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individual you're not denied the opportunity that others have in the individual you're not denied the opportunity that others have in the

marketplace you're given that same opportunity with a voucher now to go marketplace you're given that same opportunity with a voucher now to go

seek out private health care insurance on your own terms backed by the taxpayer ||||||||||financiada||| seek out private health care insurance on your own terms backed by the taxpayer

to ensure that you still have access to the system and a waiver for deductibles ||||||||||||isenção|| to ensure that you still have access to the system and a w aiver for deductibles

and copay so you don't have to pay them but you still get to choose your and copay so you don't have to pay them but you still get to choose your

insurance company you still get to choose from managed care iman it's a insurance company you still get to choose from managed care iman it's a

system that is very patient focused very individual focused and it's a healthcare system that is very patient focused very individual focused and it's a healthcare

system that that really is at the top of its class world-class healthcare system that that really is at the top of its class world-class healthcare

outcomes no systemic delay and access to healthcare services and some of the outcomes no systemic delay and access to healthcare services and some of the

finest medical facilities that you would find in the world it's a really great finest medical facilities that you would find in the world it's a really great

healthcare system that has been created by private for-profit health care healthcare system that has been created by private for-profit health care

providers that has been created by money following patients it has been created providers that has been created by money following patients it has been created

by competition and appropriate incentives there was a referendum in by competition and appropriate incentives there was a referendum in

sweden where they actually asked the public do you want to go to a more sweden where they actually asked the public do you want to go to a more

canadian-style approach or stay with what we have and what we have won canadian-style approach or stay with what we have and what we have won

and i i don't know all the fine details of what was marketed out there goodness and ii don't know all the fine details of what was marketed out there goodness

they chose that because they would have been choosing a system that has none of they chose that because they would have been choosing a system that has none of

the joys and wonders they have in healthcare of having healthcare the joys and wonders they have in healthcare of having healthcare

available when you need it in a universal basis as a result of available when you need it in a universal basis as a result of

competition it's kind of remarkable but i imagine that there must have been a competition it's kind of remarkable but i imagine that there must have been a

referendum because there are a group of people who are unhappy with elements of referendum because there are a group of people who are unhappy with elements of

the swiss system and i suppose it's enticing to think that you would never |||||||tentadora|||||| the swiss system and i suppose it's enticing to think that you would never

have to pay a dollar out of pocket for for medical care and maybe that's part have to pay a dollar out of pocket for for medical care and maybe that's part

of part of the the challenge is that some people do believe that you of part of the the challenge is that some people do believe that you

shouldn't have to pay any money out of pocket for medical care because it's so shouldn't have to pay any money out of pocket for medical care because it's so

important it's so valuable it's so necessary why should we pay for it at important it's so valuable it's so necessary why should we pay for it at

all is there is there some argument you would you would make all is there is there some argument you would you would make

to challenge that notion i think it's not about paying for the to challenge that notion i think it's not about paying for the

healthcare someone has to pay for the healthcare at some point we often hear healthcare someone has to pay for the healthcare at some point we often hear

the term free healthcare well it's not free it costs thousands of dollars per the term free healthcare well it's not free it costs thousands of dollars per

family a year in taxes that go to the health care system the taxpayer does family a year in taxes that go to the health care system the taxpayer does

foot the bill cost sharing is not about paying for health care it's about foot the bill cost sharing is not about paying for health care it's about

encouraging more informed decision making let's step back a minute to our encouraging more informed decision making let's step back a minute to our

initial conversation about the canada health act and drugs and physicians in initial conversation about the canada health act and drugs and physicians in

canada i will go to my physician at no charge to me so i can go to my emergency canada i will go to my physician at no charge to me so i can go to my emergency

room my pharmacist my nurse practitioner my general practitioner or as long as i room my pharmacist my nurse practitioner my general practitioner or as long as i

have a recent referral my specialist at no charge to me is an individual the have a recent referral my specialist at no charge to me is an individual the

