5.0 Accessibility

5.1 Access to Insured Health Services

Access to insured health services in Newfoundland and Labrador is provided on uniform terms and conditions. There are no co-insurance charges for insured hospital services and no extra-billing by physicians in the province.

5.2 Access to Insured Hospital Services

In Newfoundland and Labrador there is a health care workforce of nearly 19,000 individuals. Half of this workforce belongs to regulated professional groups.

The supply of health professionals is a high-priority issue in the province, especially in rural areas.

In 2005-2006, the Department continued with its commitment to health human resource planning in the province. The Physician Resource Planning Committee was formed in March 2005 to develop a human resource plan for physicians in the province and is continuing work in this regard. The Department participates in the Provincial Nursing Network, which was formed to develop human resource strategies for registered nurses and licensed practical nurses. The Department also created a Chief Nurse position.

The Atlantic Health Human Resources Planning Study was completed in 2005-2006. The study's deliverables include comparative analysis of the previous provincial studies and roll-up of data, inventories of health education programmes, an environmental scan, reusable simulation modelling software and recommendations. The study's executive summary is available at www.ahhra.ca.

Five health human resource projects were completed, including: 1) developing province-wide standards related to HHR data; 2) developing best practices for the recruitment and retention of physicians; 3) implementing a system in one organization to establish the collection of nursing workload data; 4) provision of community mental health services in the province; and 5) assisting regional health authorities to develop and sustain quality professional practice environments for registered nurses and licensed practical nurses to positively impact nurse retention and client outcomes. These projects were funded by Health Canada.

The department continued to offer recruitment incentives for physicians, registered nurses, audiologists, speech language pathologists, pharmacists and other health professionals in 2005-2006.

Insured hospital services are provided by 36 hospitals and health centres across Newfoundland and Labrador. All facilities provide 24 hour emergency services, out-patient clinics, laboratory and x-ray services. The other services vary by facility and range from general surgery, internal medicine and obstetrics to specialized services such as cardiology and neurology. Quaternary care is not offered in Newfoundland and Labrador and provincial residents travel to other jurisdictions to access services.

Federal funding through the 2004 Health Accord enabled Newfoundland and Labrador to invest $23.2 million in 2005-2006 to improve access to key services by purchasing new medical equipment, modernizing diagnostic and medical equipment and expanding select services in all of the province's major health care centres. These monies will allow the delivery of 43,344 additional MRI, CT, cardiac and other key diagnostic procedures, surgeries, as well as cancer treatments to reduce wait times for provincial residents. The new equipment includes a second MRI in St. John's, replacement of aging CT scanners with multislice scanners, new and replacement ultrasound equipment at four sites and four new mammography machines. The MRI scanners, ultrasound and mammography equipment at the St. John's tertiary sites became operational in late 2005-2006. Ultrasound and mammography in other health regions will be available in 2006-2007. Expanded select services include increased cardiac surgeries, increased surgical capacity for joint replacement and cancer, and extended hours of operation to give cancer patients greater access to chemotherapy and radiation. Progress was made in increasing the number of surgeries performed and cancer treatments delivered in 2005-2006.

Newfoundland and Labrador is making progress in reducing wait times for select health services. The province is already at or near the national benchmarks in the five priority areas identified in the 2004 Health Accord. The Department hired a provincial wait times coordinator in 2005-2006 and is completing baseline assessment of wait times in the province. Government is working in partnership with health authorities and health care professionals in improving access to insured hospital services.

In late 2005-2006, Newfoundland and Labrador announced a $14.5 million investment in a province wide Picture Archiving and Communications System (PACS) by 2007. This amount includes a contribution of $10.5 million by Canada Health Infoway Inc. and a provincial investment of $4 million. PACS will benefit patients, health care providers and managers through improved access to diagnostic imaging services in rural areas, reduced wait time for patients in physicians' offices, improved access to specialist consultations due to improved image portability, and improved test-to-results time. A combined investment of $14.5 million by government and Infoway will result in the implementation of the PACS project in the Western and Labrador-Grenfell regions of the province allowing these regions to link into existing sites in Central and Eastern regions.

The provincial Primary Health Care framework, Moving Forward Together: Mobilizing Primary Health Care is providing direction for remodelling primary health care in Newfoundland and Labrador through population-health based approach to service delivery, and using a voluntary and incremental approach. PHC services include all the health services delivered in a geographic area (minimum population 6000 to maximum population of 25,000) from primary prevention through to and including acute and episodic illness at the primary health care service delivery level.

The framework supports four goals: (1) enhanced access to, and sustainability of, primary health care; (2) an emphasis on self-reliant and healthy citizens and communities; (3) promotion of a team-based, interdisciplinary and evidence-based approach to services provision; and (4) enhanced accountability and satisfaction of health professionals. Provincial supports have included an Office of Primary Care, the Primary Health Care Advisory Council, linkages with local college and university programs and professional associations, and developing provincial working groups to support learning/problem-solving and provider capacity-building.

Eight interdisciplinary, team-based, primary health care team areas have initiated changes to service delivery based on the provincial framework, including the development of Community Advisory Committees and enhanced activities support health promotion and illness prevention. In addition, three PHC team areas have completed proposals and provided with funding for implementation, and four other areas have been provided funds for proposal development. Registration processes for primary health care services have commenced in one of the team areas. Formal evaluation of these changes is ongoing by external evaluators, and a report will be available in fall 2006.

Primary health care working groups, with associations, university, PHC team area and other partnerships, have developed processes and tools for scope of practice shifts, physician funding and payment models, and information management. Scope of practice processes have been implemented in the eight initial primary health care team areas, with the development of action plans to assist in shifting scope of practices.

A discussion document has been developed for physician funding and payment models, and a research project has been initiated at Memorial University regarding a funding and payment model. Physician networks are in development in the initial eight primary health care team areas, and a physician network contract (for signing by the Department of Health and Community Services, the region, and the physician network for medical services to the PHC team area) is in the later stages of completion.

In spring 2005, a Chronic Disease Prevention and Management Collaborative program, with diabetes as the first collaborative, was funded provincially on an operational basis, and initiated in eight PHC team areas. These collaboratives will support CDPM from primary prevention through to management, and include provincial learning sessions to promote professional development regarding chronic diseases. In addition, a software application is being supported through Eastern Health Authority that will provide information regarding adherence to clinical practice guidelines, and also for service planning at the individual client, PHC team area, regional and provincial levels. There are plans in the early stages to move forward with collaboratives for mental health and arthritis.

Newfoundland and Labrador is currently involved in two Atlantic Canada projects. Building a Better Tomorrow Initiative has been supporting team and inter-professional development and change management in primary health care team areas through a variety of training modules (team development, conflict resolution, adult learning, understanding primary health care, community development and program planning and evaluation).

In partnership with New Brunswick, a Memorandum of Understanding is being completed for a 24/7 nurse health advice telephone, and plans are in place for implementation, including identification of a site for the call center.

5.3 Access to Insured Physician and Surgical-Dental Services

The number of physicians practicing in the province has been relatively stable, with an upward trend since 2003. The Department is committed to working with regional health boards to develop a provincial human resource plan for physicians based on the principle of access to services.

As of March 31, 2006, there were 471 general practitioners and 500 specialists in practice, compared with 460 general practitioners and 494 specialists as of March 31, 2005. This represents a two percent increase in general practitioners and a one percent increase in specialists.

The Department initiated several measures to ensure access for insured physician services. Some of these included:

• funding for the Provincial Office of Recruitment;
• retention bonuses for salaried physicians based on geography and years of service;
• annual bursary program valued at $1.2 million for medical residents and students (matched to FP in CaRMS) willing to commit to provide medical services in areas of need within the province. During fiscal year 2005-2006, 39 bursaries and travelling fellowships were funded.

5.4 Physician Compensation

The legislation governing payments to physicians and dentists for insured services is the Medical Care Insurance Act (1999).

The current methods of remuneration to compensate physicians for providing insured health services include fee-for-service, salary, contract and sessional block funding.

Compensation agreements are negotiated between the provincial government and the Newfoundland and Labrador Medical Association (NLMA), on behalf of all physicians. Representatives from the regional health authorities play a significant role in this process.

In 2005, a four-year agreement was negotiated with the provincial medical association effective October 1, 2005. The award provides for agreed-to increases to fees and salaries during the life of the agreement, additional payments for on-call and recognition of on-call services by salaried physicians. The current methods of remuneration to compensate physicians for providing insured health services are fee-for-service (63% of physicians); salaried (35% of physicians); and alternate payment plans (2% of physicians) such as block funding and new case payments.

5.5 Payments to Hospitals

The Department is responsible for funding regional health authorities for ongoing operations and capital purchases. Funding for insured services is provided to the regional health authorities as an annual global budget. Payments are made in accordance with the Hospital Insurance Agreement Act (1990) and the Hospitals Act. As part of their accountability to the Government, the health authorities are required to meet the Department's annual reporting requirements, which include audited financial statements and other financial and statistical information. The global budgeting process devolves the budget allocation authority, responsibility and accountability to all appointed boards in the discharge of their mandates.

Throughout the fiscal year, the regional health authorities forwarded additional funding requests to the Department for any changes in program areas or increased workload volume. These requests were reviewed and, when approved by the Department, funded at the end of each fiscal year.

Any adjustments to the annual funding level, such as for additional approved positions or program changes, were funded based on the implementation date of such increases and the cash flow requirements.

Regional health authorities are continually facing challenges in addressing increased demands when costs are rising, staff workloads are increasing, patient expectations are higher and new technology introduces new demands for time, resources and funding. Regional health authorities continue to work with the Department to address these issues and provide effective, efficient and quality health services.

6.0 Recognition Given to Federal Transfers

Funding provided by the federal government through the Canada Health Transfer (CHT) and the Canada Social Transfer (CST) has been recognized and reported by the Government of Newfoundland and Labrador in the annual provincial budget, through press releases, government websites and various other documents. For fiscal year 2005-2006, these documents included:

• the 2005-2006 Public Accounts;
• the Estimates 2005-2006; and
• the Budget Speech 2005.

The Public Accounts and Estimates, tabled by the Government in the House of Assembly, are publicly available to Newfoundland and Labrador residents and have been shared with Health Canada for information purposes.

7.0 Extended Health Care Services

Newfoundland and Labrador has established long-term residential and community-based programs for persons discharged from hospital, seniors, and persons with disabilities. These programs are provided by the regional health authorities. Services include the following:

• Long-term residential accommodations are provided for residents requiring high levels of nursing care in 21 community health centres and 20 nursing homes. There are approximately 2,800 beds located in these facilities. Residents pay a maximum of $2,800 per month based on each client's assessed ability to pay, using provincial financial assessment criteria. The balance of funding required to operate these facilities is provided by the Department.
• Persons requiring supervised care or minimal assistance with activities of daily living can avail themselves of residential services in personal care homes. There are approximately 2,750 beds located in 94 homes across the province. These homes are operated by the private for-profit sector. Residents are subsidized to a maximum of $1,138.10 per month, based on an individual client assessment using standardized financial criteria.

Home Care Services

Home care services include professional and nonprofessional supportive care to enable people to remain in their own homes for as long as possible without risk. Professional services include nursing as well as some rehabilitative programs. These services are publicly funded and delivered by staff employed by the four regional health authorities. Non-professional services include personal care, household management, respite and behavioural management. These services are delivered by home support workers through agency or self-managed care arrangements. Eligibility for non-professional services is determined through a client financial assessment using provincial criteria. The monthly ceiling for home support services (fiscal 2005-2006) is $2,707 for seniors and $3,875 for persons with disabilities.

Special Assistance Program

The Special Assistance Program is a provincial program that provides basic supportive services to assist financially eligible clients in the community with activities of daily living. The benefits include access to health supplies, oxygen, orthotics and equipment.

Drug Programs

The Senior Citizens' Drug Subsidy Program is provided to residents over 65 years of age who receive the Guaranteed Income Supplement and who are registered for Old Age Security benefits. Eligible individuals are given coverage for the ingredient portion of benefit prescription items. Any additional cost, such as dispensing fees, is the client's responsibility. Income support recipients are eligible for the Income Support Drug Plan, which covers the full cost of benefit prescription items, including a set mark-up amount and dispensing fee.

Other Programs

The Department administers the Emergency Air and Road Ambulance Programs.

The Road Ambulance Program provides quality prehospital emergency and routine treatment, care and transportation. It also includes the transfer of patients between facilities and return of patients to their place of residence. Road ambulances are operated by 56 organizations -- 30 private companies, 22 community or volunteer groups, and four regional health authorities.

The Air Ambulance Program provides air transport for patients requiring emergency care who could not be transported by a commercial airline or by road ambulance because of urgency or time, or remoteness of location. This program uses two fixed-wing aircraft and five chartered helicopters. These helicopters are also used for routine transportation of doctors and nurses to remote communities for clinics. A third fixed-wing aircraft is used in Labrador for regional medical services transports, including routine appointments by coastal residents in Happy Valley/Goose Bay, Labrador.

Residents who travel by commercial air to access medically insured services that are not available within their area of residence or within the province, may qualify for financial assistance under the Medical Transportation Assistance Program. This program is administered by the Department. Kidney donors and bone marrow/stem-cell donors are eligible for financial assistance, as administered by Eastern Health, when the recipient is a Newfoundland and Labrador resident eligible for coverage under the provincial Hospital Insurance and Medical Care Plans.

The Dental Health Plan incorporates a children's dental component and an income support component. The children's program covers the following dental services for all children up to and including the age of 12: examinations at six-month intervals; cleanings at 12-month intervals; fluoride applications at 12-month intervals for children aged 6 to 12; x-rays (some limitations); fillings and extractions; and some other specific procedures that require approval before treatment. Services are available to recipients of income support who are 13 to 17 years of age: examinations (every 24 months); x-rays (with some limitations); routine fillings and extractions; emergency extractions, when the patient is seen for pain, infection or trauma.

Adults receiving income support are eligible for emergency care and extractions. Beneficiaries covered under the Dental Health Plan must pay a variable amount directly to the dentist for each service provided (e.g., fillings, extractions, etc.). In circumstances where the beneficiary is receiving income support, a $5 co-payment is paid by the Dental Health Plan.

The Department administers the Emergency Air and Road Ambulance Programs. The Road Ambulance Program provides quality pre-hospital emergency and routine treatment, care and transportation. It also includes the transfer of patients between facilities and return of patients to their place of residence. Road ambulances are operated by 56 organizations - 30 private companies, 22 community or volunteer groups, and four regional health authorities.

The Air Ambulance Program provides air transport for patients requiring emergency care who could not be transported by a commercial airline or by road ambulance because of urgency or time, or remoteness of location. This program uses two fixed-wing aircraft and five chartered helicopters. These helicopters are also used for routine transportation of doctors and nurses to remote communities for clinics. A third fixed-wing aircraft is used in Labrador for regional medical services transports, including routine appointments by coastal residents in Happy Valley/Goose Bay, Labrador.

Prince Edward Island

Introduction

The Ministry of Health is a large and complex system of integrated services whose aim is to protect, maintain and improve the health and well-being of Prince Edward Islanders. The role of the Department is to provide sound leadership in innovation and ongoing improvement, quality administration and regulatory services, and delivery of client-centred health services consistent with commu-nity needs.

The ministry is responsible for a variety of health services to promote and help foster the optimal health of Islanders, including public health services, primary care, acute care, community hospital and continuing care services. These services are delivered by a staff of over 4,000 dedicated professionals through a large number of facilities and programs across the province. Among them are acute care facilities, community hospitals, provincial manors, an in-patient mental health facility, provincial addictions treatment facilities and programs, family health centres, public health, home care, community addictions programs and community mental health.

In spring 2005, a major reorganization of the health and social service system was undertaken. As a result of the reorganization, the Department of Health and Social Services was divided into the Department of Health, and the Department of Social Services and Seniors. All regional health authorities were disbanded, and health services were brought together under a centralized management model.

In addition to creating two new departments and the attendant realignment of services, the restruc-turing also resulted in a number of administrative and systemic changes. Some of the most significant include the following:

• The role of the Department of Health changed from responsibility for quality of advice and assistance to line services to a responsibility for direct service delivery.
• Administrative and support services for line services moved from a regional to a departmental model, in line with the dissolution of the health authorities.
• Under the previous organizational structure, each of the five regional health authorities had governing boards. Under the new organizational model, each of the five community hospitals has a governing board.

Overview of the Health System

Prince Edward Island has a publicly administered and funded health system that guarantees universal access to medically necessary hospital and physician services as required by the Canada Health Act.

A Minister of the Crown is ultimately accountable to the rest of government and the citizens of Prince Edward Island for the Department of Health and its performance and results. The Department is managed by a Departmen-tal Management Committee comprised of the Deputy Minister and eight senior directors whose responsibility it is to direct the overall departmental management and day-to-day operations. A summary of the principal division of roles is outlined below.

Acute Care: Provides regional and provincial secondary, specialty services and in-patient mental health services to residents of Prince Edward Island. Facilities include Prince County Hospital (PCH), the Queen Elizabeth Hospital (QEH) and Hillsborough Hospital. Administratively, one Executive Director is responsible for PCH and one Executive Director is responsible for QEH / Hillsborough Hospital, each of whom is a member of the Departmental Management Committee.

Community Hospitals and Continuing Care: Provides acute care services to rural communities and support services to adults and seniors in need of continuing care on Prince Edward Island. Programs and facilities include the five rural community hospitals, provincial manors, home care, palliative care, dialysis and adult protection. Administratively, the Director of Community Hospitals and Continuing Care is responsible for this division and is a member of the Departmental Management Committee.

A governing board has been put in place for each of the five community hospitals. Each board is accountable to the minister, and is responsible for ensuring the comple-tion of annual business plans and reporting on facility performance and results.

Primary Care: Provides primary health services to citizens of Prince Edward Island. Programs and facilities include: Community Mental Health and Addictions which en-compasses the Provincial Addictions Treatment Facility, seven Family Health Centres, Public Health Nursing and Chronic Disease Prevention. The Director of Primary Care has the administrative responsibility for this division and is a member of the Departmental Management Committee

Population Health: Provides public health and regulatory services to the citizens of Prince Edward Island. The programs and services include the Office of Chief Health Officer, Emergency Health Services, Communicable Disease Control and Immunization, Epidemiology, Environmental Health, Vital Statistics, Community Care / Nursing Home Inspection, and Dietetic Services. The Director of Population Health has administration responsibility for this division and is a member of the Departmental Management Committee.

Facilities

Prince Edward Island has two referral hospitals and five community hospitals, with a combined total of 463 beds. Along with nine government manors (and facilities) that house 558 (plus 10 respite) long-term care nursing beds, Islanders have access to an additional 389 (plus 11 temp-orary beds) in nine private nursing homes. The system also operates several addictions and mental health facilities, 1,146 seniors' housing units and 468 family housing units.

A $50 million health facility, the Prince County Hospital, was opened in April 2004 in Summerside. Computed Tomography (CT) scanning and a wide range of diagnostic imaging, surgical and other specialty services are available at the referral hospitals. Phase I of a multi-phase redevelopment plan to upgrade the 23-year-old Queen Elizabeth Hospital was recently announced and construction will begin in 2007.

Human Resources

The public sector health workforce has approximately 4,000 employees. There isongoing recruitment to address vacancies in the physician complement in this province, although enticing new physicians to the province and retaining the appropriate number of required physicians to meet the needs of Islanders is challenging. These chal-lenges are being met by developing a long-term physician resource plan, by providing salary options to new graduates and existing physicians, and with more communication with Prince Edward Island students and residents through the Medical Education Program. A coordinator has been hired for the Physician Recruitment and Medical Education Programs who will be responsible for their administration as well as establishing a centralized locum support program.

The following vacancies currently exist in the physician complement: Family Medicine, Internal Medicine, Emergency Medicine, Psychiatry, Radiology, Pathology, Hospitalists, Ophthalmology and Plastic Surgery. Recruitment to find suitable placements for these positions is ongoing.

In addition to the aforementioned programs, there are other current and planned initiatives such as the Nurse Recruitment Strategy, Provider Registry, Supports for Other Health Care Providers, and the Musco-skeletal Injury Prevention Program (workplace safety).

In the 2005-2006 provincial budget, the government announced that the Registered Nurse Recruitment and Retention Strategy would be delayed for 2005-2006. However, 32 third-year Bachelor of Nursing students who received sponsorships during the 2004-2005 year were eligible to receive sponsorship for their final year of study. On March 30, 2006, the Government announ-ced in the 2006-2007 provincial budget that this strategy would be reinstated.

The Physician Master Agreement is effective until March 31, 2007 and ensures Prince Edward Island remains competitive with other jurisdictions and that Islanders continue to access a quality health care system. The government has also made investments intended to make the health system more competitive in order to maintain services and increase the success of recruitment and retention efforts for physicians.

Financial Resources

The 2005-2006 budget estimate for the Department of Health amounts to $312 million. Prior to the reorganiza-tion of the health and social service system, the 2005-2006 combined budget for the Department of Health and Social Services totalled $422 million. The remaining $110 million represents the budget of the new Department of Social Services and Seniors.

Major health expenditures are allocated as following: Provincial Acute Care, 36 percent; Medical Programs, 27 percent; Community Hospitals and Continuing Care, 24 percent; Primary Care, eight percent; and other services such as Corporate Services, Financial Services and Population Health, five percent.

In 2005-2006, funding for the Oncology Centre increased by $275,000. Approval was given for the development and implementation of a $14 million Clinical Information System within the seven acute care hospitals and four community health centres. Funding in the amount of $2.2 million was made available to create a fourth ortho-paedic surgeon position in an effort to alleviate wait times for procedures such as hip and knee replacements.

Critical Issues

Health Care in Small Communities

Prince Edward Island is a rural province where a large segment of the population resides outside the main service centres. Local access to health services, including acute services delivered through community hospitals, is important to small communities. Rural hospitals have historically played an important role in health care delivery and serve vital and central roles in their respective communities. Rural hospitals and other health services delivered in these areas face a number of challenges, such as the recruitment and retention of health care providers and keeping pace with evolving standards of care and quality. To enhance health care service delivery in rural areas, family health centres will be established. The planned Clinical Information System / Integrated Electronic Health Record will link all hospitals in the province to electronic patient information.

Access to Care

In Prince Edward Island, as across Canada, access to care is a significant public concern, whether from the perspective of ensuring appropriate wait times for services, access to specialty services, or access to services which are delivered in the official language of choice and or in a culturally sensitive way for linguistic and ethnic minorities. A variety of local initiatives have been undertaken to address these and other access related issues.

Current and/or Planned Initiatives

• A part of the Wait Times Strategy, the staffing complement at the Prince Edward Island Cancer Treatment Center was increased in the area of Radiation Oncology; a fourth Orthopedic Surgeon has been added; and an Oncology Associate has been put in place at PCH.
• Family Health Centres have initiated a variety of specialized clinics (i.e. influenza vaccination).
• Ambulatory Care, currently in place at the new PCH, and enhancements planned as part of the QEH redevelopment allow patients to receive many hospital treatments on an out-patient basis. This would previously have required admission.
• Health Human Resource Recruitment Strategies and other initiatives help ensure that an adequate number of health professionals are in place to deliver services to Islanders.
• New information technology systems, such as the Clinical Information System/Integrated Electronic Health Record will improve timeliness and the availability of patient information for health care providers.

Functional or Community Needs

The health service delivery system is large and complex. Issues or decisions in one area typically affect components elsewhere in the system. For instance, elderly patients or adults with special requirements may not be able to return home upon discharge from hospital and may require admission to long term care. When long term care beds are not available, they may need to remain in the hospital until a long term care bed becomes available. This is a problem for these patients, since they require the kind of care provided by a manor B not a hospital. This is also a problem for people who need access to hospital care, since an occupied hospital bed is not available for other patients. Inconsistent availability of community supports, including drugs and supplies for home care/ambulatory patients, further challenges the ability to provide the right service at the right place by the right provider.

The provincial hospitals undertook a number of initia-tives to help improve patient flow from acute to long term care. A "First Available Bed Policy" was put in place for QEH and PCH and a transition unit was put in place at the QEH.

Initiatives such as the QEH Redevelopment and the new PCH with their emphasis on ambulatory care; the PCH Restorative Care Unit; and the Primary Care Redesign all help the frail elderly and adults with special functional or community needs to live in the community as long as possible, if that is best choice for them. The Provincial Palliative Care Program helps ensure continuity of care for individuals at end of life and their care givers, by the provider and at the location most appropriate to their needs.

Chronic Diseases

The rate of chronic diseases continues to rise. As the population ages, so too will the number of people affected by chronic disease. Several initiatives are planned or underway which could directly or indirectly address current and future levels of chronic disease, including:

• Primary care redesign, including establishment of family health centers.
• Innovations and improvements in areas of pharmacare, home care and wait times are being developed and implemented.
• The Clinical Information System / Electronic Health Record will improve health care provider access to timely and accurate information.

Furthermore, models of service delivery and health care provider roles continue to evolve. Increased adoption of collaborative/inter-disciplinary approaches as well as en-hancements in the areas of ambulatory care (including the QEH Redevelopment Project) and primary health care will contribute to chronic disease prevention, treatment, and management. A number of other targeted strategies have been adopted or are planned, such as the Cancer Control Strategy, the Healthy Living Strategy and the Diabetes Education and the Stroke Strategy.

Emerging Technologies

The exponential rate of growth of societal knowledge translates into new technologies, standards and procedures which render previous technologies, standards and procedures obsolescent. New MRI and linear accelerator technology was recently installed at the Cancer Treatment Center; a Provincial RIS/PACS system was recently implemented; and new CT Scan equipment was recently installed at PCH and QEH. There has been an increased adoption of laparoscopic surgical techniques and the use of less-invasive devices. Finally, Clinical Information Systems/Electronic Patient Health Record systems are under development.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Hospital Care Insurance Plan, under the authority of the Minister of Health, is the vehicle for delivering hospital care insurance in Prince Edward Island. The enabling legislation is the Hospital and Diagnostic Services Insurance Act (1988), which insures services as defined under section 2 of the Canada Health Act.

As a result of the reorganization of the Department and the dissolution of the former health authorities, the Department of Health is now responsible for service delivery, operates hospitals, health centres, manors and mental health facilities. The Public Service Commission hires physicians, nurses and other health related workers.

Under Part I of the Hospital and Diagnostic Services Insurance Act, it is the function of the Minister, and the Minister has the power, to:

• ensure the development and maintenance throughout the province of a balanced and integrated system of hospitals and schools of nursing and related health facilities;
• approve or disapprove the establishment of new hospitals and the establishment of, or additions to, related health facilities;
• approve or disapprove all grants to hospitals for construction and maintenance;
• establish and operate, alone or in cooperation with one or more organizations, institutes for training hospital and related personnel;
• conduct surveys and research programs and to obtain statistics for its purposes;
• approve or disapprove hospitals and other facilities for the purposes of the Act in accordance with the Regulations; and
• subject to the approval of the Lieutenant Governor in Council, to do all other acts and things that the Minister considers necessary or advisable for carrying out effectively the intent and purposes of the Act.

In addition to the duties and powers enumerated in Part I of the Act, it is the function of the Minister, and the Minister has power, to:

• administer the plan of hospital care insurance establi-shed by this Act and the Regulations;
• determine the amounts to be paid to hospitals and to pay hospitals for insured services provided to insured persons under the plan of hospital care insurance and to make retroactive adjustments with hospitals for under payment or over payment for insured services according to the cost as determined in accordance with the Act and the Regulations;
• receive and disburse all monies pertaining to the plan of hospital care insurance;
• approve or disapprove charges made to all patients by hospitals in Prince Edward Island to which payments are made under the plan of hospital care insurance;
• enter into agreements with hospitals outside Prince Edward Island and with other governments and hospital care insurance authorities established by other governments for providing insured services to insured persons;
• prescribe forms necessary or desirable to carry out the intent and purposes of the Act;
• appoint inspectors and other officers with the duty and power to examine and obtain information from hospital accounting records, books, returns, reports and audited financial statements and reports thereon;
• appoint medical practitioners with the duty and power to examine and obtain information from medical and other hospital records, including patients' charts with medical records and nurses' notes, reports and accounts of patients who are receiving or have received insured services;
• appoint inspectors with the duty and power to inspect and examine books, accounts and records of employers and collectors to obtain information related to the hospital and insurance plan;
• withhold payment for insured services for any insured person who does not, in the opinion of the Minister, medically require such services;
• act as a central purchasing agent to purchase drugs, biologicals or related preparations for all hospitals in the province; to supervise, check and inspect the use of drugs, biologicals or related preparations by hospitals in the province; and to withhold or reduce payments under the Act to a hospital that does not comply with regulations relating to purchasing drugs, biologicals or related preparations; and
• supervise and ensure the efficient and economical use of all diagnostic or therapeutic aids and procedures used by or in hospitals and to withhold or reduce payments under the Act to a hospital that does not comply with the regulations relating to using such aids and procedures.

The Health Ministry, through the Department, has the responsibility for the overall efficiency and effectiveness of the provincial health system.

