ArrowArrow IconLightbulbLightbulb IconLightbulbLarge Lightbulb IconBriefcaseBriefcase IconBriefcaseLarge Briefcase IconSurveySurvey IconStroke 1ClipboardClipboard IconClipboardLarge Clipboard IconConvergeConverge IconConvergeLarge Converge IconExpandExpand IconFacebookFacebook IconFeaturesFeatures IconCountryCountry IconFlowchartFlowchart IconFlowchartLarge Flowchart IconStrategyStrategy IconStrategyLarge Strategy IconGovernmentGovernment IconGovernmentGovernment IconInfoInfo IconIntegrationIntegration IconIntegrationLarge Integration IconArrow Pagination LeftPeoplePeople IconPeoplePeople IconStatsStats IconPhonePhone IconPhoneLarge Phone IconFeaturesFeatures IconTagTag IconTagLarge Tag IconTwitterTwitter Icon

The Canadian Health Care System

by Sara Allin and David Rudoler, University of Toronto & Centre for Addiction and Mental Health

What is the role of government?

Provinces and territories in Canada have primary responsibility for organizing and delivering health services and supervising providers. Many have established regional health authorities that plan and deliver publicly funded services locally. Generally, those authorities are responsible for the funding and delivery of hospital, community, and long-term care, as well as mental and public health services. The federal government cofinances provincial and territorial programs, which must adhere to the Canada Health Act (1985), which in turn sets standards for “medically necessary” hospital, diagnostic, and physician services.1 The act states that to be eligible to receive full federal cash contributions for health care, each provincial health care insurance plan needs to be: publicly administered, comprehensive in coverage, universal, portable across provinces, and accessible (for example, without user fees).

The federal government also regulates the safety and efficacy of medical devices, pharmaceuticals, and natural health products; funds health research; administers a range of services for certain populations, including First Nations, Inuit, members of the Canadian Armed Forces, some veterans, resettled refugees and some refugee claimants, and inmates in federal penitentiaries; and administers several public health functions.

Who is covered and how is insurance financed?

Publicly financed health care: Total and publicly funded health expenditures were forecast to account for an estimated 11.1 percent and 8.0 percent of GDP, respectively, in 2016; by that measure, 69.8 percent of total health spending comes from public sources.2 The provinces and territories administer their own universal health insurance programs, covering all provincial and territorial residents in accordance with their own residency requirements.3 Temporary legal visitors, undocumented immigrants, those who stay in Canada beyond the duration of a legal permit, and those who enter the country “illegally,” are not covered by any federal or provincial program, although provinces and territories provide some limited services.

The main funding sources are general provincial and territorial spending, which was forecast to constitute 93 percent of public health spending in 2016.4 The federal government contributes cash funding to the provinces and territories on a per capita basis through the Canada Health Transfer, which will total an estimated CAD36 billion (USD28.8 billion) in 2016–2017, accounting for an estimated 24 percent of total provincial and territorial health expenditures.5

Private health insurance: Private insurance, held by about two-thirds of Canadians, covers services excluded from public reimbursement, such as vision and dental care, prescription drugs, rehabilitation services, home care, and private rooms in hospitals. In 2014, approximately 94 percent of premiums for private health plans were paid through employers, unions, or other organizations under a group contract or uninsured contract (by which a plan sponsor provides benefits to a group outside of an insurance contract).6 In 2014, private insurance accounted for approximately 12 percent of total health spending.7 The majority of insurers are for-profit.

What is covered?

Services: To qualify for federal financial contributions under the Canada Health Transfer, provincial and territorial insurance plans must provide first-dollar coverage of medically necessary physician, diagnostic, and hospital services (including inpatient prescription drugs) for all eligible residents. There is no nationally defined statutory benefit package; most public coverage decisions are made by provincial and territorial governments in conjunction with the medical profession. Provincial and territorial governments’ insurance plans provide varying levels of additional benefits, such as outpatient prescription drugs, nonphysician mental health care, vision care, dental care, home care, and hospice care. They also provide public health and prevention services (including immunizations) as part of their public programs.