taxpayer pays the bill i'll then get a script for a drug that is going to ||||||||receita||||||| taxpayer pays the bill i'll then get a script for a drug that is going to

actually do the healing now that it's been properly identified by the medical actually do the healing now that it's been properly identified by the medical

professional that drug i now have a copay for whether i'm in my public professional that drug i now have a copay for whether i'm in my public

scheme or my private scheme depending on my particular income level of course scheme or my private scheme depending on my particular income level of course

there are there are protections for local individuals there are there are protections for local individuals

what if we turn that system on its head what if we say to people we know drug what if we turn that system on its head what if we say to people we know drug

compliance is an issue we know drug compliance results in readmissions and |||||||adesão|||| compliance is an issue we know drug compliance results in readmissions and

additional physician visits and poorer outcomes what if we say to people you additional physician visits and poorer outcomes what if we say to people you

must pay to go see the doctor and get the initial script because we want you must pay to go see the doctor and get the initial script because we want you

to be informed about where you're going with the healthcare system maybe we say to be informed about where you're going with the healthcare system maybe we say

the general practitioner is no copay but you'll pay for specialist care and the general practitioner is no copay but you'll pay for specialist care and

emergency care and other things but when you get that script the drug is emergency care and other things but when you get that script the drug is

now no copay because we're thinking the system in a complete and holistic sense now no copay because we're thinking the system in a complete and holistic sense

we have an option we have a private alternative we have copays we have |||||||||||copagamentos|| we have an option we have a private alternative we have copays we have

profit competition so now the system is efficient and we can afford to have profit competition so now the system is efficient and we can afford to have

these additional services that's a very different way now about thinking about these additional services that's a very different way now about thinking about

copays and about thinking about the cost of drugs and drug compliance and copays and about thinking about the cost of drugs and drug compliance and

encouraging greater drug compliance there's some interesting work that was encouraging greater drug compliance there's some interesting work that was

being done around this in the 2000s around what is an optimal copay being done around this in the 2000s around what is an optimal copay

structure the problem i think from a canadian structure the problem i think from a canadian

perspective is we're already paying enough for a world-class healthcare perspective is we're already paying enough for a world-clas s healthcare

system we're paying more than just about anybody else's for healthcare right now system we're paying more than just about anybody else's for healthcare right now

we don't have the healthcare system to show for it we're buying that if you we don't have the healthcare system to show for it we're buying that if you

want to go to houses where we're buying the great big estate in downtown toronto want to go to houses where we're buying the great big estate in downtown toronto

the problem is we're getting the shack in a really not great part of town ||||||cabana|||||||| the problem is we're getting the shack in a really not great part of town

and if we change our construct and think about health care and if we change our construct and think about health care

more in a more informed way i think when it more in a more informed way i think when it

comes to health care policy when we think about what all these constructs comes to health care policy when we think about what all these constructs

can do what they have already done for sweden for switzerland for can do what they have already done for sweden for switzerland for

for australia for other countries the netherlands france the netherlands for australia for other countries the netherlands france the netherlands

eliminated a waiting list problem by embracing this eliminated a waiting list problem by embracing this

the swiss approach to health care they had a waiting list problem they became the swiss approach to health care they had a waiting list problem they became

more like switzerland now the winless problem is gone there's solve these |||||sem vitória|||||| more like switzerland now the winless problem is gone there's solve these

things if we think about that we can then think more intelligently about how things if we think about that we can then think more intelligently about how

do some of these other services that are not property canada fit in properly i do some of these other services that are not property canada fit in properly i

think where we are now we shouldn't be tacking anything on we need to fix the think where we are now we shouldn't be tacking anything on we need to fix the

problem we have we're just going to create a bigger problem for us problem we have we're just going to create a bigger problem for us

talk to me a bit because i think you've done some work on how much the copay talk to me a bit because i think you've done some work on how much the copay

needs to be to change behavior and surprisingly low it's not like you need needs to be to change behavior and surprisingly low it's not like you need

to charge thousands of dollars in either co-payments or deductibles what what to charge thousands of dollars in either co-payments or deductibles what what

what would be the guide there there's no real guide there's a lot of what would be the guide there there's no real guide there's a lot of

experience to sort of frame thinking now if we look at what happened in the rand experience to sort of frame thinking now if we look at what happened in the rand

health insurance experiment they did a 25 of 15 and 95 co-pay and certainly the health insurance experiment they did a 25 of 15 and 95 co-pay and certainly the

