Cutting through the health system information fog: Royal College environmental scan

Transcription

1 Cutting through the health system information fog: Royal College environmental scan 2017 Edition

2 Introduction This environmental scan is an evergreen document and provides a snapshot in time of various aspects of Canada s healthcare system. In keeping with previous editions, this reference document provides a national overview of key indicators and trends in the following five domains: Political environment, Economic environment, Socio-demographic environment, Healthcare system environment: Performance and Human Resources for Health Technological environment The health policy related events and data captured in this report is drawn from the most recent information that is publicly available at the time of release. As this edition has been drafted in early 2017, the scan largely utilizes sources that were released in We encourage Fellows and all other readers to contact us at healthpolicy@royalcollege.ca if they have any comments, questions, or to suggest new content areas for future iterations of this environmental scan.

3 Political environment On November 4, 2015, the Liberal Party formed a majority federal government. It replaced a Conservative government led by incumbent Prime Minister Stephen Harper, which held office for nearly a decade. Prime Minister Justin Trudeau s mandate letter to the Minister of Health, Jane Philpott, explicitly called on the minister to deliver on a number of priorities, which included the areas of home care, mental health, prescription medicines, substance abuse, Indigenous health, public health and the legalization/regulation of marijuana. 1 To date, the government has developed two federal budgets. The table below outlines some of the key health care related announcements made in these two budgets. Table 1 The Canadian federal budget, 2016, 2017: Health care highlights Source: Department of Finance, 2016, Budget 2016; Department of Finance, 2016, Budget Federal Budget 2017 Federal Budget New funding of $95 million dollars on an ongoing basis to the research granting councils, which includes an additional $30 million to the Canadian Institutes of Health Research $39 million over three years to Canadian Foundation for Healthcare Improvement to support the organization s efforts around healthcare innovation. $50 million over two years to Canada Health Infoway, to support digital health activities in e-prescribing and telehomecare. $5 million over 5 years to the Heart and Stroke foundation to support research in women s health $4 million dollars over 4 years to the Canadian Men s Health Foundation on men s health initiatives. $47.5 million per year ongoing funding to the Canadian Partnership Against Cancer. $25 million over five years to the Public Health Agency of Canada targeted at improving immunization coverage. $500 million in to develop a pan-canadian framework on child care and early learning. $100 million over five years to support the Canadian Drugs and Substances Strategy, aimed at addressing the country s opioid crisis. $828.2 million over five years to support investments aimed at improving health outcomes in First Nations and Inuit communities. $140.3 million over five years to Health Canada, the Patented Medicine Prices Review Board and the Canadian Agency for Drugs and Technologies in Health, aimed at improving drug prices, prescribing practices and access prescription medications. $53.0 million over five years to the Canadian Institute for Health Information to strengthen health data and reporting on health system performance. $300 million over five years to Canada Health Infoway, to expand e- prescribing, virtual care initiatives and the adoption of electronic medical records.

4 From a national health accord to bilateral health agreements the new landscape of Federal/Provincial/Territorial cooperation in health care. The 2004 accord formalized a ten year agreement by First Ministers on a series of commitments to improve Canada s health care system. The accord established a funding scheme that the federal government agreed to transfer to provincial/territorial governments mostly through the Canada Health Transfer. In December 2011, the federal Conservative government announced that there would no The Federal government has integrated substantive changes to the CHT through bilateral agreements with the provinces and territories, which raises various questions around the fiscal burden being placed on provinces/territories in the coming decade. longer be a 6% annual increase (termed as the annual escalator) in the Canada Health Transfer (CHT), the federal funding scheme for health care. It was stated that following the fiscal year, annual increases in the CHT would be tied to nominal Gross Domestic Product (GDP). 2 In December 2016, the federal, provincial and territorial ministers of health and gathered to discuss this change to the CHT, requesting that the current Liberal government revert to an annual escalator of 5.2%. The federal government countered with an annual escalator of 3.5% and additional targeted funding of $11 billion towards home care and mental health. The ten provinces and three territories rejected the federal government s offer. 3 Subsequently however, the provinces and territories have come to terms individually with the federal government through bi-lateral agreements. These agreements include an annual CHT escalator which will be tied to nominal GDP (with a minimum 3% guaranteed), targeted funds in home care and mental health (see Figure 1 below) 4,5,6,7,8,9,10,11,12, and a commitment to develop performance indicators and annual reporting practices. The Federal government has committed to jointly develop, in conjunction with the provinces and territories, performance and reporting measures. Long-term, this initiative may be the defining feature of leadership displayed by the Federal government in health care. Figure 1 - Funding agreements on home care and mental health care services with the Federal Government

5 Provincial Developments Apart from discussions on the CHT transfer, there have also been a number of salient developments at the political level as it relates to health policy, over the past year. Some of the provincial highlights include the following: Alberta The government and the Alberta Medical Association have agreed to implement various financial and non-financial amendments to their physician services agreement, set to expire in The deal notably introduces a cap on billings (which, if exceeded, is subject to financial penalties for physicians), the development of a blended capitation model option, a new peer-review/audit process and the formation of a Physician Resource Planning Committee assigned to develop a needs-based physician resource plan. 13 British Columbia The government has announced that it will be reducing monthly health premiums that residents pay by half, in The government anticipates the cut will cost the government $810 million in the fiscal year. 14 In September 2016, the Cambie Surgery Centre, a private clinic based in Vancouver, led a constitutional challenge of the province s Medicare Protection Act. The plaintiffs are challenging the province s ban on the purchase of private insurance for medically necessary services and its prohibitions on physicians practicing simultaneously in the public and private system. 15 The case, which is being heard in the British Columbia Supreme Court, has been adjourned until September The province s Budget 2017 has outlined various mental health and substance abuse initiatives, totaling $140 million over three years. The funding announcement includes hiring additional 120 mental health practitioners and providing 28 new substance-use treatment beds across the province. 17 Manitoba The provincial government is considering a report prepared by Health Intelligence Inc., a consulting firm which was commissioned by the previous NDP government to investigate the province s health care services. The report outlines 10 recommendations on reorganizing service delivery, including the consolidation of acute care services in hospitals, the re-branding of select hospitals as convalescent and rehabilitation centers, use of technologies like Telehealth, and adopting new team-based models of care. 18 The government has also contracted a separate consulting group, KPMG, to assess its health spending. 19 Although not released publicly, KPMG s interim report reportedly recommends significant cuts related to staffing (e.g. staffing levels, overtime). 20 In the coming year, the Manitoba government has set savings targets for its five regional health authorities, which includes a mandate to the Winnipeg Regional Health Authority to find $83 million in savings in the coming year. 21 New Brunswick The provincial government intends to develop a health strategy framed around key determinants of health such as poverty and gender equality. 22 The government will showcase the framework for action, titled the Family Plan, at various stakeholder summits planned in The government s Council on Aging has produced a report on addressing the province s aging population following consultations with multiple stakeholders. Focused on ensuring that seniors stay at home and living independently, the report proposes various initiatives such as developing a dementia strategy, enhanced training and recruitment of caregivers, forming age-friendly communities and establishing New Brunswick as an exemplar in aging

6 research and innovation % of the population in New Brunswick was aged 65 and above in the highest proportion of seniors among Canada s provinces and territories. 25 Newfoundland and Labrador In its efforts to streamline management structures, the government cut 93 positions from the province s regional health authorities and Centre of Health Information, a crown corporation responsible for the province s electronic health records. 26 A committee comprised of all political parties produced a report on addressing mental health and addictions. The report, chaired by Health Minister John Haggie, offers 54 recommendations including increased spending on mental health addictions from 5.7% of the health care budget, to 9% by April The Minister of Health and Community Services announced Bill 70, which contains legislation addressing various issues around patient safety. The legislation includes mandatory reporting on quality indicators such as handwashing and infection rates, requirement for regional health authorities to form a quality assurance committee, and enhanced rights for patients to access their health information. 28 Nova Scotia Doctors Nova Scotia has ratified two four-year contracts, the Physicians Master Agreement and a clinical-academic funding plan, with the provincial government. The contract freezes fee increases for two years, followed by a one per cent and 1.5 per cent increase in fees in subsequent years. It also offers additional investments in select areas including the hiring of new specialists and new fees for physicians providing patient care by telephone. In a news release, Dr. Michelle Dow, president of Doctors Nova Scotia, states that While physicians accepted the contract and welcomed modest critical investments, they were disappointed that this contract brought little innovation or opportunities to advance patient care. 29 The government announced that it is investing an additional $1.9 million to reduce wait lists for hip and knee replacements. The new funding brought the province s overall investment in orthopaedic surgeries to $8.1 million in Nova Scotians have some of longest wait times for hip and knee replacements among Canadian provinces (see p.30). Ontario The Ontario Medical Association (OMA) and the provincial government have not come to terms on a physician services agreement for the past three years. In December 2016, the OMA rejected a three year contract proposed by the government. The proposal offered to increase the physician services compensation by 2.5% annually. However, the proposal also called for cuts by 10 percent on various fees for diagnostic tests and procedures, reduced fees to physician who bill over $1 million annually, and adjustments to select contracts with specialists. 31 Subsequently, the Relations between the medical community and governments are often strained. Present-day relations pose a threat to physicians critical role in the health care system and potentially damage the profession s image and trust with patients and the public. OMA established a new negotiating committee due to the resignation of its executive committee in February ,33 On July 17, 2017, the OMA announced that its members have tentatively agreed on a binding arbitration process with the government to facilitate a return to negotiations. 34 Bill 41 was introduced, which makes changes to primary care delivery by giving new responsibilities to the province s 14 local health integration networks (LHINs) at home, community, primary and hospital levels of care. 35 OMA has expressed concerns, asserting that the Bill will erroneously add layers of bureaucracy (through the initiative s creation of 80 sub-lhins ). Further the OMA argues that act imposes reporting requirement on doctors that will take away time from providing direct patient care. 36

