Psychological Services and the Future of Health Care in Canada
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Featured Article Psychological Services and the Future of Health Care in Canada ROY J. ROMANOW ceived lack of adequate funding. These issues had Former Premier of Saskatchewan, Former Chair already precipitated a number of arms-length govern- of the Commission on the Future of Health Care ment studies. In April 2001, when the CFHCC was in Canada, and Senior Policy Fellow established, the governments of Québec (2000) and University of Saskatchewan and University of Regina Saskatchewan (2001) had already been provided with their own Commission reports. Moreover, the Alberta GREGORY P. MARCHILDON government (2001) was about to receive its report. Former Executive Director of the Commission on the Given the provincial context of these studies, however, Future of Health Care in Canada and Canada the reports barely touched upon the national dimen- Research Chair in Public Policy and Economic History sions of health care. University of Regina As for the federal government, it had already decid- ed to reduce its social (including health) transfers to Abstract the provinces before receiving the recommendations The implications of the Commission on the Future of of an earlier commissioned study. As a consequence, Health Care in Canada’s (CFHCC) recommendations the recommendations of the National Forum on extend beyond the necessarily limited scope of its report. Health (1997) were initially sidelined as the federal This article explores the potential role of psychologists in a and provincial governments began to debate their restructured public health care system that goes beyond respective roles and responsibilities in the funding, hospital and physician care to home care and a revamped administration, and delivery of public health care. By primary care system. Public plans would also benefit from 1999, the Senate Standing Committee on Social the use of psychological alternatives to prescription drug Affairs, Science and Technology had begun to study therapies. Such evidence-based extensions to the existing the federal role in health care, but it was not perceived Canadian model would improve both health and medical as acting on behalf of the federal government, nor was outcomes. They could also introduce new cost-savings to its mandate considered, at least initially, to be directly provincial health plans that are presently under immense relevant to the provinces. financial strain. Unlike previous Royal Commissions that had three to five years to complete their work, the CFHCC was given a mere 18 months. The debate concerning the sustainability of public health care was then reaching a The Commission on the Future of Health Care in crescendo. Federal-provincial conflict in particular Canada (CFHCC) was created to address some very spe- had escalated to the point of destabilizing the health cific problems facing Canada’s public health care sys- care system itself. The sources of this conflict were tem. These included escalating costs, timely access to varied, but the main fault lines were constitutional, certain services and procedures, and shortages of institutional, financial, and ideological in nature. The some types of providers. Questions had also been debate that this conflict triggered was confusing, and raised concerning the quality of health care as well as it was unclear as to whether the fundamental values of the range of services that should be offered by the the system were in question. Moreover, it was unclear public sector and the role of the private sector in the whether governments agreed or disagreed as to the delivery of those services. Beyond these specific chal- general framework within which change and reform lenges was the question of whether the governance of could take place over the coming years. As a conse- the health system was failing. There was also a grow- quence, it was believed that any report released ing dysfunction within the federal system as each beyond the 18-month time period might be too late to order of government attempted to blame the other for provide answers directed to these basic questions and the shortcomings of the public system and its per- provide the recommendations that would help shape the policy outcome in the country. In addition, the CFHCC was required by its original Canadian Psychology/Psychologie canadienne, 44:4 2003 order-in-council to deliver an interim report, which
284 Romanow and Marchildon was released in February 2002 (Canada, 2002a). This The Canadian Medicare Model left nine months to conduct one of the most extensive Canadian medicare is, first and foremost, a histori- and intensive public consultation processes ever cal construct. The first pillar of our contemporary engaged by a Royal Commission in Canada and to public health care system was initiated by write a final report with a broad range of recommen- Saskatchewan in 1947, followed by other variants of dations on the future of health care. This report was hospitalization in Alberta and British Columbia. With delivered in November 2002, amidst saturation-level the passage of the Hospital Insurance and Diagnostic media attention and at the peak of federal-provincial Services Act by the federal Parliament in 1957, and the conflict over the future of public health care (Canada, offer of federal cost-sharing transfers, the 2002b). Although the recommendations went beyond Saskatchewan model of universal public hospital at least some of the immediate issues that were of con- insurance was adopted in all the provinces and territo- cern when the CFHCC was created, the extremely ries by 1961 (Boychuk, 1999; Taylor, 1987, 1990). short time frame meant that the recommendations Psychiatric health services were, however, excluded could not cover the entire waterfront of longer-term from the definition of hospital services, and federal issues, including the role of psychology in the health government inspectors actually counted the number of Canadians (Allon & Service, 1999). Instead, the of psychiatric beds in general hospitals to exclude report delivered a limited package of fiscally and polit- them from the federal share of provincial hospital ically feasible recommendations, many of which would expenditures. This encouraged the pre-existing ten- be capable of implementation within a short period of dency to keep long-term mental health facilities such time. Particular emphasis was placed on lancing the as psychiatric hospitals separate from the “regular” sys- federal-provincial boils because of the difficulty of tem. Nonetheless, some emergency mental health achieving positive health care change on the ground services were covered under hospitalization, and this without addressing the malfunctions at the highest meant that psychiatrists and psychologists could pro- governance level. Moreover, contrary to most recent vide critical care mental health services under the health care reports in Canada, much time was spent rubric of