John Muscedere is scientific director and CEO of Canadian Frailty Network (CFN), an interdisciplinary network dedicated to improving care of frail elderly Canadians. He is also a critical care physician at Kingston General Hospital. Samir Sinha is director of geriatrics at Sinai Health System and the University Health Network Hospitals in Toronto, co-chair of the National Institute on Aging’s Advisory Board, and a member of the CFN Research Management Committee.
KINGSTON, TORONTO – HEALTH – Canada’s per capita health funding formula fails to address the clear and growing need created by our frail population.
When the previous Health Accord expired in 2014, the Conservative government unilaterally established a new funding model for federal health transfer payments to the provinces and territories on an equal per capita basis. It included a guarantee that no province would receive less than its 2013 transfer amount, with a further guaranteed minimum three per cent growth rate from 2017 onward.
So what’s not to love?
In a country as diverse as Canada, per capita funding creates winners and losers. For provinces with flourishing economies and/or younger populations, the formula may be welcome. But this formula fails to recognize and accommodate the needs of many provinces and territories. The per capita models fundamentally ignore the sometimes extreme variations in socio-economic, demographic and health status of regional populations. That’s a significant oversight.
The good news is that new Liberal Health Minister Jane Philpott has promised a fresh Health Accord to be finalized over the coming year. Atlantic premiers have called for federal health funding based on the needs of their aging populations. Others, such as the Canadian Federation of Nurses Unions and certain pundits, have similarly called for fiscal transfers based on specific provincial demographic needs such as age.
That makes sense. But the health minister should also craft a new federal funding arrangement based on the more precise and evidence-based concept of frailty.
A model based on age alone is attractive because health-care spending rises with increasing age. But not all Canadians age in the same way. Consider an individual in their 60s with multiple medical problems requiring repeated use of the health system compared to a healthy octogenarian with few or no health problems.
In a recent review in the Canadian Journal of Aging, along with our colleagues, we highlight frailty as an essential concept that needs more attention in order to direct precious health-care dollars efficiently – and to provide the right care at the right time to the right populations.
Frailty is common in our aging population but it remains highly under-recognized. It’s estimated that more than one million Canadians are clinically frail. Clinical frailty can occur at any age and describes individuals who are in precarious health, have significant multiple health impairments and are at higher risk of dying. The hallmark of frailty is that minor illnesses such as infections or minor injuries that would be handled easily by non-frail individuals may trigger major deteriorations in health.
Frailty is a better determinant of outcomes and health-care utilization than age alone.
Our health system came into existence when people generally died younger and more commonly with of a single illness. As well, many more of us lived in intergenerational households or close to relatives who provided help for living independently.
Jump forward several decades and our health system scrambles to meet the needs of older individuals with multiple simultaneous and often inter-related health and social issues that threaten their independence – the essence of frailty.
The system excels at illness-specific interventions, but many of these pose higher risks and offer lower potential benefits in frail individuals. Health care may provide those with frailty both too much care and the wrong kind of care. This can be expensive and harmful, and threaten the overall sustainability of the system.
So why should a new Health Accord include an understanding of frailty – and base fiscal transfers on the concept – along with other important factors? Because a large proportion of our health spending is and will increasingly be focused around frail older Canadians, particularly those nearing the end of life.
Targeting federal funding based in part on frailty would help those provinces and territories that have more significant health- and social-care needs in this area.
It would also make it clear that the issue of frailty in Canadians needs to be urgently addressed.