7 Prince Edward Island The government announced that it will provide abortion services in the province, for the first time in nearly 35 years. 37 The province passed a new health information act that will come into effect in 2017, requiring health providers to inform patients if their privacy has been breached. 38 The government has released a 10 year mental health and addictions strategy. The plan outlines five strategic priorities: 1) a focus on children, young people and their families, 2) mental health promotion and illness prevention, 3) a tiered system of access based on need 4) a mental health workforce strategy, 5) fostering a process of recovery and wellbeing. 39 Quebec Regulation was passed on January 26, 2017, abolishing user fees for medically required procedures that are covered by the province s public insurance scheme. The move has drawn a mixed response from the medical community; groups such as the Quebec Doctors for Medicare have expressed concerns in the past regarding the use of user fees in the province, arguing that it contradicts provisions in the Canada Health Act. 40 In contrast, Quebec's federation of medical specialists, the FMSQ, has criticized the government for the lack of consultation with the medical community. The organization has also noted that the government has not Disputes around extrabilling in the provinces of British Columbia, Quebec and Saskatchewan highlight the tensions that persist regarding the role of the private sector in health care. provided adequate compensation measures for doctors in freestanding clinics that will lose revenue as a result of the new rules. 41 Government announced it will invest $100 million towards creating additional spaces for mental health services, rehabilitations and convalescence, and full-time care facilities for seniors. The move is aimed at enhancing the transition of patients out of acute care settings. 42 The government has also committed $76.1 million over 10 years on a preventative health strategy which includes reducing the number of smokers in the province by half, and an 18% increase in the number of seniors in home care. 43 Saskatchewan The province plans to amalgamate its current 12 existing regional health authorities into one provincial health authority, by fall The move follows the recommendations of an advisory panel commissioned by the provincial government, which also called on the government to pursue the consolidation of various clinical services such as tertiary acute services, laboratory and diagnostic imaging and emergency medical services. 45 Announced budgetary cuts to health spending amounting up to $63.9 million in , which includes a hiring freeze in regional health authorities, reduced use of unscheduled temporary and casual staff and adjustments to various programs and grants. 46,47 The Federal Government has expressed concerns regarding the province s sanctioning of private-pay MRI services, arguing that it is in contravention of the Canada Health Act. Since 2015, private clinics have been allowed to charge residents for an MRI in the province, with the proviso that clinics provide a scan to another patient that is on the public waitlist at no charge. In its response to the federal government, the province has asserted that it has saved approximately $1 million in spending and removed over 1,100 patients from its public wait-list as a result of the private-pay option. 48

8 Other Healthcare Issues A number of issues have been foremost on the agendas of the federal, provincial and territorial governments. Following are a few examples. Marijuana In June 2016, the federal taskforce on cannabis legalization and regulation was struck to review the potential impact of legalizing cannabis in Canada. The taskforce produced a final report recommending a regulatory framework that includes: o provisions on manufacturing practices, Public health will be of foremost concern as Canada continues to move towards the legalization of Marijuana for recreational purposes. o restrictions on advertising and marketing, o controls on the density and location of cannabis retail stores, o a separate medical cannabis regime, such as the current framework that falls under the purview of the Access to Cannabis for Medical Purposes Regulations (ACMPR), o promotion and support for pre-clinical and clinical research on the use of cannabis and cannabinoids, o development and dissemination of information and tools for the medical professions and patients. 49 On April 13, 2017, the federal government tabled (Bill C-45) legislation to legalize recreational use of cannabis in addition to increasing punitive measures regarding drug impaired driving(bill C-46). The federal government anticipates full implementation of both Bill C-45 & C-46 no later than July The federal government has previously stated that expected tax revenues of these legislative changes will be re-invested into mental health, addiction treatment and public health prevention programs. 51 Regulatory and professional medical associations such as the Canadian Medical Association (CMA), the Canadian Psychiatric Association (CPA) and the Canadian Paediatric Society (CPS) have stated that they would support federal legislation that leads with a strong public health approach, including an emphasis on: o preventing drug abuse and dependency, o ensuring assessment, counselling and treatment services are available for those who wish to stop using, and, o increasing safety for vulnerable groups such as young people, pregnant women and those with psychological and psychiatric illnesses. 52,53,54 Canada s Lower-Risk Cannabis Use Guidelines which were released on June 23, 2017 aim to help protect public health and public safety. 55 Medical cannabis has become a far more common treatment among veterans with the number of reimbursed patients going from one veteran in 2007, to 3000 in Estimates suggest that the cost of medical cannabis treatment will reach $75 million in As such, starting April 1, 2017, Veterans Affairs Canada will be imposing limits on the amount of cannabis per person that will be reimbursed to a maximum of 3 mg/day down from the current maximum of 10 mg/day. 56 Opioid Crisis Canadians are the second largest consumers per capita of prescription opioids in the world. 57

9 Between 1991 and 2007, annual prescriptions for opioids increased from 458 to 591 per 1000 individuals while opioid-related deaths doubled from 1991 to In spring 2016, British Columbia declared a public health emergency in response to the increase in drug overdoses being witnessed in the province. In 2016, there were 914 deaths recorded in the province due to overdose deaths. The opioid fentanyl, was detected in 60% of these fatalities. 59 Opioid poisonings result in more than 13 hospitalizations a day in Canada. From to , the rate of emergency room visits due to opioid poisoning increased by 54% in Alberta (17.8 to 27.3 visits per 100,000 population) and 22% in Ontario (14.2 to 17.4 visits per 100,000 population). 60 Seniors aged 65 and above consistently record the highest hospitalization rates, reaching 20 per 100,000 population in A National Issue Multiple specialists prescribe opioids to manage acute and chronic pain, making the issue opioid related harms of relevance to the scope of practice of many Royal College Fellows. In November 2016, Federal Health Minister Jane Philpott and Ontario Health Minister Eric Hoskins hosted the Opioid Conference and Summit. Forty-two organizations representing government and health care organizations, including the Royal College, signed a joint statement of action committed to improving prevention, treatment, and harm reduction measures to mitigate problematic opioid use. 62 Moving forward, the Royal College is looking to: Develop a Royal College statement of principles on safe opioid prescribing. Create a central online catalogue to host educational and practice-related reference resources, accessible to all Fellows and residents. Engage with and disseminate knowledge to Fellows. Medical Assistance in Dying (MAiD) Prompted by a Supreme Court decision, the federal government passed bill C-14 in June 2016, which permits mentally competent adults to request MAiD. The legislation is restricted to those who have a serious and incurable illness, disease or disability, and where death is "reasonably foreseeable". 63 Since the legislation was passed, a survey of provincial and territorial health ministries found that there were at least 744 medically assisted deaths in As illustrated in Table 2 below, these deaths have been largely concentrated in the provinces of Alberta, British Columbia, Ontario and Quebec. Quebec, which legalized MAiD in December 2015, recorded the highest number of medically assisted deaths during this time period. Table 2 - Number of medically assisted deaths, by province, by select time frame. Source: CTV News, 2016, At least 744 assisted Province Medical assisted deaths between June 17 and December 16, 2016 Alta. 63 B.C. 154 Man. 18 N.B. N/A

10 N.L. 4 N.S Ont. 180 P.E.I 0 Que.* 300* Sask. 8 *Includes data from December of Number of medically assisted deaths between June 17 and Oct. 31, 2016 On December 13, 2016, the federal government announced that it is tasking the Council of Canadian Academies, an independent think tank, to conduct studies on MAID requests made by mature minors, advance directives and individuals who are solely suffering from a mental illness. 65 The Royal College s role in MAID: The Royal College is committed to ensuring that Fellows and Residents are equipped to discuss the ethical principles associated with MAID. The Royal College has developed two bioethics cases: the first addresses the ethical issues relevant to a typical patient who meets the MAID eligibility criteria; and the second addresses the conscientious objection of a physician to participate in MAID. A MAiD web page was created on the Royal College website and includes links to available resources:

11 Canadian economy: Overview Economic environment In June of 2016, according to the Bank of Canada s governor, Stephen Poloz, the biggest issue facing Canada s economy is the uncertainty in resource prices particularly in the oil sector. This has resulted in a low Canadian dollar. Inflation is expected to be about two per cent for 2016/ In November of 2016, the OECD s economic forecast for Canada predicted a growth rate of 2.3 per cent into The OECD echoed the Bank of Canada s inflation rate of two per cent. Contraction in the resources sector is expected to slow and the The economic impact of the new Trump administration in the United States presents some uncertainty for Canada s economic outlook. economy is expected to strengthen in non-energy sectors mainly due to stronger exports and a low Canadian dollar compared to the U.S. dollar. 67 The Business Development Bank of Canada (2017) predicts Canadian economic indicators to improve in 2017 due to more stable oil prices and a continued low Canadian dollar which is attractive to a surging U.S. economy. This being said, the economic impact of the new Trump administration presents some uncertainty for Canada s economic outlook. 68 Table 3 shows the key economic indicators from Global Affairs Canada. Table 3 - Canada: Economic Indicators Source: Global Affairs Canada, 2017, Annual Economic Indicators 69 Indicator Canada s population in millions GDP (Gross Domestic Product in $B) 1,823 1,898 1,983 1,986 2,027 GDP per capita (measure of productivity) 52,454 53,975 55,972 55,405 55,857 Health, education, social and government 20.9% 20.5% 20.2% 20.2% 20.3% services sector contribution to real GDP Rate of inflation of Consumer Price Index 1.5% 0.9% 2.0% 1.1% 1.4% Unemployment rate 7.3% 7.1% 6.9% 6.9% 7.0% Gross expenditures on R & D in $B n/a Average prime rate of interest 3.00% 3.00% 3.00% 2.78% 2.70% Average exchange rate of 1 Cdn$ in US$ Ratio of exports/imports as % of GDP 30.2/ / / / /33.4 Health expenditure Total spending on healthcare in Canada is estimated to be $228.1 billion in As depicted in Figure 2 below, health expenditures have trended upwards for the last two decades. However, the growth in expenditures has slowed down in recent years. In constant dollars, total health spending on health care increased by 20.8% from 2005 to Whereas from 2011 to 2015, total health spending increased at a lower rate of 5.7%. This moderated rate of growth in health spending is indicative of Canada s modest economic growth and focus on balanced budgets by governments.