Specifically, the Department is responsible for:

• setting overall directions and priorities;
• developing policies and strategies, legislation, provincial standards and measures;
• monitoring provincial health status;
• monitoring and ensuring that the provincial hospitals and community hospital authority boards comply with regulations and standards;
• evaluating the performance of the health system;
• allocating funds to the provincial hospitals and the community hospital authority boards;
• improving the quality and management of a compre-hensive province-wide health information system;
• ensuring access to high quality health services;
• addressing emerging health issues and examining new technology before implementation; and
• directly administering certain services and programs.

Health care services will continue to be subject to the accreditation process. The next scheduled accreditation is to take place in 2007.

1.2 Reporting Relationship

An annual report is submitted by the Department to the Minister responsible who tables it in the Legislative Assembly. The Report provides information on the operating principles of the Department and its legislative responsibilities, as well as an overview and description of the operations of the departmental divisions and statistical highlights for the year.

The community hospital authority boards are accountable to the Minister pursuant to the Community Hospital Authorities Act and must submit annual business plans and provide information to the Minister as and when required.

1.3 Audit of Accounts

The provincial Auditor General conducts annual audits of the Public Accounts of the Province of Prince Edward Island. The Public Accounts of the Province include the financial activities, revenues and expenditures of the Department of Health.

The provincial Auditor General, through the Audit Act, has the discretionary authority to conduct further audit reviews on a comprehensive or program specific basis. Community hospital authorities are reporting entities under the Financial Administration Act.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured hospital services are provided under the Hospital and Diagnostic Services Insurance Act (1988). The accom-panying Regulations (1996) define the insured in- and out-patient hospital services available at no charge to a person who is eligible. Insured hospital services include: necessary nursing services; laboratory; radiological and other diagnostic procedures; accommodations and meals at a standard ward rate; formulary drugs, biologicals and related preparations prescribed by an attending physician and administered in hospital; operating room, case room and anaesthetic facilities; routine surgical supplies; and radiotherapy and physiotherapy services performed in hospital.

As of March 2006, there were seven acute care facilities participating in the province's insurance plan. In addition to 427 acute care beds, these facilities house 20 rehabili-tative beds and 20 day surgery beds, as defined under the Hospitals Act (1988), for a total of 467 beds.

2.2 Insured Physician Services

The enabling legislation that provides for insured physician services is the Health Services Payment Act (1988). Amend-ments were passed in 1996. Changes were made to include the physician resource planning process.

Insured physician services are provided by medical practitioners licensed by the College of Physicians and Surgeons. The number of practitioners who billed the Insurance Plan as of March 31, 2006, was 211.

Under section 10 of the Health Services Payment Act, a physician or practitioner who is not a participant in the Insurance Plan is not eligible to bill the Plan for services rendered. When a non-participating physician provides a medically required service, section 10(2) requires that physicians advise patients that they are not participating physicians or practitioners and provide the patient with sufficient information to enable recovery of the cost of services from the Minister of Health.

Under section 10.1 of the Health Services Payment Act, a participating physician or practitioner may determine, subject to and in accordance with the Regulations and in respect of a particular patient or a particular basic health service, to collect fees outside the Plan or selectively opt out of the Plan. Before the service is rendered, patients must be informed that they will be billed directly for the service. Where practitioners have made that determination, they are required to inform the Minister thereof and the total charge is made to the patient for the service rendered.

As of March 31, 2006, no physicians had opted out of the Health Care Insurance Plan.

Any basic health services rendered by physicians that are medically required are covered by the Health Care Insurance Plan. These include: most physicians' services in the office, at the hospital or in the patient's home; medically necessary surgical services, including the services of anaesthetists and surgical assistants where necessary; obstetrical services, including pre- and post-natal care, newborn care or any complications of pregnancy such as miscarriage or Caesarean section; certain oral surgery procedures performed by an oral surgeon when it is medically required, with prior approval that they be performed in a hospital; sterilization procedures, both female and male; treatment of fractures and dislocations; and certain insured specialist services, when properly referred by an attending physician.

The process to add a physician service to the list of insured services involves negotiation between the Department and the Medical Society.

2.3 Insured Surgical-Dental Services

Dental services are not insured in the Health Care Insurance Plan. Only oral maxillofacial surgeons are paid through the Plan. There are currently two surgeons in that category. Surgical-dental procedures included as basic health services in the Tariff of Fees are covered only when the patient's medical condition requires that they be done in hospital or in an office with prior approval as confirmed by the attending physician.

A surgical-dental service (post-operative removal of mandibular wires in an office setting) has been added as a result of negotiations between the Dental Association and the Department.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Provincial hospital services not covered by the Hospital Services Plan include:

• services that persons are eligible for under other provincial or federal legislation;
• mileage or travel, unless approved by the Department;
• advice or prescriptions by telephone, except anticoagulant therapy supervision;
• examinations required in connection with, e.g. employment, insurance, education;
• group examinations, immunizations or inoculations, unless prior approval is received from the Department;
• preparation of records, reports, certificates or communications, except a certificate of committal to a psychiatric, drug or alcoholism facility;
• testimony in court;
• travel clinic and expenses;
• surgery for cosmetic purposes unless medically required;
• dental services other than those procedures included as basic health services;
• dressings, drugs, vaccines, biologicals and related materials;
• eyeglasses and special appliances;
• physiotherapy, chiropractic, podiatry, optometry, chiropody, osteopathy, psychology, naturopathy, audiology, acupuncture and similar treatments;
• reversal of sterilization procedures; in vitro fertilization;
• services performed by another person when the supervising physician is not present or not available;
• services rendered by a physician to members of the physician's own household, unless approval is obtained from the Department; and
• other services that the Department may, upon the recommendation of the negotiation process between the Department and the Medical Society, declare non-insured.

Provincial hospital services not covered by the Hospital Services Plan include:

• private or special duty nursing at the patient's or family's request;
• preferred accommodation at the patient's request;
• hospital services rendered in connection with surgery purely for cosmetic reasons;
• personal conveniences, such as telephones and televisions;
• drugs, biologicals and prosthetic and orthotic appliances for use after discharge from hospital; and
• dental extractions, except in cases where the patient must be admitted to hospital for medical reasons with prior approval of the Department.

The process to de-insure services by the Health Care Insurance Plan is done in collaboration with the Medical Society and the Department.

All Island residents have equal access to services. Third parties such as private insurers or the Workers' Comp-ensation Board of Prince Edward Island do not receive priority access to services through additional payment.

Prince Edward Island has no formal process to monitor compliance; however, feedback from physicians, hospital administrators, medical professionals and staff allows the Department to monitor usage and service concerns.

3.0 Universality

3.1 Eligibility

The Health Services Payment Act and Regulations, section 3, define eligibility for the health care insurance plans. The plans are designed to provide coverage for eligible Prince Edward Island residents. A resident is anyone legally entitled to remain in Canada and who makes his or her home and is ordinarily present on an annual basis for at least six months plus a day in Prince Edward Island.

All new residents must register with the Department in order to become eligible. Persons who establish permanent residence in Prince Edward Island from elsewhere in Canada will become eligible for insured hospital and medical services on the first day of the third month following the month of arrival.

Residents who are ineligible for coverage under the health care insurance plan in Prince Edward Island are members of the Canadian Forces, Royal Canadian Mounted Police (RCMP), inmates of federal peniten-tiaries and those eligible for certain services under other government programs, such as Workers' Compensation or the Department of Veterans Affairs' programs.

Ineligible residents may become eligible in certain circumstances. Members of the Canadian Forces or RCMP become eligible on discharge or completion of rehabilitative leave. Penitentiary inmates become eligible upon release. In such cases, the province where the individual in question was stationed at the time of discharge or release, or release from rehabilitative leave, would provide initial coverage during the customary waiting period of up to three months. Parolees from penitentiaries will be treated in the same manner as discharged parolees.

Foreign students, tourists, transients or visitors to Prince Edward Island do not qualify as residents of the province and are, therefore, not eligible for hospital and medical insurance benefits.

3.2 Registration Requirements

New or returning residents must apply for health coverage by completing a registration application from the Department. The application is reviewed to ensure that all necessary information is provided. A health card is issued and sent to the resident within two weeks. Renewal of coverage takes place every five years and residents are notified by mail six weeks before renewal.

The number of residents registered for the Health Care Insurance Plan in Prince Edward Island as of March 31, 2006, was 144,159.

3.3 Other Categories of Individual

Foreign students, temporary workers, refugees and Minister's Permit holders are not eligible for health and medical coverage. Kosovar refugees are an exception to this category and are eligible for both health and medical coverage in Prince Edward Island.

4.0 Portability

4.1 Minimum Waiting Period

Insured persons who move to Prince Edward Island are eligible for health insurance on the first day of the third month following the month of arrival in the province.

4.2 Coverage During Temporary Absences in Canada

Persons absent each year for winter vacations and similar situations involving regular absences must reside in Prince Edward Island for at least six months plus a day each year in order to be eligible for sudden illness and emergency services while absent from the province, as allowed under section 5.(1)(e) of the Health Services Payment Act.

The term "temporarily absent" is defined as a period of absence from the province for up to 182 days in a 12 month period, where the absence is for the purpose of a vacation, a visit or a business engagement. Persons leaving the province under the above circumstances must notify the Registration Department before leaving.

Prince Edward Island participates in the Hospital Reciprocal Billing Agreement and the Medical Reciprocal Billing Agreement. The total amount paid under these agreements was $24,465,674.

The payment rate currently ranges from $717 at the community hospitals to $724 at Prince County Hospital and $959 at the Queen Elizabeth Hospital per day for hospital stays. The standard interprovincial outpatient rate is $158. The methodology used to derive these rates is as if the patient had the services provided in Prince Edward Island.

4.3 Coverage During Temporary Absences Outside Canada

The Health Services Payment Act is the enabling legis-lation that defines portability of health insurance during temporary absences outside Canada, as allowed under section 5.(1)(e) of the Health Services Payment Act.

Insured residents may be temporarily out of the country for a 12-month period one time only. Students attending a recognized learning institution in another country must provide proof of enrolment from the educational institution on an annual basis. Students must notify the Registration Department upon returning from outside the country.

For Prince Edward Island residents leaving the country for work purposes for longer than one year, coverage ends the day the person leaves.

For Island residents travelling outside Canada, coverage for emergency or sudden illness will be provided at Prince Edward Island rates only, in Canadian currency. Residents are responsible for paying the difference between the full amount charged and the amount paid by the Department.

The amount paid for insured emergency services outside Canada in 2005-2006 was $86,475.

4.4 Prior Approval Requirement

Prior approval is required from the Department before receiving non-emergency, out-of-province medical or hospital services. Island residents seeking such required services may apply for prior approval through a Prince Edward Island physician. Full coverage may be provided for (Prince Edward Island insured) non-emergency or elective services, provided the physician completes an application to the Department. Prior approval is required from the Medical Director of the Department to receive out-of-country hospital or medical services not available in Canada.

5.0 Accessibility

5.1 Access to Insured Health Services

Both of Prince Edward Island's hospital and medical services insurance plans provide services on uniform terms and conditions on a basis that does not impede or preclude reasonable access to those services by insured persons.

5.2 Access to Insured Hospital Services

The new Prince County Hospital in Summerside was completed and occupied in April 2004.

As of March 31, 2006 the Department has agreements with five private ambulance operators in the province who provided emergency and non-emergency ground ambulance services on a 24-hour, seven day per week basis. The Department provides operating subsidies to operators who deliver service as per the requirements and standards contained within these agreements.

The Out-of-Province Medical Transport Support Program subsidizes the user fee for patients who require ground ambulance services to access specialized medical care outside the province.

There is activity underway with Health Infostructure Atlantic to further develop an Electronic Health Record within Atlantic Canada. The major focuses of these activities include the overall Electronic Health Record, Health Surveillance and Telehealth activities.

5.3 Access to Insured Physician and Surgical-Dental Services

Physician services are accessible throughout the province except for specialties where there are vacancies. Recruitment processes have been undertaken for family physicians, anaesthetists, radiologists, radiation and medical onco-logists, psychiatrists, and a pathologist and plastic surgeon.

5.4 Physician Compensation

A collective bargaining process is used to negotiate physician compensation. Bargaining teams are appointed by both physicians and government to represent their interests in the process.

The legislation governing payments to physicians and dentists for insured services is the Health Services Payment Act.

Most physicians work on a fee-for-service basis. However, alternate payment plans have been developed and some physicians receive salary, contract and sessional payments. Alternate payment modalities are growing and seem to be the preference for new graduates. Currently almost 50 percent of physicians are compensated under salary or sessional payments.

5.5 Payments to Hospitals

The community hospital authorities are responsible for delivering hospital services in the province under the Community Hospital Authorities Act. The budgetary requirements are established annually through annual business plans approved by the Minister and are subject to approval by the Legislative Assembly through the annual budget process.

Advance payments to provincial hospitals and the community hospital authorities for hospital services are approved for disbursement by the Department in line with cash requirements and are subject to approved budget levels.

The usual funding method includes using a global budget adjusted annually to take into consideration increased costs related to such items as labour agree-ments, drugs, medical supplies and facility operations.

6.0 Recognition Given toFederal Transfers

The Government of Prince Edward Island acknowledged the federal contributions provided through the Canada Health Transfer in its 2005-2006 Annual Budget and related budget documents and its 2004-2005 Public Accounts, which were tabled in the Legislative Assembly and are publicly available to Prince Edward Island residents.

7.0 Extended Health Care Services

Extended health care services are not an insured ser-vice, except for the insured chronic care beds noted in section 2.1.

Nursing Home Intermediate Care and Adult Residential Care Services

Nursing home services are available on approval from regional admission and placement committees for place-ment into public manors and licensed private nursing homes. There are currently 18 long-term care facilities in the province, nine public manors and nine licensed private nursing homes, with a total of 968 beds, including respite and temporary beds. Nursing home admission is for individuals who require 24-hour registered nurse supervision and care management. The standardized Seniors Assessment Screening Tool is used to determine service needs of residents for all admissions to nursing homes. Payment for long-term care is the responsibility of the individual. When a resident of a facility or someone coming into a facility does not have the financial resources to pay for their own care, they can apply for financial assistance under the Social Assistance Act Regulations, Part II. The Province subsidizes 72 percent of residents in nursing homes. The federal government subsidizes approximately 8.7 percent of nursing home residents through Veterans Affairs Canada. The remaining 18.4 percent finance their own care.

In addition to nursing home facilities, there are 38 licensed community care facilities in Prince Edward Island. As of March 31, 2006, the total number of licensed community care facility beds was 938. A Community Care Facility is a privately operated, licensed establishment with five or more residents. These facilities provide semi-dependent seniors and semi-dependent physically and mentally challenged adults with accommodation, housekeeping, supervision of daily living activities, meals and personal care assistance for grooming and hygiene. Care needs are assessed using the Seniors Assessment Screening Tool and are at Level 1, 2 or 3. Residents are eligible to apply for financial assistance under the Social Assistance Act Regulations, Part I. It should be noted that payment to community care is the responsibility of the individual. Clients lacking adequate financial resources may apply for financial assistance under the Prince Edward Island Social Assistance Act.

Home Care Services

Home Care and Support provides assessment and care planning to medically stable individuals, and defined groups of individuals with specialized needs, who, without the support of the formal system, are at risk of being unable to stay in their own home, or are unable to return to their own home from a hospital or other care setting. Services provided through Home Care and Support include nursing, personal care, respite, occupational and physical therapies, adult protection, palliative care, home and community based dialysis, assessment for nursing home placement and community support. The Seniors Assessment Screening Tool is used to determine the nature and type of service needed. Professional services in home care are currently provided at no cost to the client. Visiting homemaker services are subject to a sliding fee scale based on an individual's income assessment, which is generally waived for palliative care clients.

Ambulatory Health Care Services

Prince Edward Island has public adult day programs that provide services such as recreation, education and sociali-zation for dependent elders. Individuals who require this service are assessed by regional home care staff. The overall purpose of adult day programs is to allow clients to remain in their homes as long as possible, provide respite for care givers, monitor client's health and provide social interac-tion. There are adult day programs located across Prince Edward Island.

The Prince Edward Island dialysis program is a com-munity-based service that operates under the medical direction and supervision of the nephrology team at the Queen Elizabeth II Health Sciences Centre in Halifax.

There are five hemodialysis clinics in the province. This is a publicly-funded service. Prince Edward Island also offers a hemodialysis service to out-of-province/country visitors from the existing clinic locations. The provision of this service is based on the capacity within the clinics and the availability of human resources to provide this treatment at the time of the request. Cost of the service is covered through reciprocal billing if from another Canadian jurisdiction and by the visitor if from out of Canada.

Nova Scotia

Introduction

The Nova Scotia Department of Health's mission is to ensure, through leadership and collaboration, an appropriate, effective and sustainable health system that promotes, maintains and improves the health of Nova Scotians. This requires that health care services in Nova Scotia be integrated, community-based and sustainable.

In February 2006, the Government of Nova Scotia created a new Department of Health Promotion and Protection that brought together two areas in the Department of Health: the Office of the Chief Medical Officer of Health and the Public Health Branch.

The Health Authorities Act, Chapter 6 of the Acts of 2000, established the province's nine District Health Authorities (DHAs) and their community-based supports, the Community Health Boards (CHBs). DHAs are responsible for governing, planning, managing, delivering, monitoring and funding health services within each respective district and for providing planning support to the CHBs. Services delivered by the DHAs include acute and tertiary care, public health, mental health and addictions.

The province's 37 CHBs develop community health plans with primary health care and health promotion as their foundation. District Health Authorities draw two-thirds of their board nominations from CHBs. Their community health plans are part of the DHAs annual business planning process. In addition to the nine DHAs, the IWK Health Centre (Women and Children's Tertiary Care Hospital) continues to have separate board, administrative and service delivery structures.

The Department of Health is responsible for setting strategic direction and standards for health services which are meant to ensure the availability of quality health care; for, monitoring, evaluating and reporting on performance and outcomes and for funding health services. The Department of Health is directly responsible for physician and pharmaceutical services, emergency health, continuing care, and many other insured and publicly funded health programs and services.

Under the Health Authorities Act, the DHAs are required to provide the Minister of Health with monthly and quarterly financial statements and audited year-end financial statements. They are also required to submit annual reports, which provide updates on implementing DHA business plans. These provisions ensure greater financial accountability. The sections of the Health Authorities Act related to financial reporting and business planning came into effect on April 1, 2001.

Pursuant to the Provincial Finance Act (2000) and government policies and guidelines, the Department of Health is required to release annual accountability reports outlining outcomes against its business plan for that fiscal year. The 2005-2006 accountability report will be available in late 2006.

The spending of Nova Scotia's 2005-2006 health care dollars was consistent with commitments in Your Health Matters -- a report released by the Department of Health in March 2003 outlining its multi-year plan for better health care. This plan focuses on five key areas:

• helping people stay healthy;
• training, recruiting, and keeping more doctors, nurses, and health professionals;
• shortening wait lists for tests, treatment, and care;
• caring for our seniors; and
• accessing health services close to home.

This report can be viewed at: Department of Health

As part of the commitments contained in Your Health Matters, Nova Scotia publishes annual reports on progress made, which account for how the year's activities matched plans. It reports specifically on issues such as quality, access and efficiency, as well as progress in primary or community-based health care, home care and drug coverage.

Nova Scotia faces a number of challenges in the delivery of health care services. Nova Scotia's population is aging. Currently, 14.1% of the Nova Scotia Population is sixty-five or over and this figure is expected to nearly double by 2026. Aging populations increase the pressure to expand the basket of publicly-insured services to include home care, long-term care and enhanced pharmaceutical coverage. The burden of illness resulting from much higher than average rates of chronic diseases such as cancers and diabetes are major contributors to the rising costs of health care delivery in Nova Scotia. Other major cost drivers are a highly competitive labour market for health human resources, the increasing costs of pharmaceuticals and aging facility infrastructure.

Despite these ever-increasing pressures and challenges, Nova Scotia continues to be committed to the delivery of medically necessary services consistent with the principles of the Canada Health Act.

Additional information related to health care in Nova Scotia may be obtained from the Department of Health website.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

Two plans cover insured health services in Nova Scotia: the Hospital Insurance Plan (HSI) and the Medical Services Insurance Plan (MSI). The Department of Health administers the HSI Plan, which operates under the Health Services and Insurance Act, Chapter 197, Revised Statutes of Nova Scotia, 1989: sections 3(1), 5, 6, 10, 15, 16, 17(1), 18 and 35.

The MSI is administered and operated by an authority consisting of the Department of Health and Medavie Blue Cross (formerly called Atlantic Blue Cross), under the above-mentioned act (sections 8, 13, 17(2), 23, 27, 28, 29, 30, 31, 32 and 35).

Section 3 of the Health Services and Insurance Act states that subject to this Act and the Regulations, all residents of the province are entitled to receive insured hospital services from hospitals on uniform terms and conditions. As well, all residents of the province are insured on uniform terms and conditions in respect of the payment of insured professional services to the extent of the established tariff. Section 8 of the Act gives the Minister of Health, with approval of the Governor in Council, the power to, from time to time, enter into agreements and vary, amend or terminate the same with such person or persons as the Minister deems necessary to establish, implement and carry out the MSI Plan.

The Department of Health and Medavie Blue Cross entered into a new service level agreement, effective August 1, 2005. This new ten-year agreement replaced the 1992 Memorandum of Agreement between Medavie and the Department of Health. Under the agreement, Medavie is responsible for operating and administering programs contained under MSI, Pharmacare Programs and Health Card Registration Services.

There were no changes to the Health Services and Insurance Act or regulations under this act in 2005-2006.

1.2 Reporting Relationship

Medavie is obliged to provide reports to the Department under various Statement of Requirements for each Business Service Description as listed in the contract.

Section 17(1)(i) of the Health Services and Insurance Act, and sections 11(1) and 12(1) of the Hospital Insurance Regulations, under this Act, set out the terms for reporting by hospitals and hospital boards to the Minister of Health, their annual budget estimates and their monthly reports of actual revenues and expenditures.

1.3 Audit of Accounts

The Auditor General's office audits all expenditures of the Department of Health. A contract is in place to have an annual audit performed on the Insured Prescription Drug Plan Trust Fund. The Department of Health has a new service level agreement in place with Medavie Blue Cross, effective August 1, 2005. An audit plan is under development for this agreement, including Medicare payments, which has been recommended by the Auditor General's office.

All long-term care facilities, home care and home support agencies are required to provide the Department with annual audited financial statements.

Under section 34(5) of the Health Authorities Act, every hospital board is required to submit to the Minister of Health by July 1st each year, an audited financial statement for the preceding fiscal year.

The June, 2006 Report of the Auditor General of Nova Scotia contained audits with respect to:

• District Health Authorities -- Colchester East Hants and Cumberland & Pictou County
• Payments to Physicians

1.4 Designated Agency

Medavie Blue Cross Care administers and has the authority to receive monies to pay physician accounts under a new service level agreement with the Department of Health, effective August 1, 2005. Medavie Blue Cross Care receives written authorization from the Department for the physicians to whom it may make payments. The rates of pay and specific amounts depend on the physician contract negotiated between Doctors Nova Scotia and the Department of Health.

All Medavie Blue Cross Care system development for MSI and Pharmacare is controlled through a joint committee. All MSI and Pharmacare transactions are subject to a review by the Office of the Auditor General.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Nine DHAs and the IWK Health Centre (Women and Children's Tertiary Care Hospital) deliver insured hospital services to both in-patients and out-patients in Nova Scotia in a total of 35 facilities.

Accreditation is not mandatory, but all facilities are accredited at a facility or district level. The enabling legislation that provides for insured hospital services in Nova Scotia is the Health Services and Insurance Act, Chapter 197, Revised Statutes of Nova Scotia, 1989: sections 3(1), 5, 6, 10, 15, 16, 17(1), 18 and 35. Hospital Insurance Regulations were made pursuant to the Health Services and Insurance Act.

In-patient services include: accommodation and meals at the standard ward level; necessary nursing services; laboratory, radiological and other diagnostic procedures; drugs, biologicals and related preparations, when administered in a hospital; routine surgical supplies; use of operating room, case room and anaesthetic facilities; use of radiotherapy and physiotherapy services, where available; and blood or therapeutic blood fractions.

Out-patient services include: laboratory and radiological examinations; diagnostic procedures involving the use of radio-pharmaceuticals; electroencephalographic examinations; use of occupational and physiotherapy facilities, where available; necessary nursing services; drugs, biologicals and related preparations; blood or therapeutic blood fractions; hospital services in connection with most minor medical and surgical procedures; day-patient diabetic care; services other than medical services provided by and within the Nova Scotia Hearing and Speech Clinics; ultrasonic diagnostic procedures; home parenteral nutrition; and haemodialysis and peritoneal dialysis.

In order to add a new hospital service to the list of insured hospital services, DHAs are required to submit a New and/or Expanded Program Proposal to the Department of Health. This process is carried out annually by request through the business planning process. A Department-developed process format is forwarded to the DHAs for their guidance. A departmental working group reviews and prioritizes all requests received. Based on available funding, a number of top priorities may be approved by the Minister of Health.

2.2 Insured Physician Services

The legislation covering the provision of insured physician services in Nova Scotia is the Health Services and Insurance Act, sections 3(2), 5, 8, 13, 13A, 17(2), 22, 27-31, 35 and the Medical Services Insurance Regulations.

The Health Services and Insurance Act was amended in 2002-2003 to include section 13B stating that: "Effective November 1, 2002, any agreement between a provider and a hospital, or predecessors to a hospital, stipulating compensation for the provision of insured professional services, for the provider undertaking to be on-call for the provision of such services or for the provider to relocate or maintain a presence in proximity to a hospital, excepting agreements to which the Minister and the Society are a party, is null and void and no compensation is payable pursuant to the agreement, including compensation otherwise payable for termination of the agreement."

Under the Health Services and Insurance Act, persons who can provide insured physician services include:

• general practitioners, who are persons who engage in the general practice of medicine;
• physicians, who are not specialists within the meaning of the clause; and
• specialists, who are physicians and are recognized as specialists by the appropriate licensing body of the jurisdiction in which he or she practises.

Physicians (general practitioner or specialist) must be licensed by the College of Physicians and Surgeons in Nova Scotia in order to be eligible to bill the MSI system. Dentists receiving payment under the MSI Plan must be registered with the Provincial Dental Board and be recognized as dentists. In 2005-2006, 2,220 physicians and 33 dentists were paid through the MSI Plan.

Physicians retain the ability to opt into or out of the MSI Plan. In order to opt out, a physician notifies MSI, relinquishing his or her billing number. Patients who pay the physician directly due to opting out are reimbursed for these services by MSI. As of March 31, 2006, no physicians had opted out.

Insured services are those medically necessary to diagnose, treat, rehabilitate or otherwise alter a disease pattern. There are no limitations on medically necessary insured services.

No new large-scale services were added to the list of insured physician services in 2005-2006. On a quarterly, ongoing basis, new specific fee codes are approved that represent enhancements, new technologies or new ways of delivering a service.

The addition of new fee codes to the list of insured physician services is accomplished through a committee structure. Physicians wishing to have a new fee code recognized or established must first present their cases to Doctors Nova Scotia, which puts a suggested value on the proposed new fee.

The proposal is then passed to the Joint Fee and Tariff Committee for review and approval. The Joint Committee is comprised of equal representation from Doctors Nova Scotia and the Department of Health. When approved by the Joint Fee Schedule Committee, the approved proposed new fee is forwarded to the Department of Health for final approval and Medavie Blue Cross Care is directed to add the new fee to the schedule of insured services payable by the MSI Plan.

2.3 Insured Surgical-Dental Services

Under the Nova Scotia Health Services and Insurance Act, a dentist is defined as a person lawfully entitled to practice dentistry in a place where that person carries on such practice.

To provide insured surgical-dental services under the Health Services and Insurance Act, dentists must be registered members of the Nova Scotia Dental Association and must also be certified competent in the practice of dental surgery. The Health Services and Insurance Act is so written that a dentist may choose not to participate in the MSI Plan. To participate, a dentist must register with MSI. A participating dentist who wishes to reverse election to participate must advise MSI in writing and is then no longer eligible to submit claims to MSI. As of March 31, 2006, no dentists had opted out. In 2005-2006, 33 dentists were paid through the MSI Plan for providing insured surgical-dental services.

Insured surgical-dental services must be provided in a health care facility. Insured services are listed in the Insured Dental Services Tariff Regulations. Services under this program are insured when the conditions of the patient are such that it is medically necessary for the procedure to be done in a hospital and the procedure is of a surgical nature. Generally included as insured surgical-dental services are orthognathic surgery, surgical removal of impacted teeth and oral and maxillary facial surgery. Routine extractions services are provided for cardiac patients, transplant patients, immunocompromised patients and radiation patients when these patients are undergoing active treatment in a hospital setting and the attendant medical procedure requires the removal of teeth. Other approved services include coverage for all precancerous or cancerous dental surgical biopsies.

