Answered Questions...

Sometimes questions come up in the seminars I've hosted or the emails I receive. My answers to those questions are provided on this page.  While I try my best to answer questions as accurately as I can, I do occasionally get it wrong... So here is my disclaimer: use the answers here to support the research that you are doing on your own and please do not rely on my answers as fact alone. Also, these questions were answered at a particular moment in time, so they may not reflect the present context (i..e, may not be "up-to-date").

Do you think there is content here that I can update? Did I miss something important in an answer?  Have a question? Write me: cameron.fani@raisehealth.net 

List of questions answered so far:

  • What is the extent that other provinces fund Gender Reassignment Surgery (GRS) and how does one access the program?
  • Governance structure – Covenant Health
  • Are Vasectomies covered under the Alberta Health Care Insurance Plan? 
  • What happened to Family Care Clinics (FCCs) in Alberta?

Please scroll downwards to see my answers. 


Question: What is the extent that other provinces fund Gender Reassignment Surgery (GRS) and how does one access the program?

What is GRS?
GRS is surgery conducted to physically alter the sexual anatomy of one person's gender to match another's. See this link to a clinic in Montreal specializing in this type of surgery and related surgeries. (Use Google Chrome browser to translate the page to English). 

GRS in Alberta: 
GRS was funded by the Alberta Health Care Insurance Plan (AHCIP) until April of 2009, until which it went unfunded for two years up until June 15, 2012 due to "cost-saving measures"[1]. The decision to re-fund it did not go without criticism from the leader of the opposition party at that time [2]. To access the program, your physician (in this case, a psychiatrist) will have to apply to Alberta Health (the provincial health ministry) on your behalf and you will have to meet certain conditions for the surgeries that fit under the GRS category [3]. GRS surgery does not take place in Alberta, but at a "private hospital" in Quebec [4] The AHCIP will cover this specific surgery, but not other surgeries conducted with the aim of looking more like the other gender (i.e., facial feminization, tracheal shave and voice pitch surgery) [5].

GRS in Other Provinces:
All provinces now cover  GRS (to an extent), with the final 'hold-out' province, New Brunswick, announcing provincial coverage for the surgery in June of 2016 [6]. It appears to me that the same Quebec clinic (Chirurgies) is used by most provinces for this type of surgery.  

Cam's take: 
While GRS is insured in all provinces, it does not appear that it's insured in the same way that meets the criteria for a 'medically necessary' health care service in Canada.

Why do I think that way? Well, for starters, it appears that access is limited to formal applications to ministerial-managed programs (a program per province) and that it does not appear that public hospitals are doing this surgery–the provinces either refer to the same private hospital in Quebec for major GRS components or they fund limited surgeries within the province at private facilities (as far as i can tell). If you didn't want to wait for the province to approve the surgery, there is nothing stopping you from paying out of pocket [7], unlike publicly insured health care services, like hip or heart surgery.   

Until I see public facilities doing this surgery regularly and consistently and without a formal application process for ministerial approval, I'm not confident that this treatment is covered in the same way that other already well-defined medically-necessary health care services are, like hip or heart surgery. 

And considering the decision that Alberta made in 2009 to defund GRS when it was previously funded, that makes me question the government's view of whether that surgery is considered medically necessary. I'm sure after legal review, the government felt that they could cut the program without attracting federal consequences by violating the principles of the Canada Health Act. Their decision to publicly-fund the surgery some time later had more to do with transgender rights advocacy, public pressure, evolving political views on transgender issues and rights, and legal challenges applied within the province's human rights commission. There likely is a difference when considering "listed" versus "funded" services. Listed services can be considered medically necessary, while funded ones can be reviewed, cut or renewed at any time.  

So think of GRS as a publicly funded, program based health care service that doesn't cross the threshold of being considered medically necessary. If it were, it would be offered ubiquitously within provincial health care systems.

