JANUARY

CANADA
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
benefits package; most public coverage decisions are made by provincial and territorial governments in
conjunction with the medical profession. Provincial and territorial governments provide varying levels of
additional benefits, such as outpatient prescription drugs, nonphysician mental health care, vision care, dental
care, home health 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. 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 2012, out-of-pocket payments represented about 14.2 percent of total health spending (Canadian
Institute for Health Information, 2015a), 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%)
(Canadian Institute for Health Information, 2015a).
Safety net: 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, the prescription drug program
in Ontario exempts low-income seniors and social assistance recipients from all cost-sharing except a CAD2.00
(USD1.60) copayment, which is often waived by pharmacies. Low income is defined as annual household income
of less than CAD16,018 (about USD12,700) for single people and less than CAD24,175 (USD19,168) for couples.
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 (above 3% of
income). A disability tax credit and an attendant care expense deduction also provide relief to individuals (or their
dependents) who have prolonged mental or physical impairments, and to those who incur expenses for care that
is needed to allow them to work.
How is the delivery system organized and financed?
Primary care: In 2014, about half of all practicing physicians (2.24 per 1,000 population) were general
practitioners, or GPs (1.14 per 1,000 population) and half were specialists (1.10 per 1,000 population) (Canadian
Institute for Health Information, 2015b). Primary care physicians act largely as gatekeepers, and many provinces
pay lower fees to specialists for nonreferred 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 2013–2014, fee-for-service payments made up 45 percent of payments
to GPs in Ontario, compared with 67 percent in Quebec and 84 percent in British Columbia (Canadian Institute
for Health Information, 2015c). 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 (National Physician Survey, 2014).
In some provinces, such as 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. Clinical fee-forservice
payments to primary care physicians in Canada averaged CAD249,154 (USD197,550) in 2013–2014
(Canadian Institute for Health Information, 2015c); these do not account for alternative payments and nonclinical
payments. It has been estimated that the average payment, including alternative payments, for primary care
physicians in Ontario is 21 percent higher than for fee-for-service alone (Henry et al., 2012).
In several provinces, networks of GPs work together and share resources. For instance, Primary Care Networks
in Alberta, My Health Teams in Manitoba, and Family Health Teams in Ontario support interdisciplinary health
professionals (e.g., nurses, pharmacists, and dietitians). In Ontario, the minimum size of practice for physicians
in alternative payment models (not fee-for-service) is three (Sweetman and Buckley, 2014). In Family Health
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The Commonwealth Fund