12 Figure 2 Total Health Expenditure, Canada, Source: CIHI, 2016, National Health Expenditure Trends 250, ,000.0 Current Constant (1997) $ Billions 150, , , In international comparisons, statistics from 2014 (Figure 3) show that Canada s health expenditure as a proportion of GDP was above peer OECD countries such as the United Kingdom, Sweden, New Zealand and Australia. However, the divergence is much more significant in the United States, which recorded the highest ratio to GDP at 16.6%. Figure 3 Total Health Expenditure as a % of GDP, Select Countries, 2014 Source: CIHI, 2016, National Health Expenditure Trends Australia UK Sweden New Zealand Canada Germany France Netherland US 9.0% 9.9% 11.2% 9.4% 10.0% 11.0% 11.1% 10.9% 16.6% 0.0% 5.0% 10.0% 15.0% 20.0% Public-Private expenditure The public-private sector share of total health expenditure has remained stable, maintaining approximately a split proportionately since In 2016, it is forecasted that the public sector will spend $159.1 billion on health care. The private sector, which primarily consists of health expenditures by households and private insurance companies, will account for $68.9 billion of spending. 72

13 Use of funds Hospitals, drugs and physicians are the three largest components of health care spending, amounting up to $131.3 billion, 60.8% of total health expenditures in Hospitals and physicians were primarily funded by the public sector while drugs and other health professionals received the majority of financing from the private sector. 74 Figure 4 Proportion of total health expenditure, by use of funds, 2014 Source: CIHI, 2016, National Health Expenditure Trends Public Health 5.60% Other Health Spending* 13.07% Hospitals 29.54% Drugs 16.02% Other Professionals (Dental, vision etc.) 9.90% Physicians 15.26% Other institutions 10.60% Drug spending 75,76 In 2014, the cost of drugs reached $34.6 billion, 16.02% of total health expenditures. The public sector accounted for 36.2% of total spending on drugs, whereas private sector spending accounted for 63.8% of total spending on drugs. Drug spending is predominantly made up of prescribed drug spending. In 2014, the public sector financed $12.5 billion (42.6%) of prescribed drug spending. Compared to the tempered growth in health spending overall, public drug program spending increased 9.2% from 2014 to The spending increase has been largely associated with the introduction of new drugs used to treat hepatitis C

14 A Pharmacare plan for Canada A study commissioned by the Canadian Federation of Nurses Unions compared Canada with select OECD countries that provide universal public drug insurance, and found that Canadians misspend approximately $7.3 billion a year due to Canadians paying among the world s highest prices for prescription drugs. 77 In October 2016, the Citizens Reference Panel on Pharmacare 35 randomly selected Canadians from across the country met in Ottawa for five days to hear from a range of experts and consider diverse options on the issue of pharmacare. The reference panel was funded by UBC's Centre for Health Services and Policy Research, the Canadian Institutes of Health Research, and other partners. The panel s efforts culminated in a report which called on the Federal government to establish a national pharmacare strategy which ensures universal drug coverage for all Canadians. 78 Indeed, Canada is the exception rather than the norm, when it comes to providing universal health insurance without prescription drug coverage. 79 There is no targeted funding around pharmacare in the bilateral funding agreements that have been struck between the federal, provincial and territorial governments (see Political Environment section), despite prior claims implying otherwise. 80 Therefore, pharmacare remains an orphan element of healthcare. Physician spending As highlighted in Figure 5, physician services accounted for 15.26% of health expenditures in Spending has increased on an annual basis high rates of growth were particularly apparent from , keeping pace with the growth of physician supply. Since 2009, the rate of growth has slowed down, with annual growth rates in physician spending ranging between 3-4%. 81 Figure 5 Annual growth rates in physician services spending, Source: CIHI, 2016, National Health Expenditure Trends Percentage Growth % 7.87% 7.93% 9.77% 8.06% 7.43% 6.29% 3.45% 4.67% 4.10% Year Physicians are the third largest category of spending in health care. Over the last decade, spending has grown on an annual basis. However, the rate of growth in physician spending has slowed down in recent years, which is indicative of the ongoing attempts by governments to control costs in health spending. Provincial Overview Figures 6 and 7 show that public and private health expenditure per capita vary across the provinces and territories.

15 Public sector spending in 2014 shows that territorial governments reported the largest per capita spending in the country. Among provinces, Newfoundland and Labrador and Manitoba spend more per person than any other province, at $5, and $5, respectively. Whereas public sector spending was lowest in Ontario and Quebec, at $4, and $3, per capita respectively. Figure 6 Public sector health expenditure per capita, by province, 2014 Source: CIHI, 2016, National Health Expenditure Trends Canada Nun. N.W.T Y.T. B.C. Alta. Sask. Man. Ont. Que. N.B. N.S. P.E.I N.L. $0.00 $4, $8, $12, $16, $ per capita Private sector spending per capita in 2014 was recorded to be the highest in Yukon and Nova Scotia, at $2, and $1, respectively. Whereas Saskatchewan and Nunavut reported the lowest private spending, at $1, and $ per capita respectively. Figure 7 Private sector health expenditure per capita, by province, 2014 Source: CIHI, 2016, National Health Expenditure Trends Canada Nun. N.W.T Y.T. B.C. Alta. Sask. Man. Ont. Que. N.B. N.S. P.E.I N.L. $4, $4, $4, $5, $5, $4, $3, $4, $4, $4, $5, $ $7, $1, $13, $12, $1, $2, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, , , , , $ per capita

16 Socio-demographic environment The Canadian Population In 2016, Canada's population was estimated to be over 36 million. The population has increased by 11.41% over the last ten years. There is nearly an equal split of males and females in Canada s population. 8 in 10 Canadians reside in urban settings (i.e. communities over 1,000 population). In 2016, approximately 16% of the population was aged 65 and above. For the first time, Canada s elderly population surpassed the population of children and it is projected to accelerate at a pace that will continue to widen this gap in the future. 4 out of 5 Canadians live in four provinces: Ontario, Quebec, British Columbia and Alberta. Figure 8 Population Estimates, Canada, Source: Statistics Canada, 2016, Table ,000,000 36,000, million Population 35,000,000 34,000,000 33,000,000 32,000,000 31,000,000 30,000, million Gender (2016) 82 Age (2016) 83 Rural-Urban (2011) 84 Male Female < Rural Urban 49.59% 50.41% 16.07% 67.42% 16.51% 18.9% 81.1% (<1000 pop.) (1000+ pop.) Population by province/territory (2016). 85 N.L. 530,376 P.E.I 149,278 N.S. 952,333 N.B. 757,997 Que. 8,349,793 Ont. 14,063,256 Man. 1,323,958 Sask. 1,155,393 Alta. 4,268,929 B.C. 4,773,345 Y.T. 37,624 N.W.T 44,204 Nvt. 37,146

17 Health Conditions As illustrated in Figure 9, major chronic diseases such as cancers, diabetes, heart and respiratory diseases are among the leading causes of death. 3 in 5 Canadians aged 20 years or older have a chronic disease. 86 Figure 9 Canada, Leading causes of death by proportion, 2012 Source: Statistics Canada, 2015, Leading Causes of Death Kidney disease 1.3% Suicide 1.6% Influenza and pneumonia 2.3% Alzheimer's disease 2.6% All other 25.1% Heart disease 19.7% Stroke 5.3% Cancers 30.2% Unitentional Injuries 4.6% Chronic lower respiratory diseases 4.5% Diabetes 2.8% Looking at the top three causes of death by age group (Figure 10), accidents and suicide are particularly pervasive among youth and young adults aged between Whereas cancer and heart disease are the leading causes of death among those aged 45 and above. 87 Figure 10 - Top three leading causes of death, number of cases, by age group, 2012 Source: Statistics Canada, 2015, Leading Causes of Death, OMA Economics, Research and Analytics, Top 3 causes of death Age Group Accidents (161) Cancer (93) Congenital Abnormalities (68) Accidents (852) Suicide (518) Cancer (141) Accidents (848) Suicide (548) Cancer (387) Cancer (1,220) Accidents (857) Suicide (662) Cancer (5,231) Heart Disease Accidents (1,197) (2,003) Cancer (12,889) Heart Disease Accidents (1,103) (4,5867) Cancer (7,519) Heart Disease Chronic Lower Resp. (509) (2,620) Cancer (18,910) Heart Disease Chronic Lower Resp. (2,133) (7,277) Cancer (21,500) Heart disease Stroke (4,052) (13,070) 85+ Heart disease (21,065) Cancer (13,975) Stroke (6,319) Cancer Cancer is the leading cause of death in Canada. Approximately 2 in 5 Canadians will develop cancer and 1 in 4 will die of cancer.