Cost-sharing and out-of-pocket spending: There is no cost-sharing for publicly insured physician, diagnostic, and hospital services. User fees for ambulance services vary considerably across provinces.8 All prescription drugs provided in hospitals are covered publicly, with outpatient coverage varying by province or territory. Physicians are not allowed to charge patients prices above the negotiated fee schedule. In 2014, out-of-pocket payments represented about 14 percent of total health spending, going mainly toward prescription drugs (21%), nonhospital institutions, mainly long-term care homes (22%), dental care (16%), vision care (9%), and over-the-counter medications (10%).9

Safety nets: Cost-sharing exemptions for noninsured services such as prescription drugs vary among provinces and territories, and there are no caps on out-of-pocket spending. For example, Ontario administers a universal prescription drug program for seniors and social assistance recipients10 that includes copayments and deductibles.11 There are no caps on out-of-pocket spending. However, the federal Medical Expense Tax Credit supports tax credits for individuals whose medical expenses, for themselves or their dependents, are significant.12,13

How is the delivery system organized and financed?

Primary care: In 2015, there were 2.28 practicing physicians per 1,000 population, about half of whom were general practitioners, or GPs (1.15 per 1,000 population), and the rest specialists (1.13 per 1,000 population).14 Primary care physicians act largely as gatekeepers, and many provinces pay lower fees to specialists for non-referred consultations. Most physicians are self-employed in private practices and paid fee-for-service, although there has been a movement toward group practice and alternative forms of payment, such as capitation. In 2014–2015, fee-for-service payments made up 45 percent of payments to GPs in Ontario, compared with 68 percent in Quebec and 84 percent in British Columbia.15 In 2014, 46 percent of GPs reported to work in a group practice, 19 percent in an interprofessional practice, and 15 percent in a solo practice.16

Patients have free choice of primary care doctor. The requirement for patient registration varies.17 Clinical fee-for-service payments to primary care physicians in Canada averaged CAD271,417 (USD217,134) in 2014–2015.18 In several provinces, networks of GPs work together and share resources, with variations across provinces in the composition and size of teams.

Provincial and territorial ministries of health negotiate physician fee schedules (for primary and specialist care) with provincial and territorial medical associations. In some provinces, such as British Columbia and Ontario, payment incentives have been linked to performance.19

Outpatient specialist care: The majority of specialist care is provided in hospitals, although there is a trend toward providing services in private nonhospital facilities. Specialists are mostly self-employed and paid fee-for-service, although there is variation across provinces.20 Specialists in Canada received an average of CAD370,091 (USD296,073) annually in clinical fee-for-service payments in 2014–2015.21 In most provinces, specialists have the same fee schedule as primary care physicians. In 2014, 65 percent of specialists reported to work in a hospital, compared with 24 percent in a private office or clinic.22 Patients can choose, and have direct access to, a specialist, but it is common for GPs to refer patients to specialty care. Specialists who work in the public system are not permitted to receive payment from private patients for publicly insured services. There are few formal multispecialty clinics.

Administrative mechanisms for paying primary care doctors and specialists: The majority of physicians and specialists bill provincial governments directly, although some are paid a salary by a hospital or facility. There are no direct payments from patients to physicians; there is no cost-sharing, although patients may be required to pay for services that are not medically necessary.23

After-hours care: After-hours care is provided generally by physician-led (and mainly privately owned) walk-in clinics and by hospital emergency rooms. In most provinces and regions, a free telephone service (“telehealth”) is available 24 hours a day for health advice from a registered nurse. Traditionally, primary care physicians were not required to provide after-hours care, although many of the government-enabled group practice arrangements have requirements or financial incentives for providing after-hours care to registered patients.24 In 2015, 48 percent of primary care physicians in Canada (67% in Ontario) reported having arrangements for patients to see a doctor or nurse after hours.25

Hospitals: Hospitals are a mix of public and private, predominantly not-for-profit, organizations, often managed locally by regional authorities or hospital boards representing the community. In provinces with regional health authorities, many hospitals are publicly owned,26 whereas in other provinces, such as Ontario, they are predominantly private nonprofit corporations.27 There are no data on the number of private for-profit clinics (which are mostly diagnostic and surgical).28

Hospitals in Canada generally operate under annual global budgets, negotiated with the provincial or territorial ministry of health or regional health authority. However, several provinces, including Ontario, Alberta, and British Columbia, have considered introducing activity-based funding for hospitals.29 Hospital-based physicians generally are not hospital employees and are paid fee-for-service directly.