hospitalization. These services would on how to achieve change, most significantly on how expand over time but even by the mid-1980s, no to create new intergovernmental structures and Canadian hospital offered admitting privileges to psy- processes, such as the establishment of a Health chologists, nor would most hospital patients be Council of Canada, to replace existing intergovern- assessed and/or treated by psychologists except after mental processes and institutions (see CFHCC imple- physician referral (Arnett, Martin, Streiner, & mentation plan, Canada 2002b, 255-256). Goodman, 1987). There was a price to be paid for this focus in the The second phase of medicare was the implementa- CFHCC’s final report. Professional psychologists were tion of universal public health insurance for primary not alone, for example, in wishing that the CFHCC had medical care services outside hospitals by gone further into the issues of greatest interest to Saskatchewan in 1962. Despite the existence of other them (Canadian Psychological Association, 2002). As models, including a targeted subsidy approach in a consequence, the purpose of this article is to Alberta, it was the Saskatchewan model that was rec- explore at greater length the implications of key rec- ommended for national implementation to the federal ommendations in the report for the future of psycho- government by the Royal Commission on Health logical services. We begin by summarizing the princi- Services – the Hall Commission – two years later ple features of the Canadian model of medicare as it (Canada, 1964). It took another 50:50 cost-sharing has evolved over time in order to understand why psy- offer by Ottawa, plus years of negotiation, but all the chological services are largely outside the core of pub- provinces and territories had implemented universal lic health care. We then review the major systemic medicare by 1972 (Naylor, 1986; Taylor, 1987, 1990). changes recommended by the report – home care and There were two significant factors in this phase. First, primary health care – and the role that psychological the family/general physician was seen as the centre of services could potentially play in their organization the primary care universe. Second, the fee-for-service and delivery in the future. This is followed by an (FFS) methods of physician remuneration that predat- examination of prescription drugs, the most signifi- ed medicare were continued, except that the govern- cant cost-driver in health care today, and the alterna- ment rather than individuals or private insurers paid tives to physician-directed drug therapies. Finally, we the physicians’ bills. In the beginning, therefore, look at some of the more immediate challenges in other professions, including professional psychologists, Canadian health, in particular, rural, remote, and abo- were largely excluded from the FFS medicare system. riginal health and health care. This changed little over time, in large part because
Psychological Services and the Future of Health Care in Canada 285 of the desire by governments to limit their expendi- their respective health plans, it has meant that both tures of public funds on new services and new hospital services and primary care physician services providers. A few other professions such as chiroprac- are historically privileged. Moreover, given the focus tors were occasionally, and temporarily, let into the of general/family physicians on physical ailments, this FFS public system by particular provincial govern- has resulted in a lack of emphasis on mental health ments, but professional psychologists provided prima- services, other than mental disorders that can be easi- ry care services in the private sector. This was despite ly identified and referred to a psychiatrist by other the replacement of shared-cost funding schemes for physicians. The result is that almost 80% of consulta- both medicare and hospitalization with a block fund- tions with psychologists – the majority of which likely ing transfer known as Established Programs Financing involve mental health issues – occur within the private (EPF) in 1977. One of the reasons behind the change rather than the public system (Canadian Psychological was the provinces’ desire for greater flexibility in their Association, 2001). Of this 80%, a portion is covered use of federal health transfer funds, which was trig- through private insurance (largely employment gered in part by an interest in new organizational based) and the remainder is paid out-of-pocket. models of primary care delivery (Canada, 1972) and The enormous burden of mental disorders in population health through the Lalonde Report Canada is one of the more unfortunate legacies of the (Canada, 1974). Canadian medicare model. Without a doubt, mental By the end of the 1970s, provincial health care disability has a major impact on the health status of plans were covering or subsidizing health services well the population. Despite this, our public system invests beyond hospitals and primary care physicians, includ- disproportionately on addressing physical diseases, ing prescription drugs, as well as home/community particularly those associated with death (Bland, 1998). care and long-term care. At the same time, advances One estimate of the economic cost of mental disor- in drug therapy and changes in mental health treat- ders in Canada was $14.4 billion in 1998, a little more ment modalities had resulted in the “de-institutional- than 25% of the total invested in public health care ization” of many patients previously resident in that year. This is a consequence of the fact that provincial psychiatric hospitals. Despite these approximately 3% of the Canadian population suffers changes, the medical model of treatment, with the from serious mental disorders in any given year, while physician at the centre, remained the norm. Most pri- about 1 in 5 Canadians suffer a less serious, but mary care continued to flow through general/family nonetheless potentially disabling, mental condition practitioners who referred patients with serious men- (Canada Mental Health Association, 2001). Canada is tal disorders or difficulties to psychiatrists while not alone in terms of this burden and the fact that it is attempting to cope with less serious cases on their own inadequately addressed. As the World Health or, very occasionally, by sending them to a psychiatric Organization (2001) recently pointed out, mental nurse or psychologist. health remains one of the most neglected areas of In 1984, the federal Parliament passed the Canada public health care throughout the world. Health Act (CHA, 1985). The motives for passing the In Canada, there is a gradiant of services. Within Act were varied, although the chief preoccupation of the core medicare system, most serious mental disor- the federal Minister of Health at the time was to cur- ders are treated by psychiatrists. Unfortunately, less tail the practices of extra billing by physicians and serious mental conditions are often not being diag- user fees