Canada - World Health Organization Regional Office for Europe
Canada - World Health Organization Regional Office for Europe
Canada - World Health Organization Regional Office for Europe
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
78<br />
<strong>Health</strong> systems in transition <strong>Canada</strong><br />
3.8 Payment mechanisms<br />
3.9.1 Paying <strong>for</strong> health services<br />
To the extent that hospitals are integrated in RHAs in <strong>Canada</strong>, there is no<br />
purchaser–provider split. In the case of those hospitals that contract with<br />
RHAs – <strong>for</strong> example, all hospitals in Ontario and Catholic hospitals in Western<br />
<strong>Canada</strong> – most payments are generally made on the basis of the previous year’s<br />
allocation adjusted <strong>for</strong> inflation and budget growth. However, some RHAs have<br />
introduced or experimented with other modes of funding, including activitybased,<br />
patient-centred and incentive-based funding models (McKillop, 2004;<br />
Sutherland, 2011a). There has been limited study of payment systems <strong>for</strong> health<br />
care organizations in <strong>Canada</strong>.<br />
3.9.2 Paying health workers<br />
Most non-physician health care personnel are paid a salary to work within<br />
hierarchically directed health organizations. Within this group, regulated nurses<br />
are the most numerous. Most nurse remuneration and conditions of work are<br />
negotiated through collective bargaining by nurses’ unions and province-wide<br />
employer organizations, often with provincial governments setting broad<br />
fiscal parameters. Nurse dissatisfaction with working conditions and stagnant<br />
remuneration during the provincial health re<strong>for</strong>ms led to labour strife and rising<br />
sick leave by the latter part of the 1990s. Since that time, staffing levels have<br />
climbed and nurse remuneration has improved considerably as governments<br />
and health organizations have attempted to recruit nurses in a tight labour<br />
market (CIHI, 2011a).<br />
The majority of physicians continue to be remunerated on the basis of fee<br />
<strong>for</strong> service (FFS) although alternative payment methods including capitation,<br />
blended (salary and fee) payments are also applied – most commonly salary<br />
and fee or capitation and fee. In recent years, incentive-based bonuses have<br />
become more common. While many health policy analysts have been critical<br />
of the incentives created by FFS – including the incentive <strong>for</strong> overprovision of<br />
medical services – the system remains popular among many physicians and the<br />
organizations that represent them (Grignon, Paris & Polton, 2004).<br />
Since family physicians continue to provide the majority of primary care<br />
services in <strong>Canada</strong>, primary care re<strong>for</strong>m has involved some shifts in payment<br />
systems. Provincial ministries of health have considered the advantages and<br />
disadvantages of fee <strong>for</strong> service, capitation and mixed payment systems. In