95 reduced access to healthcare services more than the 25. what was very 95 reduced access to healthcare services more than the 25. what was very

interesting is the majority of the horsepower was 0-25 interesting is the majority of the horsepower was 0-25

and if we look at a country like the slovak republic they instituted co-pays and if we look at a country like the slovak republic they instituted co-pays

in the 2000s and the dollar amounts were quite small relative to the average in the 2000s and the dollar amounts were quite small relative to the average

industrial income if you took it as a share it was four or five dollars to go industrial income if you took it as a share it was four or five dollars to go

see a doctor or go to the emergency room a couple of dollars to see a general see a doctor or go to the emergenc y room a couple of dollars to see a general

practitioner nurse practitioner and the reductions in access to healthcare practitioner nurse practitioner and the reductions in access to healthcare

service were in the range of 20 to 30 percent service were in the range of 20 to 30 percent

a meaningful difference in the number of people assessing the health care systems a meaningful difference in the number of people assessing the health care systems

now studies show that generally speaking there's going to be no health impact now studies show that generally speaking there's going to be no health impact

there is a reduction in both necessary and there is a reduction in both necessary and

unnecessary health care uses uh as as viewed ex post however on balance or unnecessary health care uses uh as as viewed ex post however on balance or

does not appear to be a negative impact on individuals except for those in a does not appear to be a negative impact on individuals except for those in a

state of low income with chronic health care conditions so obviously a clear state of low income with chronic health care conditions so obviously a clear

exemption for them but what we see is now a healthcare exemption for them but what we see is now a healthcare

system that has additional resources and time to look after the problems that do system that has additional resources and time to look after the problems that do

present to it that has lower waiting list for very small dollar amounts it present to it that has lower waiting list for very small dollar amounts it

needs to be even in the swedish case it's 20 or 25 dollars to go see a needs to be even in the swedish case it's 20 or 25 dollars to go see a

practitioner maybe up to 50 depending on on what area we're talking about which practitioner maybe up to 50 depending on on what area we're talking about which

practitioner but if you think from from the perspective of a middle income practitioner but if you think from from t he perspective of a middle income

canadian a 20 to see a practitioner amount is not a massive trade-off as |||||praticante|||||||| canadian a 20 to see a practitioner amount is not a massive trade-off as

long as we're not talking about someone in the state of low income or someone long as we're not talking about someone in the state of low income or someone

with a chronic condition who's continuous watchers day after day so you with a chronic condition who's continuous watchers day after day so you

could you could make exemptions from co-payments and you could also if you could you could make exemptions from co-payments and you could also if you

want as you say for people not to have a barrier to getting their pharmaceutical want as you say for people not to have a barrier to getting their pharmaceutical

drugs because that's a way to make sure the condition doesn't deteriorate you drugs because that's a way to make sure the condition doesn't deteriorate you

could create a system where you where you take the co-payment off that so you could create a system where you where you take the co-payment off that so you

can actually manage around some of those issues let me let me ask you about one can actually manage around some of those issues let me let me ask you about one

of the other challenges uh with activity-based funding to see if there's of the other challenges uh with activity-based funding to see if there's

a way to manage around this i think there'd be a concern that if you're a way to manage around this i think there'd be a concern that if you're

getting funding following the patient then all of a sudden you get surcharged ||||||||||||cobrado getting funding following the patient then all of a sudden you get surcharged

for every little thing so now you have a meal charge and you've got the charge for every little thing so now you have a meal charge and you've got the charge