by hospitals in parts of the country. These nosed much less treated within the existing system. were contrary to the operating principles of the origi- Finally, the systematic pursuit of mental health, as nal federal legislation underpinning the federal trans- opposed to the treatment of mental disorders, is poor- fers but made almost unenforceable through the EPF ly resourced and rarely done in Canada. Each of these changes (Bégin, 1987). On this count, the CHA was a categories will be examined in turn. great success, rolling back almost $247 million in Serious mental disorders are now mainly addressed extra billing and user fees within three years. through drug therapies under the supervision of psy- However, the CHA also entrenched the hospital and chiatrists. Drugless therapies are much less common physician-centred model of medicare by limiting for two reasons. The first relates to the major insured health services covered by the five governing advances in psychotropic drugs over the past 30 years principles of the Act – public administration, univer- and the fact that drug therapy has become the treat- sality, accessibility, portability, and comprehensiveness – ment of choice among psychiatrists. The second is to medically necessary hospital and physician services. that clinical psychologists, who are not permitted to Although the CHA has never blocked the provinces prescribe medication, are rarely consulted in such from providing a broader range of services under cases, in part because they are not part of the
286 Romanow and Marchildon Canadian medicare model, unless hired by hospitals extremely difficult to overcome institutional rigidities or community mental health clinics. Both psycholo- that are, to a considerable extent, the historical legacy gists and psychiatrists can provide psychotherapy but of the Canadian medicare model. in most provinces, psychotherapy is only funded pub- In practice, it is much more feasible to target those licly if provided by physicians, a consequence of a tra- parts of the model that governments have now agreed ditional FFS system, discussed earlier, in which physi- can, and should, be changed as part of an agreed- cian services are automatically covered but psycholo- upon plan of health system reform. Some of this con- gists’ services are not. This is despite the fact that sensus was reflected in the common recommenda- PhD-level clinical psychologists receive far more tions of recent health commission reports in Canada. extensive training and education in psychotherapy The CFHCC went a step further in attempting to deter- than physician-trained psychiatrists (Ontario mine what the general public desired and supported Psychological Association, 2001). Although Canada is in terms of directional change through an innovative similar to many Organization for Economic “citizen’s dialogue” involving a representative sample Cooperation and Development (OECD) countries in of Canadians in 12 day-long deliberative sessions this respect, there are exceptions. In Germany, for (Maxwell, Rosell, & Forest, 2003). To better under- example, psychoanalytical services provided by either stand what would be within the realm of politically psychologists or psychiatrists are covered in the public possible, the CFHCC kept in touch with all provincial system (Canadian Psychoanalytic Society, 2001). and territorial governments as well as aboriginal orga- If diagnosed, less serious, but nonetheless debili- nizations through a formal intergovernmental liaison tating, mental disorders are addressed both inside and as well as informal but high-level contacts with first outside the public system. For such ailments, drugless ministers. The CFHCC final report reflected a judg- therapies provided by psychologists play a correspond- ment on not only the changes that needed to occur ingly larger role. Although the economic benefit of but the reforms that had the most chance of success psychological services has not been fully studied, the given the level of public support in the context of initial results are very encouraging (Hunsley, 2002, what was politically and fiscally feasible. The next step 2003). Indeed, treating depression and various addic- was for governments to act on the basis of the existing tions, as well as anxiety, conduct, mood, and personal- consensus, and a little more than two months follow- ity disorders through cognitive behaviour therapies ing the report, federal, provincial, and territorial first (CBT) and other empirically supported psychological ministers agreed to a basic package of reforms interventions holds considerable promise for the through the Health Accord of February 5, 2003 future (Hunsley, Dobson, Johnston, & Mikail, 1999). (Canadian Intergovernmental Conference Secretariat, In addition, psychologists have been central in treat- 2003). We now turn to the key areas of health system ing stress-exacerbated physical conditions such as reform (relevant to the future of psychological ser- hypertension and ulcerative colitis. Psychologists also vices) that were an integral part of the 47 recommen- play a recognized role in treating the psychological dations made in the CFHCC final report. dimension of physical diseases such as cancer, through group and individual therapies. In addition to their Home Care clinical effectiveness, some of these therapies are also Home care has never been part of the basket of proving to be cost-effective. In a recent study of “insured health services” under the Canada Health Act. female breast cancer patients in Calgary, for example, In many instances, however, health care provided in the availability of group therapy lowered health care the home can be less expensive and more appropriate costs by 24% (Ontario Psychological Association, for an individual than hospital or institutional treat- 2001). ment. In fact, since the 1970s, provinces have been Each of the treatment modalities for mental disor- adding home care services to their respective health ders and the psychological dimensions of physical ill- plans in an effort to improve the continuum of public ness or disability, including drugs, psychotherapy, CBT, health care services and to contain acute care and as well as family and group therapies, have their inher- long-term institutional care costs. The provinces were ent advantages and disadvantages. Moreover, treat- encouraged to continue down this track by the relax- ment effectiveness will also depend on the unique ing of federal transfer conditions with the introduc- needs of the individual being treated. Nonetheless, tion of EPF in 1977. This was more formally recog- for both financial and quality-of-outcome reasons, nized when Ottawa expressly permitted federal trans- there should be, in theory, a far greater availability of fer funding to flow to “noninsured health services” psychological therapies within the public system in the such as home care and long term care as defined future. It needs to be emphasized, however, that it is under the Canada Health Act (1985).