18 Age 89 Estimates project 202,400 Canadians will be diagnosed with cancer and 78,800 Canadians will die due to cancer in Lung cancer is the leading cause of cancer-related death. Lung cancer, along with colorectal, prostate and breast cancer, accounts for half of new cancer cases. Prostate cancer is the most commonly diagnosed cancer in Canadian males and breast cancer is most commonly diagnosed in females % of all new cases of cancer are diagnosed among Canadians aged 50 and above. Approximately half of these new cases are estimated to occur among people aged 70 and above. Gender 90 The probability of developing cancer is higher for males than females, with males having a 45% lifetime probability of developing cancer, in contrast to a 42% lifetime probability in females. Although challenges remain significant, there has been progress in the battle against cancer. As illustrated in Figure 12 Figure 11 Age standardized incidence rates for all cancers by select age group, Canada, 2016 Source: Canadian Cancer Society, 2016, Canadian Cancer Statistics below, mortality rates in cancer have declined in the last two decades, with notable decreases in lung, colorectal and prostate cancers for men and decreases in deaths from breast and colorectal cancers for women. Incidence rates in males have declined this time period as well. However, there has been moderate growth in incidence rates amongst females, partly attributed to increases in incidence rates of specific cancers, such as melanoma, thyroid, uterine and liver cancer. 50% 40% 30% 20% 10% 0% 17% 28% 44% years years 70 years and above Figure 12 Age standardized incidence (ASIR) and mortality rates (ASMR) for all cancers, by gender, Canada, Source: Canadian Cancer Society, 2016, Canadian Cancer Statistics Cases per 100, Males, ASIR Females, ASIR Males, ASMR Females, ASMR

19 Income Mortality data from the Canadian censuses highlight the disparity in life expectancy among low-income households in comparison to the highest-income households. In the lowest income households, males were 1.61 times more likely to die from all cancers, and females were 1.43 times more likely to die from all cancers. Table 4 ASMR for all cancers, by household income, by gender, per 100,000 Source: Statistics Canada. Tjepkema, Wilkins and Long, 2013 Lowest Income quintile Males Females Highest Income quintile Males Females Per, 100, Per, 100, Indigenous Peoples Survey data from 1991 to 2001 show that Indigenous peoples record lower mortality rates for cancer. Table 5 ASMR for all cancers, by Indigenous ancestry income, by gender, per 100,000 Source: Statistics Canada, 2009, Tjepkema, Wilkins, Senécal, Guimond and Penney Males First Nations Métis Non-Indigenous Females First Nations Métis Non-Indigenous Per, 100, Per, 100, Cardiovascular Disease Cardiovascular diseases are the second leading cause of death amongst Canadians. Statistics Canada reports that in 2012, cardiovascular diseases accounted for over 48,000 deaths. Nearly 14,000 deaths occurred due to stroke during the same time period. 91 The Cardiovascular Health in Ambulatory Care Research Team (CANHEART) health index, a measurement for optimal heart health, analyzed responses from 464,883 Canadians that participated in the Canadian Community Health Survey from Maclagan et al. found that according to their CANHEART health index (which is based on health behaviors and factors that influence heart health), less than 10% of adults and 20% of youth met the criteria for ideal cardiovascular health. The researchers cited increasing trends of overweight/obesity, hypertension and diabetes as key factors that have influenced these scores. 92 Over 740,000 Canadian adults aged 20 and above suffered from the effects of a stroke in The impact of heart disease and stroke on the Canadian economy has been profound. In 2010, the Conference Board of Canada reported that heart disease and stroke costs over

20 $20 billion every year in physician services, hospital costs, lost wages and decreased productivity. 94 Age Seniors aged 65 and above were the highest proportion of Canadians that reported they have a cardiovascular disease in 2014 (Figure 13). Figure 13 Prevalence rate of cardiovascular diseases (self-reported) by age group, 2014 Source: Canadian Community Health Survey, % 18.00% 16.00% 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% 18.30% 7.10% 0.70% 1.50% Age group The Public Health Agency of Canada reports that from , the death rate among people aged 20 and above was: o 3 times higher among those who have been diagnosed with heart disease. o 4 times higher among those who have had a heart attack. 95 Gender In 2014, 7.2% of males and 5.2% of females respectively reported living with a cardiovascular disease. 96 The Public Health Agency of Canada reports that in , males were twice more likely to suffer a heart attack than females. 97 Further, males were first diagnosed with heart disease approximately 10 years younger than females (55-64 years of age for the former and years of age for the latter). 98 Diabetes Provincial and territorial administrative health databases report that in 2011, 2.74 million Canadians lived with diabetes. Numbers have more than doubled since It has been projected that the number of Canadians with the disease will continue to grow - the Canadian Diabetes Association estimates that there are 3.34 million Canadians with diabetes. 100 A significant number of diabetics tend to have compounding chronic diseases to contend with. Over a third of Canadian adults with diabetes reported having two or more other serious chronic conditions. Diabetics are also over three times more likely to be hospitalized with cardiovascular disease than individuals without diabetes. In 2008, 30% of all individuals who died suffered from diabetes along with other conditions. 101

21 Age and Gender In 2011, there were 1.4 million males and 1.3 million females living with diabetes. During this time period, there were 109,590 males and 92,830 females that were diagnosed with the disease for the first time. 102 Table 6 shows that the proportion of prevalence and incidence is the highest among the elderly males and females aged 65 and above. Table 6 Diabetes prevalence and incidence*, by gender and age, 2011 Source: Public Health Agency of Canada, Last retrieved January 25, 2017, The Canadian Chronic Disease Population (p) Diabetes Prevalence Diabetes Incidence Males Females Cases (c) Percentage (p/c) Cases (c) Percentage (p/c) 1 to % % 25 to % % 45 to % % 65 to % % 80 and above % % 1 to % % 25 to % % 45 to % % 65 to % % 80 and above % % * Individuals diagnosed with diabetes for the first time during the time period. Income Canadian adults in the lowest income quintile are more likely to report living with diabetes. In 2013, 10% of Canadians in the lowest income quintile reported living with diabetes, double the proportion of those in the highest income quintile (Figure 14). Figure 14 Proportion living with diabetes by income quintile, 2013 Source: CIHI, 2015, Trends in income-related Q5 (highest income quintile) 4.9 Q4 Q Q2 8.9 Q1 (lowest income quintile) Age-standardized rate (%)

22 Indigenous Peoples Combined data from the 2011 to 2014 Canadian Community Health Survey suggest that off-reserve First Nations and Métis have a higher prevalence of diabetes in comparison to the non-indigenous population (Figure 15). Figure 15 Prevalence of self-reported diabetes, by Indigenous identity, Source: Statistics Canada, Last retrieved February 26, 2017, Canadian Community Health Survey Indigenous Identity Age Standardized rate First Nations (off-reserve) 8.2 Métis 6.0 Inuit 3.2* Non-Indigenous 4.9 *Interpret with caution due to potential of statistical error The prevalence rate is particularly high among First Nations adults who live onreserve. Data collected from reported that the age-standardized prevalence of diabetes was 20.7% for Indigenous adults aged 25 and above. 107 Mental Illness A national survey conducted in 2014 found that 6.3% of Canadians aged 12 and above rated their mental health as fair or poor. 108 A simulation model commissioned by the Mental Health Commission of Canada estimates that in 2011, one in 5 Canadians 6.7 million people in total lived with a mental illness. 109 Mood and anxiety disorders are the most common mental disorders. The abovementioned model estimates that 4 million Canadians lived with a mood and/or anxiety disorder in 2011, and projects that this will increase to approximately 4.9 million by the year As of January 29, 2017, 40,081 Syrian refugees have arrived in Canada since November 4, Studies suggest that the health status of refugees can be unique in comparison to Canadian born individuals and immigrants. 104,105 A Senate report tasked with reviewing the integration of Syrian refugees, cited mental health as a major area of concern. Witnesses that were part of the Senate s investigation identified a shortage of psychiatrists and mental health resources, language barriers and cultural norms as being factors that delay or impede access to mental health resources. 106 Age and Gender The prevalence rates of mental illness for males and females are comparable 20.9% for the former and 18.7% for the latter. Furthermore, both genders track similarly in terms of age. 111 In 2011, prevalence rates were estimated to be high among youth and young adults, dropping in subsequent years and rising again among those aged 70 and above (Figure 16).

23 Figure 16 Estimated annual prevalence rates of mental illness, by age and sex, 2011 Source: Mental Health Commission of Canada, 2013, Making the case for 45% 42.1% Estimated Prevalence Rate 40% 35% 30% 25% 20% 15% 10% 5% 15.6% 15.1% 25.9% 28.1% 25% 29.1% 28.7% 26.3% 20.6% 19.5% 17.5% 17.6% 12.8% 10.6% 25.9% 17.8% 36.7% 28.3% 33.8% Females Males 0% 9-12 years years years years years years years years years 90+ years Age Income Low income adults are more likely to rate their mental health as fair or poor in comparison to the highest income-canadian adults. Survey data suggests that this disparity is widening over time. As illustrated in Figure 17 below, in 2003, the percentage of Canadians rating their mental health as fair or poor was four times higher among adults in the lowest income quintile in comparison to those in the highest-income quintile. Whereas in 2013, the lowest-income Canadian adults were reporting fair or poor mental health at rates that were five times higher than those in the highest-income bracket. 112 Figure 17 Prevalence rate of population aged 18 and older who rated their own mental health status as poor or fair, by income quintile, 2003, 2014 Source: CIHI, 2015, Trends in income-related Age standardized rate (%) Highest Income Quintile Lowest Income Quintile Year Indigenous Peoples Combined data from the 2007 to 2010 Canadian Community Health Survey suggest that a higher proportion of off-reserve First Nations and Métis rate their own mental health as fair or poor, in comparison to the non-indigenous population. 113

24 Table 7 Perceived mental health, by Indigenous identity, Source: Gionet & Roshanafshar, 2013, Select health indicators of Indigenous Identity Perceived mental health, Very good or excellent Perceived mental health, fair or poor First Nations (off-reserve) 66 8 Métis 67 8 Inuit 65 5* Non-Indigenous 75 5 *Interpret with caution due to potential of statistical error Injuries In 2010, over 15,000 Canadians deaths occurred due to injury. Over 230,000 Canadians were hospitalized due to serious injury in the same year. 114 From 2004 to 2010, the injury death rate increased by 2.8% from per 100,000 population to per 100,000 population. 115 The direct and indirect costs (i.e. costs from reduced productivity due to hospitalization, disability and premature death) of injuries was estimated to amount to $26.8 billion in As illustrated in Figure 22 below, falls are the leading cause of unintentional injury deaths and suicide/self-harm incidents are the leading cause of intentional injury deaths, accounting for 4071 (25.7%) and 3948 (24.9%) deaths respectively. Table 8 Number of injury deaths, by cause, 2010 Source: Parachute Canada, 2015, The Cost of Injury Description Number of Deaths Falls 4071 Other Unintentional Injuries 1792 Transport Incidents 2620 Fire/Burns 234 Undetermined intent 749 Unintentional Poisoning 1568 Violence 515 Suicide/Self-harm 3948 Struck by sports equipment 5 Drowning 369 Age and Gender (Falls) As depicted in Table 9 below, among both genders, there is a higher likelihood that Canadians aged 65 and above die, get hospitalized and make emergency room visits as a result of a fall. These high rates within Canada s elderly population are particularly significant among males and females aged 85 and above. For instance, the rate of deaths per 100,000 among males aged 85 and above was 21 times the rate of males aged and nearly 5 times the rate of males aged The rate of deaths per 100,000 among females aged 85 and above was 31 times the rate of females aged and over 5 times the rate of females aged