Requests for an addition to the list of surgical-dental services are accomplished by first approaching the Dental Association of Nova Scotia and having them put forward a proposal to the Department of Health to add a new procedure. The Department of Health, in consultation with specific experts in the field, renders the decision as to whether or not the new procedure becomes an insured service.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital services include: preferred accommodation at the patient's request; telephones; televisions; drugs and biologicals ordered after discharge from hospital; cosmetic surgery; reversal of sterilization procedures; surgery for sex reassignment; in vitro fertilization; procedures performed as part of clinical research trials; services such as gastric bypass for morbid obesity, breast reduction/augmentation and newborn circumcision, except because of medical necessity; and services not deemed medically necessary that are required by third parties, such as insurance companies.

Uninsured physician services include: those a person is eligible for under the Workers' Compensation Act or under any other federal or provincial legislation; mileage, travelling or detention time; telephone advice or telephone renewal of prescriptions; examinations required by third parties; group immunizations or inoculations unless approved by the Department; preparation of certificates or reports; testimony in court; services in connection with an electrocardiogram, electromyogram or electroencephalogram, unless the physician is a specialist in the appropriate specialty; cosmetic surgery; acupuncture; reversal of sterilization; and in vitro fertilization.

Major third-party agencies purchasing medically necessary health services in Nova Scotia include Workers Compensation, the Canadian Armed Forces and the Royal Canadian Mounted Police (RCMP).

All residents of the province are entitled to services covered under the Health Services and Insurance Act. If enhanced goods and services, such as foldable intraocular lens or a fiberglass cast can be purchased, it is required to fully inform patients about the cost. They are not to be denied service based on their inability to pay. The Province provides alternatives to any of the enhanced goods and services.

The Department of Health also carefully reviews all patient complaints or public concerns that may indicate that the general principles of insured services are not being followed.

The de-insurance of insured physician services is accomplished through a negotiation process between Doctors Nova Scotia and Department of Health representatives, who jointly evaluate a procedure or process to determine its medical necessity. If a process or procedure is deemed not to be medically necessary, it is removed from the physician fee schedule and will no longer be reimbursed to physicians as an insured service. Once a service has been de-insured, all procedures and testing relating to the provision of that service also become de-insured. The same process applies to dental and hospital services. The last time there was any significant de-insurance of services was in 1997.

3.0 Universality

3.1 Eligibility

Eligibility for insured health care services in Nova Scotia is outlined under section 2 of the Hospital Insurance Regulations made pursuant to section 17 of the Health Services and Insurance Act. All residents of Nova Scotia are eligible. A resident is defined as anyone who is legally entitled to stay in Canada and who makes his or her home and is ordinarily present in Nova Scotia.

A person is considered to be "ordinarily present" in Nova Scotia if the person:

• makes his or her permanent home in Nova Scotia;
• is physically present in Nova Scotia for at least 183 days in any calendar year (short term absences under 30 days, within Canada, are not monitored); and
• is a Canadian citizen or "Permanent Resident" as defined by Citizenship and Immigration Canada.

Persons moving to Nova Scotia from another Canadian province will normally be eligible for MSI on the first day of the third month following the month of their arrival. Persons moving permanently to Nova Scotia from another country are eligible on the date of their arrival in the province, provided they are Canadian citizens or hold "Permanent Resident" status as defined by Citizenship and Immigration Canada.

Members of the RCMP, members of the Canadian Forces, federal inmates and members of the North Atlantic Treaty Organization (NATO) are ineligible for MSI coverage. When their status changes, they immediately become eligible for provincial Medicare.

There were no changes to eligibility requirements in 2005-2006.

3.2 Registration Requirements

To obtain a health card in Nova Scotia, residents must register with MSI. Once eligibility has been determined, an application form is generated. The applicant (and spouse if applicable) must sign the form before it can be processed. The applicant must indicate on the application the name and mailing address of a witness. The witness must be a Nova Scotia resident who can confirm the information on the application. The applicant must include proof of Canadian citizenship or provide a copy of an acceptable immigration document.

When the application has been approved, health cards will be issued to each family member listed. MSI registration information is maintained as a family unit. Each health card number is unique and is issued for the lifetime of the applicant. Health cards expire every four years. The health card number also acts as the primary health record identifier for all health service encounters in Nova Scotia for the life of the recipient. Proof of eligibility for insured services is required before residents are eligible to receive insured services. Renewal notices are sent to most cardholders three months before the expiry date of the current health card. Upon return of a signed renewal notice, MSI will issue a new health card.

There is no legislation in Nova Scotia forcing residents of the province to apply for MSI. There may be residents of Nova Scotia who, therefore, are not members of the health insurance plan.

In 2005-2006, there were 933,259 residents registered with the health insurance plan.

3.3 Other Categories of Individual

The following persons may also be eligible for insured health care services in Nova Scotia, once they meet the specific eligibility criteria for their situations:

Immigrants: Persons moving from another country to live permanently in Nova Scotia are eligible for health care on the date of arrival. They must possess a landed permanent residency document. These individuals, formerly called "landed immigrants", are now referred to as "Permanent Residents".

Convention Refugees and Non-Canadians married to Canadian Citizens/Permanent Residents (copy of Marriage Certificate required) who possess any other document and who have applied within Canada for Permanent Resident status, will be eligible on the date of application for permanent residency, provided they have a letter from the Immigration Department stating that they have applied for Permanent Residence.

Non-Canadians married to Canadian Citizens/ Permanent Residents (copy of Marriage Certificate required), who possess any other document and who have applied outside Canada for Permanent Resident status, will be eligible on the date of arrival, provided they have a letter from the Immigration Department stating that they have applied for Permanent Residence.

In 2005-2006, there were 22,098 Permanent Residents registered with the health care insurance plan.

Work Permits: Persons moving to Nova Scotia from outside the country who possess a work permit can apply for coverage on the date of arrival in Nova Scotia, provided that they remain in Nova Scotia for at least one full year. A declaration must be signed to confirm that the worker will not be outside Nova Scotia for more than 31 consecutive days, except in the course of employment. MSI coverage is extended for a maximum of 12 months at a time. Each year a copy of their renewed immigration document must be presented and a declaration signed. Dependants of such persons, who are legally entitled to remain in Canada, are granted coverage on the same basis.

Once coverage has terminated, the person is to be treated as never having qualified for health services coverage as herein provided, and must comply with the above requirements before coverage will be extended to him/her or their dependents.

In 2005-2006, there were 1,230 individuals with Employment Authorizations covered under the health care insurance plan.

Study Permits: Persons moving to Nova Scotia from another country, who possess a Study Permit will be eligible for MSI on the first day of the thirteenth month following the month of their arrival, provided they have not been absent from Nova Scotia for more than 31 consecutive days, except in the course of their studies. MSI coverage is extended for a maximum of 12 months at a time and only for services received within Nova Scotia. Each year, a copy of their renewed immigration document must be presented and a declaration signed. Dependants of such persons, who are legally entitled to remain in Canada, will be granted coverage on the same basis, once the student has gained entitlement.

In 2005-2006, there were 943 individuals with Student Authorizations covered under the health care insurance plan.

Refugees: Refugees are eligible for MSI if they possess either a work permit or study permit.

4.0 Portability

4.1 Minimum Waiting Period

Persons moving to Nova Scotia from another Canadian province or territory are eligible for MSI on the first day of the third month following the month of their arrival.

4.2 Coverage During Temporary Absences in Canada

The Agreement of Eligibility and Portability is followed in all matters pertaining to portability of insured services.

Generally, the Nova Scotia MSI Plan provides coverage for residents of Nova Scotia who move to other provinces or territories for a period of three months as per the Eligibility and Portability Agreement. Students, and their dependants, who are temporarily absent from Nova Scotia and in full-time attendance at an educational institution, may remain eligible for MSI on a yearly basis. To qualify for MSI, the student must provide to MSI a letter directly from the educational institution, which states that they are registered as full-time students. MSI coverage will be extended on a yearly basis pending receipt of this letter.

Workers who leave Nova Scotia to seek employment elsewhere will still be covered by MSI for up to 12 months, provided they do not establish residence in another province, territory or country. Services provided to Nova Scotia residents in other provinces or territories are covered by reciprocal agreements. Nova Scotia participates in the Hospital Reciprocal Billing Agreement and the Medical Reciprocal Billing Agreement. Quebec is the only province that does not participate in the medical reciprocal agreement. Nova Scotia pays for services provided by Quebec physicians to Nova Scotia residents at Quebec rates if the services are insured in Nova Scotia. The majority of such claims are received directly from Quebec physicians. In-patient hospital services are paid through the interprovincial reciprocal billing arrangement at the standard ward rate of the hospital providing the service. The total amounts paid by the plan in 2005-2006, for in- and out-patient hospital services received in other provinces and territories were: $16,285,032 for out-of-province, in-patient services and $7,345,702 for out-of-province, out-patient services. Nova Scotia pays the host province rates for insured services in all reciprocal-billing situations.

There were no changes made in Nova Scotia in 2005-2006 regarding in-Canada portability.

4.3 Coverage During Temporary Absences Outside Canada

Nova Scotia adheres to the Agreement on Eligibility and Portability for dealing with insured services for residents temporarily outside Canada. Provided a Nova Scotia resident meets eligibility requirements, out-of-country services will be paid, at a minimum, on the basis of the amount that would have been paid by Nova Scotia for similar services rendered in this province. Ordinarily, to be eligible for coverage, residents must not be outside the country for more than six months in a calendar year. In order to be covered, procedures of a non-emergency nature must have prior approval before they will be covered by MSI.

Students and their dependants who are temporarily absent from Nova Scotia and in full-time attendance at an educational institution outside Canada may remain eligible for MSI on a yearly basis. To qualify for MSI, the student must provide to MSI, a letter obtained from the educational institution that verifies the student's attendance there in each year for which MSI coverage is requested.

Persons who engage in employment (including volunteer/ missionary work/research) outside Canada, which does not exceed 24 months, are still covered by MSI; providing the person has already met the residency requirements.

Emergency out-of-country services are paid at a minimum on the basis of the amount that would have been paid by Nova Scotia for similar services rendered in this province.

The total amount spent in 2005-2006 for insured inpatient services provided outside Canada was $1,495,313.

There were no changes made in Nova Scotia in 2005-2006 regarding out-of-Canada portability.

4.4 Prior Approval Requirement

Prior approval must be obtained for elective services outside the country. Application for prior approval is made to the Medical Director of the MSI Plan by a specialist in Nova Scotia on behalf of an insured resident. The medical consultant reviews the terms and conditions and determines whether or not the service is available in the province, or if it can be provided in another province or only out-of-country. The decision of the Medical Consultant is relayed to the patient's referring specialist. If approval is given to obtain service outside the country, the full cost of that service will be covered under MSI.

5.0 Accessibility

5.1 Access to Insured Health Services

Insured services are provided to Nova Scotia residents on uniform terms and conditions. There are no user charges or extra charges under the plan.

Nova Scotia continually reviews access situations across Canada to ensure that it is not falling behind. In areas where improvement is deemed necessary, depending on the Province's financial situation, extra funding is generally allocated to that area.

In 2005-2006 Nova Scotia Department of Health invested $650,000 to increase the number of community-based, multi-disciplinary teams available to serve the primary health-care needs of Nova Scotians.

To address the access needs of its culturally diverse population, the Nova Scotia Department of Health produced Guidelines for Diversity and Social Inclusion in Primary Health Care with plans to begin implementation of these guidelines in 2006-2007.

5.2 Access to Insured Hospital Services

The Government of Nova Scotia continues to emphasize the provision of sustainable, quality health care services to its citizens. In December 2005, Nova Scotia Department of Health released the Health Human Resources Action Plan as a first step in the development of a comprehensive health human resources strategy for the province which will ensure that the supply of health care professionals in Nova Scotia is sufficient, has the right mix of health professionals, and has the right geographical distribution.

In 2005-2006, there were a total of 2,220 physicians operating in Nova Scotia, 53 more than in the previous year. This includes 948 general practitioners and 1,270 specialists. As in previous years, all were participating in the health insurance plan.

Nova Scotia has a nursing strategy, which was introduced in 2001. It is a multi-year plan that provides a comprehensive and coordinated approach to enhancing the quality of work life for nurses, retaining experienced nurses in the system, and creating an environment in which recruitment efforts will be successful. Nova Scotia invests approximately $10 million annually on the strategy and on training more nurses.

Nova Scotia has a Telehealth Network (NSTHN), which connects DHAs and the IWK Health Centre with a sophisticated videoconferencing communications network. The network allows patients in rural areas to consult with specialists in large health centres. The NSTHN enhances access to health services closer to home for patients and their families. The NSTHN also provides health professionals across Nova Scotia with access to educational opportunities without leaving their communities.

In October of 2005, Nova Scotia officially launched its wait times website.

This site provides Nova Scotians with information to help them, and their health-care providers, make decisions about their testing and treatment options. It provides provincial health-care wait times for tests, treatments and services by the various choice locations in Nova Scotia.

In 2005-2006, Nova Scotia announced a number of investments that will improve access to health care services for Nova Scotians. Some of these included:

• A $2 million renovation project at the Lillian Fraser Memorial Hospital to improve access to community health care services
• More than $1 million in the Picture Archive and Communication System expansion project.
• $3 million investment in a PET scans.
• Establishment of a new primary health care clinic at Yarmouth Regional Hospital.
• $78 million commitment to replace Colchester Regional Hospital.
• $9.3 million investment in St. Martha's Hospital.
• Plans to establish a provincial renal care program.
• The completion of the Nova Scotia Hospital Information System with implementation in 34 hospitals with over 1 million patients on file.

5.3 Access to Insured Physician and Surgical-Dental Services

In 2005-2006, 2,220 physicians and 33 dentists actively provided insured services under the Canada Health Act or provincial legislation.

According to the 2005 Canadian Community Health Survey, 95.1 percent of Nova Scotians have a regular family physician. The Canadian average is 86.4 percent.

Innovative funding solutions for physicians, such as block funding and personal services contracts, have enhanced recruitment. A five-year incentive program is offered in 21 rural communities to recruit doctors. The program provides an annual bonus for each completed year of service, moving expenses, continuing medical education funding and guaranteed minimum billing (income) for the year.

Other provincial programs include: start-up contracts for family doctors, alternative payment plans, a debt assistance program, and a physician recruitment office that maintains a recruitment website and co-ordinates site visits, advertising, and c.v. distribution within the province.

The Province has increased the capacity for medical education and has provided funding to create a reentry program for general practitioners wishing to enter specialty training after completing two years of general practice service in the province.

5.4 Physician Compensation

The Health Services and Insurance Act, RS Chapter 197 governs payment to physicians and dentists for insured services. Physician payments are made in accordance with a negotiated agreement between Doctors Nova Scotia and the Nova Scotia Department of Health. Doctors Nova Scotia is recognized as the sole bargaining agent in support of physicians in the province. When negotiations take place, representatives from Doctors Nova Scotia and the Department of Health negotiate the total funding and other terms and conditions. The current master agreement is effective from April 1, 2004 through March 31, 2008. The agreement lays out what the medical services unit value will be for physician services and addresses other issues such as Canadian Medical Protective Association, membership benefits, emergency department payment, on-call funding, specific fee adjustments, dispute resolution processes, and other process or consultation issues.

Fee-for-service is still the most prevalent method of payment for physician services. However, there has been significant growth in the number of alternative payment arrangements in place in Nova Scotia.

Over the past number of years, we have seen a significant shift toward alternative payment. In the 1997-1998 fiscal year, about nine percent of our doctors were paid solely through alternative funding. In 2005-2006 over 30 percent of physicians are remunerated through alternative funding. They can be broken down into three groups:

• Academic Specialists (these physicians are mainly located in Halifax at the QEII and the IWK centres). Most of the Academic Specialist groups are on alternate funding arrangements with the exception of Urology and Ophthalmology.
• District Specialists (Obstetrics/Gynecology, Anaesthesiology, Pediatrics).
• General Practice (including General Practice/Nurse Practitioner Contracts).

There are also a number of physicians who receive a portion of their remuneration through alternative funding. These alternative funding mechanisms include Sessional, Psychiatry, Remote Practice, Facility On-Call and Emergency Room funding. In total, over 60 percent of physicians in Nova Scotia receive all or a portion of their remuneration through alternative funding mechanisms.

In 2005-2006 total payments to physicians for insured services in Nova Scotia were $540,495,196. The Department paid an additional $6,619,938 for insured physician services provided to Nova Scotia residents outside the province, but within Canada.

Payment rates for dental services in the province are negotiated between the Department of Health and the Nova Scotia Dental Association and follow a process similar to physician negotiations. Dentists are paid on a fee-for-service basis. The current agreement, which was reached in April 2004, expires on March 31, 2008.

5.5 Payments to Hospitals

The Department of Health establishes budget targets for health care services. It does this by receiving business plans from the nine DHAs, the IWK Health Centre and other non-DHA organizations. Approved provincial estimates form the basis on which payments are made to these organizations for service delivery.

The Health Authorities Act instituted the nine DHAs that replaced the former regional health boards. This change came into effect in January 2001, under the District Health Authorities General Regulations. The implementation of community health boards under the Community Health Boards' Member Selection Regulations was effective April 2001. Under section 20 of the Health Authorities Act, the DHAs are responsible for overseeing the delivery of health services in their districts and are fully accountable for explaining their decisions on the community health plans through their business plan submissions to the Department of Health.

Section 10 of the Health Services and Insurance Act and sections 9 through 13 of the Hospital Insurance Regulations define the terms for payments by the Minister of Health to hospitals for insured hospital services.

In 2005-2006, there were 2,891 hospital beds in Nova Scotia (3.0 beds per 1,000 population). Department of Health direct expenditures for insured hospital services operating costs were increased to $1.13 billion.

6.0 Recognition Given to Federal Transfers

In Nova Scotia, the Health Services and Insurance Act acknowledges the federal contribution regarding the cost of insured hospital services and insured health services provided to provincial residents. The residents of Nova Scotia are aware of ongoing federal contributions to Nova Scotia health care through the Canada Health Transfer (CHT) as well as other federal funds through press releases and media coverage.

The Government of Nova Scotia also recognized the federal contribution under the CHT in various published documents including the following documents released in 2005-2006:

• Public Accounts 2004-2005; and
• Budget Estimates 2005-2006.

7.0 Extended Health Care Services

The Nova Scotia Department of Health's Continuing Care branch offers home care and long-term care services. These services promote independence, fairness, equity, and choice for people with care needs. The Department of Health provides a Single Entry Access to its continuing care services. Nova Scotians can connect with Continuing Care through a single toll-free number.

In 2006, the Department of Health released a broad based, multi-year Continuing Care strategy that will see the addition of long-term care beds and the expansion and enhancement of community and home based services over the ensuing five to ten years.

7.1 Nursing Home Intermediate Care and Adult Residential Care Services

The Department of Health provides residentially based long-term care services in the following facility types:

Nursing Homes & Homes for the Aged which provide a range of personal care and/or skilled nursing care to individuals who require the availability of a registered nurse on-site at all times;

Residential Care Facilities which provide supervisory care and/or personal care in a residential setting; and

Community Based Options which provide accommodation, minimal supervision and the development of self-care skills for three or less residents.

Residents who live in nursing homes, residential care facilities, and community-based options under the Department of Health's mandate have the costs of their health care services covered by the provincial government. Residents pay the accommodation cost portion of the long-term care services they receive. Long-term care accommodation charges are based on the type of facility and the resident's income, up to a daily maximum. For more information.

7.2 Home Care Services

Broad-based, provincially funded home care services are available to Nova Scotians of all ages and help individuals to reach and maintain their maximum level of health and to prolong independent living in the community. Both chronic care services over the longer term and short-term acute services are provided through home care. Home care services can be provided to people who are chronically ill, convalescent, palliative, disabled or to individuals with an acute illness. The services available to individuals through home care include professional nursing care, assistance with personal care, nutritional care, aid with home making activities, home oxygen services and respite care. The program also provides referrals to and linkages with other services such as adult day programs, volunteer services, meals on wheels and community rehabilitation services.

In December 2005, the Department of Health introduced a Self-Managed Care service component to assist physically disabled Nova Scotians to increase control over their lives. The program provides funds to eligible individuals so that they may directly employ caregivers to meet their home support and personal care needs.

In addition to the services outlined above, the following services and programs are provided to Nova Scotians outside the requirements of the Canada Health Act.

• Nova Scotia Seniors' Pharmacare Program -- This provincial drug insurance plan helps seniors manage their prescription drug costs. Eligible persons include all residents aged 65 years or older and who do not have prescription drug coverage through Veterans Affairs Canada, First Nations and Indian Health, or a private drug plan. The program provides access to prescription drugs, and diabetic and ostomy supplies listed as benefits in the Nova Scotia Formulary. Persons using this program are responsible for user charges of 33 percent of the total cost to a maximum of $30 for each drug and supply with an annual maximum of $360. General information regarding Pharmacare.
• Special Funding for Drugs for Specific Disease States -- The Province provides special funding for drug therapies for a few specific disease states including cystic fibrosis, diabetes insipidus, cancer and growth hormone deficiency. There are no user charges for this coverage. General information regarding Drug Programs and Funding.
• Diabetes Assistance Program. In 2005-2006, $2.5 million was allocated to design and start this program. This program helps cover the cost of most diabetes medications and supplies and is available to Nova Scotians under 65 years of age who have no other drug coverage. General information.
• Emergency Health Services -- Pre-hospital Emergency Care -- Emergency Health Services Nova Scotia (EHS) is responsible for the continual development, implementation, monitoring and evaluation of pre-hospital emergency health services in Nova Scotia. EHS integrates various pre-hospital services and programs into one system to meet the needs of Nova Scotians. These services include: EHS ground ambulance system, EHS LifeFlight (the provincial air medical transport system), EHS Communications Centre, Medical Oversight (Management and Direction), the EHS NS Trauma Program, EHS Atlantic Health Training and Simulation Centre and the EHS Medical First Response program. This integrated province-wide systemhas been rated in the top 10 percent of systems in North America. Residents in Nova Scotia are levied a user charge of $120, to be transported to hospital by ambulance (regardless of distance). There is no charge for transport from hospital to hospital.
• Children's Oral Health Program (COHP) -- This program has two components: 1) the Insured Services Treatment component provides diagnostic, preventative and restorative services; and 2) the Public Health Services component provides prevention-oriented activities through the application of public health initiatives. Children are eligible for services up to the end of the month in which they turn 10 years of age. All eligible children are entitled to one dental examination and two radiographs per year.
• Special Dental Plans -- The program covers all dental services required, including prosthetics and orthodontics required by persons diagnosed as having a cleft palate cranofacial disorder; in-hospital dental services provided to the severely mentally challenged who, because of their condition, require the services to be provided in hospital; and a full range of diagnostic, preventive and restorative procedures to residents of the Nova Scotia School for the Blind. There are no user charges for these services. Eligible residents include the following: 1) patients registered with the Cleft Palate Cranofacial Clinic at the IWK Health Centre; 2) registered students at the School for the Blind; and 3) patients with a signed statement to the effect that they are severely mentally challenged and require hospitalization for dental treatment.
• Community Mental Health Program -- All of the DHAs and the IWK Health Centre offer acute psychiatric treatment. Services are provided across the life span of a person. Specialized services are offered and are in-patient, day treatment, and community- based (e.g. forensic, eating disorders, psychogeriatrics and psychosocial rehabilitation). There are early intervention programs for children with Autism Spectrum Disorder (0-6 yrs). Intensive Community Based Treatment teams in two DHAs and one provincial mental health residential/rehabilitation program for children and youth exists to enhance the continuum of mental health services. Youth Forensic services, including a treatment program for sexually aggressive youth, exist under the authority of the IWK Health Centre. There are no user charges for these services. They are available to all residents in the province.
• Nova Scotia Addiction Services -- A range of treatment and rehabilitation options are provided, including withdrawal management (detoxification and treatment orientation) programs and community-based structured treatment, out-patient and extended care services. Treatment options are tailored to individual needs and are based on an ongoing assessment. Short-term and long-term treatment goals are identified with each client. Programs and services may be available on a residential, day or out-patient basis, and may include individual, group and/or family programming. Targeted programming is offered where appropriate and may include programming for adolescents, women, families or impaired drivers. There are no user charges for these services except for the program for "Driving While Impaired Offenders".
• Optometric Benefit -- This benefit provides insurance for visual analysis carried out by optometrists. Vision analysis is defined as: "... an examination that includes the determination of: 1) the refractive status of the eye; 2) the presence of any observed abnormality in the visual system, and all necessary tests and prescriptions connected with such determination." Coverage is limited to one routine vision analysis every two years for those under 10 years of age and those 65 and over. Those between 10 and 65 are not covered for routine analyses, but are covered where medical need is indicated.
• Prosthetic Services -- All insured residents of the province are eligible for financial assistance in acquiring and replacing standard arm and leg prostheses prescribed by a qualified physician and repairs on such prostheses as required. Patients are responsible for all costs over and above stated coverage.
• Interpreter Service Program -- This program guarantees equal access to government services, offered to the general public, to eligible deaf and hard of hearing residents of Nova Scotia.
• Speech and Language Pathology Program -- The service options of this program include: 1) one-to-one therapy; 2) small-group therapy; and 3) consultations (e.g. classroom, day-cares, developmental preschools, and residential facilities for individuals with special needs). The Nova Scotia Hearing and Speech Centres provide specialized services such as dysphagia (swallowing) programs and pervasive developmental delay programs at limited locations in the province. There are no user charges. Eligible persons include children from birth to school age and individuals when they leave school through their adult lifespan. Provincial school boards service children in the public school system.

New Brunswick

Introduction

New Brunswick's ongoing commitment to the principles of public administration, comprehensiveness, universality, portability and accessibility in health care services -- the principles that form the foundation of the Canada Health Act -- was reaffirmed during the 2005-2006 fiscal year as the Government of New Brunswick implemented its Provincial Health Plan.

The Provincial Health Plan, released in June 2004, sets key goals, principles, strategies and priorities to guide health care investments and improvements. It set out a vision of a single, integrated, patient-focused, community-based health services system, accessible to all New Brunswickers in both official languages and managed in a fiscally sustainable manner. It sets out strategies to improve health care services through investments in health promotion, primary health care, recruitment and retention of health human resources, and enhanced accountability and evidence-based decision making.

The goals set out in the Provincial Health Plan are in line with the priorities agreed to by First Ministers in the 10-Year Plan to Strengthen Health Care. The New Brunswick plan includes initiatives to improve patient access to health care services, provide access to needed drug therapies, increase the supply of valued health professionals, and promote wellness and healthy living.

A number of initiatives to implement aspects of the Provincial Health Plan were undertaken during the 2005-2006 fiscal year.

On February 14, 2006 the Department was renamed the Department of Health, as responsibility for wellness moved to another ministry.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

In New Brunswick, the health care insurance plan is known as the Medical Services Plan. The public authority responsible for operating and administering the plan is the Minister of Health, whose authority rests under the Medical Services Payment Act and its Regulations, which were proclaimed on January 1, 1971.

The Act and Regulations specify eligibility criteria, the rights of the beneficiary and the responsibilities of the provincial authority, including the establishment of a medical service plan, the insured and the uninsured services. The legislation also stipulates the type of agreements the provincial authority may enter into with provinces and territories and with the New Brunswick Medical Society. As well, it specifies the rights of a medical practitioner; how the amounts to be paid for entitled services will be determined; how assessment of accounts for entitled services may be made; and confidentiality and privacy issues as they relate to the administration of the Act.

The Minister of Health is responsible for establishing a medical services plan that identifies beneficiaries, which services are and are not covered, and the amounts to be paid for entitled services. Under the Plan, the Minister assesses and audits physician billings through inspectors appointed by him or her and through a professional review committee as defined in sections 24(1) to 33 of the Medical Services Payment Act and Regulations. The Minister also has the authority to recover the cost of entitled services from a person who is negligent.

1.2 Reporting Relationship

The Medicare Branch of the Department of Health has a mandate to administer the Medical Services Plan. The Minister reports to the Legislative Assembly through the Department's annual report and through regular legislative processes.

The Regional Health Authorities Act, which came into force on April 1, 2002, sets out the relationship between the eight RHAs and the Department. Under the Act, RHAs must prepare regional health and business plans that are in harmony with the Provincial Health Plan developed by the Department. The business and affairs of the RHA are to be controlled and managed by a board of directors, appointed or elected in accordance with the Act and its regulations. The chief executive officer of each RHA reports to the Deputy Minister of Health. Under sections 7(1) and 7(2) of the Act, the Minister of Health shall establish an accountability framework, drafted in consultation with RHAs, to specify the responsibilities that each party has to the other in the provincial health system.

1.3 Audit of Accounts

Three groups have a mandate to audit the Medical Services Plan.

The Office of the Auditor General

In accordance with the Auditor General Act, the Office of the Auditor General conducts the external audit of the accounts of the Province of New Brunswick, which includes the financial records of the Department of Health. For 2005-2006, all financial transactions of the Department were subject to audit. These procedures are completed on a routine basis each year. Following the audit, the Auditor General issues a management letter or report to identify errors and control weaknesses. The Auditor General also conducts management reviews on programs as he or she sees fit and follows up on prior years' audits

The Office of the Comptroller

The Comptroller is the chief internal auditor for the Province of New Brunswick and provides accounting, audit and consulting services in accordance with responsibilities and authority set out in the Financial Administration Act. The Comptroller's internal audit objectives cover Appropriations Audit, Information Systems Audit, Statutory Audits and Value-For-Money Audits. The audit work performed by the Office varies, depending on the nature of the entity audited and the audit objectives. During 2005-2006, the Office of the Comptroller continued to gather risk assessment data on programs offered by the Department and reviewed common services in the Department and other selected departments.