Mental health care: There is universal coverage for physician-provided mental health care, along with a fragmented system of allied services. Hospital mental health care is provided in specialty psychiatric hospitals and in general hospitals with mental health beds. The provinces and territories all provide a range of community mental health and addiction services including case management, help for families and caregivers, community-based crisis services, and supportive housing.30,31 Psychologists may work privately and are paid out-of-pocket or through private insurance, or under salary in publicly funded organizations. Mental health has not been formally integrated into primary care; any coordination or colocation of mental health services with primary care is unique to its particular practice. In Ontario, an inter-sectoral mental health strategy has been in place since 201132 and was expanded in 201433 to better integrate mental health care into primary care.

Long-term care and social supports: Long-term care and end-of-life care provided in nonhospital facilities and in the community are not considered insured services under the Canada Health Act.34 All provinces and territories fund services, but coverage varies among and within them. All provinces provide some nursing home care and some combination of case management and nursing care for home care clients, but there is considerable variation when it comes to other services, including medical equipment, supplies, and home support, and many jurisdictions require client contributions.35 About half of the provinces and territories provide some home care without means-testing, but access may depend both on assessed priority and on availability within capped budgets.36

Eligibility criteria for home and institutional long-term care services generally include a needs assessment based on health status and functional impairment. Some provinces have established minimum residency periods as an eligibility condition for facility admission. Spending on nonhospital institutions, of which the majority are long-term care facilities, accounted for just under 11 percent of total health expenditure in 2015, with financing mostly from public sources (70%).37

A mix of private for-profit (44%), private not-for-profit (30%), and public facilities (27%) provide facility-based long-term care.38 Public funding of home care is provided either through provincial or territorial government contracts with agencies that deliver services or through government stipends to patients to purchase their own services.39

Provinces and territories are responsible for delivering palliative and end-of-life care in hospitals, where the majority of such costs occur. But many provide some coverage for services outside those settings, such as doctors, nurses, and drug coverage in hospices, in nursing facilities, and at home.

Support for informal caregivers (estimated to provide 66% to 84% of care to the elderly) varies by province and territory.40 In Ontario, for example, the Family Caregiver Leave Bill offers job protection to caregivers. There are also some federal programs, including the Family Caregiver Tax Credit and the Employment Insurance Compassionate Care Benefit.41

diagram of health care system

What are the key entities for health system governance?

Because of the high level of decentralization, provinces have primary jurisdiction over administration and governance of their health systems. The federal ministry of health, Health Canada, plays a role in the following: promoting overall health; funding and delivery of certain health services for First Nations and Inuit; food and drug safety; and medical device and technology review. The Public Health Agency of Canada is responsible for public health, emergency preparedness and response, and infectious and chronic disease control and prevention.

At the national level, several intergovernmental nonprofit organizations aim to improve governance by monitoring and reporting on health system performance; disseminating best practices in patient safety (the Canadian Patient Safety Institute); providing information to the public on health and health care and standardizing health data collection (the Canadian Institute for Health Information); and providing funding and support for provincial health information systems (Canada Health Infoway). The Canadian Agency for Drugs and Technologies in Health oversees the national health technology assessment process, which produces information about the clinical effectiveness, cost-effectiveness, and broader impact of drugs, medical technologies, and health systems. The agency’s Common Drug Review reviews the clinical effectiveness and cost-effectiveness of drugs and provides common, nonbinding formulary recommendations to the publicly funded provincial drug plans (except in Quebec) to support greater consistency in access and evidence-based resource allocation.

Nongovernmental organizations with important roles in system governance include professional organizations such as the Canadian Medical Association; provincial regulatory colleges, which are responsible for licensing professions and developing and enforcing standards of practice; and Accreditation Canada (see below). Most providers are self-governing under provincial and territorial law; they are registered with professional associations that ensure that education, training, and quality-of-care standards are met. The professional associations for physicians are also responsible for negotiating fee schedules with the provincial ministries of health. Most provinces have an ombudsperson providing patient advocacy.