References
([1] - http://news.nationalpost.com/news/canada/alberta-gender-reassignment-surgery 
[2] - Ibid. (for those unfamiliar with the word, "Ibid.", it's a latin word that means something like "see the same source as previously listed"). 
[3] - http://www.health.alberta.ca/documents/AHCIP-Bulletin-Med-166A-2012.pdf
[4] - Ibid. Also, the link, http://www.grsmontreal.com/fr/chirurgies.html, that was mentioned earlier is the same clinic or "hospital" that is being referred to.
[5] - Ibid. See also http://www.tesaonline.org/grs-funding-in-alberta.html.
[6] - http://www.cbc.ca/news/canada/new-brunswick/gender-confirming-surgeries-1.3614766
[7] - http://www.cbc.ca/news/canada/calgary/trans-surgery-wait-list-grows-1.3537921


Question: Governance structure – Covenant Health  

A question brought forward during the seminar asked about the governance structure of Covenant Health and how it is related to Alberta Health Services and the Ministry of Health. From the research I conducted, I was surprised by the lack of publicly available information on the subject. But here's what I found:  

But first, what is Covenant Health? 
Covenant Health is "Canada's largest Catholic healthcare organization" operating" 17 hospitals in 12 communities across Alberta" [1]It has over 11,120 employees, 812 physicians, and 2,536 volunteers as of 2015/16 [2]. Covenant health is just one of three entities that make up the "Covenant family", which also includes Covenant Care, which provides "supportive living, long-term care and hospice services", and Covenant Living, which operates as a non-profit that provides housing options for seniors [3]. It appears that that these two other organizations have their own leadership structures that ultimately report to Covenant Health [4]. 

Covenant Health's Governance Structure and Reporting: 
Covenant Health's governance structure is similar to AHS' in terms of the way it's organized; they both have structures that resemble private companies. The "President and CEO" of Covenant Health is Patrick Dumelie. Covenant Health has a Board of Directors whose members are appointed by a "Catholic sponsor, Catholic Health of Alberta", who are made up of Catholic Archdiocese [5]. The Board is chaired by Ed Stelmach, who you might remember was the Premier of Alberta between 2006 to 2011 [6]. The board also includes Edmonton’s Catholic Archbishop, Richard Smith [7]. This is important—the Archbishop, among others, and prior to the amalgamation of all Catholic health providing entities under the Covenant Health banner, hired the current Covenant Health CEO and appointed members of the Covenant Health Board of Directors [8]. Now, there are some differences in governance between AHS and Covenant Health: in AHS' case, the health minister appoints AHS' Board of Directors who then hires AHS' CEO. In the Covenant Health structure, the Archbishop, through a collection of Catholic Archdioceses, had originally appointed both the CEO and the Covenant Health Board of Directors (of which Archbishop Richard Smith is also a sitting member) [9]. It's assumed that the Covenant Health Board also hires the CEO, but since there has not been a leadership change at the CEO level, I'm not sure. Less clear is how the organization is accountable to the Ministry—I mean, there is a definite connection to the Minister's office [10] but in terms of reporting, I'm not sure if the Ministry liaises through the Board of Directors at Covenant Health or through the Catholic Archdioceses. There are examples where the Archdiocese are directly consulted by ministerial request, for example when contributing to the discussion around physician-assisted death [11]. And it looks to me that it can be both or either depending on the circumstance (see [8] and [11]). While AHS has a more direct reporting relationship to the Ministry, it's clear that Covenant Health's relationship with the ministry takes into account the historical circumstances of catholic provided health care services which began in the early 1900's (link), but what's unclear is how 'equal footed' the Catholic Archdiocese and the Ministry are  when determining the strategic path for the organization. The Ministry's mandate in the area of health is perhaps greater considering that it is also publicly accountable by virtue of being an body overseen by an publicly elected official. Also, since hospitals are publicly funded and protected from private operation without ministerial approval, it's natural that the Ministry would assume a greater role in managing affairs related to these entities regardless of who they are in partnership with.  

In terms of the relationship to AHS, there are two agreements that are referenced in various articles and documents [12], and they are identified as "the Minister’s agreement 1994 and the Cooperation and Service Agreement". Unfortunately, I was not able to find examples of these documents online, so I'm not certain about the details, but what can be assumed is that AHS and Covenant Health have formed a partnership to deliver health services together with a certain level of coordination and that Covenant Health operates like a contracted provider under AHS but with unique and separate oversight. If you look at Covenant Health's financial statements, you'll see that AHS provides the bulk of their funding [13]. So, out of the funding that AHS gets from the Alberta government for health care services, AHS passes a portion along to Covenant Health. How it is assessed for funding is not clear in publicly available documents (for example, can AHS reduce Covenant Health's funding unilaterally?)