Psychological Services and the Future of Health Care in Canada 287 Today, every province has its own unique set of was becoming clear, as described by the Canadian home care services in place. Unlike hospital and pri- Mental Health Association (2001, p. 8) in its written mary physician care services, the absence of federal submission to the CFHCC: funding tied to legislated conditions or principles per- mits enormous variability in the quality and quantity For many former hospital residents, the new system meant of home care programming, as well as the conditions either abandonment, demonstrated by the increasing of access, across the provinces and territories. numbers of homeless mentally ill people; ‘trans-institu- Moreover, most jurisdictions have little in place to sup- tionalization’: living in grim institution-like conditions port home and community care for individuals with such as those found in the large psychiatric boarding mental disabilities. This stands in stark contrast to the homes; or a return to family who suddenly had to cope provincial infrastructure for institutionalized patients with an enormous burden of care with very little support. with chronic physical and mental disabilities. In addition, fears and prejudices about mental illness, in Indeed, mental asylums, psychiatric hospitals, and part responsible for the long history of segregation in similar institutions were a familiar part of the health institutions, compounded the problems in the community. care landscape in most of Canada long before hospi- talization and medicare. In many cases, these served The current system has some perverse features to “warehouse” a small group of individuals with seri- associated with it. In a recent study of Ontario, for ous mental conditions but did little or nothing for the example, the Canada Mental Health Association many more with less serious conditions. Moreover, in (2001) discovered that people with serious mental dis- terms of the institutionalized patients, the existing sys- orders are generally not eligible for home care in the tem fell short of acute care hospitals in having cura- province unless they have previously been admitted to tive objectives. This led the Hall Commission to state: a hospital: this, despite the fact that effective home “Of all the problems presented before the supports for such individuals may be able to prevent a Commission, that which reflects the greatest public hospital admission in the first place. Moreover, even concern, apart from the financing of health services serious mental disorders are not the chronic, incur- generally, is mental illness” (Canada, 1964, p. 21). In able, conditions once believed, and our knowledge a bid to put mental disorders on the same level as base concerning appropriate and effective interven- physical illness in terms of the organization and provi- tions is growing rapidly (Trainor, Pomeroy, & Pape, sion of services, Hall recommended that mental 1997). health care be integrated into the hospital system by For a broad range of mental disorders, professional adding psychiatric wards and wings to hospitals and home care is much more than simply an alternative to replacing the larger, segregated mental asylums. His institutionalization. It is often an essential element in commission also recommended that the majority of ensuring that a treatment regime (drug or nondrug) children with mental disorders should be treated at is strictly adhered to in order to avoid periodic relaps- home or in the community rather than placed in es and destructive behaviours as well as repeated read- long-term institutional care (Canada, 1964, p. 24). missions to hospital. According to Hollander and However, these recommendations were bypassed to Chappell (2002), very large savings to the public some extent by a major societal shift that would have health care system can be realized by focusing home been difficult to predict by the Hall Commission. mental health services on individuals who generally In the 1960s and 1970s, the deinstitutionalization live well in their communities, but who may have occa- movement took hold in Canada and other advanced sional problems. This is particularly true for individu- industrial countries (Trainor, Pape, & Pomeroy, 1997). als who only rarely exhibit violent behaviour during New psychotropic drug therapies and a new vision of these problem periods but, when they do, are then community psychiatry, along with the cost advantages hospitalized or institutionalized to protect the care- of treatment outside expensive long-term mental insti- givers around them. Currently, intervention, general- tutions, led to the release of many patients back to ly by the police and emergency response units, only home and community environments. But while takes place after the situation boils over and causes provinces invested heavily in paying for the drug ther- damage to both patients and caregivers. This form of apies for these individuals, little was done to improve emergency intervention is costly to society while doing the home and community care infrastructure for indi- little or nothing to improve the quality of lives of viduals with mental disorders in most provinces those most directly affected. despite the fact that this should have also been part of To address this situation, the CFHCC recommended deinstitutionalization (Gatz & Smyer, 1992). By the that two types of home mental health care services be mid-1970s, the negative side of deinstitutionalization the planks in a new national floor. The first was case
288 Romanow and Marchildon management and the second was behavioural inter- atrists in Canada despite the growing demand for vention. In the former, a case manager would work such services. Even in Ontario, which has more than directly with the patient and a range of health care the national average of psychiatrists, there are 7,000 providers and community agencies to monitor the children waiting an average of 6 months for psychi- individual’s health and ensure continuity and coordi- atric services (Canadian Mental Health Association, nation of care with the appropriate supports in place. 2001). This waiting list could be reduced or eliminat- The latter category would involve more systematic ed over time if clinical child psychologists could intervention services to assist and support clients and become an integral part of the public system. their caregivers during periods of disruptive behav- Whether home care will trigger major changes in iour that pose a threat to themselves or their care- the public utilization of psychological services ulti- givers. Clearly, the two services are directly connected mately depends on the precise range of specialized in the sense that it would be almost impossible to have services that provincial governments and (where dele- timely and effective intervention without the case gated) regional health authorities (RHAs) will pay for management infrastructure in place, an infrastructure with public funds. If provinces automatically privilege which is largely absent in most provinces. As a conse- psychiatrists, psychiatric nurses, and nurse practition- quence, of the estimated $568 million annualized cost ers for home-based mental health care, this will leave for mental health home care, almost all ($528 mil- only limited space for specialized clinical psychology lion) would be needed to create a case management services. If, on the other hand, provinces or RHAs fun- infrastructure in Canada (Canada, 2002b). damentally reassess the membership of the home care This reform involves more than a timely crisis team, or allow case managers a significant amount of