15 - Casemix systems – past, present, and future: The Canadian experience

Summary

Introduction

Canada, with a population of over 32 million, is a democratic federation consisting of ten provinces and three territories (spread over almost ten million square kilometers – comprised of very large rural / northern sparsely-populated regions).

Canada has a national health insurance program, often referred to as “Medicare,” which is designed to ensure that all residents have reasonable access to medically necessary hospital and physician services, on a prepaid basis. Instead of having a single national plan, Canada has a national program, composed of thirteen interlocking provincial and territorial health insurance plans, all of which share certain common features and basic standards of coverage. Roles and responsibilities for Canada's health care system are shared between the federal and provincial / territorial governments.

While provincial and territorial governments are responsible for the actual management, organization and delivery of health services for their residents, the Canada Health Act (CHA), Canada's federal health insurance legislation, outlines five key principles that provinces and territories must meet through their health insurance plans to qualify for full federal funds under the Canada Health Transfer (CHT).

Canada Health Act Principles

1. Public administration: Health insurance plans are administered and operated on a non-profit basis by a public authority responsible to provincial and territorial governments.

2. Comprehensiveness: Provincial and territorial health insurance plans must cover all health services insured under the Act (mostly physician and hospital services) and, where permitted, services rendered by other health care practitioners.

3. Universality: Every eligible resident of a province or territory is entitled to insured health services covered by the insurance plans. Residents are generally required to register with the plans in order to get coverage. […]