(Dennis, I'm sorry this is occupying so much of your list. However, as health
care in Canada takes up increasing amounts of public service expenditures,
less is available to support other important initiatives that influence
health. Primary care cooperatives seem to be one way to improve citizen
engagement and empowerment-answer to Terry follows)

Terry,

Following this note is information from the Canadian Federal Government on
Cooperative development initiatives including Federal government interest in
projects to improve access to health care and home care.

There is no reason that American Communities couldn't become involved in such
initiatives. One financial reason however, is that in the USA payment for
health care for employees is a deductible expense to the employer, so
employer's end up with a strong and unecessary influence on who provides care.
 Cooperatives in the USA would be a possibility of the citizen themself could
deduct the cost of health insurance premiums.

As background you might be interested to know that Canada has a multi-tier
health care system with regard to quality of service.  A single tier system
with regard to payment.  Individuals are not permitted to pay for services
that are insured by the public health care system.

However, social capital  (who you know, or how persuasive you are) influences
access to care. And certain groups including the Military, RCMP and Workers
Compensation Board clients often get preferred access.  In Nova Scotia the
Military chose private MRI services because they felt it was inappropriate to
make their soldiers and sailors wait.

Some clinical practices, blessed by government, have information tools and
technology, and patients in these government funded community health centers
often have access to a wide range of health professionals and can choose who
to go to for advice.  The majority of Canadians are in areas served by primary
care physician offices where the nature of government insurance coverage,
influences how care is provided and the ability of the practice to work with
non-physician health professionals.  Nursing services, physiotherapy, drugs,
and many other valuable health services are not insured services.  A telephone
call to the doctor is not an insured service, nor is e-mail advice.

In British Columbia and elsewhere in  Canada nurses lines have been developed.
 Nurses are paid to provide phone advice, but the patient doesn’t really have
a choice since their own doctor, who knows them as an individual would not be
paid for providing similar advice by phone.  The point is that patients don’t
really have a choice of provider because how governments reimburse providers
has a strong influence on the services providers make available.  Although
nurses provide primary telephone advice as government employees, few or none
have developed offices to deliver first contact nursing services and advice
direct to the public. Nurses do provide a number of valuable direct to public
services but normally not as a first contact.

The consequence is that many people are forced to go to the physician’s
office, when a simple telephone call to their own doctor (or a nurse who knew
them) would be sufficient. A primary care cooperative could make these
services available to their members.

Provincial governments pay about $24.00 (Canadian) for a visit to a family
doctor. This amount includes all of the cost of overhead including rent, heat,
supplies, telephone and support staff. The fee is no higher if the patient
sees a doctor and a nurse;   and the fee for service or encounter amount paid
by government for a visit to a nurse is $0.

Federal Government Comment on Cooperative Development Initiative:
"The Co-operative Development Initiative (CDI) is the Government of Canada's
new program to help people develop co-ops, and to research and test innovative
ways of using the co-operative model. CDI will make the co-op option more
readily available to Canadians, to respond to their present-day challenges.

What are co-operatives, and what do they do for Canada?
Co-operatives are jointly owned enterprises formed by people coming together
to meet their needs. They are based on ethical values and principles including
self-help, democracy, equality, and concern for community. The 10,000
co-operatives in Canada engage 70,000 volunteers and employ 150,000 people.
They empower individuals, and encourage healthier and stronger communities by
enabling people to pool their resources, share risks and achieve common goals.
Co-ops provide such vital services as affordable housing, childcare and
financial services, and contribute to local economic development and job
creation.

Are there priority areas for CDI-Innovation and Research funding?
Building on the recognized strengths of co-ops, we are interested in learning
more about how co-operatives can contribute to economic and social
development, community capacity building, and service delivery for
disadvantaged or hard-to-reach Canadians. Within this context, we are
particularly looking for projects that can assist in the following areas:

adding value to agriculture
access to health care and home care
economic development in rural, remote or Northern communities
development of aboriginal communities
integration of immigrants into Canadian communities
community solutions to environmental challenges”


Brian Crowley, speaking to the MACKINAC Center for Public Policy had this to
say about health care in Canada.

There appears to be no legal obligation for governments actually to supply the
services they have promised to the population. This is an appalling double
standard, as no responsible regulator would permit a private supplier of
insurance to behave in this way

The full text of his talk to the U. S.A based MACKANACK Centre  for Policy  is
titled “The Top Ten Things People Believe about Canadian Health Care But
Shouldn’t”

It is at the following address and I suspect that it will generate  thoughtful
commentary from members of this list.

http://www.mackinac.org/article.asp?ID=5869

Best wishes

David Zitner



>===== Original Message From Social Determinants of Health <[log in to unmask]>
=====
>I'm enjoying the discussion of CHCs and coops, but feel at a loss in this
>area.  I'm currently in a public health graduate program at Univ of
>Washington and am pretty much ignorant of these health structures.  Could
>someone recommend some reading (overview would be better) that would
>elucidate this type of delivery of health care.  Is this happening in the
>US?
>Thanks.
>Terry Mitchel
>
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David Zitner, M.A., M.D., C.C.F.P., F.C.F.P.
Director, Medical Informatics
Dalhousie University Faculty of Medicine
902-494-3802

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