response, diverting individuals from inpatient hospi- discretion in selecting the professional services most talization. It involves comprehensive monitoring and appropriate to an individual home mental health evaluation by skilled health professionals, at least one client, then much more space for psychological ser- of whom has built up a trusting relationship with the vices will be created. mental health patient and this individual’s caregivers. Part of the solution may lie in determining who the It is a methodology that strives to improve clinical sta- home mental health case managers of the future will tus by preserving, promoting, and restoring mental be and how much they will be paid. There are a num- health. It also involves the active participation of both ber of possibilities that range from nurse and nurse clients and caregivers in treatment and care. practitioners to social workers and psychologists. In the 2003 First Ministers’ Accord on Health Care Although the nursing professions have much training Renewal, the Prime Minister and the Premiers all in health care, social workers are experienced in case agreed to provide full public coverage for “short-term management and the business of co-ordinating a acute home care,” including “acute community men- diverse range of services. Psychologists, in particular tal health” services and case management within the those clinical psychologists with a broad knowledge of next three years (Canadian Intergovernmental the health system, should also be considered. At the Conference Secretariat, 2003). Although the word same time, it must be admitted that there is no perfect “acute” may end up limiting what governments do or professional background for such a role and that no provide, this commitment by all governments likely one provider group has all the skills necessary for a marks the first major step in addressing mental health home mental health care case manager. In this new services since the introduction of medicare decades home care landscape, we require case managers, irre- ago. The question remains, however: What role will spective of label, who are aware of the full breadth of psychological services play in this reform? psychological services, including the advantages and The simplest response by provinces may be to layer disadvantages of alternative therapies (Service, Allon, onto the existing physician-centred approach by allow- & Mikail, 2001). ing the provision of professionally accredited psycho- That said, clinical psychologists may be in the best logical services that are already well recognized by the position to work on a regular basis with such clients if medical professions in the U.S. and Canada. In this they can gain expertise in the nonmental health care regard, Dobson (2001) identifies three specializations: aspects of case management and service co-ordina- clinical psychology, including clinical child psycholo- tion. Moreover, this may be a very cost-effective gy; clinical neuropsychology; and clinical health psy- approach from a provincial government’s (or RHAs) chology. Such an approach could fill in some obvious perspective as well, given the already demonstrated gaps in the current system. It could also be a substi- savings gained through psychological treatment of tute for specialized physician services that are in short anxiety disorders, depression, and borderline person- supply. There are, for example, very few child psychi- ality disorder (Hunsley, 2003). There should be
Psychological Services and the Future of Health Care in Canada 289 ample opportunity for large-scale pilot projects in home care policies and programs are in place that will home care that can be used as a comparative bench- forestall hospital and institutional care, including psy- mark for both cost-effectiveness and quality in home chological assistance for caregivers (Grunfeld, mental health case management. Glossop, McDowell, & Danbrook, 1997). Providing In reality, the amount the public system is willing to care for older individuals suffering mental disabilities pay home care case managers will determine the can exact an enormous psychological toll on family range of possibilities. If case managers are perceived and loved ones. Much of the support for home care to be at the very low end of the skilled professional can actually become support for the caregivers to facil- continuum (as they are now), they will be paid accord- itate their ability to continue to provide high-quality ingly. In such a situation, they are not likely to attract care to loved ones. Moreover, it must be recognized more highly educated professionals such as psycholo- that, at some point, because of the severity of the dis- gists. If, however, such positions are reconfigured as abilities and the difficulty and high cost of continuing high-skill occupations, new possibilities will open up to provide care in the home, the individual may need not only for psychologists but also for other well-edu- to be transferred to an institutional setting. cated professionals. The question is whether we, as a The CFHCC recommendations on home care went society, are willing and/or able to make the public beyond mental health services to include post-acute investment necessary for this to occur. home care and palliative, or end-of-life, care (Canada, The aging of the Canadian population will increase 2002b). These services are also part of the 2003 First the demand for home care for the simple reason that Ministers’ Accord on Health Care Renewal, slated for the incidence of brain disorders – dementia and delir- implementation by 2006 (Canadian Intergovernmen- ium – increases with age. Alzheimer’s alone now tal Conference Secretariat, 2003). In the case of post- accounts for over 50% of dementia cases. The finan- acute home care, the CFHCC recommended that the cial burden imposed by this disease is already sizeable 14 days covered following release from hospital be in advanced industrial societies (Heston & White, extended to 28 days if rehabilitation is involved. 1991; LaRue, Dessonville, & Jarvik, 1985). One Psychologists who specialize in rehabilitation work Canadian study estimated the cost to be $3.9 billion in with patients to speed up recovery, prevent relapse, 1991, slightly over half of which was for long-term and help with the adjustments necessary in the case of institutional care (Ostbye & Crosse, 1994). A recent chronic disability could be critical in the delivery of study using 1994 Canadian data, found that the aver- this service if the recommendation is adopted by the age annual cost of care for an individual suffering provinces (Canadian Mental Health Association, from Alzheimer’s ranges from $9,451 for a mild case, 2001). Services that improve the quality of care while $25,724 for a moderate case, and $36,794 for the saving the public system money will be the most severe type (Hux, O’Brien, Iskedjian, Goeree, immediate impetus for change. Gagnon, & Gauthier, 1998). Another Canadian study In the case of palliative home care, end-of-life found that delirium was associated with 51% of older patients and their loved ones may benefit from psy- patients who had been admitted to hospital, and that chological counseling. This is often the time when patients suffering from both delirium and dementia unresolved issues come to the fore and may cause were at much higher risk of being moved into expen- more suffering if not addressed constructively. More sive long-term institutional care (McCusker, Cole, importantly, as in the case of mental disorders, the Dendukur, Belzile, & Primeau, 2001) than older emotional toll on palliative caregivers is often enor- patients suffering neither condition. mous, in many cases heavier than that faced by a At present, this age group, and those that support dying patient. As Grunfeld, Glossop, McDowell, and their care in the home, do not receive the public ser- Danbrook (1997) point out, the percentage of care- vices they require (Gatz, Karel, & Wolkenstein, 1991). givers suffering anxiety and depression is often For years now, brain disorders of the type described greater than the percentage of terminally ill patients above account for more admissions and hospital inpa- suffering the same difficulties. Thus, for palliative tient days for older individuals than any other condi- home care to be a viable option in the future, the psy- tion in advanced industrial countries (Christie, 1982). chological burden of caregivers must be addressed. Although only a small percentage of people under the Given their education and experience, clinical psy- age of 60 suffer from dementia, approximately 30% of chologists may be in the best position to provide this individuals over 80 years of age do (Heston & White, type of support. 