Health Committee on Feb. 14th, 2013

[The Chair, Conservative, Joy Smith]

We've had a very wonderful presentation today.

Now we'll go into our seven-minute Qs and As.

We will begin with Ms. Davies.

[Libby Davies, NDP, Vancouver East, BC]

Thank you very much, Madam Chair. And thank you for the Valentine's cookies. I already ate mine. It was very nice.

Thank you to the witnesses for being here today. I feel like we've had quite an unusual diversity of opinions.

I'd like to begin with Madame Gagné.

I have a couple of questions about the health co-ops. I'm very familiar with co-ops, but I have to say I'm not familiar with health co-ops.

I understand there are about 50 of them in Canada. Are they primarily in Quebec?

[Michaël Béland, Communications and Programs Manager, Conseil canadien de la coopération et de la mutualité]

I will answer for Mrs. Gagné.

In fact, the vast majority of these co-operatives are located in Quebec, especially the new generation co-operatives. But there are also some in British Columbia, Manitoba, Saskatchewan, New Brunswick and Nova Scotia.

[Libby Davies, NDP, Vancouver East, BC]

Thank you. I just wanted to clarify that.

I found your brief very interesting, but I'm not clear on two things. When a co-op operates, it's not necessarily a physical location. It's a co-op that is arranging services for its members that may be in other locations. I want to make sure I'm right on that.

Second, I wasn't clear about the membership fee. I wonder if you would tell us the range of the membership fee. I'm not clear on what you get. I can go to my family doctor now and I don't have to pay anything. I can be referred to a specialist, to the hospital, to a community clinic, and I do not have to pay anything. What is the service that comes from a health co-op? That's my second question.

If there's time, I have a third question. Could you talk a little about the demographics? Are your co-ops providing services to all kinds of Canadians? Do you deal with people who have chronic diseases? You say it's about people having to be vested in their own health. Who is your target in the community? Who are the people who are being served by your co-op?

[Michaël Béland]

I will try to answer all three questions.

The co-operative model is interesting because the members decide on the type of services they want to offer. Most of the time, it is a physical site, generally understood to be a clinic with a doctor. Other times, it might be a mobile clinic. It could also be telehealth or a clinic that travels within the community. Therefore, the members will determine their needs during their annual general meeting or after speaking with their board of directors, and they will decide whether the service provided will be a telehealth service or whether the town clinic will be kept. It really depends on the community's needs.

In general, as we mentioned in the presentation, it will be a real physical clinic. Basically, if we want there to be a doctor in the community when there isn't one or if we are losing doctors, the community creates a co-op. It is important to understand that the co-op will be a vehicle.

To answer your second question, I would say that the member contributions will be used to fund the vehicle, meaning the building, the additional equipment, additional nurses, additional prevention or other services. The advantage for members is to ensure that these services are available in the community and that people have access, perhaps at a lower cost, to services that are not covered by the government.

Obviously, people always want to know why they would pay an average annual contribution of $60 when members do not have privileged access to doctors over non-members. It is important to point out that annual contributions are not always required. In fact, most of the time, it is really an investment for the community. This sometimes also involves adding services that are not otherwise available. Prevention services under the Japanese model are a good example. We see this often. So additional prevention services not covered by the government are created. In this case, it might be available only to members. But for government paid services, members do not have an advantage over non-members.

To answer your third question about demographics, it is interesting to note that the demographics of members of health care co-ops are similar to that of the general population. You might think that older people need medical services the most and that they would more often be members, but the opposite is true. We have members who are in their twenties and thirties, for example. We have all kinds of members.

[Libby Davies, NDP, Vancouver East, BC]

If you don't mind, perhaps I can interrupt for a minute.

I'm still trying to understand why people would join versus what we have now—recognizing that we need to make a lot of changes. You have 50 co-ops in 50 years, so that's not a lot. For example, if your co-op wanted to engage the services of Dr. Dibble or Dr. Ballagh, why wouldn't those patients be able to directly go to those specialists?

I'm having trouble actually making the connection that you...what the benefit is.

[Michaël Béland]

Health co-ops are generally found in rural or remote communities. You rarely have specialists there. You usually have general practitioners or other types of health professionals. If there aren't physiotherapists, nutritionists or general practitioners in the community, and if it takes 20 minutes, half an hour or 45 minutes to get to the nearest clinic or to get to another clinic, the people in the community are going to decide to invest in having these doctors closer to them.