Department of Health Internal Audit Branch

The Department's Internal Audit Branch was established to independently review and evaluate departmental activities as a service to all levels of management. This group is responsible for providing management with information about the adequacy and the effectiveness of its system of internal controls and adherence to legislation and stated policy. The Branch also performs program audits to report on the efficiency, effectiveness and economy of programs in meeting departmental objectives.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Legislation providing for insured hospital services includes the Hospital Services Act, 1973, and section 9 of Regulation 84-167 and the Hospital Act, assented to on May 20, 1992, and its Regulation 92-84.

There are eight RHAs, established under the authority of the Regional Health Authorities Act. Each RHA includes a regional hospital facility and a number of smaller facilities, all of which provide insured services for both in- and outpatients. Each RHA has other health facilities or health centres, without designated beds, that provide a range of services to entitled persons.

Under Regulation 84-167 of the Hospital Services Act, New Brunswick residents are entitled to the following in-patient and out-patient insured hospital services.

In-patient services in a hospital facility operated by an approved regional health authority as follows:

• accommodation and meals at the standard ward level;
• necessary nursing service;
• laboratory, radiological and other diagnostic procedures, together with the necessary interpretations for maintaining
  health, preventing disease and helping diagnose and treat any injury, illness or disability;
• drugs, biologicals and related preparations, as provided for under Schedule 2; use of operating room, case room and anaesthetic facilities, including necessary equipment and supplies;
• routine surgical supplies;
• use of radiotherapy facilities, where available;
• use of physiotherapy facilities, where available; and
• services rendered by persons who receive remuneration therefore from the RHA.

Out-patient services in a hospital facility operated by an approved RHA as follows:

• laboratory and diagnostic procedures, together with the necessary interpretations, when referred by a medical practitioner or nurse practitioner, when approved facilities are available;
• laboratory and diagnostic procedures, together with the necessary interpretations, where approved facilities are available, when performed for the purpose of a mammography screening service that has been approved by the Minister of Health;
• the hospital component of available out-patient services
  when prescribed by a medical practitioner or nurse practitioner and provided in an out-patient facility of an approved RHA for maintaining health, preventing disease and helping diagnose and treat any injury, illness or disability, excluding the following services:
  • the provision of any proprietary medicines;
  • the provision of medications for the patient to take home;
  • diagnostic services performed to satisfy the requirements of third parties, such as employers and insurance companies;
  • visits solely for the administration of drugs, vaccines, sera or biological products; and
  • any out-patient service that is an entitled service under the Medical Services Payment Act.

2.2 Insured Physician Services

The enabling legislation providing for insured physician services is the Medical Services Payment Act.

The Act was given Royal Assent on December 6, 1968. Regulation 84-20 was filed on February 13, 1984. Regu lation 93-143 was filed on July 26, 1993. Regulation 96-113 was filed on November 29, 1996, since repealed and replaced with 2002-53 filed on June 28, 2005, and Schedule 4 (surgical-dental services) Regulation 84-20 was filed on April 13, 1999.

No changes, pertaining to physician services, to this Act and regulations were introduced during 2005-2006.

The New Brunswick Medical Services Plan covers physicians who provide medically required services. The conditions that a physician must meet to participate in the New Brunswick Medical Services Plan are:

• maintain current licensure with the New Brunswick College of Physicians and Surgeons;
• maintain membership in the New Brunswick Medical Society;
• hold privileges in a RHA; and
• have signed the Participating Physicians Agreement.

The number of practitioners participating in New Brunswick's Medical Services Plan as of March 31, 2006, was 1,461.

A total of 751 general or family practitioners, 844 specialists, seven dentists and five oral maxillofacial surgeons provided insured services in New Brunswick in 2005-2006. No orthodontists provided insured services in the same period.

Physicians in New Brunswick have the option to opt out totally for selected services. Totally opted-out practitioners are not paid directly by Medicare for the services they render and must bill patients directly in all cases. Patients are not entitled to reimbursement from Medicare.

The selective opting-out provision may not be invoked in the case of an emergency or for continuation of care commenced on an opted-in basis. Opted-in physicians wishing to opt out for a service must first obtain the patient's agreement to be treated on an opted-out basis, after which they may bill the patient directly for the service. In these cases, the following procedure must be adhered to in every instance. The physician must advise the patient in advance and:

• the charges must not exceed the Medicare tariff;
• the practitioner must complete the specified Medicare claim forms and indicate the exact total amount charged to the patient; and
• the beneficiary seeks reimbursement by certifying on the claim form that the services have been received and by forwarding the claim form to Medicare.
• If the charges will be in excess of the Medicare tariff, the practitioner must inform the beneficiary before rendering the service that:
  • they are opting out and charging fees above the Medicare tariff;
  • in accepting service under these conditions, the beneficiary waives all rights to Medicare reimbursement; and
  • the patient is entitled to seek services from another practitioner who participates in the Medical Services Plan.

The physician must obtain a signed waiver from the patient on the specified form and forward that form to Medicare.

As of March 31, 2006, no physicians rendering health care services had elected to completely opt out of the New Brunswick Medical Services Plan.

The range of entitled services under Medicare includes the medical portion of all services rendered by medical practitioners that are medically required. It also includes certain surgical-dental procedures when performed by a physician or a dental surgeon in a hospital facility. The range of non-entitled services is set out under Schedule 2, Regulation 84-20, Medical Services Payment Act. No new services were de-insured during 2005-2006.

An individual, a physician or the Department may request the addition of a new service. All requests are considered by the New Service Items Committee, which is jointly managed by the New Brunswick Medical Society and the Department. The decision to add a new service is usually based on conformity to "medically necessary" and whether the service is considered generally acceptable practice (not experimental) within New Brunswick and Canada. Considerations under the term "medically necessary" include services required for maintaining health, preventing disease and/or diagnosing or treating an injury, illness or disability. No public consultation process is used.

2.3 Insured Surgical-Dental Services

Schedule 4 of Regulation 84-20 (filed June 23, 1998, under the Medical Services Payment Act) identifies the insured surgical-dental services that can be provided by a qualified dental practitioner in a hospital, if the condition of the patient requires services to be rendered in a hospital. In addition, a general dental practitioner may be paid to assist another dentist for medically required services under some conditions.

The conditions that a dental practitioner must meet to participate in the medical plan are maintaining current registration with the New Brunswick Dental Society and completing the Participating Physician's Agreement (included in the New Brunswick Medicare Dental registration form).

As of March 31, 2006, there were 78 dentists registered with the plan.

Dentists have the same opting-out provision as previously explained for physicians and must follow the same guidelines. The Department has no data for the number of non-enrolled dental practitioners in New Brunswick.

New Brunswick expanded the role of Oral Maxillofacial Surgeons in New Brunswick by amending the Medical Services Payment Act and Regulations to provide payment for entitled services when they admit and discharge patients and perform physical examinations. The range of services and procedures was expanded and includes those done in an out-patient setting.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital services include the following: patent medicines; take-home drugs; third-party requests for diagnostic services; visits to administer drugs, vaccines, sera or biological products; televisions and telephones; preferred accommodation at the patient's request; and hospital services directly related to services listed under Schedule 2 of the Regulation under the Medical Services Payment Act.

Services are not insured if provided to those entitled under other statutes.

There are no specific policies or guidelines, other than the Act and regulations, to ensure that charges for uninsured medical goods and services (i.e. enhanced medical goods and services such as intra-ocular lenses, fibreglass casts, etc.), provided in conjunction with an insured health service, do not compromise reasonable access to insured services.

Uninsured Physician and Surgical-Dental Services

The services listed in Schedule 2 of New Brunswick Regulation 84-20 under the Medical Services Payment Act are specifically excluded from the range of entitled services under Medicare, namely:

• elective surgery or other services for cosmetic purposes;
• correction of inverted nipple;
• breast augmentation;
• otoplasty for persons over the age of 18;
• removal of minor skin lesions, except where the lesions are, or are suspected to be, pre-cancerous;
• abortion, unless the abortion is performed by a specialist in the field of obstetrics and gynaecology in a hospital facility approved by the jurisdiction in which the hospital facility is located and two medical practitioners certify in writing that the abortion was medically required;
• surgical assistance for cataract surgery unless such assistance is required because of risk of procedural failure, other than the risk inherent in removing the cataract itself, due to the existence of an illness or other complication;
• medicines, drugs, materials, surgical supplies or prosthetic devices;
• vaccines, serums, drugs and biological products listed in sections 106 and 108 of New Brunswick Regulation 88-200 under the Health Act;
• advice or prescription renewal by telephone which is not specifically provided for in the Schedule of Fees;
• examinations of medical records or certificates at the request of a third party, or other services required by hospital regulations or medical by-laws;
• dental services provided by a medical practitioner;
• services that are generally accepted within New Brunswick as experimental or that are provided as applied research;
• services that are provided in conjunction with, or in relation to, the services referred to above;
• testimony in a court or before any other tribunal;
• immunization, examinations or certificates for travel, employment, emigration, insurance purposes, or at the request of any third party;
• services provided by medical practitioners to members of their immediate family;
• psychoanalysis;
• electrocardiogram (ECG) where not performed by a specialist in internal medicine or paediatrics;
• laboratory procedures not included as part of an examination or consultation fee;
• refractions;
• services provided within the province by medical practitioners or dental practitioners for which the fee exceeds the amount payable under this Regulation;
• the fitting and supplying of eyeglasses or contact lenses;
• transsexual surgery;
• radiology services provided in the province by a private radiology clinic; acupuncture;
• complete medical examinations when performed for a periodic check-up and not for medically necessary purposes;
• circumcision of the newborn;
• reversal of vasectomies;
• second and subsequent injections for impotence;
• reversal of tubal ligations;
• intrauterine insemination;
• gastric stapling or gastric by-pass; and
• venipuncture in order to take blood when performed as a stand-alone procedure in a facility that is not an approved hospital facility.

Dental services not specifically listed in Schedule 4 of the Dental Schedule are not covered by the Plan. Those listed in Schedule 2 are considered the only non-insured medical services.

The decision to de-insure physician or surgical-dental services is based on the conformity of the service to the definition of "medically necessary," a review of medical service plans across the country and the previous use of the particular service. Once a decision to de-insure is reached, the Medical Services Payment Act dictates that the government may not make any change to the Regulation until the advice and recommendations of the New Brunswick Medical Society are received or until the period within which the Society was requested by the Minister of Health to furnish advice and make recommendations has expired. Subsequent to receiving their input and resolution of any issues, a regulatory change is completed. Physicians are informed in writing following notification of approval. The public is usually informed through a media release. No public consultation process is used.

No medical or surgical-dental services were removed from the insured service list in 2005-2006.

3.0 Universality

3.1 Eligibility

Sections 3 and 4 of the Medical Services Payment Act and its Regulation 84-20, define eligibility for the health care insurance plan in New Brunswick.

Residents are required to complete a Medicare application and to provide proof of Canadian citizenship, Native status or a valid Canadian immigration document. A resident is defined as a person lawfully entitled to be, or to remain, in Canada, who makes his or her home and is ordinarily present in New Brunswick, but does not include a tourist, transient or visitor to the province.

All persons entering or returning to New Brunswick (excluding children adopted from outside Canada) have a waiting period before becoming eligible for Medicare coverage. Coverage commences on the first day of the third month following the month of arrival.

Residents who are ineligible for Medicare coverage include:

• regular members of the Canadian Armed Forces;
• members of the Royal Canadian Mounted Police (RCMP);
• inmates of federal prisons;
• persons moving to New Brunswick as temporary residents;
• a family member who moves from another province to New Brunswick before other family members move;
• persons who have entered New Brunswick from another province to further their education and who are eligible to receive coverage under the medical services plan of that province; and
• non-Canadians who are issued certain types of Canadian authorization permits (e.g. a Student Authorization).

Provisions to become eligible for Medicare coverage include:

• non-Canadians who are issued an immigration permit that would not normally entitle them to coverage are eligible if legally married to, or in a common-law relationship with, an eligible New Brunswick resident.

Provisions when status changes include:

• persons who have been discharged or released from the Canadian Armed Forces, the RCMP or a federal penitentiary. Provided that they are residing in New Brunswick at the time, these persons are eligible for coverage on the date of their release. They must complete an application, provide the official date of release and provide proof of citizenship.

3.2 Registration Requirements

A beneficiary who wishes to become eligible to receive entitled services shall register, together with any dependents under the age of 19, on a form provided by Medicare for this purpose, or be registered by a person acting on his or her behalf.

Upon approval of the application, the beneficiary and dependents are registered and a Medicare card with an expiry date is issued to the beneficiary and each dependent.

A Notice of Expiry form providing all family information currently existing on the Medicare files is issued to the beneficiary two or three months before the expiry date of the Medicare card or cards. A beneficiary who wishes to remain eligible to receive entitled services is required to confirm the information on the Notice of Expiry, to make any changes as appropriate and return the form to Medicare. Upon receiving the completed form, the file is updated and new card(s) are issued bearing a revised expiry date.

Currently in New Brunswick, only those individuals deemed eligible are registered.

All family members (the beneficiary, spouse and dependents under the age of 19) are required to register as a family unit. Residents who are co-habiting, but not legally married, are eligible to register as a family unit if they so request.

Residents may opt out of Medicare coverage if they choose. They are asked to provide written confirmation of their intention. This information is added to their files and benefits are terminated.

3.3 Other Categories of Individual

Non-Canadians who may be issued an immigration permit that would not normally entitle them to Medicare coverage are eligible, provided that they are legally married to, or living in a common-law relationship with, an eligible New Brunswick resident and still possess a valid immigration permit. At the time of renewal, they are required to provide an updated immigration document.

4.0 Portability

4.1 Minimum Waiting Period

There is a three-month waiting period to obtain eligibility for Medicare coverage in New Brunswick. Coverage commences the first day of the third month following the month of arrival.

4.2 Coverage During Temporary Absences in Canada

The legislation that defines portability of health insurance during temporary absences in Canada is the Medical Services Payment Act, Regulation 84-20, sections 3(4) and 3(5).

Students in full-time attendance at a university or other approved educational institution who leave New Brunswick to further their education in another province are granted coverage for a 12-month period that is renewable provided that they do the following:

• provide proof of enrolment;
• contact Medicare once every 12-month period to retain their eligibility;
• do not establish residence outside New Brunswick; and
• do not receive health coverage in another province.

Residents temporarily employed in another province or territory are granted coverage for up to 12 months provided that they:

• do not establish residence in another province;
• do not receive coverage in another province; and
• intend to return to New Brunswick.

If absent longer than 12 months, residents should apply for coverage in the province or territory where they are employed and should be entitled to receive coverage there on the first day of the thirteenth month.

New Brunswick has formal agreements with all Canadian provinces and territories for reciprocal billing of insured hospital services. As well, New Brunswick has reciprocal agreements with all provinces except Quebec for the provision of insured physicians' services. Services provided by Quebec physicians to New Brunswick residents are paid at Quebec rates if the service delivered is insured in New Brunswick. The majority of such claims are received directly from Quebec physicians. Any paid claims submitted by the patient are reimbursed to the patient according to New Brunswick regulations.

4.3 Coverage During Temporary Absences Outside Canada

The legislation that defines portability of health insurance during temporary absences outside Canada is the Medical Services Payment Act, Regulation 84-20, sections 3 (4) and 3 (5).

Students: Those in full-time attendance at a university or other approved educational institution, who leave New Brunswick to further their education in another country, will be granted coverage for a 12-month period that is renewable, provided that they do the following:

• provide proof of enrollment;
• contact Medicare once every 12-month period to retain their eligibility;
• do not establish permanent residence outside New Brunswick; and
• do not receive health coverage elsewhere.

Temporary Workers: Residents temporarily employed outside the country are granted coverage for up to 12 months, regardless if it is known beforehand that they will be absent beyond the 12-month period, provided they do not establish residence outside Canada. Any absence over 182 days, whether it be for work purposes or vacation, would require the Director's approval. This approval can only be up to 12 months in duration and can only be granted once every three years. Families of workers temporarily employed outside Canada will continue to be covered, provided that they reside in New Brunswick.

Exception for Temporary Workers: Mobile workers are residents whose employment requires them to travel frequently outside the province. Certain guidelines must be met to receive Mobile Worker designation:

• applications must be submitted in writing;
• documentation is required as proof of Mobile Worker status (e.g. a letter from an employer or photocopy of an Immigration Permit);
• the worker's permanent residence must remain in New Brunswick;
• the worker must return to New Brunswick during their off-time; and
• the Mobile Worker designation is assigned for a maximum of two years, after which the resident must re-apply and re-submit documentation to confirm his or her status.

Contract Workers: Any New Brunswick resident accepting an out-of-country employment contract must supply the following information and documentation:

• letter of request from the New Brunswick resident with his or her signature, detailing his or her absence, including Medicare number, New Brunswick address, date of departure, destination and forwarding address, reason for absence and date of return; and
• copy of the contractual agreement between employee and employer that defines a start date and end date of employment.

Contract worker status is assigned for a maximum of two years. Any further requests for contract worker status must be forwarded to the Director of Medicare for approval on an individual basis.

New Brunswick Medicare covers out-of-country medical and hospital services for emergency out-patients and resulting in-patient services only. Medicare pays New Brunswick rates for physician services associated with the emergency interventions. The associated facility rates, paid in Canadian funds, are as follows: in-patient services $100 per day; and out-patient services $50 per visit.

Medicare will cover out-of-country services that are not available in Canada on a prior approval basis only. Residents may opt to seek non-emergency out-of-country services; however, those who receive such services will assume responsibility for the total cost.

4.4 Prior Approval Requirement

New Brunswick residents may be eligible for reimbursement if they receive elective medical services outside the country, provided they fulfill the following requirements:

• the required service, or equivalent or alternate service, must be unavailable in Canada;
• it must be rendered in a hospital listed in the current edition of the American Hospital Association Guide to the Health Care Field (guide to United States hospitals, health care systems, networks, alliances, health organizations, agencies and providers);
• the services must be rendered by a medical doctor; and
• the service must be an accepted method of treatment recognized by the medical community and be regarded as scientifically proven in Canada. Experimental procedures are not covered.

If the above requirements are met, it is mandatory to request prior approval from Medicare in order to receive coverage. A physician, patient or family member may request prior approval to receive these services outside the country, accompanied by supporting documentation from a Canadian specialist or specialists.

The following are considered exemptions under the out-of-country coverage policy:

• haemodialysis: patients will be required to obtain prior approval and Medicare will reimburse the resident at a rate equivalent to the interprovincial rate of $220 per session; and
• allergy testing for environmental sensitivity: all tests sent outside the country will be paid at a maximum rate of $50 per day, an amount equivalent to an outpatient visit.

Prior approval is also required to refer patients to psychiatric hospitals and addiction centres outside the province, because they are excluded from the Interprovincial Reciprocal Billing Agreement. A request for prior approval must be received by Medicare from the Addiction Services or Mental Health branches of the Department of Health.

5.0 Accessibility

5.1 Access to Insured Health Services

New Brunswick charges no user fees for insured health services as defined by the Canada Health Act. Therefore, all residents of New Brunswick have equal access to these services.

5.2 Access to Insured Hospital Services

The New Brunswick Hospital Master Plan identifies the number of approved beds for each Regional Health Authority.

All facilities that provide insured services in accordance with the Canada Health Act have appropriate medical, surgical, rehabilitative and diagnostic equipment or systems corresponding to their designated levels of care. As of March 31, 2006, there were nine Computed Tomography (CT) scanners operating in New Brunswick -- one in each of the eight RHAs, with a second unit operating in RHA 2. The Province also has two mobile Magnetic Resonance Imaging (MRI) units operating and three fixed-site MRI systems.

5.3 Access to Insured Physician and Surgical-Dental Services

As of March 31, 2006, there were 668 GPs, 715 Specialists, 78 Dentists (69 dentists, five oral maxillofacial surgeons, four orthodontists) registered with the plan.

In fiscal year 2005-2006, the Department continued to work on its recruitment and retention strategy, aimed at attracting newly licensed family practitioners and specialists. This strategy, announced in 1999-2000, included a contingency fund to allow the Department to more effectively respond to potential recruitment opportunities; the provision of location grants of $25,000 for family practitioners and $40,000 for specialists willing to practice in under-serviced areas of the province; and the purchase of five additional seats at the University of Sherbrooke's medical school, which began in September 2002. The recruitment and retention strategy also provides for increased government involvement in post-graduate training of family physicians; the maintenance of 300 weeks in summer rural preceptorship training for medical students; and moving physician remuneration toward relative parity with other Atlantic provinces.

5.4 Physician Compensation

Fiscal year 2004-2005 marked the third year of an agreement with fee-for-service physicians that provides for a 15 percent increase in fees over a three-year period (2002-2003 to 2004-2005). Discussions were held during the year with the New Brunswick Medical Society to implement the initiatives contained in that agreement.

On March 29, 2006, a tentative agreement was reached with the New Brunswick Medical Society for a new collective agreement.

There is no formal negotiation process for dental practitioners in New Brunswick.

Payments to physicians and dentists are governed under the Medical Services Payment Act, Regulations 84-20, 93-143 and 96-13.

The methods used to compensate physicians for providing insured health services in New Brunswick are fee-for- service, salary and sessional or alternate payment mechanisms that may also include a blended system.

5.5 Payments to Hospitals

The legislative authorities governing payments to hospital facilities in New Brunswick are the Hospital Act, which governs the administration of hospitals and the Hospital Services Act, which governs the financing of hospitals. The Regional Health Authorities Act, which provides for the delivery and administration of health services in defined geographic areas within the province, came into force on April 1, 2002.

There were no changes during the 2005-2006 fiscal year affecting the hospital payment process.

The Department uses two components to distribute available funding to New Brunswick's eight RHAs.

The main component is a "Current Service Level" (CSL) base. This component addresses five main patient-care delivered services as follows:

• tertiary services (cardiac, dialysis, oncology);
• psychiatric services (psychiatric units and facilities);
• dedicated programs (e.g. addictions services);
• community-based services (Extra-Mural Program; health service centres); and
• general patient care.

Added to this are non-patient care support services (e.g. general administration, laundry, food services, energy).

The CSL approach establishes base budgets for the eight RHAs for the above-noted programs and services, with measures for population and service volumes. The base budgets are then adjusted annually for inflation and other factors such as centrally negotiated salary rates.

The population-based funding distribution formula, which was enhanced during fiscal year 2000-2001, was still in use in fiscal year 2005-2006. This methodology attempts to predict the appropriate distribution of available funding for the RHAs based on demographic characteristics and current market share of patient volumes, with cases measured by "Resource Intensity Weights." Currently, this methodology is more suitable to in-patient volumes because of a lack of case grouping and weighting methodologies for out-patient volumes, especially tertiary out-patient services (e.g. oncology and haemodialysis).

The current budget process may extend over more than one fiscal year and includes several steps. By January of each year, RHAs are to provide the Department with their utilization data and revenue projections for the following fiscal year, as well as their actual utilization data and revenue figures for the first nine months of the current fiscal year. This information, along with the audited financial statements from the previous two fiscal years, are used to evaluate the expected funding level for each RHA.

Budget amendments are provided during the year to allow for adjustments to applicable programs and services on either recurring or non-recurring bases. The "year-end settlement process" reconciles the total annual approved budget for each RHA to its audited financial statements and reconciles budgeted revenues and expenses to actual revenues and expenses.

6.0 Recognition Given to Federal Transfers

New Brunswick routinely recognizes the federal role regarding its contributions under the Canada Health Transfer (CHT) in public documentation presented through legislative and administrative processes. These include the following:

• the Budget Papers presented by the Minister of Finance on March 30, 2006;
• the Public Accounts presented by the Minister of Finance on December 20, 2005; and
• the Main Estimates presented by the Minister of Finance on March 30, 2006.

New Brunswick does not produce promotional documentation on its insured medical and hospital benefits.

7.0 Extended Health Care Services

The New Brunswick Long-Term Care program, a non-insured service, was transferred to the Department of Family and Community Services on April 1, 2000. Nursing home care, also a non-insured service, is offered through the Nursing Home Services program of the Department of Family and Community Services. Other adult residential care services and facilities are available through a variety of agencies and funding sources within the province.

Residential and Extended Care Services

Nursing homes are private, not-for-profit organizations, except for one facility that is owned by the Province. In order to be admitted to a nursing home, clients go through an evaluation process based on specific health condition criteria.

Adult Residential Facilities are, for the most part, private and not-for-profit organizations. The number of available beds fluctuates constantly as private entrepreneurs open and close residential facilities. Clients are admitted after going through the same evaluation process used for nursing home admissions.

Public housing units are available for low-income elderly persons. Admission criteria are based on age and the applicant's financial situation. The Victorian Order of Nurses offers support services to some units.

Ambulatory Health Care

In New Brunswick, ambulatory health care includes services provided in hospital emergency rooms, day or night care in hospitals and in clinics if it is available in hospitals, health centres and Community Health Centres. This is considered an insured service under the provincial Hospital Services Plan.

Extra-Mural Program

The New Brunswick Extra-Mural Program, also known as the hospital-at-home program, is an active treatment program of acute, palliative and long-term health care and rehabilitation services provided in community settings (an individual's home, a nursing home or a public school). Since 1996, this program has been delivered by New Brunswick's eight RHAs. Service providers include nurses, social workers, dieticians, respiratory therapists, physiotherapists, occupational therapists and speech language pathologists. These services, although not covered by the Canada Health Act, are considered an insured service under the provincial Hospital Services Plan.

Quebec

1.0 Public Administration

1.1 Health Insurance Plan and Public Authority

Quebec's hospital insurance plan, the Régime d'assurance hospitalisation du Québec, is administered by the Ministère de la Santé et des Services sociaux (MSSS). [Quebec Department of Health and Social Services]

Quebec's health insurance plan, the Régime d'assurance maladie du Québec, is administered by the Régie de l'assurance maladie du Québec (RAMQ) [Quebec Health Insurance Board], a public body established by the provincial government and reporting to the Minister of Health and Social Services.

1.2 Reporting

The Public Administration Act (R.S.Q., chapter A-6.01) sets out the government criteria for preparing reports on the planning and performance of public authorities, including the MSSS and the RAMQ.

1.3 Audit of Accounts

Both plans (the Quebec Hospital Insurance Plan and the Quebec Health Insurance Plan) are operated on a non-profit basis. All books and accounts are audited by the Auditor General of Quebec.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured in-patient services include: standard ward accommodation and meals; necessary nursing services; routine surgical supplies; diagnostic services; use of operating rooms, delivery rooms and anesthetic facilities; medications, prosthetic and orthotic devices that can be integrated with the human body; biologicals and related preparations; use of radiotherapy, radiology and physiotherapy facilities; and services rendered by hospital staff.

Out-patient services include: clinical services for psychiatric care; electroshock, insulin and behaviour therapies; emergency care; minor surgery (day surgery); radiotherapy; diagnostic services; physiotherapy; occupational therapy; inhalation therapy, audiology, speech therapy and orthoptic services; and other services or examinations required under Quebec legislation.

Other services covered by insurance are: mechanical, hormonal or chemical contraception services; surgical sterilization services (including tubal ligation or vasectomy); reanastomosis of the fallopian tubes or vas deferens; and ablation of a tooth or root when the health status of the person makes hospital services necessary.

The MSSS administers an ambulance transportation program that is free-of-charge to persons aged 65 or older. In addition to basic insured health services, the RAMQ also covers the following, with some limitations, for certain residents of Quebec, as defined by the Health Insurance Act, and for employment assistance recipients: optometric services; dental care for children and employment assistance recipients, and acrylic dental prostheses for employment assistance recipients; prostheses, orthopedic appliances, locomotion and postural aids, and other equipment that helps with a physical disability; external breast prostheses; ocular prostheses; hearing aids, assistive listening devices and visual aids for people with a visual or auditory disability; and permanent ostomy appliances.

Since January 1, 1997, in terms of drug insurance, the RAMQ covers, over and above its regular clientele (employment assistance recipients and persons 65 years of age or older), individuals who do not have access to a private drug insurance plan. The drug insurance plan covers 3.15 million insured persons.

2.2 Insured Medical Services

The services insured under this plan include medical and surgical services that are provided by physicians and are required from a medical standpoint.

2.3 Insured Surgical-Dental Services

Services insured under this plan include oral surgery performed in a hospital centre or university institution determined by regulation, by dental surgeons and specialists in oral and maxillo-facial surgery.

2.4 Uninsured Hospital, Medical and Surgical-Dental Services

Uninsured hospital services include: plastic surgery; in vitro fertilization; a private or semi-private room at the patient's request; televisions; telephones; drugs and biologics ordered after discharge from hospital; and services for which the patient is covered under the Act Respecting Industrial Accidents and Occupational Diseases or other federal or provincial legislation.