1991). This is a concern given the ever-growing per- For some patients dying from cancer or other dis- centage of the population exceeding that age. We can eases, pain management is a major concern. prepare for Canada’s graying population by ensuring Although drug therapy assists greatly in alleviating
290 Romanow and Marchildon pain, patients might also benefit from some evidence- care team provides a range of broadly defined treat- based psychological therapies aimed at managing ments as well as disease prevention and health educa- chronic pain. These may also prove to be cost effec- tion services. As the first point of contact with the tive. Jacobs (1987, 1988), for example, found that health system, such services would ideally be available treatment of chronic pain conditions produced a sav- 24 hours a day, 7 days a week, with the expertise and ing of $5 for every dollar invested in psychological co-ordinating capacity to refer individuals quickly and treatment. Here again, psychologists have researched effectively for acute and other care when necessary. the impact of chronic pain and have pioneered some As the first line of contact, primary care units, rather of the most important treatment methodologies to than acute care hospitals, should be the central focus cope with such pain. of the health care system (Mikail, McGrath, & Service, Home care is an important illustration of how to 2000). build on the existing medicare model while redefin- As Hutchison, Abelson, and Lavis (2001) note, ing public health care beyond hospitals and primary however, this is easier said than done in a public care physicians. By targeting public resources towards health care system that was historically built upon three very specific aspects of home care – mental publicly insuring an existing pattern of physician-cen- health, post-acute health care, and palliative care – tred primary care. As the current primary health the result can be a catalyst for even more profound gatekeepers to the public system, physicians currently and long-term change in the future. In other words, deal with a host of psychological conditions. this change is a financially and politically feasible first According to one estimate, 60% of the “conditions step that is built upon a public consensus. What presented to primary care physicians are psychologi- remains missing, however, is for such change to be cal, have a psychological component,” or are “highly “locked-in.” The CFHCC recommended that the influenced” by psychological factors. In addition, Canada Health Act be amended to include these partic- although about 40% of high-end primary care users ular home care services so that they become perma- suffer from some form of depression, well over one- nently protected under the principles and conditions half of these individuals receive no treatment for their of the Act (Canada, 2002b). If the federal govern- condition (Ontario Psychological Association, 2001). ment takes this step, medicare will forever have to be Stress and other conditions that substantially increase defined beyond hospitals and primary care physicians. medical costs often go untreated (Saskatchewan Until then, any progress on the home care front is Psychological Association, 2001). This focus on physi- more easily reversed. In this sense, the CFHCC judged cian care in the Canadian model reduces quality for that the risk of opening the CHA was less than the patients and may be costly for provincial health plans. opportunity of using the legislation to reshape the Aside from the Canadian system’s focus on hospital Canadian model of medicare. and physician care, other barriers to primary care change include: increasing professional specialization Primary Health Care Reform and protection of turf; fragmented health care deliv- Changes in the organization and delivery of prima- ery; marginalized health promotion activities and ill- ry health care services are pivotal to the future sustain- ness prevention services; limited patient empower- ability and quality of the public system in Canada. ment; and a lack of health information (Canada 2002, The concept is simple. As a society, we should invest p. 119). Consistent with recent provincial and federal more in front-end health services aimed at reducing reports (Alberta, 2001; Québec, 2000; National Forum the demand for illness care services at the back end. on Health, 1997; Saskatchewan, 2001; Senate, 2002), As well as early detection of illness, these services the CFHCC recommended a less fragmented approach involve health promotion and disease prevention, to primary health care. Given the vast and diverse which, in turn, should include managing stress, anger, nature of the country, as well as the very different and chronic disease, improving parenting and caregiv- needs, organizations, and providers available in differ- er skills, and ending addictions such as smoking ent communities, the CFHCC did not propose a single (Ontario Psychological Association, 2001). model or approach as the final solution to achieving a Although there has long been agreement among reformed primary care system. Instead, it proposed, health policy experts on this proposition, most gov- in order of priority, four essential building blocks that ernment efforts over the last three decades to change must be put in place for any given approach to suc- the nature of primary delivery have had limited ceed: 1) continuity and co-ordination of care; 2) early impact. The purpose of most of the reforms was to detection (including prevention) and action; 3) better move from a physician-centred, fee-for-service, deliv- information flow concerning needs and outcomes for ery model to one in which a multidisciplinary health both providers and patients; and 4) new and stronger