25 Table 9 - Rates of deaths, hospitalizations, and emergency room visits due to falls by age and sex, 2010 Source: Parachute Canada, 2015, The Cost of Injury Age group (per 100,000) Deaths (per 100,000) Hospitalizations (per 100,000) Emergency Room Visits (per 100,000) Male , Male , Male , Male , Male , Male , Male , Male , , Male , , Female , Female , Female , Female , Female , Female , Female , Female , , Female , , Age and Gender (Suicide) The suicide rate for males (17.4 per 100,000) was three times higher than the suicide rate for females (5.7 per 100,000) in The higher rate of suicide among males is consistent with long-term trends in Canada over the last six decades. 118 Suicide rates are highest among those aged 40 to Figure 18 Suicide rate by select age group, 2013 Source: Statistics Canada, CANSIM, Table Rate per 100,000 population to to to to 59 All Ages Age group Indigenous Peoples Survey data collected from found that among First Nations adults who live on-reserve, one-in-five aged 18 and above (18.6%) reported they sustained an injury in the previous year. 120 In 2012, 20% of First Nations living off reserve, 21% of Métis and 16% of Inuit aged 19 years and older reported they sustained an injury in the previous year. 121

26 In 2016, tragic events in Northern Manitoba s Pimicikamak Cree Nation and Northern Ontario s Attawapiskat First Nation exposed the ongoing suicide risk in Indigenous communities. Survey data collected from found that among First Nations adults who live on-reserve, 22% reported having had thoughts of suicide at some point in their life. 122 As illustrated in Figure 19 below, suicidal thoughts have been reported to be high in off-reserve First Nations, Métis and Inuit adults as well. 123 Figure 19: Prevalence of lifetime suicidal thoughts among Indigenous adults aged 18 and over, by Indigenous identity, 2012 Source: Statistics Canada, 2016, Lifetime and past-year suicidal Indigenous Identity Percent First Nations (off-reserve) 21.1 Métis 17.5 Inuit 22.3 Non-Indigenous 11.5 Risk Factors Obesity Obesity is a major risk factor for numerous diseases, including cardiovascular diseases, diabetes, musculoskeletal disorders and certain cancers. Childhood obesity has also been associated with increased breathing difficulties, risk of fractures, hypertension, cardiovascular concerns and psychological effects. 125 The rate of obesity has trended upwards over the last decade. In 2014, 20.2% of Canadians aged 18 and older self-reported their Body Mass Index (BMI) that classified them as obese. Age and Gender 2014 data shows that males recorded a slightly higher rate of obesity than females, 21.8% and 18.7% respectively. Both genders Social determinants of health The health status of population groups are strongly influenced by limited access to social, cultural and economic resources. Among Canada s Indigenous populations, the issue is further compounded by the historical remnants of racism and colonialism. For instance: Half of First Nations children live in poverty. 48% of children and youth in foster care are Indigenous (from 4.3% of the population). There are more than 40,000 Indigenous children and youth in foster care more than three times the number of children in residential schools at the height of the Indian residential schools system. Secondary school graduation rates are 35% for First Nation students on-reserve, compared to 85% graduation rates for other Canadians. There are more than 1,200 cases of missing and murdered Indigenous women and girls. Indigenous individuals account for almost onequarter of all adults and youth incarcerated in Canada. As of 2015, 132 First Nations communities were under boil water advisories. 124 Addressing these types of issues will be critical in ensuring health and wellness equity at the individual, community and jurisdictional levels.

27 track similarly in terms of age. Self-reported rates of obesity rose between the ages of 18 and 54 and dropped at the age of 65 and above. Figure 20 Percentage of those that were obese (self-reported) Source: Canadian Community Health Survey, 2014 Percentage Males Females to to to 64 Age Group Survey data collected in 2013 showed that the prevalence of obesity among females in low income households was 1.5 times higher than that among females in higherincome households. This significant disparity in obesity based on income, was not observed in males. 126 Indigenous Peoples Obesity rates are significantly higher among Indigenous peoples in comparison to the general population. In 2012, nearly one in three (31%) First Nations people offreserve reported being obese. 127 Survey data collected from found that among First Nations adults who live on-reserve, 40% aged 18 and above reported they were obese. 128 Smoking Smoking rates have consistently declined over time. In 1999, 25.2% of Canadians were smokers. In 2013, 14.6% of Canadians, approximately 4.2 million were smokers. 129 Notwithstanding, smoking remains a major risk factor to multiple diseases and conditions including heart disease, oral, lung and cervical cancer, emphysema and bronchitis, to list a few. 130 Income Survey data from 2013 found that 29.1% of adults aged 18 and above in low income households reported they were smokers. Whereas 15.2% of adults aged 18 and above in the highest income quintile indicated they smoked. 131

28 Age Smoking rates were highest among young adults aged between Figure 21 Smoking prevalence, by age group, Canada, 2013 Source: Reid, Hammond & Burkhalter, 2015, Tobacco use in Canada Prevalence (%) Age group Indigenous Peoples Table 10: Smoking prevalence among adults aged 18 and over, by Indigenous identity, Source: Gionet and Roshananfshar, 2013, Select health indicators of Indigenous Identity Percent First Nations (off-reserve) 40 Métis 36 Inuit 48 Non-Indigenous 21 Combined data from showed that Indigenous peoples had a higher smoking prevalence than non-indigenous people. 133 Survey of First Nations adults on reserve from found that over half (57%) smoked daily or occasionally. 134 Health Indicators How we compare As Table 11 shows, life expectancy for Canadians is comparable with peer countries. Canada performed strongly compared to its peers in regards to self-reported health status and mortality due to stroke. However, Canada lagged behind in indicators such as infant mortality and mortality due to cancer areas that might merit further consideration. 135

29 Table 11 - International comparisons on select health status indicators, 2013 or most recent year Source: Canadian Institute for Health Information, OECD Interactive Tool: International Comparisons Select Indicator Canada Australia Germany Sweden New Zealand United Kingdom Life Expectancy: Males (Years) Life Expectancy: Females (Years) Infant Mortality (Age standardized rate per 100,000) Perceived health status: Age +15 (% report health to be good or better) Cancer Mortality: Males (Age standardized rate per 100,000) Cancer Mortality: Females (Age standardized rate per 100,000) Heart Disease Mortality (Age standardized rate per 100,000) Stroke Mortality (Age standardized rate per 100,000) Suicide: Males (Age standardized rate per 100,000) Suicide: Females (Age standardized rate per 100,000)

30 Health System Performance Wait Times Health System Environment In December 2005, first ministers of health agreed to establish evidence based benchmarks in the priority areas of radiation therapy, cardiac surgery, hip fracture repair, hip and knee replacement and cataract surgery. 136 National estimates show that approximately 3 out of 4 patients receive priority procedures within established benchmarks. There has been mixed progress since As shown in Figure 22 below: o Most patients receive radiation treatment for cancer care within the benchmark of four weeks. o Wait times for hip fracture repair has improved by 5 percentage points since o Progress has stagnated in wait times for hip and knee replacements. o The percentage meeting the established benchmark for cataract surgeries has trended downwards, declining by 10 percentage points since Figure 22 - Proportion of patient s accessing care within wait time benchmarks, by priority area, Source: CIHI, 2016, Wait times for priority 100% 95% 97% 97% Radiation Therapy Hip Replacement 90% Cataract Surgery 85% 80% 75% 70% 86% 84% 81% 81% 79% 76% 73% 73% Hip fracture repair Knee Replacement Note: Quebec s hip fracture repair data not included due to the methodological differences. There are certain instances where the disparity between provinces is significant. Approximately nine in 10 from Newfoundland and Labrador residents receive cataract surgery within 16 weeks, in contrast to approximately 3 in 10 in Manitoba. For knee replacements, the proportion of citizens receiving surgery within the established benchmark is significantly higher in Ontario (81%) than Nova Scotia (38%).

31 Table 12 - Proportion of patient s accessing care within wait time benchmarks, by priority area, by province, 2012, 2016 Source: CIHI, 2012, 2017, Wait times for priority Province Alta % point change since 2012 B.C. % point change since 2012 Man. % point change since 2012 N.B. % point change since 2012 N.L. % point change since 2012 N.S. % point change since 2012 Ont. % point change since 2012 P.E.I % point change since 2012 Que. % point change since 2012 Sask. % point change since 2012 Hip replacement 48 hours 82% -2 61% % % % -6 56% +9 85% -4 70% % +6 80% +11 Knee replacement 26 weeks 77% -2 47% % % -4 70% % +5 81% -3 77% % +4 73% +18 Hip fracture repair 48 hours 91% % +5 91% +5 89% +9 90% +9 85% +9 85% +3 76% +3 Cataract surgery 16 weeks 58% % % % -7 90% +8 65% +7 70% % +25 ** 86% -2 79% - 79% +22 Radiation therapy 4 weeks 99% +2 91% % - 98% % +2 94% +5 99% +1 95% -4 98% - 97% -1 +/- 10% +/- 11 to 19% +/- 20% and above **Data not included due to methodological differences Looking at performance over time, since 2012, Variances in wait times Saskatchewan has observed an improvement of percentage points in the proportion of patients having hip provincially highlight the replacements, knee replacements, and cataract surgeries. disparities in access that Whereas British Columbia has trended in the opposite persist for Canadians. direction, declining by percentage points in the proportion of patients meeting the benchmark of the three procedures. Many provinces are also reporting wait times for select cancer surgeries, CT scans and MRIs. Among provinces reporting, Nova Scotia recorded the longest wait times for CT scans and MRIs, with 9 out of 10 patients receiving services within 74 days and 202 days respectively.