What are the major strategies to ensure quality of care?

Many provinces have agencies responsible for producing health care system reports and for monitoring system performance, and many quality improvement initiatives take place at the provincial and the territorial level.42 The use of financial incentives to improve quality is limited. At the physician level, these have had little demonstrable effect on quality to date.43 Professional revalidation for physicians, including requirements for continuing education and peer review, varies across provinces.

The federally funded Canadian Patient Safety Institute promotes best practices and develops strategies, standards, and tools. The Optimal Use Projects program, operated by the Canadian Agency for Drugs and Technologies in Health, provides recommendations (though not formal clinical guidelines) to providers and consumers to encourage the appropriate prescribing, purchasing, and use of medications. The Canadian Institute for Health Information produces regular public reports on health system performance, including indicators of hospital and long-term care performance. To date, there is no information available on doctors’ performance. The federally funded Canadian Foundation for Healthcare Improvement works with the provinces and territories to implement performance improvement initiatives, recently, for example, to reduce inappropriate prescribing for seniors in long-term care facilities.44 Accreditation Canada—a not-for-profit organization—provides noncompulsory accreditation services to about 1,200 health care organizations across Canada, including regional health authorities, hospitals, long-term care facilities, and community organizations.

Provincial cancer registries feed data to the Canadian Cancer Registry, a national administrative survey that tracks cancer incidence. There is no national patient survey, although a standardized acute-care hospital inpatient survey developed by the Canadian Institute for Health Information has been implemented in several provinces. Each province has its own strategies and programs to address chronic disease (see below). The provinces’ and territories’ premiers established the Health Care Innovation Work Group in 2012 to improve quality, for example, to promote guidelines for treating heart disease and diabetes and to reduce costs.45

What is being done to reduce disparities?

The Public Health Agency of Canada includes in its mandate reporting on health disparities, and the Canadian Institute for Health Information also reports on disparities in health care and health outcomes, with a focus on lower-income Canadians.46 No formal and periodic process exists to measure disparities; however, several provincial or territorial governments have departments and agencies devoted to addressing population health and health inequities.

Aboriginal health is a concern for federal as well as provincial and territorial governments. The 2016 federal budget47 included CAD8.4 billion (USD6.7 billion) over a five-year period earmarked for services for indigenous people, including education, environment (e.g., water quality), and health and social services. In Ontario, a new strategy to improve the health of indigenous people was launched in 2016, with emphasis on investments in primary care, cultural competency training for health care providers, access to fresh fruit and vegetables, and mental health services for youth for First Nations.48 In 2008, the Truth and Reconciliation Commission was established to collect stories regarding the events and effects of the Indian Residential School legacy. In 2015, the commission ended its mandate, releasing a series of calls to action including several to address health disparities affecting Aboriginal communities.49

What is being done to promote delivery system integration and care coordination?

Provinces and territories have introduced several initiatives to improve integration and coordination of care for chronically ill patients with complex needs. These include Divisions of Family Practice (British Columbia),50 the Regulated Health Professions Network (Nova Scotia), and Health Links (Ontario). Also, Ontario has long-standing alternative community-based and multidisciplinary primary care models including Community Health Centres and Aboriginal Health Access Centres. Also in Ontario, a pilot program that bundles payments across different providers is being expanded (from one to six communities) to improve coordination of care for patients as they transition from hospital to the community.51,52

Each province determines its own structure for the coordination of health and social care services.53 In Ontario and Quebec, there is a single ministry responsible for health care that includes long-term and social care, with funding devolving to the regional level.

What is the status of electronic health records?

Uptake of health information technologies has been slowly increasing in recent years. Provinces and territories are responsible for developing their own electronic information systems, with support from Canada Health Infoway; however, there is no national strategy for implementing electronic health records and no national patient identifier. According to Canada Health Infoway, provinces have systems for collecting data electronically for the majority of their populations.54 However, interoperability is limited.55 In 2014, 42 percent of GPs reported using exclusively electronic records to enter and retrieve patient clinical notes, and 38 percent used a combination of paper and electronic charts.56 In the same survey, 87 percent of GPs report that their patients are not able to access their personal health record for any function, and only 6 percent reported that patients can request appointments online.