Psychological Services and the Future of Health Care in Canada 291 incentives so that providers are encouraged to provide priate to the individual. In this sense, the current more comprehensive and integrated care. These four trend towards increasing professional specialization building blocks were also accepted as the “key” to an within psychology may actually work against the feasi- “effective primary health care system” in the 2003 First bility of providing primary care through such a Ministers’ Accord on Health Care Renewal (Canadian methodology. In addition, the tendency to jealously Intergovernmental Conference Secretariat, 2003). guard the “scope of practice” within any old (e.g., psy- The first building block would, as in home care, chiatry) or new (e.g., clinical psychology) specializa- likely require case managers to guide individuals tion can be a formidable barrier to change. To create through the health care system and co-ordinate their the primary health care teams of the future, it will be care services. Although a truncated version of this essential to draw on the broadest possible range of role is currently occupied by primary care physicians, health-provider skills and knowledge. one recent Health Transition Fund project in primary care demonstrated that the case manager of the Prescription Drug Therapies and Future Options future need not be a physician or nurse as long as As in other OECD countries, prescription drug ther- access to those providers can be assured (Durand, apies have become a major part of the Canadian Tourigny, Bonin, Paradis, Lemay, & Bergeron, 2001). health care system. As is the case with home care, pre- Whether some psychologists could ever work as case scription drug therapy is not an insured health service managers in a reconfigured primary care setting under the CHA. Nonetheless, because of the growing would depend on factors similar to those discussed importance of drugs in medical treatment, every above in relation to home care. This would certainly province and territory has created its own drug plan require knowledge and experience beyond a narrow to provide public coverage for defined prescription specialization. Unlike home care, however, remunera- drugs to certain classes of individuals. For the most tion for case managers should be less of an issue given part, these plans supplement existing private insur- that primary care physicians currently act as de facto ance plans, which are primarily employer-based in case managers in the current system, and most receive Canada. As is the case with home care, provincial and incomes that exceed those of the majority of practic- territorial drug plans vary considerably by jurisdiction. ing psychologists. Scientific breakthroughs, combined with intensive The more plausible scenario is for psychologists to research and development activities by pharmaceuti- become full-fledged members of the multidisciplinary cal companies, have produced a wealth of prescrip- primary health care teams of the future. In this tion and over-the-counter ( OTC ) drugs that now regard, the Prime Minister and the Premiers have accompany medical treatments, as well as substitute committed their governments to provide all for older treatments and interventions, including Canadians with access to 24-hour a day, 7 days a week, surgery. Based on Québec data, the following six cate- care from “multidisciplinary health care organizations gories of pharmaceuticals now account for over 50% or teams,” with one-half of their respective popula- of total spending in provincial drug plans: lipid reduc- tions to have access to this reconfigured type of prima- tion, antihypertensives, antiinflammatories (anal- ry health care within 8 years (Canadian Inter- gesics), gastrointestinal, antiinfectives, and psy- governmental Conference Secretariat, 2003, p. 3). In chotropic (Québec, 2001). this respect, psychologists already enjoy a comparative These pharmaceutical categories are largely advantage due to their “specific training in interper- responsible for the surge in public and private drug sonal, group and workgroup dynamics that help them spending in Canada, the fastest growing sector of work collaboratively with colleagues as team mem- health expenditures for the last two decades. In 1980, bers” (Canadian Psychological Association, 2001, p. prescription drug expenditures represented 5.8% of 2). total (public and private) health expenditures in Going beyond the referral system, which lies at the Canada. By 2001, this prescription drug share had heart of the curative medical model, the future prima- risen to 12% (Canadian Institute for Health ry health care team will not only diagnose, treat, and Information, 2001, 2002). Combined spending on rehabilitate a given roster of patients, but will take prescription and OTC drugs now surpasses total proactive steps to prevent illness or disease, provide spending on physician services in Canada. Inferring public health services, and promote health through again from Québec data, prescription drug costs have education. Although team members gain entry into grown by almost 60% from 1997 to 2000. By far, the such teams by virtue of their specialized education fastest growing pharmaceuticals are psychotropic and training, they work as general health care practi- drugs, which grew by an astounding 115.4% during tioners providing the advice and services most appro- the same period (Québec, 2001).
292 Romanow and Marchildon Many would argue that such rates of growth are physical illnesses and disabilities (Canadian unsustainable for the provincial drug plans that have Psychological Association, 2001). been underwriting 44% of total prescription drug The profession of psychology seems to be divided costs based on a national average of 1999 data on a related issue. Some would like to see clinical psy- (Canadian Institute for Health Information, 2002). chologists receive prescription privileges in Canada. They may also be unsustainable in the long run for They point to the efforts in certain American territo- private insurance plans, which cover approximately ries and states that have resulted in some psychologists 34% of total prescription drug outlays, as well as for being permitted to write prescriptions for their individual Canadians, who pay out-of-pocket for 22% patients or clients. Others oppose the idea of the pro- of these drugs. Concerns have also been raised about fession having prescription privileges, emphasizing inaccurate prescribing and inappropriate utilization the efficacy of drugless treatment modalities (Dozois behaviours that are detrimental to the health of & Dobson, 1995). Given the cost pressure of current Canadians. drug plans, however, it is almost inconceivable that The more fundamental question is whether the any provincial government would allow another pro- existing health care system is, as a general rule, overly fession to write prescriptions for fear that this would weighted toward drug therapies as opposed to drug- drive up consumption and costs. The stronger argu- less alternatives. There is some evidence to support ment in an environment of scarce resources is that the the proposition that some nondrug psychological drugless therapies provided by psychologists are both therapies may be just as effective as drug therapies. In less costly and more effective than the prescription one study of severely depressed outpatients, nondrug drug alternatives. Research in this area should take cognitive behaviour therapy (CBT) was directly com- on greater importance. As a society, we allocate enor- pared to antidepressant medication, the most com- mous resources to pharmaceutical research, mainly mon therapy recommended by psychiatrists. The out- through the private sector. This could be offset by a comes associated with the use of CBT for very severely combination of increasing public and private funding depressed individuals were as positive as antidepres- for research into drugless therapies. Moreover, this sant drug therapy (DeRubeis, Gelfard, Tang, & research must include cost effectiveness as well as clin- Simons, 1999). This points out the need for more ical effectiveness. research in light of the fact that Canada may be on an unsustainable prescription drug trajectory if current Rural, Remote, and Aboriginal Health prescription and utilization patterns persist. In terms and Health Care of cost, virtually every provincial