So is Covenant Health a subsidiary of AHS?
I can perhaps suggest that it isn't; typically, a subsidiary would be under more direct oversight and control of its parent organization. In this case, it's like two separate entities with two separate governing relationships that have partnered to deliver the same services, mostly due to historical circumstance and, perhaps, by honoring the fact that the 'catholic health system' pre-existed other formal, coordinated interpretations of a health care system in Alberta. It's definitely a unique arrangement—and a similar parallel structure can be seen in Alberta's public education system where there is a Catholic entity also providing educational services in parallel with a public one, with both funded by public tax dollars.  

[1] https://www.covenanthealth.ca/corporate-information
[2] https://www.covenanthealth.ca/corporate-information/figures-at-a-glance  
[3] https://www.covenanthealth.ca/media/122772/report-to-the-community-2016.pdf
[4] https://medicalstaff.covenanthealth.ca/news-events/latest-news/2016/june/2016-06-28-new-president-for-covenant-care-and-covenant-living
[5] https://www.covenanthealth.ca/corporate-information/board-of-directors/ 
[6] Ibid.  
[7] Ibid. 
[8] http://www.covenanthealth.ca/resources/pdf/COVH_CatholicHealthofAlbertaNewsRelease.pdf and http://www.assembly.ab.ca/ISYS/LADDAR_files/docs/committees/pb/legislature_27/session_2/20090407_1200_01_pb.pdf#page=7
[9] Ibid. 
[10] http://www.wcr.ab.ca/This-Week/Stories/entryid/6249
[11] http://www.calgarydiocese.ca/articles/alberta-bishops-submission-pad.html and http://caedm.ca/Portals/0/documents/archbishops%20office/2016-03-24_Submission-PhysicianAssistedSuicideandEuthanasiaConsultation.pdf
[12] http://www.wcr.ab.ca/This-Week/Stories/entryid/6249 and http://www.albertahealthservices.ca/Assets/about/board/ahs-brd-2010-12-02-summary.pdf and http://www.health.alberta.ca/documents/AHA-Feedback-Covenant-Health-2.pdf
[13] https://www.covenanthealth.ca/media/109728/20151008-covenant-health-financial-statements-2015.pdf (you'll notice that this financial statement is prepared separately from AHS', which further suggests that these entities are just in partnership and not in a subsidiary relationship, unlike other examples of parent-subsidiary relationships where there is a more 'proactive' stake by the parent in the operations of the subsidiary and where it would be defined as such). 

Other interesting links:  
Former Alberta premier Ed Stelmach tackles new role as Covenant Health board boss
http://edmontonjournal.com/news/local-news/former-alberta-premier-tackles-new-role-as-covenant-health-board-boss


Question: Are Vasectomies covered under the Alberta Health Care Insurance Plan? 

Are vasectomies covered? The answer is yes! But the reversal of a vasectomy is not covered [1]. Through the same link, you can see which other health services are covered and which are not. And you can find which are definitely not covered here [2].  

Cam's take: 
Now, are vasectomies are medical necessity? I think it's debatable, but perhaps it fits under the larger mandate of promoting sexual health within the domain of public health. And while it can be argued that that it might not be really medically necessary, it does pass some important tests in terms of how it's covered in Alberta: one being that it's not subject to ministerial approval, unlike, for example, Gender Reassignment Surgery (GRS), and another being that it appears to be performed by publicly funded physicians within the province.   

For your interest: http://www.vasectomyedmonton.com/costs/. You'll learn that while the clinic will conduct a basic vasectomy at no cost because it is covered by Alberta Health Care Insurance, they offer a "premium" service if you want a more comfortable experience. Is it legal? I'm not sure...but perhaps it is if the surgery itself is completely different from what is normally offered when performing a regular vasectomy. But that's just a guess. Perhaps it begs a related question: how do we reward innovation in medical services that are publicly funded?

[1] http://www.health.alberta.ca/AHCIP/what-is-covered.html
[2] http://www.health.alberta.ca/AHCIP/what-is-not-covered.html


Question: What happened to Family Care Clinics in Alberta? 