32 Provincial performance varied in wait times for breast, colorectal, prostate, lung and bladder cancer. The 90 th percentile wait is lowest o in Saskatchewan for bladder cancer (29 days) and lung cancer (27 days) surgeries, o in Newfoundland and Labrador for colorectal cancer surgery (32 days), o in British Columbia and New Brunswick for prostate cancer surgery (70 days). Table 13 Wait times by select procedure, by province, 2015 Source: CIHI, 2017, Wait times for priority Benchmark CT Scan 90 th Percentile (in Days) MRI Scan 90 th Percentile (in Days) Bladder Cancer Surgery 90 th Percentile (in Days) Colorectal Cancer Surgery 90 th Percentile (in Days) Lung Cancer Surgery 90 th Percentile (in Days) Prostate Cancer Surgery 90 th Percentile (in Days) Alta B.C. N/A N/A Man N/A N/A 34 N/A N.B. N/A N/A N.L. N/A N/A N.S Ont P.E.I N/A N/A Que. N/A N/A Sask International Comparisons In an international survey of 11 countries, 93% of Canadians indicated that they had a regular doctor or place of care. However, they reported longer wait times than peer countries in a number of areas. Canadians were the lowest proportion of respondents to indicate that they were able to get a same or next-day appointment at their regular place of care (Figure 23). 34% of Canadians stated that they found it very or somewhat difficult to get medical care in the evenings, weekends or holidays unless they went to an emergency department. Further, Canada recorded the longest waits for primary and specialist care (Figure 24) against these select countries. Figure 23 Percent of respondents indicating they could get a same- or next-day appointment to see a doctor or a nurse, by country. Source: CIHI, 2017, How Canada Compares Figure 24 Percent of respondents indicating they waited 4 weeks or longer to see a specialist, by country. Source: CIHI, 2017, How Canada Compares New Zealand Australia United Kingdom Switzerland France Germany United States Sweden Norway Canada 77% 76% 67% 57% 57% 56% 53% 51% 49% 43% 0% 50% 100% Netherlands United States Germany Australia France United Kingdom Sweden New Zealand Norway Canada 22% 23% 24% 25% 35% 36% 37% 42% 44% 52% 0% 20% 40% 60%

33 Quality of Care: Table 14 - Quality of care, by indictor Source: CIHI, 2017, Health Indicators Quality Indicator ` Data Year Measure Indicator Result Repeat Hospital Stays for Mental Illness Percentage 11.2% Obstetric Trauma (With Instrument) Percentage 18.3% In-Hospital Sepsis Per 1, Potentially Inappropriate Medication Prescribed to Seniors Percentage 49.7% Worsened Pressure Ulcer in Long-Term Care Percentage 2.9% All Patients Readmitted to Hospital Percentage 13.6% Hospital Deaths Following Major Surgery: Percentage 1.6% Ambulatory Care Sensitive Conditions* Per 100, * Age-standardized acute care hospitalization rate for conditions where appropriate ambulatory care prevents or reduces the need for admission to hospital, per 100,000 population younger than age 75. How Canada measures up internationally As displayed in Table 15, Canada ranks relatively well on certain indicators such as survival rates for breast, colorectal and cervical cancer. However, in the areas of patient safety and adverse events, Canada reported high rates of obstetric trauma and a number of cases where unwanted foreign bodies were left in during procedures. Table 15 - Quality of care, by indictor, by select OECD country Source: OECD, 2016, Health Data Quality Indicator Measure Canada Germany Italy United Kingdom United States Avoidable Admissions, Diabetes Admissions per 100, *** *** 43.5 *** 64.3 *** ** Avoidable Admissions, Asthma Admissions 14.9 *** 22.6 *** 9.8 *** 60.5 *** ** per 100,000 Breast cancer: Percentage Five-year survival rate. Cervical cancer: Percentage Five-year survival rate. Colorectal cancer: Five-year survival rate. Obstetric Trauma: With Instrument Foreign Body left in during procedure Percentage Rate per 100 patients Rate per 100,000 * 2011 Data ** 2012 Data *** 2013 Data Data Data 17.1 *** 8.1 * 1.4 *** 7.2 *** 10.3 *** 8.6 *** N/A 1.7 *** 7.1 *** 7.8 ***

34 Human Resources for Health (HRH) Appropriate supply, mix, and distribution of physicians and other health professionals are essential to ensure timely access to quality health care services. A number of global and Canadian initiatives are afoot to look at human resources for health (HRH) planning. For example: In early 2016, the World Health Organization launched their report entitled Global strategy on human resources for health: Workforce Canadian HRH initiatives include the Committee on Health Workforce (CHW) 139 and its subcommittee, the Pan-Canadian Physician Resources Planning Advisory Committee (PRPAC). A physician supply-based model has been developed by PRPAC with efforts currently underway to build a needs-based modeling tool. This section provides a high-level snapshot of the physician workforce supply in Canada using several authoritative data sources including the Canadian Resident Matching Service (CaRMS), the Canadian Post-M.D. Education Registry (CAPER), the College of Family Physicians of Canada (CFPC), the Royal College of Physicians and Surgeons of Canada (RCPSC), and the Canadian Institute for Health Information (CIHI). Post-Graduate Trainees In 2016, 3,310 residency positions were available during the R-1 match (incl. first and second iteration). 140 Overall, 46% of these positions were allocated to Family Medicine with the remainder distributed between Medical (40%), Surgical (12%), and Laboratory specialties (2%). 141 Nearly all available positions were filled (98%), leaving only 51 vacant positions at the end of the matching process (80% of vacancies in Family Medicine). Allocation of residency quota is changing. For example, the Quebec government has created a Special Quota, which applies to certain types of applicants (e.g. Canadian citizens who trained abroad) and limits specialties (e.g., Psychiatry, Family Medicine). Source: McGill University, 2017, Contingent particulier Figure 25 - Physicians matched into a Canadian residency program. Source: CaRMS, 2016, Summary of match results CMG IMG USMG Matched Unmatched Physicians As shown in Figure 25, almost all Canadian medical graduates (CMGs) were placed into a residency program (95%) as compared to only 22% of international medical graduates (IMGs). 142 In the academic year, 80% of IMGs in first-year residency training were Canadian citizens/permanent residents (CCPRs); an increase from 64% in

35 CCPRs who completed their MD degree abroad are eligible to participate in the match whereas visa trainees are not and therefore access residency by way of contractual agreements between the source country & the faculty of medicine CCPRs who study abroad commonly complete their medical degree in different geographic regions as compared to Visa trainees. 144 Figure 26 Top five countries where International Medical Graduates received their MD degree (CCPRs vs. Visa Trainees). Source: CAPER, , Table C-2 Ireland Australia Iran United States Egypt CCPRs Saudi Arabia India United Kingdom Oman Ireland Visa Trainees In the academic years, 16,200 total trainees (regardless of rank) were enrolled in specialty and subspecialty residency programs across Canada. 145 Approximately 55% of all trainees were registered in medical residencies; comprised of large programs such as Family Medicine (n=3476), Internal Medicine (n=1651), Psychiatry (n=997), and Anesthesiology (n=820) with the remainder in other medical (n=5470), surgical (n=3340), and laboratory disciplines (n=446). Slightly more females than males were present in residency programs (53.4% vs. 46.6%), excluding visa trainees; representing a consistent trend since the demographic shift in 2005/ Differences in the gender distribution exist by broad specialty with 46.7% female surgical trainees versus 61.2% female family medicine trainees. 147 Figure 27 - Gender distribution by broad specialty, academic year. Source: CAPER, , Table I-3 Family Medicine 39% 61% Medical Specialties 48% 52% Male Female Laboratory Specialties 48% 52% Surgical Specialties 53% 47% 0% 50% 100%

36 New Certificants Since 2011, the Royal College has been conducting a survey of its new certificant population to study physician employment status after certification % response rate (5,143 individuals/14,244 new certificants) over 6 years. As shown in Figure 28, physician employment challenges are still present with 14-18% of specialists and subspecialists indicating overall that they could not find a job placement. Several disciplines have a higher rate of unemployment compared to the overall average (Table 16). For example, over 65% of Radiation Oncologists specified that they were unable to find a job placement post-certification in Figure 28 - Summary of employment status for newly certified specialists and subspecialists. Source: Royal College, , Employment Survey 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Additional Training Already Planned 44% 46% 42% 45% Found Employment 34% 36% 38% 38% No Job Placement, Pursuing Training No Job Placement, Not Pursuing Training 11% 8% 8% 10% 7% 6% 6% 4% No job placement (TOTAL) Table 16- Most impacted disciplines reporting unemployment (discipline-specific response rate > 25%), Source: Royal College, , Employment Survey Unable to find a job placement Discipline 2015 (%) 2016 (%) Neonatal-Perinatal Medicine 3/9 (33.3%) 2/7 (28.6%) Nephrology 5/15 (33.3%) 3/8 (37.5%) Neurosurgery 7/13 (53.9%) 3/5 (60.0%) Orthopedic Surgery 17/35 (48.6%) 13/34 (38.2%) Pediatric Emergency Medicine 4/10 (40.0%) 2/6 (33.3%) Plastic Surgery 3/12 (25.0%) 7/14 (50.0%) Radiation Oncology 8/12 (66.7%) 7/11 (63.6%) Vascular Surgery 4/5 (80.0%) 2/5 (40.0%)

37 In 2014, the Cohort Study was launched to further monitor individuals facing employment challenges in the initial survey including those who 1) had not yet found employment but were successful in securing additional training; 2) had not yet found employment and were not pursuing further training; 3) had not yet applied for employment. 51% response rate for (230 respondents /453 physicians experiencing employment challenges). Over 60% of respondents indicated that they had found a job placement within years after their Royal College certification in 2015 (Figure 29). Of those that indicated that they had not yet found a job placement, a large proportion of this group was continuing training (47% in 2013; 39% in 2014; 48% in 2015). The remaining individuals were either unemployed, waiting to hear back from job applications, or had indicated another reason for not finding employment. Figure 29 - Summary of employment status within the Cohort population. Source: Royal College, , Cohort Study 0% 20% 40% 60% 80% 100% Yes No Licensed Physician Workforce Between Nov. 1, 2014 and Nov. 1, 2015, 4,275 physicians exited post-m.d training at a rank level consistent with completion of training. 149 In 2015, the total licensed physician workforce in Canada was 82,198 with Head counts and physician-population a near 50/50 split between family ratios are often utilized in studying human physicians (41,551) and specialists resources for health. These metrics are (40,647) 150, shown in Table 17. limited as they do not take into account As seen in Table 17, Nova Scotia had workload, time allocation, scope of the highest proportion of physicians practice, practice organization, patient per 100,000 compared to PEI which needs and mobility among other factors. had fewer FPs & SPs per 100,000 in Canada, excluding the territories. Yukon had six times more family physicians per 100,000 than specialists.