drug plan is under The CFHCC also proposed major change in terms immense strain due to growing demand and the rapid of rural, remote, and Aboriginal populations that introduction of new and costly prescription drugs. could have some bearing on the future deployment of Some provinces have responded by reducing public psychological services. Canada has an immense geog- coverage. In terms of patient safety and health quality raphy with a rural and remote population dispersion outcomes, serious concerns have been raised about that is more extreme than any OECD country by a con- the knowledge base of some primary care physicians siderable margin. Not only is it expensive and diffi- as well as the medical profession’s overall emphasis on cult to provide health and health care services within drug treatment versus drugless alternatives. reach of these populations, but many types of health Psychological services may provide one part of the providers are in chronic short supply. In addition, the solution to the future sustainability of prescription needs of Canada’s rural and remote populations are drug plans – both public and employment-based plans greater than their urban counterparts. Both physical – as well as providing treatment modalities that actual- illness and mental disorders are more prevalent in the ly improve patient safety and health outcomes. rural, remote, and northern parts of Canada, an At a minimum, patients should be made aware of unsurprising result given the high correlation alternative treatments in such cases. These will gener- between the two (McIlwraith & Dyck, 2002). ally come down to three options: first, drug therapy Despite the prevalence of mental health problems alone; second, psychological (including cognitive in rural and remote regions, there are very few psychi- behaviour therapy and other psychotherapies) treat- atrists practicing outside urban areas. Of the 3,600 ment combined with drug therapy; and third, psycho- psychiatrists in Canada, for example, not one resides logical treatment alone. There is supporting evidence in the Yukon, according to the Canadian Mental concerning the effectiveness of psychological treat- Health Association (2001). Drawing from a larger ment for anxiety, depression, panic disorder, anger, pool of psychologists to provide mental health services and stress, as well as for coping with cancer and major in rural and remote communities could potentially
Psychological Services and the Future of Health Care in Canada 293 address the chronic shortage of psychiatrists. tion, often by location (e.g., hospital) or the profes- However, psychologists are also concentrated in urban sion delivering the services (e.g., primary-care physi- areas, generally in close proximity to university and cians). Reconstructing health care for the 21st centu- health-related research infrastructures. As is the case ry requires moving away from this simple categoriza- with all health provider professions, the ability to tion approach to a more complex assessment of alter- attract individuals who have grown up in such rural native treatments based upon proven evidence of and remote communities into the psychological pro- quality and cost outcomes, the ground work for which fession may be the determinative factor. One example has now begun (McEwan & Goldner, 2001). of such a successful program for recruitment and One potential area to begin with is for one or more retention is provided by the Rural Psychology and jurisdictions to experiment with limiting public fund- Post-Doctoral Residency Program at the Health ing to empirically supported treatments. For psychol- Science Centre in Winnipeg (Saskatchewan ogists to be “in the running,” as Hunsley, Dobson, Psychological Association, 2001). Johnston, and Mikail (1999) point out, this would Sixty-five per cent of aboriginal people live in areas require psychologists to develop treatment lists and defined as rural by Statistics Canada. More signifi- practice guidelines for a host of mental health ser- cantly, the rate of suicide among Aboriginal peoples is vices. Without doubt, there are public health care ser- eight times the national average (Canada, 1994). vices offered by psychologists that are substitutes for Clearly, there is a need for services that could be pro- the services offered by other professions. But there vided by psychologists with some broader cultural are many more unique services offered by psycholo- understanding and sensitivity. More importantly, this gists, some of which can play a critical role in improv- should indicate the need for psychologists of ing the quality of the system and ensuring its sustain- Aboriginal ancestry and the great opportunity to be ability into the future. obtained by university psychology departments to attract Aboriginal students in a very proactive way. Correspondence concerning this manuscript should be Funding here should not be an issue given ongoing addressed to Gregory P. Marchildon, Faculty of Admi- federal funding that is available to universities, col- nistration, University of Regina, Regina, Saskatchewan, leges, and other organizations that establish programs Canada S4S 0A2 (E-mail: firstname.lastname@example.org). and processes to increase the participation of Aboriginal students in courses leading to professional health careers (Canada, 2002b). In the CFHCC consultations, many Aboriginal peo- Résumé ple expressed their belief in a more traditional, spiri- Les répercussions découlant des recommandations issues tually based and holistic approach to health and de la Commission sur l'avenir des soins de santé au health care. The approaches suggested – from heal- Canada (CASSC) vont bien au-delà de la portée, par ing circles to the use of native herbal therapies – are nécessité limitée, du rapport qui en a émané. Le présent worth careful examination by psychologists. Through article explore le rôle possible que pourraient jouer les such research, many non-Aboriginal Canadians might psychologues dans un système de soins de santé public benefit from this Aboriginal knowledge. restructuré, qui déborderait les soins hospitaliers et médi- caux pour gagner les soins à domicile et un système de Conclusion soins primaires remanié. Les régimes publics de soins de The future sustainability of public health care in santé pourraient également bénéficier du recours aux Canada depends on the effective marshalling and allo- approches psychologiques comme solutions de rechange à cation of scarce public resources. Costs must be man- la pharmacothérapie. Un tel élargissement du modèle aged while constantly working to improve outcomes in canadien existant, fondé sur l’expérience clinique, pour- both population health and health care. To avoid a rait améliorer à la fois les résultats cliniques et les résultats fate similar to many managed care organizations in médicaux. Ces résultats pourraient à leur tour permettre the United States, it is not enough to simply contain aux régimes de soins médicaux provinciaux, qui sont costs without regard to outcomes. Instead, provincial soumis à des pressions financières énormes, de réaliser de health plans should be focused “cost-efficient inter- nouvelles économies. ventions with demonstrable outcomes” (Hunsley, Dobson, Johnston, & Mikail, 1999). Certain psycho- References logical services meet this criterion but the decisions Alberta (2001). A framework for reform. Report of the premier’s concerning public coverage, and the priorities within advisory council on health. Edmonton, AB: Premier’s public coverage, remain based on service categoriza- Advisory Council on Health
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