The following services are not insured:

• any examination or service not related to a process of cure or prevention of illness;
• psychoanalysis of any kind, unless such service is rendered in an institution authorized for this purpose by the Minister of Health and Social Services;
• any service rendered solely for aesthetic purposes;
• any refractive surgery, except in cases where there is documented failure in astigmatism of more than 3.00 diopters or for anisometropia of more than diopters, measured at the cornea, when corrective lenses or corneal lenses are worn; any consultation by telecommunication or by correspondence;
• any service rendered by a professional to his or her spouse or children;
• any examination, expert appraisal, testimony, certificate or other formality required for legal purposes or by a person other than one who has received an insured service, except in certain cases;
• any visit made for the sole purpose of obtaining the renewal of a prescription;
• any examinations, vaccinations, immunizations or injections, where the service is provided to a group or for certain purposes;
• any service rendered by a professional on the basis of an agreement or a contract with an employer, an association or an organization; any adjustment of eye glasses or contact lenses;
• any surgical ablation of a tooth or tooth fragment performed by a physician, except where the service is provided in a hospital in certain cases;
• all acupuncture procedures;
• injection of sclerosing substances and the examination done at that time;
• mammography used for screening purposes, unless this service is delivered on a doctor's orders in a place designated by the Minister, in either case, to a recipient who is 35 years of age or older, on condition that such an examination has not been performed on the recipient in the previous year;
• thermography, tomodensitometry, magnetic resonance imaging and use of radionuclides in vivo in humans, unless these services are rendered in a hospital centre;
• ultrasonography, unless this service is rendered in a hospital centre or, for obstetrical purposes, in a local community service centre (CLSC) recognized for that purpose;
• any radiological or anesthetic service provided by a physician if required with a view to providing an uninsured service, with the exception of a dental service provided in a hospital centre or, in the case of a radiology service, if required by a person other than a physician or dentist; any sex-reassignment surgical service, unless it is provided on the recommendation of a physician specializing in psychiatry and is provided in a hospital centre recognized for this purpose; and
• any services that are not associated with a pathology and that are rendered by a physician to a patient between 18 and 65 years of age, unless that individual is the holder of a claim card, for colour blindness or a refraction problem, in order to provide or renew a prescription for eyeglasses or contact lenses.

3.0 Universality

3.1 Eligibility

Registration with the hospital insurance plan is not required. Registration with the RAMQ or proof of residence is sufficient to establish eligibility. All persons who reside or stay in Quebec must be registered with the RAMQ to be eligible for coverage under the health insurance plan.

3.2 Registration Requirements

Registration with the hospital insurance plan is not required. Registration with the RAMQ or proof of residence is sufficient to establish eligibility.

3.3 Other Categories of Individual

Services received by regular members of the Canadian Forces, members of the Royal Canadian Mounted Police (RCMP) and inmates of federal penitentiaries are not covered by the Plan.

Certain categories of residents, notably permanent residents under the Immigration Act and persons returning to live in Canada, become eligible under the Plan following a waiting period of up to three months. Persons receiving last resort financial assistance are eligible upon registration. Members of the Canadian Forces and RCMP who have not acquired the status of Quebec resident become eligible the day they arrive, and inmates of federal penitentiaries become eligible the day they are released. Immediate coverage is provided for certain seasonal workers, repatriated Canadians, persons from outside Canada who are living in Quebec under an official bursary or internship program of the Ministère de l'Éducation, du Loisir et du Sport [Quebec Department of Education, Leasure and Sport], and refugees. Persons from outside Canada who have work permits and are living in Quebec for the purpose of holding an office or employment for a period of more than six months become eligible for the plan following a waiting period.

4.0 Portability

4.1 Minimum Waiting Period

Persons settling in Quebec after moving from another province of Canada are entitled to coverage under the Quebec Health Insurance Plan when they cease to be entitled to benefits from their province of origin, provided they register with the RAMQ.

4.2 Coverage During Temporary Absences Outside Quebec (in Canada)

If living outside Quebec in another province or territory for 183 days or more, students and full-time unpaid trainees may retain their status as residents of Quebec, In the first case, they retain it for four calendar years at most, and in the second, for two consecutive calendar years at most.

This is also the case for persons living in another province or territory who are temporarily employed or working on contract there. Their resident status can be maintained for no more than two consecutive calendar years.

Persons directly employed or working on contract outside Quebec in another province or territory, for a company or corporate body having its headquarters or a place of business in Quebec, or employed by the federal government and posted outside Quebec, also retain their status as residents of the province, provided their families remain in Quebec or they retain a dwelling there.

Status as a resident of the province is also maintained by persons who remain outside the province for 183 days or more, but less than 12 months within a calendar year, provided such absence occurs only once every seven years and provided they notify the RAMQ of the absence.

The costs of medical services received in another province or territory of Canada are reimbursed at the amount actually paid or the rate that would have been paid by the RAMQ for such services in Quebec, whichever is less. However, Quebec has negotiated a permanent arrangement with Ontario to pay Ottawa doctors at the Ontario fee rate for emergency care and when the specialized services provided are not offered in the Outaouais region. This agreement became effective November 1, 1989. A similar agreement was signed in December 1991 between the Centre de santé Témiscamingue [Témiscamingue Health Centre] and North Bay, Ontario.

Costs of hospital services received in another province or territory of Canada are paid in accordance with the terms and conditions of the interprovincial agreement on reciprocal billing regarding hospital insurance agreed on by the provinces and territories of Canada. In-patient costs are paid at standard ward rates approved by the host province or territory, and out-patient costs or the costs of expensive procedures are paid at approved interprovincial/ territorial rates. However, since November 1, 1995, Quebec reimburses a maximum of $450 per day of hospitalization when an Outaouais resident is hospitalized in an Ottawa hospital for non-urgent care or services available in the Outaouais.

Insured persons who leave Quebec to settle in another province or territory of Canada are covered for up to three months after leaving the province.

4.3 Coverage During Temporary Absences Outside Quebec (outside Canada)

Students, unpaid trainees, Quebec government officials posted abroad and employees of non-profit organizations working in international aid or cooperation programs recognized by the MSSS must contact the RAMQ to ascertain their eligibility. If the RAMQ recognizes them as having special status, they receive full reimbursement of hospital costs in case of emergency or sudden illness, and 75 percent reimbursement in other cases.

Persons directly employed or working on contract outside Canada, for a company or corporate body having its headquarters or a place of business in Quebec, or employed by the federal government and posted outside Quebec, also retain their status as residents of the province, provided their families remain in Quebec or they retain a dwelling there.

As of September 1, 1996, hospital services provided outside Canada in case of emergency or sudden illness are reimbursed by the RAMQ, usually in Canadian funds, to a maximum of $100(CDN) per day if the patient was hospitalized (including in the case of day surgery) or to a maximum of $50(CDN) per day for out-patient services.

However, hemodialysis treatments are covered to a maximum of $220(CDN) per treatment. In such cases, the RAMQ provides reimbursement for the associated professional services. The services must be dispensed in a hospital or hospital centre recognized and accredited by the appropriate authorities. No reimbursements are made for nursing homes, spas or similar establishments.

Costs for insured services provided by physicians, dentists, oral surgeons and optometrists are reimbursed at the rate that would have been paid by the RAMQ to a health professional recognized in Quebec, up to the amount of the expenses actually incurred. The cost of all services insured in the province are reimbursed at the Quebec rate, usually in Canadian funds, when they are incurred abroad.

Coverage is discontinued as of the day of departure for insured residents who move permanently to another country.

4.4 Prior Approval Requirement

Insured persons requiring medical services in hospitals abroad, in cases where those services are not available in Quebec or elsewhere in Canada, are reimbursed 100 percent if prior consent has been given for medical and hospital services that meet certain conditions. Consent is not given by the Plan's officials if the medical service in question is available in Quebec or elsewhere in Canada.

5.0 Accessibility

5.1 Access to Insured Health Services

Everyone has the right to receive adequate health care services without any kind of discrimination. There is no extra-billing by Quebec physicians.

Improved telephone access to care: The Info-Santé telephone line will be centralized in each of the 15 regions where it exists, and a new Info-Social line will be developed in all regions. An Info-médicament line and a public health branch advisory module will be incorporated into InfoSanté. The plan is to have one communication centre in each region and to link all of these centres into a network, as well as to make them accessible to the general public through a single three-digit number.

New projects for seniors: In order to respect the wishes of seniors needing medical care who wish to remain in their own homes as long as possible, the MSSS has funded new projects that offer innovative ways to deliver services directly to these persons. In order to respect the wishes of seniors needing medical care who wish to remain in their own homes as long as possible, the MSSS has funded new projects that offer innovative ways to deliver services directly to these persons. Thirty-one projects were funded at a cost of $12M to subsidize the network. This will assist some 510 persons over the three phases of the programme entitled A New Partnership for Seniors (Pour un nouveau partenariat au services des aînés).

The results of an evaluation of the programme will provide an assessment and understanding of what is required to implement similar programmes throughout the province of Quebec. This innovative way of better serving seniors whose autonomy is severely impaired will be instrumental in offering an alternative to remaining in residential or long-term care facilities.

The vision of the MSSS is that, one day, spots in residential and long-term care centres will be limited to patients who for medical reasons must remain in these facilities.

5.2 Access to Insured Hospital Services

As of March 31, 2006, Quebec had 118 institutions operating as hospital centres for a clientele suffering from acute illnesses. There were 24,457 beds for persons requiring care for acute physical or psychiatric ailments allotted to these institutions. From April 1, 2004 to March 31, 2005, Quebec hospital institutions had nearly 699,735 admissions for short stays (including births) and close to 295,707 registrations for day surgeries. These hospitalizations and registrations accounted for more than 5,080,246 patient days.

Restructuring of the health network: In November 2003, Quebec announced the implementation of local service networks covering all of Quebec. At the heart of each local network is a new local authority, the health and social services centre. These centres are the result of the merger of the public institutions whose mission it was to provide CLSC (local community service centre) services, residential and long-term care, and, in most cases, neighbourhood hospital services. The health and social services centres also provide the people in their territory with access to other medical services, general and specialized hospital services, and social services. To do so, they have to enter into service agreements with other health sector organizations. The linking of services within a territory forms the local services network. Thus, the aim of integrated local health and social services networks is to make all the stakeholders in a given territory collectively responsible for the health and well-being of the people in that territory.

Management of waiting lists: In October 2003, the MSSS began publishing waiting lists for each hospital on its website. It now provides physicians and institutions with a computerized service access management system (SGAS). This tool is based on the concept of "access within a clinically acceptable period," as defined by committees of medical experts in certain fields. Once applied uniformly throughout the province of Quebec, these guidelines will ensure that all patients, regardless of their place of origin, will be treated under the same criteria. Once implemented, this system will supply the data for the new waiting lists site and will enable the concerned patients and professionals to obtain appropriate, reliable and up-to-date information on the activities of hospital centres and waiting periods for various services.

5.3 Access to Insured Medical and Surgical-Dental Services

In 2003-2004, family medicine groups (FMGs) were established. These groups work closely with the CLSCs and other network resources to provide services such as health assessment, case management and follow-up, diagnosis, treatment of acute and chronic problems, and disease prevention. Their services are available 24 hours a day, seven days a week, for some certain registered clients.

Quebec now has 114 FMGs. A new FMG has been accredited in the Mauricie region. The number of such groups has gone from 21 to 114 within three years.

The Conseil médical du Québec established a committee to develop the concept of the physician/population ratio because interprovincial comparisons suggest that Quebec has an adequate number of physicians.

5.4 Physician Compensation

While the majority of physicians practise within the provincial plan, Quebec allows two other options: professionals who have withdrawan from the plan and practise outside the plan, but agree to remuneration according to the provincial fee schedule; and nonparticipating professionals practise outside the plan and neither they nor their patients are reimbursed by the RAMQ.

Physicians are remunerated in accordance with the negotiated fee schedule. Physicians who have withdrawn from the health insurance plan are paid directly by the patient according to the fee schedule after the patient has collected from the RAMQ. Non-participating physicians are paid directly by their patients according to the amount charged.

Provision is made in law for reasonable compensation for all insured health services rendered by health professionals. The Minister may enter into an agreement with the organizations representing any class of health professional. This agreement may prescribe a different rate of compensation for medical services in a territory where the number of professionals is considered insufficient. The Minister may also provide for a different rate of compensation for general practitioners and medical specialists during the first years of practice, depending on the territory or the activity involved. These provisions are preceded by consultation with the organizations representing the professional groups.

In 2004-2005, the RAMQ paid an amount estimated at $3,276,500 million to doctors in the province, while the amount for medical services outside the province reached an estimated $9.95 million.

5.5 Payments to Hospitals

The Minister of Health and Social Services funds hospitals through payments directly related to the cost of insured services provided.

The payments made in 2005-2006 to institutions operating as hospital centres for insured health services provided to persons living in Quebec were more than $7.3 billion. Payments to hospital centres outside Quebec were approximately $97.2 million.

6.0 Extended Health Care Services

Intermediate care, adult residential care and home care services are available. Admission is coordinated on a regional level and based on a single assessment tool. The CLSCs receive individuals, evaluate their care requirements, and either arrange for provision of services such as day care centre programs or home care, or refer them to the appropriate agencies. The MSSS offers some home care services, including nursing care and assistance, homemaker services and medical supervision.

Residential facilities and long-term care units in acute-care hospitals focus on maintaining their clients' autonomy and functional abilities by providing them with a variety of programs and services, including health care services.

Ontario

Introduction

Ontario has one of the largest and most complex publicly funded health care systems in the world. Administered by the province's Ministry of Health and Long-Term Care (MOHLTC), Ontario's health care system was supported by over $32.5 billion (including capital) in spending for 2005-2006.

MOHLTC is responsible for providing services to the Ontario public through such programs as: health insurance; drug benefits; assistive devices; mental health services; home care; community support services; and public health.

MOHLTC also regulates and funds hospitals and long-term care homes (nursing homes and homes for the aged); operates psychiatric hospitals and medical laboratories; and funds and regulates or directly operates emergency health services.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Ontario Health Insurance Plan (OHIP) is administered on a non-profit basis by MOHLTC. OHIP is established under the Health Insurance Act, Revised Statutes of Ontario, 1990, c. H-6, to provide insurance in respect of the cost of insured services provided in hospitals and health facilities, and by physicians and other health care practitioners.

1.2 Reporting Relationship

The Health Insurance Act provides that the Minister of Health and Long-Term Care is responsible in respect of the administration and operation of the Plan, and is the public authority for Ontario for the purposes of the Canada Health Act.

1.3 Audit of Accounts

MOHLTC is audited annually by the Office of the Auditor General. The Auditor General's 2005 Annual Report was released on December 6, 2005.

MOHLTC's accounts and transactions are published annually in the Public Accounts of Ontario. The 2005-2006 Public Accounts of Ontario were released on August 24, 2006.

1.4 Designated Agency

Local Health Integration Networks (LHINs) were established under the Local Health System Integration Act, 2006 to improve the health of Ontarians through better access to high-quality health services, coordinated health care, and effective and efficient management of the health system at the local level. LHINs are not-for-profit Crown Agencies that will plan, integrate and fund local health services that are delivered by hospitals, Community Care Access Centres, long-term care homes, community health centres, community support services, and mental health agencies.

The Local Health System Integration Act, 2006 requires the board of directors of each Local Health Integration Network to establish, by by-law, the committees of the board that the Minister specifies by regulation. Regulation 417/06, which came into force on September 16, 2006, prescribes two LHIN Board Committees and their responsibilities: an Audit Committee; and a Community Nominations Committee.

The Act requires LHINs to prepare an Annual Report for the Minister who is required to table the reports before the Legislative Assembly. The LHIN Annual Reports for 2005-2006 were tabled in the Legislature of Ontario on October 24, 2006.

For fiscal 2007-2008, the Ontario Ministry of Health and Long-Term Care will enter into an accountability agreement with each LHIN that will include performance goals and objectives for the networks, and the allocations for health service providers. The Act also provides the LHINs with the authority to fund health service providers and to enter into service accountability agreements with these providers.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Insured in-patient and out-patient hospital services in Ontario are prescribed under the Health Insurance Act, and Regulation 552 under that Act.

Insured in-patient hospital services include medically necessary: use of operating rooms, obstetrical delivery rooms and anaesthetic facilities; necessary nursing services; laboratory, radiological and other diagnostic procedures; drugs, biologicals and related preparations; and accommodation and meals at the standard ward level.

Insured out-patient services include medically necessary: laboratory, radiological and other diagnostic procedures; use of radiotherapy, occupational therapy, physiotherapy and speech therapy facilities, where available; use of diet counselling services; use of the operating room, anesthetic facilities, surgical supplies, necessary nursing service, and supplying of drugs, biologicals, and related preparations (subject to some exceptions), including vaccines, anticancer drugs, biologicals and related preparations (subject to some exceptions); provision of equipment, supplies and medication to haemophiliac patients for use at home; and the following drugs for take-home use: cyclosporine to transplant patients; zidovudine, didanosine, zalcitabine and pentamidine to patients with HIV infection; biosynthetic human growth hormone to patients with endogenous growth hormone deficiency; drugs for treating cystic fibrosis and thalassemia; erythropoeitins to patients with anaemia of end-stage renal disease; alglucerase to patients with Gaucher disease; clozapine to patients with treatment-resistant schizophrenia.

In 2005-2006, there were 152 public hospital corporations (excluding specialty mental health hospitals, private hospitals, provincial psychiatric hospitals, federal hospitals and long-term care homes) staffed and in operation in Ontario. This includes 134 acute care hospital corporations, 14 chronic care hospitals, and four general and special rehabilitation units. Hospitals are categorized by major activity, although they provide a mix of services. For example, many acute care hospitals offer chronic care services. A number of designated chronic care facilities also offer rehabilitation.

When insured physician services are provided in licensed facilities outside hospitals and where the total cost paid for these insured services is not included in the physician fees paid under the Health Insurance Act, MOHLTC provides funding through the payment of facility fees under the Independent Health Facilities Act. Facility fees cover the cost of the premises, equipment, supplies, and personnel used to render an insured service. Under the Independent Health Facilities Act, patient charges for facility fees are prohibited.

Facility fees are charged to the government only by facilities that are licensed under the Independent Health Facilities Act. Examples of facilities that are licensed under the Independent Health Facilities Act, include surgical/treatment facilities (e.g., those providing abortions, cataract surgery, dialysis and non-cosmetic plastic surgery) and diagnostic facilities (e.g., those providing x-ray, ultrasound, nuclear medicine, sleep studies and pulmonary function studies). New facilities are ordinarily established through a request for proposals process based on an assessment of need for the service.

2.2 Insured Physician Services

Insured physician services are prescribed under the Health Insurance Act and regulations under that Act.

Under subsection 37.1(1) of Regulation 552 of the Health Insurance Act, a service provided by a physician in Ontario is an insured service if it is medically necessary; contained in the Schedule of Benefits for Physician Services; and rendered in such circumstances or under such conditions as outlined in the Schedule of Benefits. Physicians provide medical, surgical and diagnostic services, including primary health care services. Services are provided in a variety of settings, including private physician offices, community health centres, hospitals, mental health facilities, licensed independent health facilities, and long-term care homes.

In general terms, insured physician services include: diagnosis and treatment of medical disabilities and conditions; medical examinations and tests; surgical procedures; maternity care; anaesthesia; radiology and laboratory services in approved facilities; and immunizations, injections and tests.

The Schedule of Benefits is regularly reviewed and revised to reflect current medical practice and new technologies. New services may be added, existing services revised or obsolete services removed through regulatory amendment. This process involves consultation with the Ontario Medical Association.

During 2005-2006, physicians could submit claims for all insured services rendered to insured persons directly to the Ontario Health Insurance Plan Office (OHIP), in accordance with section 15 of the Health Insurance Act, or a limited number could bill the insured person, as specified in section 15 of the Act (see also Part II of the Commitment to the Future of Medicare Act). Physicians who do not bill OHIP directly are commonly referred to as having "opted-out". When a physician has opted out, the physician bills the patient (not exceeding the amount payable for the service under the Schedule of Benefits), and the patient is then entitled to reimbursement by OHIP. However, the number of physicians who may opt out was fixed (on a "grandparented" basis) following proclamation of the Commitment to the Future of Medicare Act on September 23, 2004.

Physicians must be registered to practice medicine in Ontario by the College of Physicians and Surgeons of Ontario.

There were approximately 22,000 physicians who sub mitted claims to OHIP in 2005-2006.

2.3 Insured Surgical-Dental Services

Insured surgical-dental services are prescribed in the Dental Schedule of Benefits and section 16 under Regulation 552 of the Health Insurance Act. Ontario's health insurance plan covers certain dental services when hospitalization is medically necessary. The Health Insurance Act authorizes OHIP to cover a limited number of procedures contained in the Schedule of Benefits for services performed by a dentist on the staff of a hospital. All of the insured procedures in the dental schedule must be performed for medical reasons in a hospital by an appointed dental staff member of the hospital.

Approximately 330 dentists and dental/oral surgeons provided insured surgical-dental services in Ontario in 2005-2006.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Services prescribed by and rendered in accordance with the Health Insurance Act and regulations under that Act are insured.

Uninsured hospital services include: additional charges for preferred accommodation unless prescribed by a physician, oral-maxillofacial surgeon or midwife; telephones and televisions; charges for private-duty nursing; provision of medications for patients to take home from hospital, with certain exceptions; and in-province, out-patient hospital visits solely for administering drugs, subject to certain exceptions.

Section 24 of Regulation 552 details those physician services that are specifically prescribed as uninsured.

Uninsured physician services include: services that are not medically necessary; toll charges for long-distance telephone calls; the preparation or provision of a drug, antigen, antiserum or other substance unless the drug, antigen or antiserum is used to facilitate a procedure; advice given by telephone at the request of the insured person or the person's representative; an interview or case conference (in limited circumstances); the preparation and transfer of records at the insured person's request; a service that is received wholly or partly for producing or completing a document or transmitting information to a "third party" in prescribed circumstances; the production or completion of a document or transmitting information to any person other than the insured person in prescribed circumstances; provision of a prescription when no concomitant insured service is rendered; acupuncture procedures; psychological testing; and research and experimental survey programs.

3.0 Universality

3.1 Eligibility

To be considered a resident of Ontario for the purpose of obtaining Ontario health insurance coverage, a person must:

• hold Canadian citizenship or an immigration status as prescribed in Regulation 552 of the Health Insurance Act;
• make his or her permanent and principal home in Ontario;
• be physically present in Ontario for at least 153 days in any 12-month period; and
• in most cases, new and returning residents applying for health coverage must also be physically present in Ontario for 153 of the first 183 days following the date residency is established in Ontario (i.e., a person cannot be away from the province for more than 30 days in the first six months of residency).

With certain exceptions in which there is an exemption from the waiting period, residents of Ontario, as defined in Regulation 552 of the Health Insurance Act, are eligible for Ontario health insurance coverage subject to a three-month waiting period. MOHLTC will assess whether or not an individual is subject to the three-month waiting period at the time of their application for health coverage. Examples of those who are exempt from the three-month waiting period include newborn babies born in Ontario, children under the age of 16 adopted by an insured person, and insured residents from another province or territory who move to Ontario and immediately become residents of approved charitable homes for the aged, homes for the aged or nursing homes in Ontario.

In July 2006, MOHLTC amended section 3(4) of Regulation 552 of the Health Insurance Act to exempt Canadian citizens and Permanent Residents/Landed Immigrants from the three-month waiting period for OHIP coverage, if they arrive in Ontario after July 20th, 2006 from a foreign country where an evacuation effort is being undertaken or facilitated by the federal government.

Individuals who are not eligible for Ontario health insurance coverage are those who do not meet the definition of a resident including those who do not hold an immigration status that is set out in Regulation 552, such as tourists, transients, and visitors to the province. Other individuals such as federal penitentiary inmates, Canadian Forces and ranked Royal Canadian Mounted Police personnel do not require Ontario health insurance coverage as they have health insurance coverage under a federal health care plan.

Persons who were previously ineligible for Ontario health insurance coverage but whose status and/or residency situation has changed (e.g., change in immigration status) may be eligible, upon application, subject to the requirements of Regulation 552.

When it is determined that a person is not eligible or is no longer eligible for OHIP coverage, a request may be made to MOHLTC to review MOHLTC's decision. Anyone may request that MOHLTC review the determination of their OHIP eligibility simply by making the request in writing to the General Manager of OHIP.

3.2 Registration Requirements

Every resident of Ontario, who seeks Ontario health insurance coverage, is required to apply to MOHLTC.

A health card is issued to eligible residents upon applying to the General Manager of OHIP, pursuant to sections 2 and 3 of Regulation 552. Eligible persons should apply for coverage upon establishing their permanent and principal home in the province. Registration is done through local OHIP offices. Applicants for Ontario health coverage must complete and sign a Registration for Ontario Health Coverage form and provide MOHLTC with original documents to prove their Canadian citizenship or eligible immigration status, their residency in Ontario and their identity. Eligible applicants over the age of 15.5 are generally required to have their photographs and signatures captured for their photo health cards.

Each photo health card has a renewal/expiry date in the bottom right-hand corner of the card. MOHLTC mails renewal notices to registrants several weeks before the card's renewal date.

MOHLTC is the sole payer for insured physician, hospital, and dental surgical services. An eligible Ontario resident may not register with or obtain any benefits from another insurance plan for the cost of any insured service that is covered by OHIP (with the exception of during the waiting period).

Approximately 12.47 million Ontario residents were registered with OHIP and held valid and active health cards as of as of April 1, 2006.

3.3 Other Categories of Individual

MOHLTC provides health insurance coverage to residents of Ontario other than just Canadian citizens and Permanent Residents/Landed Immigrants. These residents are required to provide acceptable documentation to support their eligible immigration status, their residency in Ontario, and their identity in the same manner as Canadian citizen or Permanent Resident/ Landed Immigrant applicants.

The individuals listed below, who ordinarily reside in Ontario, may be eligible for Ontario health insurance coverage in accordance with Regulation 552 and prevailing MOHLTC policy. Clients applying for coverage under any of these categories should contact their local OHIP office for further details.

Applicants for Permanent Residence/Applicants for Landing -- These are persons who have submitted an application for Permanent Resident/Landed Immigrant status by Citizenship and Immigration Canada (CIC) and have passed CIC's medical requirements.

Convention Refugees and Protected Persons -- These are persons who are determined to be Convention Refugees or Protected Persons under the terms of the Immigration and Refugee Protection Act. Members of this group are exempt from the three-month waiting period.

Holders of Temporary Resident Permits/Minister's Permits -- Holders of a Temporary Resident Permit/ Minister's Permit with a case type of 80 (adoption only), 86, 87, 88 or 89 are eligible for Ontario health insurance coverage for the duration of their permit if they meet the residency requirements as defined in Regulation 552. Members of this group are exempt from the three-month waiting period. Holders of a Temporary Resident Permit/ Minister's Permit with a case type of 80 (except adoption), 81, 84, 85, 90, 91, 92, 93, 94, 95 and 96 are not eligible for Ontario health insurance coverage.

Clergy, Foreign Workers and their Accompanying Family Members -- An eligible foreign clergy is a person who is sponsored by a religious organization or denomination and has finalized an agreement to minister full-time to a religious congregation in Ontario for a period of at least six consecutive months.

A foreign worker is a person who has a finalized contract of employment or an agreement of employment with a Canadian employer located in Ontario and has been issued a Work Permit/Employment Authorization by CIC that names the Canadian employer, states the person's prospective occupation, and has been issued for a period of at least six months.

Spouses, same sex partners and/or dependant children (under 19 years of age) of an eligible foreign member of the clergy or an eligible foreign worker are also eligible for Ontario health coverage if the member of the clergy or the foreign worker is to be employed in Ontario for at least three consecutive years and if the family member will be ordinarily a resident of Ontario.

Live-in Caregivers -- Eligible Live-in Caregivers are persons who hold a valid Work Permit/Employment Authorization under the Live-in Caregivers in Canada Program (LCP) or the former Foreign Domestic Movement (FDM) administered by CIC, and ordinarily resides in Ontario. The Work Permit/Employment Authorization for LCP or FDM workers does not have to list the three specific employment conditions required by all other foreign workers.

Migrant Farm Workers -- Migrant farm workers are persons who have been issued a Work Permit/Employ-ment Authorization under the Caribbean, Commonwealth and Mexican Seasonal Agriculture Workers Program administered by CIC. Due to the special nature of their employment, migrant farm workers are exempt from the 3-month waiting period, and may be a resident for less than the required five month period, not have a permanent home in Ontario, and still qualify for OHIP.

3.4 Premiums

There are no premiums payable as a condition of obtaining Ontario health insurance coverage. The Ontario Health Premium is collected through the income tax system and is not connected to OHIP registration or eligibility in any way. Responsibility for the administration of the Ontario Health Premium lies with the Ontario Ministry of Finance.