38 Table 17 Number of Family Physicians and Specialists, by jurisdiction (2015). Source: CIHI, 2015, Supply, Distribution, and Migration Family Physicians Specialists Total Physicians British Columbia 5,852 5,065 10,917 Alberta 5,213 4,806 10,019 Saskatchewan 1, ,241 Manitoba 1,386 1,273 2,659 Ontario 15,077 15,417 30,494 Quebec 9,703 10,352 20,055 New Brunswick ,674 Nova Scotia 1,241 1,224 2,465 Prince Edward Island Newfoundland and Labrador ,282 Yukon Northwest Territories Nunavut Canada 41,551 40,647 82,198 Figure 30 - Number of Family Physicians and Specialists per 100,000 population, by jurisdiction (2015). Source: CIHI, 2015, Supply, Distribution, and Migration Physicians per 100, Canada had 2.6 practicing physicians per 1,000 population in 2014; in contrast, Norway had a higher number of doctors (4.4 per 1,000) BC AB SK MB ON QC NB NS PE NL YT NT NU CAN Jurisdiction Family Physicians Specialists Figure 31 - Comparison of select OECD countries on total number of doctors per 1,000 inhabitants, 2015 or latest available. Source: OECD, last accessed on April 12, 2017, Doctors (indicator) Total Doctors per 1,000 population Poland 2.3 United States 2.6 Canada 2.6 United Kingdom 2.8 Australia 3.5 Denmark 3.6 Germany 4.1 Sweden 4.1 Norway 4.4 The total number of doctors per 1,000 population is utilized as a broad marker for comparing physician supply. However, caution should be utilized when analyzing the ratios of various countries given the variability in their health systems. For example, the public health care system in Canada versus the private health care system in the United States.

39 Physicians in Canada: Remuneration Fee-for-service (FFS) payment programs represented the majority (71%) of total clinical payments in Mixed funding programs were also evident in as most Canadian physicians received some form of FFS payment (95%) and a large proportion (70%) received some form of APP payment. Alternative payment programs (APPs) are becoming more common in the Canadian health care system (10% of payments in vs. 29% in ). As illustrated in Figure 32, Nova Scotia had the highest proportion of physicians paid through APP; in contrast, British Columbia had the highest proportion of physicians paid through FFS. Figure 12 Distribution of total clinical payments by jurisdiction, Source: CIHI, , Understanding the Physician Workforce 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 64% 63% 53% 62% 78% 66% 71% 81% 60% 71% 36% 37% 47% 38% 22% 34% 29% 19% 40% 29% N.L. P.E.I. N.S. N.B. Que. Ont. Man. B.C. Y.T. All Jurisdiction APP clinical payments FFS clinical payments Physicians in Canada: Geographic Distribution According to the most recent Statistics Canada data (2011), 19% of Canadians were living in rural areas, that is areas with fewer than 1000 inhabitants and a population density below 400 people per square kilometer. 153 Of the 82,198 physicians in Canada in 2015, only 8% practiced in rural locations. Family Physicians comprised the largest share of physicians in rural areas (Figure 33). Figure 33 Distribution of physicians in urban vs rural locations, by broad specialty category. Source: Supply, Distribution and Migration of Physicians in Canada, 2015 (CIHI) 100% 80% 60% 40% 86% 98% Rural Urban 20% 0% Family Physicians Specialists

40 Excluding the Territories, BC, ON and QC experienced the closest alignment in the country between the distribution of physicians and populations in rural areas in 2015, whereas PEI, NB and NS experienced the greatest difference in that year (Figures 34 and 35). Figure 34 Distribution of physicians in urban versus rural locations by jurisdiction. Source: CIHI, 2015, Supply, Distribution and Migration 100% Physicians 80% 60% 40% 20% 0% 93% 93% 86% 86% 95% Figure 35 Distribution of the population in urban versus rural locations by jurisdiction. Source: Statistics Canada, 2011, Population, urban and rural 100% 90% 83% BC AB SK MB ON QC NB NS PE NL YT NT NU CAN Jurisdiction Urban Rural 80% 89% 70% 87% 78% 92% Population 80% 60% 40% 20% 86% 83% 67% 72% 86% 81% 53% 57% 47% 59% 61% 54% 81% 0% BC AB SK MB ON QC NB NS PE NL YT NT&NU CAN Physicians in Canada: Age In 2014, 14% of all licensed physicians were aged 65+ and 13% are aged < 35 (Figure 36). Figure 37 shows specialties with higher percentages of younger physicians (e.g. 47% of Emergency Medicine physicians are <45 years old compared to 28% of Cardiac Surgeons) or older physicians (e.g., 48% of Psychiatrist are >54 years old compared to 30% of Radiation Oncologists). For more information about other Royal College specialties, go to Jurisdiction Urban Rural Figure 36 - Age distribution for the total licensed physician workforce (Family Medicine and Specialists), , 14% 55-64, 24% < 35, 13% 45-54, 25% 35-44, 23%

41 Figure 37 - Age distribution, by select specialty, 2014 Percentage of Physicians 35% 30% 25% 20% 15% 10% 5% 0% 21% 13% 9% 3% Physicians in Canada: Sex 26% 30% 21% 25% 23% 27% 22% 30% 23% 23% 27% 27% 8% 7% 21% 15% < Age group Emergency Medicine Radiation Oncology Psychiatry Cardiac Surgery Almost three quarters of specialists were male in 2005; dropping to 65% in Most surgical specialties are still male-dominated with the exception of Obstetrics & Gynecology, as is seen in Figure 38. Figure 38 Distribution of males and females in the licensed physician workforce by specialty select disciplines. Source: CIHI, 2015, Supply, Distribution, and Migration Orthopedic Surgery 89% 11% Ophthalmology 77% 23% General Surgery 74% 26% Diagnostic Radiology 69% 31% Male Anesthesiology 68% 32% Female Internal Medicine Psychiatry 67% 57% 33% 43% Anatomical Pathology 57% 43% Pediatrics 44% 56% Obstetrics and Gynecology 44% 56% 0% 50% 100% Physicians in Canada: Work Hours Overall, male and female physicians report working fewer hours in 2014 compared to 1998 (excluding on-call service). Male physicians have seen a 9.7% reduction, going from 55.5 hours per week in 1998 to 50.1 in Female physicians have seen a 4.0% reduction, going from 48.2 hours per week in 1998 to 46.3 in While time spent on direct patient care has decreased, male and female physicians have both seen an increase in time spent on other professional tasks, such as indirect patient care, continuing professional development and administrative activities. Female physicians have seen a 6.4% increase in weekly time spent on other professional activities and males have seen a 1.6% increase.

42 In 2014, two-thirds of physicians said they provide on-call service, 67.0% of male physicians and 65.9% of female physicians. Those who provided on-call service said they worked an average of on-call hours per month. 154 Figure 39 Physicians average weekly work hours by type of activity and sex, Canada, 1998 and 2014 (Excluding on-call hours). Source: CMA, CFPC, Royal College, 1998 & 2014, Physician Resource Questionnaire & NPS 70 Other professional activities Hours per week Direct Patient Care MEN WOMEN Generational differences are oft discussed, be it among physicians, other professions or society more broadly. With respect to self-reported work hours, the change that has occurred among physicians has been generally uniform across age groups (see Figure 40). As shown in Figure 40 all physician age groups report working fewer hours in 2014 compared to The largest reduction (8.8%) was among physicians aged The smallest reduction (6.2%) was among physicians aged 65+. Figure 40 - Physicians' average weekly work hours by age group, Canada, 1998 and 2014 (Excluding on-call hours). Source: CMA, CFPC, Royal College, 1998 & 2014, Physician Resource Questionnaire & NPS Hours per week < Age group

43 Trends in Physician Workforce Supply The Royal College Medical Workforce Knowledgebase 155 provides key insights on the size and composition of Canada s current and future physician workforce based on four indicators. The number of residency positions offered in the first iteration of the CaRMS R-1 match New Trainees The number of first year (PGY1) post- M.D. trainees (residents) The number of physicians who became newlycertified by the CFPC and/or Royal College Total Licensed Physicians The number of active physicians in Canada as reported by CIHI R1 quota New Certificants Current highlights for primary specialties ( ) include: 13% and 12% overall increase in residency quota and new trainees, respectively 26% increase in medical, surgical, and laboratory new certificants (Figure 41) 13% increase in the licensed physician workforce Figure 41 - Snapshot of physician workforce supply by broad specialty group, Source: Royal College Medical Workforce Knowledgebase Residency quota New Trainees New Certificants Licensed Physicians Family Medicine 22% 25% 37% 15% Medical Specialties 11% 10% 28% 11% Surgical Specialties 8% 10% 22% 12% Laboratory Specialties 5% 3% 23% 10% Trending Up No Trend Trending Down Family Medicine, Anatomical Pathology and Emergency Medicine experienced above average annual growth on all four indicators Some disciplines were trending up (increased residency quota and new trainees) while others were trending down (decreased residency quota and new trainees) Figure 42 Primary specialty disciplines that were trending up (increased residency quota & new trainees) or trending down (decreased residency quota & new trainees), Source: Royal College Medical Workforce Knowledgebase. TREND UP Emergency Medicine Anatomical Pathology Family Medicine Psychiatry Dermatology Internal Medicine Pediatrics Ophthalmology General Surgery Orthopedic Surgery Radiation Oncology Plastic Surgery Otolaryngology - Head and Neck Surgery Obstetrics & Gynecology Neurology Diagnostic Radiology TREND DOWN

