Running head: HEALTH PLAN CASE STUDY 1

Health Plan Case Study

Susan Kelly

King University
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Health Plan Case Study

Spending a majority of time in the northern states, Michigan and Ohio, along with family

a lot of time was spent in Canada. Canada is a very intriguing country as well as their health care

model. Once individuals embark on a journey in health care the more knowledge gained by

researching different health care models the more the individual can contribute to their

organization through development and implemetation of process improvement inititatives.

Knowledge gained can positively impact the success of other health care organizations. Canada

and the United States not only share a boarder they share many similarities. A look into Canada’s

health care model proves to be very interesting.

Health Care Coverage

Canada’s health care plan encompasses the philosophy that all citizens will receive health

care coverage that is medically necessary as well as physician services for hospitalizations.

Canada’s health care system is made up of three territories and ten provinces that govern their

statewide health care insurance plan. The federal law guarantees insurance coverage at no cost

sharing for health care services rendered.

Although Canadians are promised coverage for physician’s services and hospitalizations,

it is the discretion of each providence whether other benefits are covered such as dental, home

health, chiropractic, or pharmaceutical services. Several Canadian citizens will take out

supplemental coverage to meet their needs. According to an article published in 2011, “nearly all

Canadian spending on dental care came from non-government dollars, 60 percent covered by

employer-sponsored plans and 35 percent paid out of pocket” (Quiñonez & Grootendorst, 2011).

Although the funds for health care coverage is governmental funded, physicians are not

government employees. Physicians are paid at a fee for service rate.

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Access to Care

According to Longarini (2007), “after obtaining health care coverage, one can register

with a primary care physician.” The Canadian Heath Act states wait times for application cannot

exceed three months. According to the Canadian Medical Association, the physician to patient

ratio is 2.4 to 1,000 patients ("Basic physician facts", 2017). As with any other state the primary

care physician is key to acquire health care services in a timely comprehensive manner.

Individuals that do not have a primary care physician which is fifteen percent according to

Breton (2017) has limited access to health care. Incentives are offered to physicians that take on

new patients in the form of a one-time buy out if the patients illness is severe. However, the

monetary incentive is driven by the province.

According to Canadian Institute for Health Information (CIHI), there are approximately

four out of five patients that have procedures done in an acceptable time frame (Canadian

Institute for Health Information, 2016). The benchmark for elective surgeries such as hip and

knee replacements are one hundred and eight-two days. However, Canada’s average is eighty-

one percent for hip replacements and seventy-seven percent for knee replacements. The

benchmark for radiation therapy is twenty-eight days with Canada’s average of ninety-seven

percent. Computed tomography (CT) scan wait times are twenty-eight to seventy-four days.

Magnetic resonance imaging wait times are ninety-one to two hundred and two days. Specialist

care wait times are two months or longer. In 2015, a survey was conducted that revealed forty

percent of the primary care physicians in Canada felt their patients had a difficult time getting

special diagnostic testing as compared to international average which is twenty-one percent

(Canadian Institute for Health Information, 2016).

Cost
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The overall cost of health care is most definitely undesirable. The universal health care

service in Canada is unique as Canadas public health care insurance does not encompass

prescription drugs outside of the hospital setting (Morgan & Boothe, 2016). Without prescription

drug coverage the hospital many individuals do not have access to medications needed to

promote the healing process. Non-coverage for prescription medications not only poses a

problem for disease control it adds a financial burden to the patient and potentially health care

organizations due to readmissions. As stated by Morgan and Boothe, “the fragmented nature of

prescription drug financing in Canada, as well as its isolation from the financing of medical and

hospital care, results in higher total per capita expenditure on pharmaceuticals in Canada than

any other Organization for Economic Co-operative and Development (DECD) country with

universal health coverage (2016).

According to Law, Daw, Cheng, and Morgan, per household Canadians spent

approximately twenty billion dollars on private insurance premiums, prescription, and dental

medications (2013). Basic services such as hospitalizations and primary care services is all

provincial health insurance covers. Financing for provincial health insurance comes from

taxation of individuals and corporate income and sales taxes along with lottery proceeds

(Longarini, 2007). The total health care expenditures in three northern territories of Canada

surpass spending of the United States:

 Yukon $10,060

 Northwest territories $12,791

 Nunavut $14,174
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According to the World Health Organization (WHO) (2016), the current United States (US)

dollars that equates to Canada’s total health costs is five thousand two hundred ninety-two

dollars.

Prevention

Prevention is a huge focus for health care systems regardless of the geographical location.

Preventative measures impact individuals, health care systems, states, and countries. The

Canadian health care system does not discriminate for preexisting conditions, socioeconomic

status, or lifestyle. All Canadian citizens are allowed preventative care and medical treatments

from a primary care physician with access to in-patient care. As with the Centers for Disease

Control and Prevention (CDC), the Public Health Agency of Canada is responsible for

emergency preparedness, public health, infection, chronic disease process/control, and

prevention (Public Health Agency Staff, 2016). The Public Health Agency of Canada is

responsible for:

 Prevention and control of infectious disease

 Prepare for and respond to public health emergencies

 Promote health

 The control of chronic disease

 Publicizing the Canadian expertise

 Work collaboratively on public health and facilitate public health and policy planning.

Introduction to Canada and Health Plan

By total area, Canada is the world’s second largest country with a population of

approximately thirty-seven million people with a life expectancy of eighty-two years. Canada is

under the leadership of Prime Minister Justin Trudeau. Individual provinces and territories
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funding is based on five principles public administration, accessibility, universality,

comprehensiveness, and portability. (Longarini, 2007)

Analysis

The Canadian legislation is responsible for the cost of health care; this is done through

multiple territorial based programs. Canada views health care as being a provincial

responsibility. To be encompassed in a Canadian health plan there is minimal criteria to meet

comprehensiveness with insured coverage for medically necessary hospitalizations and physician

coverage, university with all insured persons entitled to insured services, accessibility to services

unimpeded by charges or other means, public administration of health insurance plan on a

nonprofit basis by a public authority responsible to the government (Rakich, 2001). Canadas

health care plan has been perceived to be the health care model to follow. The health care system

in Canada is referred to as Medicare. However, it differs from Medicare in the United States.
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References

Basic physician facts. (2017). Cma.ca. Retrieved 3 February 2018, from

https://www.cma.ca/En/Pages/basic-physician-facts.

Canadian Institute for Health Information (2016). Wait times for priority procedures in Canada,

2016. Retrieved from https://secure.cihi.ca/free_products/wait_time_report2016_en.pdf

Law, M. R., Daw, J. R., Cheng, L., & Morgan, S. G. (2013). Growth in private payments for

healthcare by Canadian households. Health Policy, 110(2/3), 141-146.

Longarini, J. (2007). Canadian health care. Retrieved from

http://www.canadian-healthcare.org/

Morgan, S., & Boothe, K. (2016). Universal prescription drug coverage in Canada. Healthcare

Management Forum, 29(6), 247-254. doi:10.1177/0840470416658907

Quiñonez, C., & Grootendorst, P. (2011). Equity in dental care among Canadian households.

BioMed Central. Retrieved 3 February 2018, from

https://equityhealthj.biomedcentral.com/articles/10.1186/1475-9276-10-14#B6

Rakich, J. S. (2001). Canada's Universal-Comprehensive Healthcare System.

Hospital Topics, 69(2), 14-19. doi:10.1080/00185868.1991.10544107