[Libby Davies, NDP, Vancouver East, BC]

Are the doctors you engage on a fee for service, or are they on salary? Are you actually hiring the doctors?

[Michaël Béland]

No, doctors are not paid by the co-operatives. Doctors are paid by the public service. The co-operative pays for the offices, technology, basically everything a doctor needs.

[The Chair, Conservative, Joy Smith]

Thank you very much.

Thank you, Ms. Davies.

We'll now go on to Mr. Brown.

[Patrick Brown, Conservative, Barrie, ON]

Thank you, Madam Chair.

I have a few questions that I want to ask today.

First, to Dr. Ballagh, you mentioned your work at Base Borden. Obviously Canadian Forces are within federal jurisdiction. One of the interesting things about this study is that we are looking at areas where we can actually contribute through the federal government, and with the forces being one, that topic is of particular interest.

What type of technology do you think could be utilized, that isn't being utilized now, to make health care more efficient within the forces? Have you made any observations that might be of interest to this committee?

[Dr. Rob Ballagh]

I would answer the question in two ways. First of all, innovation is already happening in the Canadian armed forces. In the health services facility that has been built at Base Borden, the training they're doing now, particularly with regard to the physician assistants, is head and shoulders over what they were doing even a decade ago.

Some of the physician assistants I work with in our hospital and in my office are soldiers who have been in military service for 17 or 20 years. They've had the traditional trade medic training and they've gone back to Borden for the subspecialized training program in which they do two extra years of training, one in the classroom and one working in offices and hospitals like ours. It's almost the equivalent of the last two years of my medical training in medical school, in terms of what they get in didactic learning.

So that level of innovation is what they bring to the table. They bring a tremendous amount of experience as well. Physician assistants aren't physicians. They are specifically called physician extenders in the military. The military has had a physician shortage for eons. This is one of the ways they've chosen to fix it. These people come out of the program we have with a skill set that is almost at the level of a family doctor, almost at the level of a nurse practitioner, but they're under the direct supervision of physicians.

My second part of the answer would be that the technology should be for equipping those physician assistants with knowledge when they need it and also with communications skills to get back to the physician they're talking to. Many of them are available by a telephone or satellite telephone connection to those who are supervising them when they're on the very front lines.

[Patrick Brown, Conservative, Barrie, ON]

Thank you.

Dr. Dibble, you mentioned the use of robotics in technology and the delivery of the services a cardiologist would offer. I remember when the health committee went up to Nunavut a few years back and we were touring health services there. I remember they were using video services to provide some of the health care services up there. I'm sure in cardiology there is a disparity in doctors available in parts of the country. I know you've lectured on cardiology across the country.

What is your knowledge about the challenges that are faced regarding cardiologists in more remote areas, in northern Canada? Are you aware of there being significant shortages? What model would you suggest for servicing those areas?

[Dr. Bradley Dibble]

I'm definitely aware of the shortage issue. I think the problem is that a cardiologist offers a certain level of expertise that requires a certain catchment area. So the more remote you go, the farther north you go, generally there won't be enough patient population to allow you to continue to function as a cardiologist full time. I am aware of some colleagues who still wanted to choose that lifestyle, so they have gone as cardiologists, but they tend to function more as general internists. They fall back to some of the skill sets they had in other branches of internal medicine, like GI or respirology.

The issue with offering cardiology services remotely is that it has to be done through this sort of remote two-way technology. For example, I could run a clinic one day a week somewhere very remote. I could do stress tests, because there would be a trained technologist there, and I would be there not only in the two-way audio and visual approach, where I can see the patient and I can see what's happening on the treadmill, but also ideally I would see the telemetry on my computer screen as it was being sent to me remotely.

Likewise I could do a consult, in which I would spend maybe 15 minutes discussing with the patient. Then I would be able to have an echocardiogram done, again by a skilled technologist, and I would actually see the images on my screen, because there's no reason that information couldn't be transferred digitally.

I think the biggest hurdle to having cardiac services out there isn't getting cardiologists there, but making sure that the adequate infrastructure is available so that the expertise can be used. I'd say stress tests and echocardiograms provide a lot of what we need to offer.

[Patrick Brown, Conservative, Barrie, ON]

A general question I've asked each panel so far that we've had on health technological innovation has been about the federal role in the regulation of medical devices and products, because that's another area where there's federal jurisdiction.