44 Scope of Practice Scope of practice is becoming an increasingly important consideration as the health workforce grows and diversifies. In a recent report, the Canadian Academy of Health Sciences states that increased flexibility around scopes of practice and models of care is required to meet the changing population health needs and the diversity represented in communities across Canada. 156 Physicians scope of practice can change in numerous ways. For example, a physician may start providing a new type of care that they didn t in the past. A physician may practice largely as she/he did in the past, but stop providing a few specific types of medical care. Or a physician may significantly reduce his/her scope of practice, focusing in on a specific area of care and a more narrowly defined set of medical services. Older physicians are more likely to reduce their scope of practice. About 6% of physicians aged <45 report reducing their scope of practice, compared to just over 12% of those aged (see Figure 43). 157 Younger physicians are more likely to increase their scope of practice. About 11% of physicians aged <45 report increasing their scope of practice, compared to just over 5% of those aged (see Figure 43). 158 Figure 43 - Percent of physicians who reduced/increased their scope of practice in the last two years, by age group, Canada, Source: CMA, CFPC, & Royal College, 2013, National Physician Survey 25% 20% 21.5% 15% 10% 5% 11.1% 11.3% 6.2% 6.1% 9.7% 8.7% 12.3% 5.2% 2.0% 10.2% 7.7% 0% < All Physicians Reduced Scope of Practice Increased Scope of Practice Healthcare providers have overlapping scopes of practice as they share and collaborate in patient care. For example: o In 2012, Ontario became the first province to allow nurse practitioners (NPs) to admit and discharge patients from hospital. Other provinces are considering granting this authority to NPs. 159 The CMPA on scope of practice The new reality: Expanding scopes of practice Today's reality is that physicians are increasingly working with and relying on other health care professionals when treating patients. Evolving models for health care delivery mean that other health professionals are playing an increasingly significant and valuable role in the care of patients Expanding the scope of care of each member of the team improves access. Source: Canadian Medical Protective Association,

45 o o Canada s new legislation on medical assistance in dying grants physicians and nurse practitioners similar authority to provide this new area of care. 160 In most Canadian jurisdictions, the pharmacists scope of practice includes a measure of authority to prescribe and/or manage medications. 161

46 Technological environment Technology is embedded in medical practice, and technological advancements constantly change physicians ability to diagnose and treat conditions. Technology has been associated with driving up short term-costs, while concurrently facilitating savings in the medium and long-term. 162 For instance, it is estimated that since 2007, investments in telehealth, drug information systems, diagnostic imaging and physician and ambulatory clinic electronic medical records (EMRs) have produced cost savings and efficiencies in Canada worth approximately $16 billion. 163 Electronic Health Records (EHR) As of March 31, 2016, 93.8% of Canadians have EHR data available to authorized physicians across six clinical domains: client demographics, provider demographics, diagnostic images, laboratory test results, clinical reports/immunizations and drug information systems. Figure 44 shows that the availability of drug information systems lags furthest behind. Canada Health Infoway (CHI) has identified this as an area of focus moving forward and plans to develop a pan-canadian electronic prescribing system, known as PrescribeIT. The service will look to provide prescribers the ability to electronically transmit a prescription to a patient s pharmacy of choice. CHI believes the service will reduce the use of paper prescriptions, enhance patient safety and facilitate better health outcomes for Canadians. 164 Figure 44 - EHR Availability as of March 2016, by clinical domain Source: Canada Health Infoway, 2016, Annual Report % available across Canada 100% 80% 60% 40% 20% 0% 100% 100% 100% 94% 100% 69% Canada continues to make strides in providing health professionals access to EHRs across the country - but what about patients? The Federal Government s Advisory Panel on Healthcare Innovation cites this gap in its 2015 report on healthcare innovation, calling on the Federal government to support the development of policy and legislative tools to enable patient access to, and co-ownership of, their own personal health records Source: Advisory Panel on Healthcare Innovation (2015). Unleashing Innovation: Excellent Healthcare for Canada. Electronic Medical Records (EMR) In the 2014 National Physician Survey 165 : o o o 77.8% of specialist physicians reported using a combination of paper and electronic charts, or exclusively using electronic records. Specialist physicians identified technical glitches/reliability (52%) and compatibility with other systems (47.6%) as the top 2 barriers they experienced in accessing information. Medical oncologists were the highest proportion of specialists (70%) to record technical glitches as a challenge. 60.7% of specialist physicians who used EMRs stated they felt they provided better or much better quality of care since they adopted EMRs. Telehealth A bi-annual survey of jurisdictional telehealth programs and networks found that 166 : o Most jurisdictions across Canada provide desktop or mobile video conferencing services for administrative, educational and clinical consultation purposes.

47 o The total number of clinical telehealth sessions has more than doubled, from 187,385 sessions in the 2010 iteration of the survey, to 411,778 sessions in the 2014 survey. o Clinical services in mental health, neurology, oncology, pediatrics and rehabilitations were reported to be the most common services delivered with telehealth. o Telehealth is being utilized to provide educational services to healthcare professionals, with services in oncology, pediatrics and pharmacy being particularly prevalent across jurisdictions. Other digital health solutions E-booking: E-visits: Telehomecare: Enabling patients to schedule and manage their appointments online. E-booking has been shown to be a popular digital health solution among Canadians; in a 2013 survey, 90 percent of respondents stated that they would like the ability to do e-bookings. 167 Enabling secure digital communication between health providers and patients that can include s, text messaging and video conferencing. A patient survey in British Columbia found that among respondents who accessed e-visits, over 90 percent indicated saving on travel time, expressed satisfaction with the security and privacy of their information, and felt that their health issue was addressed appropriately. 168 Enabling clinicians to remotely manage chronic health conditions. Telehomecare has been shown to improve patient and caregiver quality of life and prevent unnecessary hospital visits. Approximately 5000 Canadians were enrolled in telehomecare programs in E-Renewals: E-consultation: E-Referrals: Enabling prescription renewals online. Enabling timely communication between providers through computer applications about general or patient-specific questions. In 2013, the evaluation of an e- consultation system in Ontario found high levels of satisfaction among primary care providers and specialists, enhanced integration of referrals and consultations and the prevention of unnecessary specialist visits. 170 Enabling physicians to request a referral from another health provider electronically, avoiding the need for mail, fax or phone. Emerging technologies Artificial Intelligence (AI): AI, software algorithms that perform tasks which traditionally require human intelligence, is evolving rapidly in many industries including health care. There is even a dedicated journal, Artificial Intelligence in Medicine, which publishes articles on the theory and practice of AI in medicine, human biology and health care. AI is expected to increasingly support clinical decision-making moving forward. For instance: Companies and researchers worldwide are leading It is estimated that: In 1950, it took 50 years to double the world`s medical knowledge By 1980, seven years By 2015, less than 3 years. By 2020, 73 days. 171 AI will increasingly support clinical decision-making in an increasingly complex medical data world.

48 promising clinical studies on sensors that analyze the chemical trail left by human body odor, to diagnose early signs of cancer and other diseases 172. A self-learning algorithm technique in devices and software that is often referred to as deep learning, has been shown to predict cardiovascular risk in patients 173 and diagnose skin lesions as accurately as dermatologists 174. Robotics: Specialists are using a telepresence robot named Rosie to virtually offer real-time diagnosis and monitoring of patients in the Indigenous community of Pelican Narrows, Saskatchewan. 175 The next generation of surgical robotics will include Google, which has announced a partnership with pharmaceutical company Johnson & Johnson to develop robots that will assist surgeons with minimally invasive surgeries. Google is looking to enhance surgical robotic tools by leveraging technologies it is deploying in other areas of its business, such as their self-driving car project. By 2020 surgical robotic sales are forecasted to generate $6 billion, double the sales recorded in 2014, according to a report prepared by Allied Market Research D Printing: 3-D printing is expanding rapidly and expected to revolutionize health care with its manufacturing techniques used to create three-dimensional objects such as customized implants, prosthetics, medical models and medical devices. For instance: Nia technologies, a Canadian non-profit company, is 3-D printing prosthetic sockets and ankle foot orthoses to children and youth from less developed countries with lower-limb disabilities. Preliminary results suggest that the technology is producing objects in 1.5 days, instead of 5 days through conventional methods D printers have produced over 60 million customshaped hearing-aid shells and ear molds since Prospective applications of 3-D printing include the construction of human tissues by 3-D printing cells (e.g. to address shortages in organ donations) and printing drugs (e.g. printing nonstandard doses for children or the elderly); the latter achieved by downloading pharmaceutical recipes into a 3-D printer. 179 The convergence of technologies such as artificial intelligence, robotics and 3-D printing provide a small sampling of the broader emergence of new technologies that may potentially drive significant changes to the delivery of health care in the future. What impact will new technologies have on physicians scope of practice, curriculum content, physician supply and practice standards? Will new technologies play a facilitative role, or will they replace select work of physicians moving forward? The medical profession will need to reflect on these questions, among others, as proven innovations assimilate into clinical practice moving forward. The Canadian Agency For Drugs And Technologies In Health (CADTH), an independent agency that publishes Horizon Scan Roundup, a series of reports that identify new and emerging technologies that may have an impact on Canadian healthcare. The 2016 iteration of the reports highlights various medical technologies including medical devices, laboratory tests, biomarkers, programs, and procedures that may have an impact in the future, including the following: FLEXISEQ, a topical gel for treating symptoms of osteoarthritis. GPS locator devices for people with dementia, often at risk of wandering. ReActiv8, a device that consists of a pulse generator and wires that is implanted for treating chronic low back pain. STAR Tumor Ablation System, a device used for the palliative treatment of metastatic spinal tumors. PATHFAST Presepsin, a laboratory analysis device developed for the rapid diagnosis of sepsis. Mobi-C, a prosthetic device for adults with neck problems due to cervical disc degeneration. AVATAR, computer software that looks to treat select hallucinations that are common in serious mental illnesses such as schizophrenia. Get SET Early Model, a screening tool for pediatric autism spectrum. 180