for the q-tips and you've got the charge for the changing of the towels in the for the q-tips and you've got the charge for the changing of the towels in the

bathroom that you use that's one issue the other issue is do you end up with bathroom that you use that's one issue the other issue is do you end up with

patients being um patients being um

with doctors chasing after dollars based on the diagnosis the most recent example with doctors chasing after dollars based on the diagnosis the most recent example

is the stories that came out of the united states with coveton with a covet |||||||||||cobiça|||cobiça is the stories that came out of the united states with coveton with a covet

diagnosis that if you came in with a regular old respiratory problem it was a diagnosis that if you came in with a regular old respiratory problem it was a

thirteen thousand dollar charge but if it was a covid patient now it's a thirty thirteen thousand dollar charge but if it was a covid patient now it's a thirty

nine thousand dollar charge and i wonder if there's a danger by setting up nine thousand dollar charge and i wonder if there's a danger by setting up

incentives on the payment that you do end up with some trying to uh trying to incentives on the payment that you do end up with some trying to uh trying to

increase the amount of payments that they get just by changing the diagnosis increase the amount of payments that they get just by changing the diagnosis

is that a concern i think there's three ways to to look at is that a concern i think there's three ways to to look at

there's three important things to think about and the first is we already have there's three important things to think about and the first is we already have

some some harmful incentives in the healthcare system right now some some harmful incentives in the healthcare system right now

a big concern is cherry picking around uh around activity-based funding that a big concern is cherry picking around uh around activity-based funding that

hospitals will pick off the easiest most profitable patients but as a global hospitals will pick off the easiest most profitabl e patients but as a global

budget hospital you already want the easiest most profitable patients because budget hospital you already want the easiest most profitable patients because

you want to maintain your budgets at the end of the year or consume it in you want to maintain your budgets at the end of the year or consume it in

non-patient areas because those are that's the incentive non-patient areas because those are that's the incentive

structure that is created for the hospital so we already have that structure that is created for the hospital so we already have that

incentive there the question is which is the greater the evidence around the incentive there the question is which is the greater the evidence around the

world is is not super clear but certainly what we're seeing now is world is is not super clear but certainly what we're seeing now is

emerging evidence and moving to activity-based funding actually does emerging evidence and moving to activity-based funding actually does

improve outcomes and improve adherence to best practices improve outcomes and improve adherence to best practices

it is government that is setting these structures up and it is government that it is government that is setting these structures up and it is government that

has control and levers over this so there's nothing stopping the government has control and levers over this so there's nothing stopping the government

from saying we will introduce activity-based funding you hospital from saying we will introduce activity-based funding you hospital

cannot charge extra for accommodation services you cannot charge extra for cannot charge extra for accommodation services you cannot charge extra for

these things and we very publicly air if you are not only will we come and audit ||||||||||||||||auditar these things and we very publicly air if you are not only will we come and audit

you and charge you and penalize you for these things we will also make a great you and charge you and penalize you for these thin gs we will also make a great

big public fuss because there is no port like the court of public opinion when it ||alvoroço||||||||||||| big public fuss because there is no port like the court of public opinion when it

comes to a provider acting outside of the interest of the general public and comes to a provider acting outside of the interest of the general public and

certainly we see that around the developed world when a hospital is acted certainly we see that around the developed world when a hospital is acted

inappropriately the the the weight of the public opinion inappropriately the the the weight of the public opinion

coming down on this is substantial and there's certainly consequences for them coming down on this is substantial and there's certainly consequences for them

to be had we also know from around the developed world that regular audits that to be had we also know from around the developed world that regular audits that

penalties for hospitals that violate certain rules or that have certain penalties for hospitals that violate certain rules or that have certain

negative outcomes are very effective tools within this concern negative outcomes are very effective tools within this concern

and the last piece i think is is the importance of competition in all of this and the last piece i think is is the importance of competition in all of this

you as a patient now in an activity-based funding system can choose you as a patient now in an activity-based funding system can choose