How are costs contained?

Costs are controlled principally through single-payer purchasing, and increases in real spending mainly reflect government investment decisions or budgetary overruns. Cost-control measures include mandatory global budgets for hospitals and regional health authorities, negotiated fee schedules for providers, drug formularies, and resource restrictions vis-à-vis physicians and nurses (e.g., provincial quotas for students admitted annually), as well as restrictions on new investment in capital and technology. The national health technology assessment process is one of the mechanisms for containing the costs of new technologies (see above).

The federal Patented Medicine Prices Review Board, an independent, quasi-judicial body, regulates the introductory prices of new patented medications. The board regulates “ex-factory” prices but does not have jurisdiction over wholesale or pharmacy prices, or over pharmacists’ professional fees. Since 2010, the Pan-Canadian Pharmaceutical Alliance57 has negotiated lower prices for 95 brand-name medications and has set price limits at 18 percent of equivalent brand-name drugs for the 15 most common generics.58 Notwithstanding this pan-Canadian collaboration, jurisdiction over prices of generics and control over pricing and purchasing under public drug plans (and, in some cases, pricing under private plans) are held by provinces, leading to some interprovincial variation. The “Choosing Wisely Canada” campaign provides recommendations to governments, providers, and the public on reducing low-value care.59

What major innovations and reforms have been introduced?

In June 2016, the federal government introduced legislation that amended the criminal code to allow eligible adults to request medical assistance in dying from a physician or nurse practitioner.60

Provincial health system governance: Provinces and territories continue to implement structural reforms to improve efficiency. For example, in August 2016 the new Northwest Territories Health and Social Services Authority became operational, consolidating eight former regional authorities to improve care coordination across health and social services.61 In June 2016, Ontario announced a proposal to transfer responsibility for the contracting and coordination of home and community care from Community Care Access Centres to the Local Health Integration Networks. The provincial government also announced it will increase the integration of primary care and public health within health regions.62

References

1Canada Health Act, RSC 1985, c. C-6.

2Canadian Institute for Health Information (CIHI), National Expenditure Trends 1975–2016 (Canadian Institute for Health Information, 2016).

3Health Canada, Canada Health Act Annual Report 2012–2013, (Minister of Health of Canada, 2013).

4CIHI, National Expenditure Trends.

5CIHI, National Expenditure Trends; Government of Canada, Federal Support to Provinces and Territories, www.fin.gc.ca/fedprov/mtp-end.asp (2015). Please note that, throughout this profile, all figures in USD were converted from CAD at a rate of about CAD1.25 per USD, the purchasing power parity conversion rate for GDP in 2015 reported by OECD (2016) for Canada.

6Canadian Life and Health Insurance Association Inc., Canadian Life and Health Insurance Facts. clhia.uberflip.com/i/563156-canadian-life-and-health-insurance-facts, 2015.

7CIHI, National Expenditure Trends.

8CBC, Marketplace Blog, “How Much Are Ambulance Fees in Your Area?” (map), www.cbc.ca/marketplace/blog/map-ambulance-fees; accessed Aug. 26, 2016.

9CIHI, National Expenditure Trends.

10Ontario Ministry of Health and Long-Term Care, Ontario’s Drug Plans: How Much Do I Pay? www.health.gov.on.ca/en/public/programs/drugs/programs/odb/opdp_pay.aspx, 2016; accessed Aug. 23, 2016.

11Seniors pay a CAD6.11 (USD5.00) copayment per prescription and CAD100 (USD80) annual deductible, but low-income seniors and social assistance recipients are exempt from all cost-sharing except for a CAD2.00 (USD1.60) copayment, which is often waived by pharmacies. In August 2016, the low-income threshold for seniors was increased for the first time since cost-sharing was introduced in Ontario in 1996. The threshold is set at an annual income of less than or equal to CAD19,300 (USD15,440) for single people and less than or equal to CAD32,300 (USD25,840) for couples.