4.0 Portability

4.1 Minimum Waiting Period

In accordance with subsection 3(3) of Regulation 552 under the Health Insurance Act, individuals who move to Ontario are typically entitled to OHIP coverage, three months after establishing residency in the province, unless listed as an exception in section 3(4).

Persons moving permanently to Ontario from another Canadian province or territory will typically be eligible for OHIP coverage on the first day of the third month following the date residency is established.

4.2 Coverage During Temporary Absences in Canada

Insured out-of-province services are prescribed under sections 28, 29 to 32 of Regulation 552 of the Health Insurance Act.

Ontario adheres to the terms of the Interprovincial Agreement on Eligibility and Portability; therefore, insured residents who are temporarily outside of Ontario can use their Ontario health cards to obtain insured health services.

An insured person who leaves Ontario temporarily to travel within Canada, without establishing residency in another province or territory, may continue to be covered by OHIP for a period of up to 12 months.

An insured person who seeks or accepts employment in another province or territory may continue to be covered by OHIP for a period of up to 12 months. If the individual plans to remain outside Ontario beyond the 12-month maximum, he or she should apply for coverage in the province or territory where that person has been working or seeking work.

Insured students who are temporarily absent from Ontario, but remain within Canada, may be eligible for continuous health insurance coverage for the duration of their full-time studies, provided they do not establish permanent residency elsewhere during this period. To ensure that they maintain continuous OHIP eligibility, a student should provide MOHLTC with documentation from their educational institution confirming registration as a full-time student. Family members of students who are studying in another province or territory are also eligible for continuous OHIP eligibility while accompanying students for the duration of their studies.

In accordance with MOHLTC policy, most insured residents who want to travel, work or study outside Ontario, but within Canada, must have been present for at least 153 days in the last 12-month period immediately prior to departure from Ontario.

Ontario participates in reciprocal agreements with all other provinces and territories for insured hospital in- and outpatient services. Payment is at the in-patient rate of the plan in the province or territory where hospitalization occurs. Ontario pays the standard out-patient charges authorized by the Interprovincial Health Insurance Agreements Coordinating Committee.

Ontario also participates in reciprocal billing arrangements with all other provinces and territories, except Québec (which has not signed a reciprocal agreement with any other province or territory), for insured physician services. Ontario residents who may be required to pay for doctors' services received in Québec can submit their receipts to MOHLTC for payment as an insured service.

4.3 Coverage During Temporary Absences Outside Canada

Health insurance coverage for insured Ontario residents during extended absences outside Canada is governed by sections 28.1 through 29 (inclusive) and section 31 of Regulation 552 of the Health Insurance Act.

In accordance with sections 1.1(3), 1.1(4), 1.1(5) and 1.1(6) of Regulation 552 of the Health Insurance Act, MOHLTC may provide insured Ontario residents with continuous Ontario health insurance coverage during absences outside Canada of longer than 212 days (seven months) in a 12-month period.

The Ministry requests that residents apply to MOHLTC for this coverage before their departure and provide documents explaining the reason for their absence outside Canada. In accordance with the regulations and MOHLTC policy, most applicants must also have been present in Ontario for at least 153 days in each of the two consecutive 12-month periods before their expected date of departure.

The length of time that MOHLTC will provide a person with continuous Ontario health coverage during an extended absence outside Canada varies depending on the reason for the absence. Please refer to the information below for further details: Certain family members may also qualify for continuous Ontario health coverage while accompanying the primary applicant on an extended absence outside Canada and should contact their local OHIP office for details.

Certain family members may also qualify for continuous Ontario health coverage while accompanying the primary applicant on an extended absence outside Canada and should contact their local OHIP office for details.

Out-of-country services are covered under sections 28.1 to 28.6 inclusive, and sections 29 and 31 of Regulation 552 of the Health Insurance Act.

Effective September 1, 1995, out-of-country emergency hospital costs are reimbursed at Ontario fixed per diem rates of:

• a maximum $400 (CDN) for in-patient services;
• a maximum $50 (CDN) for out-patient services (except dialysis); and
• the actual cost incurred by the patient per

During 2004-2005, emergency medically necessary out-of-country physician and other eligible practitioner services were reimbursed at the Ontario rates detailed in regulation under the Health Insurance Act or the amount billed, whichever is less. Charges for medically necessary emergency or out-of-country in-patient and out-patient services are reimbursed only when rendered in a licensed or approved hospital or a licensed health facility. Medically necessary out-of-country laboratory services when done on an emergency basis by a physician are reimbursed in accordance with the formula set out in section 29(1)(b) of the Regulation or the amount billed, whichever is less, and when done on an emergency basis by a laboratory, in accordance with the formula set out in section 31 of the Regulation.

In 2005-2006, payments for out-of-country emergency in-patient and out-patient insured hospital and medical services amounted to $23.3 million (Note: the categories of out-of-country services were realigned in 2005-2006 to provide a greater level of reporting accuracy).

4.4 Prior Approval Requirement

As set out in section 28.4 of Regulation 552 of the Health Insurance Act, prior approval from MOHLTC is required for payment for non-emergent health services provided outside of Canada. Where medically accepted treatment is not available in Ontario, or in those instances where the patient faces a delay in accessing treatment in Ontario that would threaten the patient's life or cause irreversible tissue damage, the patient may be entitled to full funding for out-of-country health services.

Under section 28.5 of Regulation 552 of the Health Insurance Act, laboratory tests performed outside Canada are paid for, with prior approval from MOHLTC, if the following conditions are met:

• the kind of service or test is not performed in Ontario;
• the service or test is generally accepted in Ontario as appropriate for a person in the same circumstances as the insured person;
• the service or test is not experimental; and
• the service or test is not performed for research purposes.

In 2005-2006, total payments for prior-approved treatment outside Canada were $56.3 million.

There is no formal prior-approval process for services provided to Ontario residents outside the province, but within Canada. The Interprovincial Agreement on Eligibility and Portability includes a schedule for high-cost services.

5.0 Accessibility

5.1 Access to Insured Health Services

All insured hospital, physician and surgical-dental services are available to Ontario residents on uniform terms and conditions.

All insured persons are entitled to all insured hospital and physician services, as defined in the Health Insurance Act.

Accessibility to insured health care services is protected under the Commitment to the Future of Medicare Act. This Act prohibits any person or any entity from charging more, or accepting payment or other benefit for more than the amount payable by OHIP. In addition, the Commitment to the Future of Medicare Act also prohibits physicians, practitioners and hospitals from refusing to provide an insured service if an insured person chooses not to pay for an uninsured service. The Act further prohibits any person or entity from paying, conferring or receiving any benefit in exchange for preferred access to an insured service.

MOHLTC implemented Health Number/Card Validation to aid health care providers and patients with access to health services and claim payment. Providers may subscribe for validation privileges to verify their patient eligibility and health number/version code status (card status). If patients require access to health services and do not have a health card in their possession, the provider may obtain the necessary information by submitting to MOHLTC a Health Number Release Form signed by the patient. An accelerated process for obtaining health numbers for patients who are unable to provide a health number and require emergency treatment is available to emergency room facilities through the Health Number Look Up service.

5.2 Access to Insured Hospital Services

Public hospitals in Ontario are not permitted to refuse to provide services in life-threatening situations because the person is not insured.

In 2005-2006, there were 152 public hospital corporations staffed and in operation in Ontario, which included chronic, general and special rehabilitation units. There were 6,764,626 acute patient days, 1,987,995 chronic patient days and 758,452 rehabilitation patient days delivered by public hospitals.

Priority services are designated highly specialized hospital-based services that deal with life-threatening conditions. These services are often high-cost and rapidly growing, which makes access a concern. Generally, these services are managed provincially, on a time-limited basis.

Priority services include: selected cardiovascular services; selected cancer services; chronic kidney disease; and organ and tissue donation and organ transplantation.

5.3 Access to Insured Physician and Surgical-Dental Services

Initiatives

• Underserviced Area Program (UAP): UAP is one of a number of supports that MOHLTC provides to help communities across the province access needed health care services. UAP provides a variety of integrated initiatives aimed at attracting and retaining health care providers. To be eligible for the UAP's recruitment and retention benefits, a community must be designated as underserviced. UAP works closely with underserviced communities to identify their need for health human resources. It provides financial incentives and practice supports, and enables community access to physician services by funding locums and outreach clinics. Currently, there are 137 communities in Ontario designated as underserviced for general/family practitioners and 14 northern Ontario communities designated as underserviced for medical specialists.
• Northern Physician Retention Initiative (NPRI): NPRI provides eligible family practitioners and specialists who maintain practices in northern Ontario for at least four years with a retention incentive as well as access to funding for continuing medical education.
• Northern Health Travel Grant Program (NHTGP): NHTGP helps defray transportation costs for residents of northern Ontario who must travel long distances to access insured non-emergency hospital and specialist medical services that are not locally available, and also promotes using specialist services located in northern Ontario, which encourages more specialists to practice and remain in the north.
• Primary Health Care: During 2005-2006, Ontario continued to align its new and existing primary care delivery models to help improve and expand access to primary care for all Ontarians by including elements such as 24-hour, seven days a week access through telephone health advisory services, increased after-hours coverage and preventive care initiatives that enhance chronic disease management and disease prevention. As of March 31, 2006, there were approximately 6.0 million patients rostered to physicians in the primary care models that have these features. New agreements were negotiated and signed for Health Service Organizations, Primary Care Networks, Rural and Northern Physician Groups and a number of other family physician groups working in high-needs practices. As part of transforming its health care system, Ontario committed to establish 150 Family Health Teams by 2007-2008 to further facilitate physicians working as part of a team with other health providers with a focus on keeping patients healthy.
• The 2004 Memorandum of Agreement between MOHLTC and the Ontario Medical Association provides for the alignment of the Primary Care Network and Health Service Organization models into one model. This new model, the Family Health Organization, is expected to be implemented in Fall 2006.

5.4 Physician Compensation

Physicians are paid for the services they provide through a number of mechanisms. Some physician payments are provided through fee-for-service arrangements. Remuneration is based on the Schedule of Benefits under the Health Insurance Act. Other physician payment models may include Alternate Payment Plans and new funding arrangements for physicians in Academic Health Science Centres.

Family physicians paid solely on a fee-for-service basis represent 49 per cent of Ontario's registered family physicians. The remaining family physicians in Ontario receive funding through one of the primary care initiatives such as Family Health Networks, Family Health Groups, Comprehensive Care Models, and Family Health Teams. Family Health Teams build upon existing primary care physician funded models by providing funding for inter-disciplinary health care professionals, who work as integral members of the team. Physicians participating in Family Health Teams are funded by one of three compensation options that include: blended salary, blended complement, or blended capitation. There are also models for physicians in Academic Health Science Centres where funding may include any combination of capitation, salary, special payments, and bonuses.

MOHLTC negotiates payment rates and other changes to the Schedule of Benefits for Physician Services with the Ontario Medical Association. A new Physician Services' Agreement with the Ontario Medical Association was negotiated for a four-year term, from April 2004 to March 2008. The Agreement provided for an across-the-board fee increase of 2 percent for specialists and 2.5 percent for general practitioners/family physicians, effective April 1, 2004. Further increases in specific fee codes are scheduled for implementation on various dates from October 1, 2005, through to January 1, 2008.

The Agreement eliminated payment thresholds effective April 1, 2005. This Agreement expands access to care in rural communities by introducing new funding to support hospital-based specialists in the north; enhances care for seniors by introducing new on-call fees in long-term care homes, home care and palliative care; supports hospital care by expanding hospital on-call coverage and in-hospital care fees for specialists and by introducing new fees for family doctors caring for their own patients in emergency departments; supports health promotion and disease prevention by introducing special fees for managing specific chronic diseases; invests in initiatives to recruit physicians to Ontario; and, makes quality of life improvements for physicians such as expanding pregnancy and parental leave benefits.

Under the Agreement, the parties have committed to begin meeting in April 2007, to undertake a performance review of the degree to which the objectives under the Agreement have been met.

With respect to insured surgical-dental services, MOHLTC negotiates changes to the Schedule of Benefits for Dental Services with the Ontario Dental Association. In 2002-2003, MOHLTC and the Ontario Dental Association agreed on a new multi-year funding agreement for dental services, which became effective on April 1, 2003, and will end on March 31, 2007.

5.5 Payments to Hospitals

The Ontario budget system is a prospective reimbursement system that reflects the effects of workload increases, costs related to provincial priority services, wait time strategies, and cost increases in respect of above-average growth in volume of service in specific geographic locations. Payments are made to hospitals on a semi-monthly basis.

Transfer payments to hospitals are based on historical global allocations and multi-year incremental increases that incorporate population growth and anticipated service demands within the available provincial budget.

Each year, public hospitals submit Hospital Annual Planning Submissions that are the result of broad consultations within the facilities (e.g., all levels of staff, unions, physicians and board) and within the community and region. Hospital Annual Planning Submissions are based on a multi-year budget and provide a corresponding multi-year planning forecast. The data submitted in the Hospital Annual Planning Submissions is used to populate schedules for service volumes and performance targets that form the contractual basis for the Hospital Accountability Agreement.

In the Hospital Accountability Agreement, hospital performance is measured through five key performance indicators: total margin; current ratio; percentage of full-time nurses; relative risk of readmission; and chronic care patient quality indicators. A review of the targets in each of the schedules and a discussion of corresponding corridors for performance indicators in the Hospital Accountability Agreement is conducted between ministry staff and hospitals.

This year, members from the Local Health Integration Networks (LHINs) will be partners in the Hospital Annual Planning Submissions and Hospital Accountability Agreement process, attending training sessions and meetings with the ministry. In April 2007, LHINs are expected to take over funding authority for hospitals in Ontario.

MOHLTC reviews chronic care co-payment regulations and rates annually, accounting for changes in the Consumer Price Index and Old Age Security each year, and determines whether revisions to the regulations and rates are appropriate.

6.0 Recognition

The Government of Ontario publicly acknowledged the federal contributions provided through the Canada health and social transfers in its 2005-2006 publications.

7.0 Extended Health Care Services

Nursing Home Intermediate Care and Adult Residential Care

Long-Term Care homes provide care and services for people who are no longer able to live independently and who require 24-hour supervision, personal care and support. The home-like environment is intended to foster the best possible quality of life. MOHLTC funds and regulates all Long-Term Care homes licensed or approved under three different Acts, including the Homes for the Aged and Rest Homes Act, the Nursing Homes Act, and the Charitable Institutions Act.

There are three types of Long-Term Care homes and each type is governed by a separate Act:

• Municipal Homes for the Aged by the Homes for the Aged and Rest Homes Act;
• Nursing Homes by the Nursing Homes Act; and
• Charitable Homes for the Aged by the Charitable Institutions Act.

Bill 140, the proposed new Long-Term Care Homes Act, 2006, received its first reading in the Legislature on October 3, 2006. The proposed Act provides a legislative framework to enable improved management of a growing and rapidly changing sector and to better plan for the needs of the population requiring the long-term care residential services provided in a Long-Term Care home.

As of April 2006, there are approximately 602 Long-Term Care homes with 75,008 beds including 252 not-for-profit homes (which consist of municipal, charitable and not-for-profit nursing homes), and 350 for-profit homes.

Long-Term Care homes provide both health care services and accommodation to residents, tailored to a range of care needs from light to heavy care. In general, Long-Term Care homes offer higher levels of personal care and support than those typically offered by either retirement homes or supportive housing. Retirement homes are neither regulated nor funded by the ministry.

MOHLTC also operates the Compliance Management Program which is designed to safeguard residents' rights, safety, security, quality of care and quality of life. Through the Compliance Management Program, MOHLTC monitors and inspects the compliance of Long-Term Care homes with legislation, regulation, standards and criteria, service agreements and, where necessary, uses enforcement measures to achieve compliance.

In January 2005, a new regulation ensured that each resident was offered a minimum of two baths per week, and that resident meal plans were reviewed and approved by dietitians. In October 2004, the ministry provided the additional funding of $191M to enable all Long-Term Care homes to hire 2000 new staff including 600 Registered Nurses. As of August 1, 2005, the ministry required all homes to provide around the clock coverage by Registered Nurses.

Effective January 1, 2006, all Long-Term Care homes were required to implement two new standards: Skin Care and Wound Management; and Continence Care. Ministry inspectors began monitoring compliance with the new standards effective April 1, 2006.

Home Care Services

Ontario home and community care programs provide a range of services that support people living in their homes or other community care settings. These services are available through Community Care Access Centres (CCACs) and Community Service agencies.

CCACs provide simplified access for eligible Ontario residents, of all ages, to home and community care; deliver, make arrangements for and coordinate the delivery of home care services to people in their homes, schools and communities; and, authorize admission to long-term care homes. There is no charge for services provided by CCACs.

The CCAC provides or purchases a range of community services on behalf of eligible clients. The range of services includes nursing, homemaking, personal support, physiotherapy, occupational therapy, speech-language pathology, social work, dietetics, medical supplies and dressings, hospital and sickroom equipment, assistance in obtaining a drug card, laboratory and diagnostic services, and transportation to medical appointments and hospitals.

The CCAC assesses an individual's requirements and determines their eligibility for professional health services, homemaking, and personal support services provided in people's homes and in the community. CCACs assess and determine eligibility for professional health and personal support services for children/youth in schools and receiving home schooling.

CCACs develop plans of service and also provide information and referral services for the public to home and community care related services. CCACs are responsible for admission to long-term care homes, and manage the Requests for Proposal process for purchased client services.

Legislation most relevant to CCACs include the Long-Term Care Act, 1994; Health Insurance Act; Community Care Access Corporations Act, 2001; Nursing Homes Act; Charitable Institutions Act; and Homes for the Aged and Rest Homes Act. Each CCAC must also be familiar with all other relevant laws, including but not limited to the Health Care Consent Act, 1996; Substitute Decisions Act, 1992; Personal Health Information Protection Act, 2004; and the Ministry of Health Appeal and Review Boards Act, 1998.

Community service agencies provide support services that include: respite, volunteer visiting hospices, services for persons with physical disabilities, Alzheimer services, homemaking, attendant care, adult day programs, caregiver support, meal services, home maintenance and repair, friendly visiting, security checks and reassurance, social and recreational services, and volunteer transportation. These services are also provided in programs which include acquired brain injury services and assisted living services in supportive housing. Community services are part of a continuum of in-home and other health services, and the assistance provided by family and friends. Community services are legislated under the Long-Term Care Act, 1994 and are delivered by community-based, not-for-profit agencies that rely heavily on volunteers, and are funded by the Ministry of Health and Long-Term Care.

The provincial End-of-Life Care Strategy helps replace hospitalizations, where appropriate, with home care services made possible through advances in treatment practices, collaborative planning between all health care sectors, and increased resources. The objectives of the strategy are to shift care of the dying from the acute setting to an appropriate alternate setting based on individual preference; to enhance/develop a client-centred and interdisciplinary end-of-life care service capacity; and to improve access to, and coordination/ consistency of comprehensive end-of-life care services. End-of-Life care services are provided in home or the community by CCACs, Community Support Service agencies and residential hospices.

Ambulatory Health Care Services

Community Health Centres are transfer payment agencies governed by acommunity board of directors. The name "Community Health Centre" reflects the fact that the agency is established by the community and provides programs and services in response to needs identified in that community. Community Health Centres deliver services through inter-disciplinary teams including physicians, nurses, counsellors, dietitians and health promoters. Services include comprehensive primary care as well as group and community programs, such as diabetes education, parent/child programs, community kitchens, and youth outreach services. Community Health Centres work within a population health framework that places an equal emphasis on providing comprehensive primary care, preventing illness, and health promotion.

Community Health Centres identify the priority populations that they will serve -- traditionally people who have experienced barriers to access based on culture, language, literacy, age, socio-economic status, mental health status and homelessness. Community Health Centres also develop partnerships to improve access to care, promote effective service integration and build community capacity to address health risks.

Service is provided through 54 Community Health Centres operating from more than 80 full-service sites across Ontario. Of these, 27 are in large urban centres, 14 are in smaller urban centres, and 13 are in either northern or rural communities. There is no legislation specific to Community Health Centres.

Historically, Community Health Centres have been developed based on expressions of interest from sponsoring groups. This has resulted in an uneven distribution and some significant gaps in coverage across the province. Between 2004-2005 and 2007-2008, the government is expanding the network of Community Health Centres by adding 22 new Centres and 27 satellite Centres. This expansion will be targeted to communities with at-risk populations facing barriers to access. Once implemented, it is expected that many of the most critical gaps in coverage will be addressed.

Manitoba

Introduction

Manitoba Health and Healthy Living provides leadership and support to protect, promote and preserve the health of all Manitobans. The Department is organized into five distinct but related functional areas: Corporate and Provincial Program Support, Healthy Living and Health Programs, Health Workforce, Regional Affairs and Administration, Finance and Accountability. Their mandates are derived from established legislation and policy pertaining to health and wellness issues. The roles and responsibilities of Manitoba Health include policy, program and standards development, fiscal and program accountability and evaluation.

Manitoba Health and Healthy Living remains committed to sustaining our universal, comprehensive and accessible health care system and improving the health status of all Manitobans. In support of these commitments, a number of activities were initiated in 2005-2006.

The Ministry of Healthy Living undertook a province-wide consultation with Manitobans about ways to maximize the health of children and youth today and into their adult lives. A Chronic Disease Prevention initiative to address risk factors associated with preventable chronic diseases was implemented. A provincial physical activity strategy entitled Manitoba in Motion and public education campaigns such as Protect Your Noggin, which focuses on the use of bicycle helmets were also launched.

Manitoba introduced a $155 million Five Point Plan to improve access to quality care and reduce wait times in key areas. The plan involves more diagnostic testing, more surgeries, more health professionals, system innovation and better wait list management, prevention and health promotion.

The Manitoba Institute for Patient Safety which was established in 2004, undertook a variety of activities to promote, coordinate and stimulate research and initiatives that enhance patient safety and quality care. These included key stakeholder consultations, culture of safety surveys, Provincial Patient Safety Workshop and other forums.

Manitoba's Pharmacare Program has been enhanced by adding 220 new drugs and 43 new interchangeable categories.

A new Long Term Care Seniors' Strategy entitled Aging in Place will increase community living support for seniors and provide alternatives to institutional care.

Significant capital investments were also made in acute care facilities, such as the initiation of the Cardiac Care Centre at St. Boniface hospital and continued redevelopment of the Critical Services area in the Health Sciences Centre in Winnipeg; expansions or upgrades to the Swan Valley Health Centre; the St. Anne and Flin Flon hospitals; and a new a Health Centre in Wabowden.

The Role and Mission of Manitoba Health

Manitoba Health and Healthy Living is a line department within the government structure and operates under the provisions of statutes and responsibilities charged to the Ministers of Health and Healthy Living. The formal mandates contained in legislation, combined with mandates resulting from responses to emerging health and health care issues, establish a framework for planning and delivering services.

Manitoba Health and Health Living's vision is healthy Manitobans through an appropriate balance of prevention and care.

It is the mission of Manitoba Health and Healthy Living to lead a publicly administered sustainable health system that meets the needs of Manitobans, and promotes their health and well-being. This is accomplished through a structure of comprehensive envelopes encompassing program, policy and fiscal accountability; by the development of a healthy public policy; and by the provision of appropriate, effective and efficient health and health care services. Services are provided through regional delivery systems, hospitals and other health care facilities. The Department also makes payments on behalf of Manitobans for insured health benefits related to the costs of medical, hospital, personal care, pharmacare and other health services.

It is also the role of Manitoba Health and Healthy Living to foster innovation in the health care system. This is accomplished by developing mechanisms to assess and monitor quality of care, utilization and cost-effectiveness; fostering behaviours and environments that promote health; and promoting responsiveness and flexibility of delivery systems and alternative, less expensive services.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The Manitoba Health Services Insurance Plan (MHSIP) is administered by the Department of Health under The Health Services Insurance Act, R.S.M. 1987, c. H35. The Act ¹ was significantly amended in 1992, dissolving the Manitoba Health Services Commission and transferring all assets and responsibilities to Manitoba Health. The dissolution took effect on March 31, 1993.

The MHSIP is administered under this Act for insurance in respect of the costs of hospital, personal care and medical and other health services referred to in acts of the Legislature or regulations there under. The Act was amended on January 1, 1999, to provide insurance for out-patient services relating to insured medical services provided in surgical facilities.

The Minister of Health is responsible for administering and operating the Plan. Under section 3(2), the minister has the power:

• to provide insurance for residents of the province in respect of the costs of hospital services, medical services and other health services, and personal care;
• to plan, organize and develop throughout the province a balanced and integrated system of hospitals, personal care homes and related health facilities and services commensurate with the needs of the residents of the province;
• to ensure that adequate standards are maintained in hospitals, personal care homes and related health facilities, including standards respecting supervision, licensing, equipment and inspection, or to make such arrangements that the Minister considers necessary to ensure that adequate standards are maintained;
• to provide a consulting service, exclusive of individual patient care, to hospitals and personal care homes in the province or to make such arrangements as the Minister considers necessary to ensure that such a consulting service is provided;
• to require that the records of hospitals, personal care homes and related health facilities are audited annually and that the returns in respect of hospitals, which are required by the Government of Canada, are submitted; and
• in cases where residents do not have available medical services and other health services, to take such measures that are necessary to plan, organize and develop medical services and other health services commensurate with the needs of the residents.

The Minister may also enter into contracts and agreements with any person or group that he or she considers necessary for the purposes of the Act. The Minister may also make grants to any person or group for the purposes of the Act on such terms and conditions that are considered advisable. Also, the Minister may, in writing, delegate to any person any power, authority, duty or function conferred or imposed upon the Minister under the Act or under the regulations.

There were no legislative amendments to the Act or the regulations in the 2005-2006 fiscal year that affected the public administration of the Plan.

1 Where reference is made to "the Act" in the text, this refers to The Health Services Insurance Act as consolidated to March 31, 2006.

1.2 Reporting Relationship

Section 6 of the Act requires the Minister to have audited financial statements of the Plan showing separately the expenditures for hospital services, medical services and other health services. The Minister is required to prepare an annual report, which must include the audited financial statements, and to table the report before the Legislative Assembly within 15 days of receiving it, if the Assembly is in session. If the Assembly is not in session, the report must be tabled within 15 days of the beginning of the next session.

1.3 Audit of Accounts

Section 7 of the Act requires that the Office of the Auditor General of Manitoba (or another auditor designated by the Office of the Auditor General of Manitoba) audit the accounts of the Plan annually and prepare a report on that audit for the Minister. The most recent audit reported to the Minister and available to the public is for the 2005-2006 fiscal year and is contained in the Manitoba Health Annual Report, 2005-2006. It will also be available on the Province's website in late October 2006.

2.0 Comprehensiveness

2.1 Insured Hospital Services

Sections 46 and 47 of the Act, as well as the Hospital Services Insurance and Administration Regulation (M.R. 48/93), provide for insured hospital services.

As of March 31, 2006, there were 98 facilities, providing insured hospital services to both in- and out-patients. Hospitals are designated by the Hospitals Designation Regulation (M.R. 47/93) under the Act.

Services specified by the Regulation as insured in- and out-patient hospital services include: accommodation and meals at the standard ward level; necessary nursing services; laboratory, radiological and other diagnostic procedures; drugs, biologics and related preparations; routine medical and surgical supplies; use of operating room, case room and anaesthetic facilities; and use of radiotherapy, physiotherapy, occupational and speech therapy facilities, where available.

All hospital services are added to the list of available hospital services through the health planning process.

Manitoba residents maintain high expectations for quality health care and insist that the best available medical knowledge and service be applied to their personal health situations. Manitoba Health is sensitive to new develop ments in the health sciences.

2.2 Insured Physician Services

The enabling legislation that provides for insured physician services is the Medical Services Insurance Regulation (M.R. 49/93) made under the Act.

Physicians providing insured services in Manitoba must be lawfully entitled to practise medicine in Manitoba, registered and licensed under the Medical Act. As of March 31, 2006, there were 2,169 physicians on the Manitoba Health Registry. This figure is taken from the Monthly Practitioner Registration Statistics and includes all physicians registered with Manitoba Health whether income was generated or not.

A physician, by giving notice to the Minister in writing, may elect to collect the fees for medical services rendered to insured persons other than from the Minister, in accordance with section 91 of the Act and section 5 of the Medical Services Insurance Regulation. The election to opt out of the health insurance plan takes effect on the first day of the month following a 90-day period from the date the Minister receives the notice.

Before rendering a medical service to an insured person, physicians must give the patient reasonable notice that they propose to collect any fee for the medical service from them or any other person except the Minister. The physician is responsible for submitting a claim to the Minister on the patient's behalf and cannot collect fees in excess of the benefits payable for the service under the Act or regulations. To date, no physicians have opted out of the medical plan in Manitoba.

The range of physician services insured by Manitoba Health is listed in the Payment for Insured Medical Services Regulation (M.R. 95/96). Coverage is provided for all medically required personal health care services that are not excluded under the Excluded Services Regulation (M.R. 46/93) of the Act, rendered to an insured person by a physician.