Have any of you been involved in a medical device or a product, and what has been your experience? What impressions do you have about how we could become more efficient on medical devices? Is there a lot of red tape in that process? Do you believe we have an atmosphere or an environment that fosters and enhances innovation, or is government a roadblock in that?

[Dr. Bradley Dibble]

I can certainly address that.

The medical devices we tend to use in cardiology would be pacemakers, and there are complex pacemakers that pump both chambers at the same time. Even beyond that, there are the implantable cardioverter defibrillators.

I think the regulations have worked quite well, from my experience. I don't implant those devices. I'm not particularly involved in that branch of cardiology, but I would say the biggest hurdle there is more likely on the provincial level, whereby the hospitals have a budget to fund so many implants per year. From my experience, those devices have been well regulated, because we tend to have access to them when we need them, at least in my part of Ontario.

[Patrick Brown, Conservative, Barrie, ON]

Is there any other comment on that?

[Dr. Rob Ballagh]

I don't think you and I have ever discussed this before, but at one time I was the CEO of a biotech company. When I was a resident in surgery, I made a discovery in the area of radiotherapy. I found something that seemed to make radiotherapy work better for cancer. I had an interesting journey with that company. I call it Canada's least successful biotechnical company, yet I'm still convinced that our product was a working product, a product that would have been helpful.

Technology transfer, which is taking something from the eureka on the bench to the marketplace, is a challenging and cumbersome prospect. It cost us $50,000 to patent our project, and we had to do that before I could even utter a word about it in public. I was a resident, and that was my project for that year. I had to patent it before I had the opportunity to present it to my colleagues and pass my residency.

[The Chair, Conservative, Joy Smith]

Thank you, Doctor. That's very interesting.

Mr. Easter, you're next.

[Wayne Easter, Liberal, Malpeque, PE]

Thank you, Madam Chair. Thank you all for coming.

I'll start with Ms. Gagné and Mr. Béland. I'm very familiar with the cooperative structure, but I'm a little like Libby. As opposed to a medical clinic that is funded either provincially or federally or both, I am led to understand that your membership, through their membership fees, uses those resources to buy equipment for telemedicine or whatever it might be. Is the purpose of the cooperative to add moneys to the system for that particular membership base that isn't there under the public health care system?

Is there a possibility of competition between that and medical clinics or the hospital sector?

[Michaël Béland]

It really is a reinvestment by the communities in their health care system. The public health care system pays the professionals, pays their salaries. When a co-op is created, it really is a reinvestment. The members want to maximize what the government is doing. They will reinvest to ensure they have the equipment, facilities and additional nurses to maximize the doctors' work.

[Brigitte Gagné]

I should point out that 46% of co-ops are created because the clinic is on the verge of closing or has closed. Furthermore, 54% of co-ops are created because people are having a lot of difficulty getting health care services nearby. They have to travel for hours to get access to them.

[Wayne Easter, Liberal, Malpeque, PE]

Thank you.

To the two doctors, I'm quite familiar with the difficulties in rural health care. I sat on a committee 10 years ago, and I expect things haven't improved.

You're saying that one in seven doctors plans to leave their rural communities, so that creates an even greater problem. What is the reason for that? Is it that they don't have the hospital facilities and the equipment to be able to use their expertise to full advantage? Is it that there's less family life for their families or job opportunities for their spouse? What's the real reason they're pulling out of rural areas?

[The Chair, Conservative, Joy Smith]

Dr. Dibble.

[Dr. Bradley Dibble]

I'll start, and I'll let Dr. Ballagh add his comments.

I think its multifactorial, just as you referred to. I think part of it is that when you work in a rural community—and I have colleagues who do that; they work very hard. They don't tend to get home in time for supper at five or six o'clock at night because they're the only ones in town. They're on call on a much greater frequency, often one in one.

The other thing is that there are greater demands on them. If they work in a larger community, they have the resources of specialists to fall back on; if something is getting a little out of their territory, they know they can pass it on to someone with greater expertise. When you're in a small, remote community, you don't have that, and it's all on your shoulders. That's a stress that a lot of people don't feel comfortable with.

I also think some people in some communities feel they don't have the infrastructure to support their needs very well medically. They fall to levels of frustration because the dollars aren't there to support something such as setting up better telehealth systems to have specialists work remotely.

I think after a while, unless they're very dedicated, they plan to go. It's a small percentage of these rural physicians, but that's what the Society of Rural Physicians of Canada has documented within the members of its group.