12Canada Revenue Agency, lines 330 and 331—“Eligible medical expenses you can claim on your return.” www.cra-arc.gc.ca/medical; accessed Aug. 26, 2016.

13Above 3 percent of income or over $2,208 (USD1,766), whichever is less.

14Canadian Institute for Health Information (CIHI), Supply, Distribution and Migration of Canadian Physicians (Canadian Institute for Health Information, 2016).

15CIHI, National Physician Database, 2014–2015 (Canadian Institute for Health Information, 2016).

16College of Family Physicians of Canada, Canadian Medical Association, and Royal College of Physicians and Surgeons of Canada, National Physician Survey, 2014, accessed Aug. 26, 2016.

17In Ontario, some new primary care teams paid partly by capitation must require patients to register to receive those partial payments; otherwise, registration is not required.

18CIHI, National Physician Database.

19Ontario Ministry of Health and Long-Term Care, Billing & Payment Guide for Family Health Organization (FHO) Physicians (2014); M. R. Lavergne, M. R. Law, S. Peterson et al., “A Population-Based Analysis of Incentive Payments to Primary Care Physicians for the Care of Patients with Complex Disease,” Canadian Medical Association Journal, Oct. 18, 2016 188(15):E375–E383.

20For example, in Quebec and Ontario, alternative payments made up about 15 percent of total payments to specialists in 2014–2015, compared to 20 percent in British Columbia and 33 percent in Saskatchewan.

21CIHI, National Physician Database.

22College of Family Physicians of Canada et al., National Physician Survey, 2014.

23For example, physician letters sent to employers when employees are ill.

24For example, in Ontario, physicians practicing in non-fee-for-service models have to provide sessions during some evenings and weekends. In some models, this amounts to a single three-hour session per week per physician in the group, up to five sessions per week. These physicians are paid a 30 percent bonus for primary care services provided during evenings, weekends, and holidays. Manitoba has implemented QuickCare clinics, staffed by registered nurses and nurse practitioners, to meet health care needs after hours.

25CIHI, How Canada Compares: Results for the Commonwealth Fund 2015 International Survey of Primary Care Physicians (CIHI, 2016).

26G. P. Marchildon, Canada: Health System Review (WHO Regional Office for Europe on Behalf of the European Observatory on Health Systems and Policies, 2013).

27Ontario Ministry of Health and Long-Term Care, Hospitals: Questions and Answers, www.health.gov.on.ca/en/common/system/services/hosp/faq.aspx, 2014.

28In Ontario, as of May 2014, the government was providing funding to 145 not-for-profit hospital corporations (with 224 facilities and sites) and six private for-profit hospitals.

29J. M. Sutherland, R. T. Crump, N. Repin, et al., Paying for Hospital Services: A Hard Look at the Options (C.D. Howe Institute, 2013). J. M. Sutherland, R. T. Crump, and N. Repin, The Alberta Health Services Patient/Care-Based Funding Model for Long-Term Care: A Review and Analysis (Centre for Health Services and Policy Research, 2013).

30P. Goering, D. Wasylenki, and J. Durbin, “Canada’s Mental Health System,” International Journal of Law and Psychiatry, May–Aug. 2000 23(3–4):345–59.

31Other common community mental health services include Assertive Community Treatment programs and Early Intervention for Psychosis programs. Some of these teams are multidisciplinary and may include nurses and physicians, but generally include social workers and case managers.

32Government of Ontario, “Open Minds, Healthy Minds: Ontario’s Comprehensive Mental Health and Addictions Strategy (2011).

33Government of Ontario, Open Minds, Healthy Minds: Ontario’s Comprehensive Mental Health and Addictions Strategy (2014), www.health.gov.on.ca/en/public/programs/mentalhealth/docs/open_minds_healthy_minds.pdf.

34Canada Health Act, RSC 1985, c. C-6.

35Organisation of Economic Co-operation and Development (OECD), Long-Term Care (OECD, 2011).