During fiscal year 2005-2006, a number of new insured services were added to a revised fee schedule. In order for a physician's service to be added to the list of those covered by Manitoba Health, physicians must put forward a proposal to their specific section of the Manitoba Medical Association (MMA). The MMA will negotiate the item, including the fee, with Manitoba Health. Manitoba Health may also initiate this process.

2.3 Insured Surgical-Dental Services

Insured surgical and dental services are listed in the Hospital Services Insurance and Administration Regulation (M.R. 48/93) under the Act. Surgical services are insured when performed by a certified oral and maxillofacial surgeon or a licensed dentist in a hospital, when hospitalization is required for the proper performance of the procedure. This Regulation also provides benefits relating to the cost of insured orthodontic services in cases of cleft lip and/or palate for persons registered under the program by their 18th birthday, when provided by a registered orthodontist. As of March 31, 2006, 600 dentists were registered with Manitoba Health, however only 115 dentists were paid for providing dental services.

Providers of dental services may elect to collect their fees directly from the patient in the same manner as physicians and may not charge to or collect from an insured person a fee in excess of the benefits payable under the Act or regulations. No providers of dental services had opted out as of March 31, 2006.

In order for a dental service to be added to the list of insured services, a dentist must put forward a proposal to the Manitoba Dental Association (MDA). The MDA will negotiate the fee with Manitoba Health.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

The Excluded Services Regulation (M.R. 46/93) made under the Act sets out those services that are not insured. These include: examinations and reports for reasons of employment, insurance, attendance at university or camp, or performed at the request of third parties; group immunization or other group services except where authorized by Manitoba Health; services provided by a physician, dentist, chiropractor or optometrist to him or herself or any dependants; preparation of records, reports, certificates, communications and testimony in court; mileage or travelling time; services provided by psychologists, chiropodists and other practitioners not provided for in the legislation; in vitro fertilization; tattoo removal; contact lens fitting; reversal of sterilization procedures; and psychoanalysis.

The Hospital Services Insurance and Administration Regulation states that hospital in-patient services include routine medical and surgical supplies, thereby ensuring reasonable access for all residents. The Regional Health Authorities and Manitoba Health monitor compliance.

All Manitoba residents have equal access to services. Third parties such as private insurers or the Workers Compensation Board do not receive priority access to services through additional payment. Manitoba has no formalized process to monitor compliance; however, feedback from physicians, hospital administrators, medical professionals and staff allows Regional Health Authorities and Manitoba Health to monitor usage and service concerns.

To de-insure services covered by Manitoba Health, the Ministry prepares a submission for approval by Cabinet. The need for public consultation is determined on an individual basis depending on the subject.

No services were removed from the list of those insured by Manitoba Health in 2005-2006.

3.0 Universality

3.1 Eligibility

The Health Services Insurance Act defines the eligibility of Manitoba residents for coverage under the provincial health care insurance plan. Section 2(1) of the Act states that a resident is a person who is legally entitled to be in Canada, makes his or her home in Manitoba, is physically present in Manitoba for at least six months in a calendar year, and includes any other person classified as a resident in the Regulations, but does not include a person who holds a temporary resident permit under the Immigration and Refugee Protection Act (Canada), unless the Minister determines otherwise, or is a visitor, transient or tourist.

The Residency and Registration Regulation (M.R. 54/93) extends the definition of residency. The extensions are found in sections 7(1) and 8(1). Section 7(1) allows missionaries, individuals with out-of-country employment and individuals undertaking sabbatical leave to be outside Manitoba for up to two years while still remaining residents of Manitoba. Students are deemed to be Manitoba residents while in full-time attendance at an accredited educational institution. Section 8(1) extends residency to individuals who are legally entitled to work in Manitoba and have a work permit of 12 months or more.

The Residency and Registration Regulation, section 6, defines Manitoba's waiting period as follows:

"A resident who was a resident of another Canadian province or territory immediately before his or her arrival in Manitoba is not entitled to benefits until the first day of the third month following the month of arrival."

There are currently no other waiting periods in Manitoba. The MHSIP excludes residents covered under the following federal statutes: Aeronautics Act; Civilian War-related Benefits Act; Government Employees Compensation Act; Merchant Seaman Compensation Act; National Defence Act; Pension Act; Royal Canadian Mounted Police Act; Veteran's Rehabilitation Act; or under legislation of any other jurisdiction (Excluded Services Regulations subsection 2(2)). The excluded are residents who are members of the Canadian Forces, the Royal Canadian Mounted Police (RCMP) and federal inmates. These residents become eligible for Manitoba Health coverage upon discharge from the Canadian Forces, the RCMP, or if an inmate of a penitentiary has no resident dependants. Upon change of status, these persons have one month to register with Manitoba Health (Residency and Registration Regulation (M.R. 54/93, subsection 2(3)).

3.2 Registration Requirements

The process of issuing health insurance cards requires that individuals inform Manitoba Health that they are legally entitled to be in Canada, and that they intend to be physically present in Manitoba for six months. They must also provide a primary residence address in Manitoba. Upon receiving this information, Manitoba Health will provide a registration card for the individual and all qualifying dependants.

Manitoba has two health-related numbers. The registration number is a six-digit number assigned to an individual 18 years of age or older who is not classified as a dependant. This number is used by Manitoba Health to pay for all medical service claims for that individual and all designated dependants. A nine-digit Personal Health Identification Number (PHIN) is used for payment of all hospital services and for the provincial drug program.

As of March 31, 2006, there were 1,173,815 residents registered with the health care insurance plan.

There is no provision for a resident to opt out of the Manitoba health plan.

3.3 Other Categories of Individual

The Residency and Registration Regulation (M.R. 54/93, sub-section 8(1)) requires that temporary workers possess a work permit issued by Citizenship and Immigration Canada (CIC) for at least 12 months, be physically present in Manitoba and be legally entitled to be in Canada before receiving Manitoba Health coverage.

As of March 31, 2006, there were 4,475 individuals on work permits covered under the MHSIP.

The definition of "resident" under the Health Services Insurance Act allows the Minister of Health or the Minister's designated representative to provide coverage for holders of a Minister's permit under the Immigration Act (Canada). No legislative amendments to the Act or the regulations in the 2005-2006 fiscal year affected universality.

4.0 Portability

4.1 Minimum Waiting Period

The Residency and Registration Regulation (M.R. 54/93, section 6) identifies the waiting period for insured persons from another province or territory. A resident who lived in another Canadian province or territory immediately before arriving in Manitoba is entitled to benefits on the first day of the third month following the month of arrival.

4.2 Coverage During Temporary Absences in Canada

The Residency and Registration Regulation (M.R. 54/93 section 7(1)) defines the rules for portability of health insurance during temporary absences in Canada. Students are considered residents and will continue to receive health coverage for the duration of their full-time enrolment at any accredited educational institution. The additional requirement is that they intend to return and reside in Manitoba after completing their studies.

Residents on sabbatical or educational leave from employment will be covered by Manitoba Health for up to 24 consecutive months. These individuals must return and reside in Manitoba after completing their leave.

Manitoba has formal agreements with all Canadian provinces and territories for the reciprocal billing of insured hospital services. Manitoba has a bilateral agreement with the Province of Saskatchewan for Saskatchewan residents who receive care in Manitoba border communities.

In-patient costs are paid at standard rates approved by the host province or territory. Payments for in-patient, high-cost procedures and out-patient services are based on national rates agreed to by provincial or territorial health plans. These include all medically necessary services as well as costs for emergency care.

Except for Quebec, medical services incurred in all provinces or territories are paid through a reciprocal billing agreement at host province or territory rates. Claims for medical services received in Quebec are submitted by the patient or physician to Manitoba Health for payment at host province rates.

In 2005-2006, Manitoba Health made payments of approximately $23.7 million for hospital services and $8.7 million for medical services provided in Canada.

4.3 Coverage During Temporary Absences Outside Canada

The Residency and Registration Regulation (M.R. 54/93, sub-section 7(1)) defines the rules for portability of health insurance during temporary absences from Canada.

Residents on full-time employment contracts outside Canada will receive Manitoba Health coverage for up to 24 consecutive months. Individuals must return and reside in Manitoba after completing their employment terms. Clergy serving as missionaries on behalf of a religious organization approved as a registered charity under the Income Tax Act (Canada) will be covered by Manitoba Health for up to 24 consecutive months. Students are considered residents and will continue to receive health coverage for the duration of their full-time enrolment at an accredited educational institution. The additional requirement is that they intend to return and reside in Manitoba after completing their studies. Residents on sabbatical or educational leave from employment will be covered by Manitoba Health for up to 24 consecutive months. These individuals also must return and reside in Manitoba after completing their leave.

Coverage for all these categories is subject to amounts detailed in the Hospital Services Insurance and Administration Regulation (M.R. 48/93). Hospital services received outside Canada due to an emergency or a sudden illness, while temporarily absent, are paid as follows:

In-patient services are paid based on a per-diem rate according to hospital size:

• 1-100 beds: $280
• 101-500 beds: $365
• over 500 beds: $570

Out-patient services are paid at a flat rate of $100 per visit or $215 for haemodialysis.

The calculation of these rates is complex due to the diversity of hospitals in both rural and urban areas.

Manitobans requiring medically necessary hospital services unavailable in Manitoba or elsewhere in Canada may be eligible for costs incurred in the United States by providing Manitoba Health with a recommendation from a specialist stating that the patient requires a specific, medically necessary service. Physician services received in the United States are paid at the equivalent Manitoba rate for similar services. Hospital services are paid at a minimum of 75 per cent of the hospital's charges for insured services. Payment for hospital services is made in U.S. funds (the Hospital Services Insurance and Administration Regulation, sections 15-23).

Manitoba Health made payments of approximately $3,410,500 for hospital care provided in hospitals out-side Canada in the 2005-2006 fiscal year. In addition, Manitoba Health made payments of approximately $1,074,000 for medical care outside Canada.

In instances where Manitoba Health has given prior approval for services provided outside Canada and payment is less than 100 per cent of the amount billed for insured services, Manitoba Health will consider additional funding based on financial need.

4.4 Prior Approval Requirement

Prior approval by Manitoba Health is not required for services provided in other provinces or territories or for emergency care provided outside Canada. Prior approval is required for elective hospital and medical care provided outside Canada. An appropriate medical specialist must apply to Manitoba Health to receive approval for coverage.

No legislative amendments to the Act or the regulations in the 2005-2006 fiscal year had an effect on portability.

5.0 Accessibility

5.1 Access to Insured Health Services

Manitoba Health ensures that medical services are equitable and reasonably available to all Manitobans. Effective January 1, 1999, the Surgical Facilities Regulation (M.R. 222/98) under the Health Services Insurance Act came into force to prevent private surgical facilities from charging additional fees for insured medical services.

In July 2001, the Health Services Insurance Act, the Private Hospitals Act and the Hospitals Act were amended to strengthen and protect public access to the health care system. The amendments include:

• changes to definitions and other provisions to ensure that no charges can be made to individuals who receive insured surgical services or to anyone else on that person's behalf; and
• ensuring that a surgical facility cannot perform procedures requiring overnight stays and thereby function as a private hospital.

On February 10, 2004, Manitoba officially opened the expanded Health Links/Info Santé, a 35-seat, state-of-the-art call centre with a call capacity of 300,000 per year.

Manitobans now have access to vital health information and assistance in 120 languages 24-hours a day, seven days a week.

Public demand for Health Links/Info Santé has increased steadily since it began as a six station call back service in 1994. Manitobans value the service. Providing this information source relieves pressure on other areas of the health care system, particularly emergency rooms.

Through the Primary Health Care Transition Fund, multi-jurisdictional envelope funds have been made available to implement a program to manage patients with congestive heart failure. Beginning in November 2004, this 17-month initiative will evaluate the benefits of using health lines to manage patients with chronic diseases.

5.2 Access to Insured Hospital Services

All Manitobans have access to hospital services including acute care, psychiatric extended treatment, mental health, palliative, chronic, long-term assessment/rehabilitation and to personal care facilities. There has been a shift in focus from hospital beds to community services, outpatients and day surgeries, which are also insured services.

Manitoba's nursing supply has improved significantly in Winnipeg, with a more gradual improvement noted in rural and northern regions. The increased supply of nurses is primarily due to an investment in nursing education. Enrolment in nursing education programs continues to be fully subscribed. The Nurses Recruitment and Retention Fund (NRRF) has also contributed significantly to improving nursing supply in Manitoba. The most recent NRRF initiative is the Conditional Grant Program that was implemented in July 2004 to encourage new graduates to work in rural and northern Manitoba regions (outside Winnipeg and Brandon).

In addition, Manitoba has a wide range of other health care professionals. Shortages in some of the technology fields persist, primarily in rural and northern areas of the Province. Shortages in some of the technology fields such as medical radiology technology, medical laboratory technology and sonography continue to be issues of concern, however recent expansions of training opportunities are expected to have positive impacts in the near future.

Manitoba currently has access to seven Magnetic Resonance Imaging (MRI) machines, six of which are used for clinical testing. The first unit was installed in 1990 by the St. Boniface Research Foundation. In Winnipeg, there are three MRI machines located at St. Boniface General Hospital, and two located at the Health Sciences Centre. One of the MRIs at the Health Science Centre was a joint initiative with the National Research Council (NRC). The sixth MRI was opened at Brandon Regional Health Centre in June 2004. This was the first MRI machine to be located outside Winnipeg. The seventh and newest MRI opened at Pan AM Clinic and became operational November 21, 2005.

Manitoba has 17 Computerized Tomography (CT) scanners: three (one for paediatric patients) at the Health Sciences Centre, two at the St. Boniface General Hospital, one each at Victoria General Hospital, Misericordia Health Centre, Seven Oaks, Grace and Concordia Hospitals all located in Winnipeg. Dauphin Regional Health Centre, Thompson General Hospital, Brandon Regional Health Centre, Boundary Trails Health Centre, Bethesda Hospital, The Pas Hospital and Selkirk Regional Health Centre are all located throughout the province. As well, planning is underway to establish a CT scanner at Portage District General Hospital. Brandon is in the process of purchasing a 64 slice scanner and Dauphin is in the process of purchasing a 16 slice CT scanner.

There are 67 ultrasound scanners located in Winnipeg health facilities and 22 scanners in rural and northern health facilities. Concordia and Seven Oaks Hospitals are reviewing proposals for a new ultrasound for each facility. Bethesda Hospital is also purchasing an ultrasound scanner. Bone density testing is funded by Manitoba Health on two machines, one located in Winnipeg and one in Brandon.

In November 2004 new community cancer programs were established in Deloraine and Pinawa. These new cancer programs operate in conjunction with CancerCare Manitoba and focus on prevention, early detection and screening, diagnosis and treatment and rehabilitation. Services are delivered by health professionals specially trained in oncology and include the preparation and administration of chemotherapy.

The Manitoba Prostate Cancer Centre became operational in October 2004. It is located on the third floor of the new CancerCare building at 675 McDermot Avenue. The Prostate Centre includes a wide variety of services for Manitoba men including clinical assessment, information to help with patient decision-making, linkages with prostate cancer support groups and research conducted in the area of prostate disease.

Wait time funding has provided for additional hip and knee joint replacements at several sites in Winnipeg, Brandon Regional Health Centre and Boundary Trails Health Centre. Rehabilitation clinics have also been established in Winnipeg, Brandon and Boundary Trails to provide care to patients while they wait for their joint replacement surgery.

Additional cataract procedures to reduce wait lists have been added at Pan Am Clinic in Winnipeg and at Brandon Regional Health Centre.

In March 2005 the expansion of pediatric dental surgery services to Misericordia Health Centre (MHC) was initiated to reduce the waiting times. Further, 200 surgeries were added to Thompson General Hospital at the beginning of August 2005.

Services at the Pain Clinic at Health Sciences Centre had been impacted by a shortage of anesthesiologists and the lack of physical space in the clinic. Renovations to expand clinic size and increase capacity were completed in 2005. The Health Sciences Centre Pain Clinic has recruited two Geriatric Rehabilitation doctors (psychiatrists) and a psychologist who are part of the multi-disciplinary team treating patients.

The WRHA Emergency Care Task Force was initiated in January 2004. The Task Force was closed effective January 2006. During its two years of work, a total of 46 recommendations for short and long term improvements in emergency care in Winnipeg hospitals were identified and plans for implementation defined. While some recommendations have been fully implemented, work continues on others as many recommendations involve system issues. Highlights include enhanced diagnostic capabilities, enhanced education for Emergency Department staff, redevelopment of physical space and improved IT support.

The Wait Times Task Force was established in 2006 to improve access to quality care and reduce wait times. The Wait-Time Reduction Strategy targets the five priority areas identified by First Ministers in their 10-year plan to strengthen health care: cancer, cardiac, diagnostic imaging, joint replacement and sight restoration. In addition, Manitoba is targeting four other priority areas: children's dental surgeries, mental health programs, pain management and treatment for sleep disorders.

A plan was developed in consultation with practitioners and stakeholders, which will increase the number of surgeries and procedures, invest in human resources, technology and capital, and provide regional health authorities with new wait-list management tools and resources.

The Wait Time Task Force established the Manitoba Patient Access Network which is charged with developing new approaches to patient navigation through better system integration and coordination, improving patient access to services and ensuring sustainability of initiatives.

5.3 Access to Insured Physician and Surgical-Dental Services

In 2005-2006, Manitoba Health continued to support initiatives to improve access to physicians in rural and northern areas of the province. One of the supported initiatives, implemented in the fall of 2005, was a co-ordinated process to assist Regional Health Authorities with the logistics of recruiting foreign-trained physicians. The co-ordinated process, administered through the Physician Resource Coordination Office (PRCO), is aimed at avoiding duplication of effort, while introducing future physician candidates to opportunities available in Manitoba.

The province supports many initiatives aimed at recruiting and retaining physicians. There is an initiative that facilitates the entry of eligible foreign medical graduates into the physician workforce. Through the program, foreign-trained physicians can achieve conditional licensure to practice family medicine in return for agreeing to work in a sponsoring rural Regional Health Authority. Another initiative assists in facilitating the assessment of physicians whose practice will be limited to a specialty field of training. Through this program clinical assessments are organized and facilitated in order for foreign trained physicians to meet the College of Physicians and Surgeons of Manitoba (CPSM) criteria for licensure.

Manitoba continues to experience increases in the number of new physicians registering with the licensing body. To encourage retention of Manitoba graduates, the Province continued to provide a financial assistance grant, introduced in 2001, for students and residents. In return for financial assistance during their training, the student or resident agrees to work in Manitoba for a specific period after graduating. In 2005 the Practice Assistance Option of the Medical Student/Resident Financial Assistance Program was enhanced to provide two grants of $50,000 each to physicians re-entering training in an area of critical need in the Province, such as emergency medicine or anaesthesia. In addition five grants of $15,000 each have been made available to Family Physicians who have been working in an urban area and five grants of $25,000 each to Family Physicians working in a rural/northern area of the Province, subject to certain eligibility criteria. Since 2001, Manitoba has supported an expansion in medical school class sizes, which continues in 2006 with the first year enrolment for the fall of this year reaching 101 students.

The Manitoba Telehealth Network under the leadership of the Winnipeg Regional Health Authority has implemented the infrastructure to link 23 Telehealth sites across the province. This modern telecommunications link means patients can be seen by specialists and medical staff can consult with each other without having to endure the expense and inconvenience of travelling from the North to Winnipeg. In September 2002, Manitoba Health launched the new Manitoba Telehealth site at St. Boniface General Hospital, officially linking its medical specialists to patients and colleagues province-wide.

5.4 Physician/Dentist Compensation

Manitoba continues to employ the following methods of payment for physicians: fee-for-service, salaried, sessional and blended.

The Health Services Insurance Act governs payment to physicians for insured services. There were no amendments to the Health Services Insurance Act (HSIA) related to physician compensation during the 2005-2006 fiscal year.

Fee-for-service remains the dominant method of payment for physician services. Notwithstanding, alternate payment arrangements constitute a significant portion of the total compensation to physicians in Manitoba. Alternate-funded physicians are those who receive either a salary (employer-employee relationship) or those who work on an independent contract basis. Manitoba also uses blended payment methods to top-up the wages of physicians whose fee-for-service income may not be competitive, yet whose services remain vital to the province. As well, physicians may receive sessional payments for providing medical services, as well as stipends for on-call responsibilities.

Representatives from the Manitoba Medical Association (MMA) and Manitoba Health typically negotiate compensation agreements for physicians.

The June 27, 2005, settlement maintained the terms of the June 2, 2002, Arbitration Agreement, (subsequently entrenched in the 2003-2005 MMA- Manitoba Heath Agreement) including:

• the continuation of a Physician Retention Fund ($5 million per annum over the duration of this agreement as well as the subsequent agreement);
• the continuation of the Professional Liability Insurance Fund ($5 million per annum for 2006 through to 2011);
• the continuation of the Continuing Medical Education Fund ($1 million per annum from 2006 through 2011);
• the continuation of a Maternity/Parental Benefits Fund ($1 million per annum from 2005 through to 2011);
• a mechanism to initiate arbitration proceedings with respect to a subsequent agreement, if notice is given by either party by January 1, 2007;
• that physicians covered by the Agreement shall refrain from stopping work or curtailing services and to continue to provide services without interruption; and
• continuation of the Grievance Arbitration procedure set forth in the March 8, 1994, Fee-For-Service Agreement between the parties.

The highlights of the June 27, 2005, Negotiated Settlement include:

• a three-year term from April 1, 2005 to March 31, 2008;
• an overall increase of 7.5 per cent (non-compounded) to the Fee-For-Service Schedule of Benefits, as well as alternate-funded agreements and arrangements)
• 2.5 per cent effective April 1, 2005; 2.5 per cent effective April 1, 2006; and 2.5 per cent effective April 1, 2007.
• an additional $10 million was applied to the schedule of benefits through a Shoring Up Fund and an additional $5.5 million was applied to outstanding fee-for-service issues through the Exceptional Issues Fund;
• an additional $5 million was applied to alternate funding contracts though the alternate Funding Shoring Up Fund.
• an extension of maternity and parental benefits to all Manitoba physicians, including interns and residents continued;
• increased incentives for family doctors to provide full-service care and to maintain hospital privileges; and,
• increases to the rates for physicians under alternate funding agreements in the amount of 2.5 per cent effective April 1, 2005; 2.5 per cent effective April 1, 2006; and 2.5 per cent effective April 1, 2007 (non-compounded); were also applied over and above the fee-for-service increase.

5.5 Payments to Hospitals

Division 3.1 of Part 4 of the Regional Health Authorities Actsets out the requirements for operational agreements between Regional Health Authorities and the operators of hospitals and personal care homes, defined as "health corporations" under the Act.

Pursuant to the provisions of this division, Authorities are prohibited from providing funding to a health corporation for operational purposes unless the parties have entered into a written agreement for this purpose that enables the health services to be provided by the health corporation, the funding to be provided by the Authority for the health services, the term of the agreement, and a dispute resolution process and remedies for breaches. If the parties cannot reach an agreement, the Act enables them to request that the Minister of Health appoint a mediator to help them resolve outstanding issues. If the mediation is unsuccessful, the Minister is empowered to resolve the matter or matters in dispute. The Minister's resolution is binding on the parties.

There are three Regional Health Authorities which have hospitals operated by health corporations in their health regions. The Regional Health Authorities have concluded the required agreements with health corporations. The operating agreements enable a Regional Health Authority to determine funding based on objective evidence, best practices and criteria that are commonly applied to comparable facilities. In all other regions, the hospitals are operated by the Regional Health Authorities Act. Section 23 of the Act requires that Authorities allocate their resources in accordance with the approved regional health plan.

The allocation of resources by Regional Health Authorities for providing hospital services is approved by Manitoba Health through the approval of the Authorities' regional health plans, which the Authorities are required to submit for approval pursuant to section 24 of the Regional Health Authorities Act. Section 23 of the Act requires that Authorities allocate their resources in accordance with the approved regional health plan.

Pursuant to subsection 50(2.1) of the Health Services Insurance Act, payments from the MHSIP for insured hospital services are to be paid to the Regional Health Authorities. In relation to those hospitals that are not owned and operated by an Authority, the Authority is required to pay each hospital in accordance with any agreement reached between the Authority and the hospital operator.

No legislative amendments to the Act or the regulations in 2005-2006 had an effect on payments to hospitals.

6.0 Recognition Given to Federal Transfers

Manitoba routinely recognizes the federal role regarding the contributions provided under the Canada Health Transfer (CHT) in public documents.

7.0 Extended Health Care Services

Manitoba has established community-based service programs as appropriate alternatives to hospital services. These service programs are funded by Manitoba Health through the Regional Health Authorities. The services include the following:

Personal Care Home Services

Insured personal care services are provided pursuant to the Personal Care Services Insurance and Administration Regulation under the Health Services Insurance Act. In 2005, the Personal Care Homes Standards Regulation and Personal Care Homes Licensing Regulation were enacted under the same Act, linking licensing to compliance with a range of standards designed to ensure safe, quality care. Both proprietary and non-proprietary homes are licensed by Manitoba Health. Residents of personal care homes pay a residential charge towards accommodation costs, with the cost of care funded by Manitoba Health through the Regional Health Authorities. Total Manitoba Health operating funding for personal care services delivered in licensed personal care homes and in two long-term care centres during fiscal year 2005-2006 was $445,588,400. This funding supported the delivery of insured personal care services in a total of 9,830 personal care beds plus a total of 190 chronic care beds in two long-term care facilities, 30 palliative care beds and 136 rehab beds. In addition, Manitoba Health provided $13,054,100 in capital funding for approved capital projects, information technology projects, safety and security upgrades, and equipment.

Home Care Services

The Manitoba Home Care Program is the oldest comprehensive, province-wide, universal home care program in Canada. Manitoba Home Care provides effective, reliable and responsive community health care services to support independent living; to develop appropriate care options to support continued community living; and to facilitate admission to institutional care when community living is no longer a viable alternative. Home Care services are delivered through the local offices of the Regional Health Authorities and include a broad range of services based on a multidisciplinary assessment of individual needs. Home Care case co-coordinators conduct assessments and develop individual care plans, which may include self or family Managed Care, personal care assistance, household maintenance, professional health care, in-home family relief, facility-based respite care, some supplies and equipment, access to adult day programs, and/or access to support services to seniors' programs that coordinate volunteers, congregate meal programs, transportation, emergency response systems and other activities that support continued independent community living.

Mental Health and Addictions Services

All Regional Health Authorities provide community mental health services. Community Mental Health Workers provide assessment, service planning, short-term counselling interventions, rehabilitation and recovery planning, crisis intervention, community consultation and in some cases education. In addition to Community Mental Health Workers, some regions have a variety of intensive and supportive programs such as Intensive Case Management, Supported Employment, Supported Housing and, in Winnipeg, the Program for Assertive Community Treatment and the Early Psychosis Prevention and Intervention Service.

Addictions services and supports are provided through provincially funded agencies. They include the Addictions Foundation of Manitoba (AFM), The Behavioural Health Foundation, Salvation Army -- Anchorage, Native Addictions Council of Manitoba, Tamarack, Laurel Centre, Esther House and Addictions Recovery Inc. These agencies work to reduce the harm associated with alcohol and other drugs. AFM also offers a gambling program. Programs include education, prevention, rehabilitation and research. In addition to the provincially funded agencies, the Winnipeg Regional Health Authority funds to detox programs and the Norman Regional Health Authority funds a residential treatment agency.

Primary Health Care

One of Manitoba Health's strategic priorities is the need to address primary care renewal. One strategy includes the development of Physician Integrated Networks (PIN) which has been evolving under the guidance of an Advisory Committee with representation from the University of Manitoba; the Colleges of Registered Nurses and Physicians & Surgeons of Manitoba; the Manitoba Medical Association; the Winnipeg and Assiniboine Regional Health Authorities and other primary care stakeholders.

The Physician Integrated Network initiative focuses on the engagement of fee-for-service physician groups. The objectives of this initiative are to improve access to primary care, to improve primary care providers' access to and use of information systems, to improve the working environment for all primary care providers, and to demonstrate high quality care with a specific focus on chronic disease management.

A PIN resource team has been established to work with four demonstration sites during the development phase of the implementation plan. The project is scheduled to be operational early in 2007.

The federal government's Primary Health Care Transition Fund per capita grant funded twenty-two initiatives in Manitoba. Some initiatives received sustainable funding from their regional health authorities while others concluded as of March 31, 2006. The final reports and evaluations, submitted by the initiatives provided many insights for future strategic planning and enhancement of primary health care in the province.

Primary Health Care participated in a national initiative to develop multidisciplinary collaborative care in order to address human resource and quality issues in maternal newborn services. Primary Health Care, in partnership with MB Telehealth, held a workshop for regional health authorities to pilot the project's tool-kit, and assess its usefulness in the provincial environment. Implementation of the model begins with an environmental scan and gap-analysis, is flexible to address northern, rural and remote situations and is designed to begin with current resources. Regional Health Authority representatives found the model practical and useful, and plan to work with Primary Health Care in development of collaborative maternal/newborn services.