Background:  
Primary care services in Alberta are almost always delivered by physicians who run privately-owned clinical practices and who bill the provincial government's health ministry, Alberta Health, (typically through the fee-for-service remuneration model) for the medically-necessary (i.e., publicly insured) health care services that they provide to Albertans. Like a private business, they hold their own hours, can set-up shop anywhere, and can define how they serve their patients, including the breadth of complimentary services they offer, like interdisciplinary care. Also like a private business, they are subject to paying for rents (or mortgages, if they own their clinical spaces) for the practices they run, the support staff they keep, the information systems they subscribe to, and any other business overhead that comes with owning a clinical practice, including advertising and promotion (because if patient don't know they exist, they won't be able to see patients and bill the province and earn income). They are "gatekeepers" to the programs and services provided by the provincial health care authority, Alberta Health Services (AHS), physician specialists, and diagnostic and laboratory services.    

Criticisms of primary care:  
Criticisms of the current primary care model include: A limited strategy for where primary care clinics are to be set-up in order to serve underserved areas (i.e., rural) and vulnerable populations; limited extended clinic hours; accountability for the quality of the services provided (an issue that inspires the public to check public rating pages, like www.ratemds.com, to seek a "good" physician); limited measurement of patient outcomes and investment in continuous improvement activities; limited integration and information sharing with the regional health care authority; does not always take advantage of a multi-disciplinary approach to care (i.e., inclusion of nursing, physiotherapy or other allied health professionals); and when access to primary care clinics are not convenient or available, patients visit Emergency Rooms instead, tying up emergency care resources for health concerns that would have otherwise been appropriately managed in a primary care setting. The Alberta Auditor General's 2017 report on the health care system provides a review of primary care services, including criticisms and recommendation for improvement.  

Solutions proposed:  
What was proposed as a solution to these criticisms? Primary Care Networks (PCN) came first. Physician clinic owners participating in PCN partnerships were provided a "top-up" for each patient they saw through a contractual relationship with AHS. The model's benefits centered on enhancing an interdisciplinary approach to care, enhancing information sharing with AHS, and better coordinating care with AHS when patients were "handed-off" or transitioned between PCNs and AHS administered programs and services. But adoption of the model was voluntary and still independently managed and led by physicians, which resulted in an inconsistent service-delivery approach between PCNs. More critically, PCN impact was not being measured well [1, pg. 25]. Most Albertans did not know what a PCN was, let alone if they were part of one [2].   

What solution was explored next? 
A new primary care service entity called Family Care Clinics (FCCs) was proposed that had the effect of limiting the administrative authority and flexibly of any one, individual physician over the management of this entity by enforcing a strict and consistent service mandate and operational strategy for all FCCs to follow (defined by the provincial health ministry). FCCs could be launched and managed by non-physicians, management groups, and non-profits, as well as any physician who wanted to support this entity (and the expectations that came with doing so), which was a departure for how primary care clinics were typically operated and administered, considering they had always been physician-led and governed. You can consult the FCC reference manual for more information about how they were to operate. 140 clinics were announced, but the political party sponsoring the entity lost its leader in a scandal and the party subsequently lost the following election, which ended the push for the spread of FCCs. FCCs also lacked support from the province’s physician union as the entity encroached on the traditional jurisdictional authority and service independence that physicians enjoyed in the primary care sphere. With the FCC roll-out "dead-in-the-water", efforts were pivoted towards improving the PCN model, which physicians liked better because they maintained administrative control that mirrored how they've usually practiced in primary care roles. A recent Alberta Auditor General's review suggests there have been improvements to PCN operation, but not without caveats.  

What happened to FCCs?  
Three of the original pilot sites are still operating and it does not appear that the health ministry plans to resurrect their expansion. In fact, I had a hard time finding information about FCCs on the ministry webpages, with the exception of the reference manual. A recent news article suggests that an FCC in northern Alberta helped significantly during the wildfires that engulfed that area.  

[1] - http://www.oag.ab.ca/webfiles/reports/OAGJuly2012report.pdf  
[2] - http://www.cbc.ca/news/canada/edmonton/primary-care-networks-need-closer-scrutiny-auditor-general-says-1.1274328