36A. Blomquist and C. Busby, Long-Term Care for the Elderly: Challenges and Policy Options (C.D. Howe Institute, 2012).

37CIHI, National Expenditure Trends.

38CIHI, Residential Long-Term Care Financial Data Tables (2012), 2012.

39For example, British Columbia’s Choice in Support for Independent Living program.

40M. Grignon and N. F. Bernier, Financing Long-Term Care in Canada (Institute for Research on Public Policy, 2012).

41Canada Revenue Agency, Family Caregiver Amount (FCA) (2014), www.cra-arc.gc.ca/familycaregiver/; Government of Canada, EI Compassionate Care Benefit—Overview, www.esdc.gc.ca/en/ei/compassionate/index.page, 2016.

42Examples include the Saskatchewan Health Quality Council, Health Quality Ontario, the British Columbia Patient Safety & Quality Council, and the New Brunswick Health Council.

43M. R. Lavergne, M. R. Law, S. Peterson et al., “A Population-Based Analysis of Incentive Payments to Primary Care Physicians for the Care of Patients with Complex Disease,” Canadian Medical Association Journal, Oct. 18, 2016 188(15):E375–E383; R. Carter, B. Riverin, J.-F. Levesque et al., “The Impact of Primary Care Reform on Health System Performance in Canada: A Systematic Review,” BMC Health Services Research, July 30, 2016 30(16):324; J. Li, J. Hurley, P. DeCicca et al., “Physician Response to Pay-for-Performance: Evidence from a Natural Experiment,” Health Economics, Aug. 2014 23(8):962–78.

44Canadian Foundation for Healthcare Improvement New National Results, “Taking Seniors Off Antipsychotics Shows Dramatic Improvement in Care,” press release, accessed Aug. 26, 2016.

45Council of the Federation, Health Care Innovation Working Group, accessed Aug. 26, 2016.

46CIHI, Trends in Income-Related Health Inequalities in Canada (CIHI, 2015).

47Government of Canada, Budget 2016, www.budget.gc.ca/2016/home-accueil-en.html, 2016.

48Government of Ontario, “Ontario Launches $222 Million First Nations Health Action Plan,” news release accessed Aug. 26, 2016.

49Truth and Reconciliation Commission of Canada, Calls to Action (Truth and Reconciliation Commission, 2015).

50Divisions of Family Practice, Welcome to the Divisions of Family Practice, 2014.

51Government of Ontario, “Ontario Funds Bundled Care Teams to Improve Patient Experience,” news release, 2015.

52As discussed above, some provinces also have implemented incentives to encourage physicians to provide guideline-based care for chronic disease. In Ontario, for example, Diabetes Education Programs (employing teams of diabetes education nurses and registered dieticians) support individuals and primary care physicians in providing guideline-based diabetes care.

53In Ontario, for instance, Community Care Access Centres are also responsible for coordinating services for vulnerable populations, particularly seniors and individuals with disabilities, including health and social care services (e.g., supportive housing and meal delivery programs), although this responsibility may be transferred to the Local Health Integration Networks.

54Canada Health Infoway, Annual Report, 2013–2014 (Canada Health Infoway, 2014).

55K. K. Ogilvie and A. Eggleton, Time for Transformative Change: A Review of the 2004 Health Accord (Standing Senate Committee on Social Affairs, Science and Technology, 2012).

56College of Family Physicians of Canada et al., National Physician Survey, 2014.

57This is a collaboration between provinces’ and territories’ premiers, as well as the Federal government as of 2016.

58The Council of the Federation, The Pan-Canadian Pharmaceutical Alliance, accessed Aug. 26, 2016.

59Choosing Wisely Canada, What Is CWC? (2015).

60Government of Canada, “An Act to Amend the Criminal Code and to Make Related Amendments to Other Acts,” (medical assistance in dying), S.C. 2016, c. 3.; accessed Aug. 2016.

61Northwest Territories Health and Social Services, Establishment of the Northwest Territories Health and Social Services Authority, accessed Aug. 26, 2016.

62Government of Ontario, Patients First: Reporting Back on the Proposal to Strengthen Patient-Centred Health Care in Ontario, accessed Aug. 26, 2016.