Midwifery, regulated in 2000, has now been introduced in seven of 11 Regional Health Authorities. In 2003-2004 only six RHAs employed midwives. Services are distributed across the province, with half provided outside the Winnipeg Region. Midwives provide primary care for women and newborns; now attending five per cent of Manitoba births, as well as providing well-woman care. Provincial direction has focused the service on priority populations, which represent over 65% of midwifery clients; including those at high social risk such as substance abusers. The program, providing comprehensive, community-based care, has significantly lower rates of pre-term birth, high and low birth weights. Development of human resources is being addressed through the introduction of the Aboriginal Midwifery Education Program at University College of the North.

The primary health care staff participated in a Pan-Canadian Primary Health Care Indicator Development Project also funded through the Primary Health Care Transition Fund. The purpose of the project was to develop a set of agreed-upon PHC indicators with which to compare and measure PHC at multiple levels within each jurisdiction across Canada.

Ambulatory Health Care Services

The Health Services Insurance Act includes a provision authorizing the designation of non-profit, publicly administered ambulatory health (primary care) centres as institutions within the meaning of the Act.

Saskatchewan

Introduction

In 2005-2006 Saskatchewan Health continued to base its work on The Action Plan for Saskatchewan Health Care, a blueprint and broad strategic plan for strengthening the health care system. Our vision for Saskatchewan remains unchanged:

"Building a province of healthy people and healthy communities." In 2005-2006 Saskatchewan Health made significant progress toward fulfilling its goals of:

• improved access to quality health services;
• effective health promotion and disease prevention;
• retaining, recruiting and training health providers; and
• a sustainable, efficient, accountable, quality health system

The following examples highlight several significant accomplishments by Saskatchewan Health during the 2005-2006 fiscal year.

• Saskatchewan achieved a significant increase in surgical capacity in 2005-2006 and a considerable drop in the number of patients waiting for surgery.
• Regina Qu'Appelle and Saskatoon Health Regions together completed about 2,000 more surgeries in 2005-2006. The number of patients waiting for surgery in those regions dropped by nearly 1,600 over the previous year.
• The total number of patients waiting for an MRI exam decreased provincially by 35.6 per cent since March 2004. With the implementation of Regina's second MRI, it is anticipated that wait times will be further reduced.
• Funding was provided to more than 500 new and continuing return service bursaries for health care providers.
• New International Medical Graduate residency seats were added at the University of Saskatchewan to allow more foreign-trained physicians to work in Saskatchewan.
• It released the comprehensive report Working Together: Saskatchewan's Health Workforce Action Plan -- an action plan designed to improve health care in Saskatchewan by keeping and attracting health care professionals.
• It expanded immunization program to include free flu shots for children between the ages of 6-23 months.
• It announced the building of a new Provincial Laboratory to ensure we can even better identify, respond to and prevent illness and disease in our province.
• It expanded the Telehealth network to now include 26 sites across the province, and serve about 5,500 Saskatchewan residents and health care providers every year.

In August 2005, Premier Lorne Calvert announced the launch of the Premier's Project Hope, a comprehensive and integrated plan to prevent and treat alcohol and drug addiction in Saskatchewan. Funding for 2005-2006 included $10 million of new annual funding in addition to the $4.7 million increase in the 2005-2006 budget for addictions programming. This amounted to a 60 per cent increase in substance abuse prevention and treatment funding.

Saskatchewan has also made exciting progress in developing new electronic health record (EHR) technologies; we were successful in securing funding from Canada Health Infoway to launch a number of important new projects such as the Pharmaceutical Information Program (PIP). We will continue to work closely with our health delivery partners to introduce innovative technologies for improving the health of our citizens. The EHR program will ensure authorized front-line care providers have access to the information they need -- improving the quality, access and effectiveness of health care services across the province into the future.

Saskatchewan Health and the health care system provide a wide range of services through a complex delivery system that includes Regional Health Authorities, the Saskatchewan Cancer Agency, affiliated health care organizations and a range of professionals many of whom are in private practice. The range and number of services provided are partially illustrated by the following examples of activity:

• 128,700 annual in-patient admissions or 2,100 (acute, psychiatric and rehabilitation) patients in hospital beds on any given day;
• 93,700 surgeries and select ambulatory procedures (e.g., endoscopies and biopsies) per year or 257 per day;
• 4.6 million visits per year or 12,600 family physician visits per day;
• 2,500 visits to specialists per day;
• 400,000 immunizations per year; and
• more than 40,000 mammograms per year.

The health system employs over 37,000 individuals, includes 26 self-regulated health professions, and operates 269 health facilities.

1.0 Public Administration

1.1 Health Care Insurance Plan and Public Authority

The provincial government is responsible for funding and ensuring the provision of insured hospital, physician and surgical-dental services in Saskatchewan. Section 6.1 of The Department of Health Act authorizes that the Minister of Health may:

• pay part of, or the whole of, the cost of providing health services for any persons or classes of person who may be designated by the Lieutenant Governor in Council;
• make grants or loans or provide subsidies to regional health authorities, health care organizations or municipalities for providing and operating health services or public health services;
• pay part of or the whole of the cost of providing health services in any health region or part of a health region in which those services are considered by the Minister to be required;
• make grants or provide subsidies to any health agency that the Minister considers necessary; and
• make grants or provide subsidies to stimulate and develop public health research and to conduct surveys and studies in the area of public health.

Sections 8 and 9 of The Saskatchewan Medical Care Insurance Act provide the authority for the Minister of Health to establish and administer a plan of medical care insurance for residents. The Regional Health Services Act provides the authority to establish 12 regional health authorities, replacing the former 32 district health boards.

Sections 5 and 11 of The Cancer Foundation Act provide for establishing a Saskatchewan Cancer Agency and for the Agency to coordinate a program for diagnosing, preventing and treating cancer.

The mandates of the Department of Health, regional health authorities and the Saskatchewan Cancer Agency for 2005-2006 are outlined in The Department of Health Act, The Regional Health Services Act and The Cancer Foundation Act.

1.2 Reporting Relationship

The Department of Health is directly accountable, and regularly reports, to the Minister of Health on the funding and administering the funds for insured physician, surgical-dental and hospital services.

Section 36 of The Saskatchewan Medical Care Insurance Act prescribes that the Minister of Health submit to the Legislative Assembly an annual report concerning the medical care insurance plan.

The Regional Health Services Act prescribes that a regional health authority shall submit to the Minister of Health:

• a report on the activities of the regional health authority; and
• a detailed, audited set of financial statements. Section 54 of The Regional Health Services Act requires that the regional health authority shall submit to the Minister any reports that the Minister may request from time to time. All regional health authorities are

required to submit a financial and health service plan to Saskatchewan Health. The Cancer Foundation Act prescribes that the Cancer

Foundation shall, in each fiscal year, submit a report about its business and a financial statement to the Minister of Health for the fiscal year immediately preceding.

1.3 Audit of Accounts

The Provincial Auditor conducts an annual audit of government departments and agencies, including Saskatchewan Health. It includes an audit of departmental payments to regional health authorities, the Saskatchewan Cancer Agency and to physicians and dental

surgeons for insured physician and surgical-dental services. Section 57 of The Regional Health Services Act requires that an independent auditor, who possesses the prescribed qualification and is appointed for that purpose by the regional health authority, shall audit the accounts of a regional health authority at least once in every fiscal year. A detailed, audited set of financial statements must be submitted annually, by each regional health authority, to the Minister of Health.

Section 34 of The Cancer Foundation Act prescribes that the records and accounts of the Foundation shall be audited at least once a year by the Provincial Auditor or by a designated representative.

The most recent audits were for the year ended March 31, 2006.

The audits of the Government of Saskatchewan, regional health authorities and Saskatchewan Cancer Agency are tabled in the Saskatchewan Legislature each year. The reports are available to the public directly from each entity or are available on their websites.

The Provincial Auditor's Office of Saskatchewan also prepares reports to the Legislative Assembly of Saskatchewan. These reports are designed to assist government in managing public resources and to improve the information provided to the Legislative Assembly. They are available on the Provincial Auditor's website.

2.0 Comprehensiveness

2.1 Insured Hospital Services

The Regional Health Services Act was proclaimed on August 1, 2002, to replace The Health Districts Act as the authority to amalgamate the existing 32 health districts into 12 regional health authorities. Section 8 of The Regional Health Services Act (the Act) gives the Minister the authority to provide funding to a regional health authority or a health care organization for the purpose of the Act.

Section 10 of The Regional Health Services Act permits the Minister to designate facilities including hospitals, special-care homes and health centres. Section 11 allows the Minister to prescribe standards for delivering services in those facilities by regional health authorities and health care organizations that have entered into service agreements with a regional health authority.

The Act sets out the accountability requirements for regional health authorities and health care organizations. These requirements include submitting annual operational and financial and health service plans for Ministerial approval (sections 50-51); establishing community advisory networks (section 28); and reporting critical incidents (section 58). The Minister also has the authority to establish a provincial surgical registry to help manage surgical wait times (section 12). The Minister retains authority to inquire into matters (section 59); appoint a public administrator if necessary (section 60); and approve general and staff practitioner by-laws (sections 42-44).

Funding for hospitals is included in the funding provided to regional health authorities.

As of March 31, 2006, the following facilities were providing insured hospital services to both in- and out-patients:

• 66 acute care hospitals provided in- and out-patient services; and
• one rehabilitation hospital provided treatment, recovery and rehabilitation care for patients disabled by injury or illness. Rehabilitation services are also provided in a geriatric rehabilitation unit in one other hospital and in two special-care facilities.

A comprehensive range of insured services is provided by hospitals. These may include: public ward accommodation; necessary nursing services; the use of operating room and case room facilities; required medical and surgical materials and appliances; x-ray, laboratory, radiological and other diagnostic procedures; radiotherapy facilities; anaesthetic agents and the use of anaesthesia equipment; physiotherapeutic procedures; all drugs, biological and related preparations required for hospitalized patients; and services rendered by individuals who receive remuneration from the hospital.

The Action Plan for Saskatchewan Health Care established new hospital categories and outlined a standard array of services that should be available in each hospital. Hospitals are grouped into the following five categories: Community Hospitals; Northern Hospitals; District Hospitals; Regional Hospitals; and Provincial Hospitals.

One of the elements of the Action Plan is to provide reliable, predictable hospital services, so people know what they can expect 24 hours a day, 365 days a year. While not all hospitals will offer the same kinds of services, reliability and predictability means:

• it is widely understood which services each hospital offers; and
• these services will be provided on a continuous basis, subject to the availability of appropriate health providers.

This service delivery framework will ensure quality, predictable hospital services and help guide decisions about where to invest new funds.

Regional health authorities have the authority to change the manner in which they deliver insured hospital services based on an assessment of their population health needs and available health professional funding resources.

The process for adding a hospital service to the list of services covered by the health care insurance plan involves a comprehensive review, which takes into account such factors as service need, anticipated service volume, health outcomes by the proposed and alternative services, cost and human resource requirements, including availability of providers as well as initial and ongoing competency assurance demands. The process is initiated by a regional health authority and, depending on the specific service request, it could include consultations involving several branches within Saskatchewan Health as well as external stakeholder groups such as health regions, service providers and the public.

2.2 Insured Physician Services

Sections 8 and 9 of The Saskatchewan Medical Care Insurance Act enable the Minister of Health to establish and administer a plan of medical care insurance for provincial residents. Amendments were made in April and October 2005 to the Physician Payment Schedule of The Saskatchewan Medical Care Insurance Payment Regulations (1994) in accordance with an agreement reached with the Saskatchewan Medical Association. Those amendments provided for the addition of new insured physician services, changes in payment levels for selected services, and definition or assessment rule revisions to existing selected services with significant monetary impact. All new fee items for physicians can be found in the Physician's Newsletter.

The Saskatchewan Health Medical Services Branch 2005-2006 Annual Statistical Report is available on the Publications Centre

Physicians may provide insured services in Saskatchewan if they are licensed by the College of Physicians and Surgeons of Saskatchewan and have agreed to accept payment from the Department of Health without extra-billing for insured services.

As of March 31, 2006, there were 1,719 physicians licensed to practice in the province and eligible to participate in the medical care insurance plan.

Physicians may opt out or not participate in the Medical Services Plan, but if doing so, must fully opt out of all insured physician services. The "opted-out" physician must also advise beneficiaries that the physician services to be provided are not insured and that the beneficiary is not entitled to be reimbursed for those services. Written acknowledgement from the beneficiary indicating that he or she understands the advice given by the physician is also required.

As of March 31, 2006, there were no "opted-out" physicians in Saskatchewan.

Insured physician services are those that are medically necessary, are covered by the Medical Services Plan of the Department of Health and are listed in the Physician Payment Schedule of The Saskatchewan Medical Care Insurance Payment Regulations (1994) of The Saskatchewan Medical Care Insurance Act.

There were approximately 3,100 different insured physician services as of March 31, 2006.

A process of formal discussion between the Medical Services Plan and the Saskatchewan Medical Association addresses new insured physician services and definition or assessment rule revisions to existing selected services (modernization) with significant monetary impact. The Executive Director of the Medical Services Branch manages this process. When the Medical Services Plan covers a new insured physician service or significant revisions occur to the Physician Payment Schedule, a regulatory amendment is made to the Physician Payment Schedule.

Although formal public consultations are not held, any member of the public may make recommendations about physician services to be added to the Plan.

2.3 Insured Surgical-Dental Services

Dentists registered with the College of Dental Surgeons of Saskatchewan and designated by the College as specialists able to perform dental surgery may provide insured surgical-dental services under the Medical Services Plan. As of March 31, 2006, 78 dental specialists were providing such services.

Amendments were made in April 2003, to The Saskatchewan Medical Insurance Branch Payment Schedule for Insured Services Provided by a Dentist. Those amendments provided for changes in payment levels for selected services.

Dentists may opt out or not participate in the Medical Services Plan, but if doing so, must opt out of all insured surgical-dental services. The dentist must also advise beneficiaries that the surgical-dental services to be provided are not insured and that the beneficiary is not entitled to reimbursement for those services. Written acknowledgement from the beneficiary indicating that he or she understands the advice given by the dentist is also required.

There were no "opted-out" dentists in Saskatchewan as of March 31, 2006.

Insured surgical-dental services are limited to: services in connection with maxillo-facial surgery required as a result of trauma; treatment services for the orthodontic care of cleft palate; extraction of teeth when medically required for the provision of heart surgery, services for chronic renal disease and services for total joint replacement by prosthesis when a proper referral has been made and prior approval obtained from the Medical Services Branch; and certain services in connection with abnormalities of the mouth and surrounding structures.

Surgical-dental services can be added to the list of insured services covered under the Medical Services Plan through a process of discussion and consultation with provincial dental surgeons. The Executive Director of the Medical Services Branch manages the process of adding a new service.

Although formal public consultations are not held, any member of the public may recommend that surgical-dental services be added to the Medical Services Plan.

2.4 Uninsured Hospital, Physician and Surgical-Dental Services

Uninsured hospital, physician and surgical-dental services in Saskatchewan include: in-patient and out-patient hospital services provided for reasons other than medical necessity; the extra cost of private and semi-private hospital accommodation not ordered by a physician; physiotherapy and occupational therapy services not provided by or under contract with a regional health authority; services provided by health facilities other than hospitals unless through an agreement with Saskatchewan Health; non-emergency cataract surgery, MRIs and bone densitometry provided outside Saskatchewan without prior written approval; non-emergency insured hospital, physician or surgical-dental services obtained outside Canada without prior written approval; non-medically required elective physician services; surgical-dental services that are not medically necessary; and services received under other public problems including The Workers' Compensation Act, the federal Department of Veteran Affairs and The Mental Health Act.

As a matter of policy and principle, insured hospital, physician and surgical-dental services are provided to residents on the basis of assessed clinical need. Compliance is periodically monitored through consultation with regional health authorities, physicians and dentists. There are no charges allowed in Saskatchewan for medically necessary hospital, physician or surgical-dental services. Charges for enhanced medical services or products are permitted only if the medical service or product is not deemed medically necessary. Compliance is monitored through consultations with regional health authorities, physicians and dentists.

Insured hospital services could be de-insured by the government if they were determined to be no longer medically necessary. The process is based on discussions among regional health authorities, practitioners and officials from the Department of Health.

Insured surgical-dental services could be de-insured if they were determined not to be medically necessary. The process is based on discussion and consultation with the dental surgeons of the province and managed by the Executive Director of the Medical Services Branch.

Insured physician services could be de-insured if they were determined not to be medically required. The process is based on consultations with the Saskatchewan Medical Association and managed by the Executive Director of the Medical Services Branch.

Formal public consultations about de-insuring hospital, physician or surgical-dental services may be held if warranted.

No health services were de-insured in 2005-2006.

3.0 Universality

3.1 Eligibility

The Saskatchewan Medical Care Insurance Act (sections 2 and 12) and The Medical Care Insurance Beneficiary and Administration Regulations define eligibility for insured health services in Saskatchewan. Section 11 of the Act requires that all residents register for provincial health coverage. The penalty provisions in section 11 of the Act (Duty to Register) provide for a fine of up to $50,000 for giving false information or withholding information necessary for registering an individual.

Eligibility is limited to residents. A "resident" means a person who is legally entitled to remain in Canada, who makes his or her home and is ordinarily present in Saskatchewan, or any other person declared by the Lieutenant Governor-in-Council to be a resident. Canadian citizens and permanent residents of Canada relocating from within Canada to Saskatchewan are generally eligible for coverage on the first day of the third month following the establishing of residency in Saskatchewan.

Returning Canadian citizens, the families of returning members of the Canadian Forces, international students and international workers are eligible for coverage on establishing residency in Saskatchewan, provided that residency is established before the first day of the third month following their admittance to Canada. The following persons are not eligible for insured health services in Saskatchewan:

• members of the Canadian Forces and the Royal Canadian Mounted Police (RCMP), federal inmates and refugee claimants; visitors to the province; and
• persons eligible for coverage from their home province or territory for the period of their stay in Saskatchewan (e.g. students and workers covered under temporary absence provisions from their home province or territory).

Such people become eligible for coverage as follows:

• discharged members of the Canadian Forces and the RCMP, if stationed in or resident in Saskatchewan on their discharge date;
• released federal inmates (this includes those prisoners who have completed their sentences in a federal penitentiary and those prisoners who have been granted parole and are living in the community); and
• refugee claimants, on receiving Convention Refugee status (immigration documentation is required).

3.2 Registration Requirements

The following process is used to issue a health services card and to document that a person is eligible for insured health services:

• every resident, other than a dependent child under 18 years, is required to register;
• registration should take place immediately following the establishment of residency in Saskatchewan;
• registration can be carried out either in person in Regina or by mail;
• each eligible registrant is issued a plastic health services card bearing the registrant's unique lifetime nine-digit health services number; and
• cards are renewed every three years. (Current cards expire in December 2008.)

All registrations are family-based. Parents and guardians can register dependent children in their family units if they are under 18 years of age. Children 18 and over living in the parental home or on their own must self-register.

The number of persons registered for health services in Saskatchewan on June 30, 2005, was 1,021,080.

3.3 Other Categories of Individuals

Other categories of individuals who are eligible for insured health service coverage include persons allowed to enter and remain in Canada under authority of a work permit, student permit or Minister's permit issued by Citizenship and Immigration Canada. Their accompanying family may also be eligible for insured health service coverage.

Refugees are eligible on confirmation of Convention status combined with an employment/student permit, Minister's permit or permanent resident, that is, landed immigrant record.

On June 30, 2005, there were 5,439 such temporary residents registered with Saskatchewan Health.

4.0 Portability

4.1 Minimum Waiting Period

In general, insured persons from another province or territory who move to Saskatchewan are eligible on the first day of the third month following establishment of residency. However, where one spouse arrives in advance of the other, the eligibility for the later arriving spouse is established on the earlier of a) the first day of the third month following arrival of the second spouse; or b) the first day of the thirteenth month following the establishment of residency by the first spouse.

4.2 Coverage During Temporary Absences in Canada

Section 3 of The Medical Care Insurance Beneficiary and Administration Regulations of The Saskatchewan Medical Care Insurance Act prescribes the portability of health insurance provided to Saskatchewan residents while temporarily absent within Canada. There were no changes to the in-Canada temporary absence provisions in 2005-2006.

Continued coverage during a period of temporary absence is conditional upon the registrant's intent to return to Saskatchewan residency immediately on expiration of the approved absence period as follows:

• education: for the duration of studies at a recognized educational facility (written confirmation by a Registrar of full-time student status is required annually);
• employment of up to 12 months (no documentation required); and
• vacation and travel of up to 12 months.

Section 6.6 of The Department of Health Act provides the authority for paying in-patient hospital services to Saskatchewan beneficiaries temporarily residing outside the province. Section 10 of The Saskatchewan Medical Care Insurance Payment Regulations (1994) provides payment for physician services to Saskatchewan beneficiaries temporarily residing outside the province.

Saskatchewan has bilateral reciprocal billing agreements with all provinces for hospital services and all but Quebec for physician services. Rates paid are at the host province rates. The reciprocal arrangement for physician services applies to every province except Quebec.

Payments/reimbursement to Quebec physicians, for services to Saskatchewan residents, are made at Saskatchewan rates (Saskatchewan Physician Payment Schedule). However, the physician fees may be paid at Quebec rates with prior approval. In recent years, the out-of-province reciprocal hospital per diem billing rates have increased significantly.

In 2005-2006, expenditures for insured physician services in other provinces were $20.54 million. Insured hospital services in other provinces were $44.72 million.

4.3 Coverage During Temporary Absences Outside Canada

Section 3 of The Medical Care Insurance Beneficiary and Administration Regulations describe the portability of health insurance provided to Saskatchewan residents who are temporarily absent from Canada.

Continued coverage for students, temporary workers and vacationers and travellers during a period of temporary absence from Canada is conditional on the registrant's intent to return to Saskatchewan residence immediately on the expiration of the approved period as follows:

• education: for the duration of studies at a recognized educational facility (written confirmation by a Registrar of full-time student status is required annually);
• contract employment of up to 24 months (written confirmation from the employer is required); and
• vacation and travel of up to 12 months.

Section 3 of The Medical Care Insurance Beneficiary and Administration Regulations provides open-ended temporary absence coverage for persons whose principal place of residence is in Saskatchewan, but who are not able to satisfy the annual six months physical presence requirement because the nature of their employment requires travel from place to place outside Canada (e.g. cruise line workers).

Section 6.6 of The Department of Health Act provides the authority under which a resident is eligible for health coverage when temporarily outside Canada. In summary, a resident is eligible for medically necessary hospital services at the rate of $100 per in-patient and $50 per out-patient visit per day.

In 2005-2006, $2.03 million was paid for in-patient hospital services and $1.49 million was spent on outpatient hospital services outside Canada. In 2005-2006, expenditures for insured physician services outside Canada were $695,900.

4.4 Prior Approval Requirement

Out-of-Province

Saskatchewan Health covers most hospital and medical out-of-province care received by its residents in Canada through a reciprocal billing arrangement. This arrangement means that residents do not need prior approval and may not be billed for most services received in other provinces or territories while travelling within Canada. The cost of travel, meals and accommodation are not covered.

Prior approval from the Department must be obtained by the patient's specialist for alcohol and drug, mental health and problem gambling services; and cataract surgery services, bone densitometry and non-urgent MRI when provided out-of-province.

Out-of-Country

Prior approval is required for the following services provided outside Canada:

• If a specialist physician refers a patient outside Canada for treatment not available in Saskatchewan or another province, the referring specialist must seek prior approval from the Medical Services Plan of Saskatchewan Health.
• The Saskatchewan Cancer Agency is consulted for out-of-country cancer treatment requests. If approved, Saskatchewan Health will pay the full cost of treatment, excluding any items that would not be covered in Saskatchewan.

5.0 Accessibility

5.1 Access to Insured Health Services

To ensure that access to insured hospital, physician and surgical-dental services is not impeded or precluded by financial barriers, extra-billing by physicians or dental surgeons and user charges by hospitals for insured health services are not allowed in Saskatchewan.

The Saskatchewan Human Rights Code prohibits discrimination in providing public services, which include insured health services on the basis of race, creed, religion, colour, sex, sexual orientation, family status, marital status, disability, age, nationality, ancestry or place of origin.

5.2 Access to Insured Hospital Services

As of March 31, 2006, Saskatchewan had 3,073 staffed hospital beds in 66 acute care hospitals, including 2,537 acute care beds, 218 psychiatric beds and 325 other beds. The Wascana Rehabilitation Centre had 48 rehabilitation beds and 204 extended care beds. Rehabilitation services are also provided in a Geriatric Rehabilitation Unit in one acute care hospital and in two special care facilities.

Saskatchewan's Health Workforce Action Plan

In September 2004, Canada's First Ministers agreed to accelerate their work on health human resource (HHR) action plans and/or initiatives to ensure an adequate supply and appropriate mix of health care professionals. They agreed to make their action plans public by December 31, 2005, including targets for the training, recruitment and retention of professionals.

On December 14, 2005 Working Together: Saskatchewan's Health Workforce Action Plan was released. The Plan expanded on 2001 Action Plan for Saskatchewan Health Care. Extensive consultations took place with stakeholders while developing the plan, including a conference focused on Finding Common Ground, hosted by the Canadian Policy Research Network (CPRN). The purpose of this event was to bring together the major partners to discuss the key elements of a provincial HHR plan. The CPRN facilitated a structured dialogue of the key issues to help achieve consensus on key elements of a framework, solutions and courses of action.

The Plan contains the following 5 goals:

• that the health care system have a sufficient number and effective mix of health care professionals who are used fully to provide safe, high-quality care;
• that the health system have safe, supportive and quality workplaces that help to retain and recruit health care professionals;
• that Aboriginal people fully participate in the health sector in all health occupations;
• that the education and training supply of Saskatchewan health care professionals be aligned with projected workforce requirements and health service needs; and
• that the health workforce be innovative, flexible and responsive to changes in the health system.

A copy of Working Together: Saskatchewan's Health Workforce Action Plan can be found at Government of Saskatchewan - Health. A copy of the CPRN conference documents can be found at the Canadian Policy Research Networks. These documents include a pre-conference report entitled: Finding Common Ground: Consultations and Directions, as well as the final conference report entitled: Setting Priorities and Getting Direction.

The Workforce Action Plan strives to improve Saskatchewan's self-sufficiency in training its own health professionals, within available resources. At the same time, it proposes employment opportunities for newly trained professionals, building a representative workforce, drawing upon the experience of veteran employees to mentor new graduates, better aligning education with health service needs, and establishing a steering committee to help implement the plan and guide continued planning efforts.

Saskatchewan's plan has been enjoying kudos from a number of groups at the national level. The Health Council of Canada noted the Saskatchewan plan for its innovative health care planning, and Saskatchewan ranked highest among all provinces and territories that reported health human resources action plans.

The plan identifies a number of initiatives/actions that will assist in recruiting and retaining nurses including:

• establishment of a provincial recruitment agency;
• enhanced clinical placement capacity;
• resources to support Occupational Health and Safety initiatives, training and research;
• working with our training and learning institutions, as well as our Aboriginal community to bridge our youth into health programs; and
• work related to recruitment of internationally educated health professionals.

Province-wide Employee Opinion Survey

Regional health authorities conducted a province-wide employee opinion survey in 2005-2006. The survey results were officially released on December 12, 2005. Health employers are using the survey results to develop more specific actions to improve workplaces, and help fulfil regional health authority accreditation requirements.

Based on the survey company's (NRC Picker) national database, Saskatchewan healthcare employees are more positive on average than their national counterparts within the NRC Picker database. Survey results showed that physical environment, and safety and respect were the highest positively rated topic areas. It also showed that the learning environment was the lowest positively rated topic area.

Bursary Program

Saskatchewan Health administers a Bursary Program, which is a recruitment and retention tool designed to improve the number of health professionals working in publicly funded organizations in the province.

Bursaries are awarded on a competitive basis based upon criteria that match the program goals. Those who are awarded a bursary agree to a return-service contract that commits them to work in a publicly funded facility in Saskatchewan upon graduation for a set period of time. Bursary amounts vary by discipline as well as the amount of return service. For each year of bursary assistance, students commit to one year if they accept a position in rural or northern Saskatchewan and two years if they work in the urban centres of Regina or Saskatoon. Failure to complete their return service means that they must repay the bursary assistance with interest.

The number of new bursaries awarded to health science (non-physician) students has been increased substantially from 2001-2002 when 27 bursaries were awarded, to 2005-2006 in which 305 new bursaries were awarded. Bursaries are awarded to a wide range of nursing and allied health disciplines, with 20 types of allied health bursaries and six categories of nursing bursaries.

Negotiations

During the 2005-2006 fiscal year, a 3-year collective agreement was reached with the Saskatchewan Union of Nurses and a 4-year collective agreement was reached with the provider unions.

Supply of Health Providers

In looking at the trend of selected health professionals, the majority of Saskatchewan's health professionals have increased between 1995 and 2004 (Table 1).

Regarding the availability of selected diagnostic, medical, surgical and treatment equipment and services in facilities providing insured hospital services, Saskatchewan Health notes the following:

• MRI machines are located in Saskatoon (2) and Regina (2). Regina Qu'Appelle Regional Health Authority's second MRI became operational in December, 2005.