菲沙研究所-反思加拿大的长期护理（英）-2021-82正式版

2021RETHINKINGLONG-TERMCAREINCANADALessonsonPublic-PrivateCollaborationfromFourCountrieswithUniversalHealthCareYanickLabrie2021•FraserInstituteRethinkingLong-TermCareinCanadaLessonsonPublic-PrivateCollaborationfromFourCountrieswithUniversalHealthCarebyYanickLabriefraserinstitute.orgContentsExecutiveSummary/iIntroduction/1TheManyChallengesFacedbytheCanadianLong-TermCareSector/3LessonsfromGermany/12LessonsfromJapan/19LessonsfromtheNetherlands/26LessonsfromSweden/33Discussionandconclusion/43References/47AbouttheAuthor/71Acknowledgments/72PublishingInformation/73Purpose,Funding,andIndependence/74SupportingtheFraserInstitute/74AbouttheFraserInstitute/75EditorialAdvisoryBoard/76fraserinstitute.orgLabrie•RethinkingLong-TermCareinCanada•iExecutiveSummaryelong-termcaresectorinCanadahasreceivedalotofmediaattentionsincethebeginningoftheCOVID-19pandemic.isisnotsurprising,giventhetragiccon-sequencesthathaveaffectedtheresidentsofpublicandprivatenursinghomesandtheirfamilies.However,thedifficultiesinmeetingthecareneedsoftheelderlyinnursinghomesorathomeprecedethearrivalofthepandemicinthecountry.Forsometimenow,callsfortheintegrationoflong-termcareintothepublichealthsystemsinCanadahavemultiplied.Variouslobbygroupsarecallingforasub-stantialincreaseinpublicspendingandamajoroverhaulofthesystem.Someopinionleadershaveevensuggestedeliminatingprivatefor-profitproviders,accusingthemofbeingattherootofthemanyfailingsobservedinthesector.esecallsarebasedontherealityofanagingpopulation,coupledwithmisconceptionsofhowotheruniversalhealth-caresystemsincludesuchcareaspartoftheirsystem.isstudyhasexaminedhowfourcountries—Germany,Japan,theNetherlands,andSweden—haveeitheruniversalizedormeaningfullyreformedtheiruniversallong-termcaresystemovertimetomakeitfinanciallysustainableandresilientandmoreadequatelymeettheneedsofelderly.esecountrieswitholderpopulationsareman-agingtointegratelong-termcareintotheiruniversalhealth-caresystem,whiledevot-ingashareoftheirGDPtohealthcomparableto,orlessthan,thatofCanada.eyhaverespondedtothegrowingconcernsabouttheagingoftheirpopulationandthefinancialsustainabilityoftheirpublichealth-caresystemmostlybyadoptingadecen-tralizedapproachthatefficientlyleveragescollaborationbetweenthepublicandpri-vatesectors.erearemanyimportantpolicylessonstodrawfromtheirexperience.Inallfourcountries,patientshaveuniversalaccesstothelong-termcareandservicestheyneedregardlessoftheirincomeandpre-existinghealthconditions.Ineachcountry,universalityreferstoeligibilityandaccesstolong-termcare,anddoesnotmeanthatcareneedsofelderlycitizensarefullyfinancedbygovernments.Indeed,patientsmustcontributetothefinancingofanon-negligiblepartofthecostsofcarethroughcostsharing.Costsofaccommodationsandmealsaregenerallynotcoveredbypublicinsuranceschemes.Onlysomepatients—thosewithincomesbelowacer-tainthreshold—receivefullpublicfunding.Cost-sharingisanintegralpartoftheseforeignhealthsystems,anddoesnotleadtoinequitableorreducedaccesstoneededcare.Importantly,theco-paymentsgivepatientsincentivestouselong-termcareservicesinamorecost-efficientmanner.esefourcountrieshaveimplementedreformsovertimeinordertoleavemoreroomforpatientstochooseaproviderandorganizetheirownlong-termcarefraserinstitute.orgii•RethinkingLong-TermCareinCanada•Labrieastheyseefit.Atthesametime,privatefor-profitentrepreneurshavebeenincreas-inglycalledupontoplayalargerroleintheprovisionoflong-termcareservices,andhaveshowntheycouldrespondeffectivelytochangesincustomers’needsandpreferences.Choiceandcompetitionamongcareprovidershavebeenencouragedbypolicymakers,andhavehelpedimprovethequalityofservicesandtheefficiencywithwhichtheyaredelivered.UnlikethepracticeinCanada,careprovidersinthesefourcountriesarenotguaranteedtheywilloperateatfullcapacity,andgoodqualityisrewardedthroughuserchoice.InCanada,incontrast,thevastmajorityoflong-termcareisstillprovidedininstitutions.Itisawell-knownfactthatmostseniorsinCanadaconsiderinstitutionalcarealastresortandwouldprefertoreceivecareservicesathomeifthesewereaccessibletothem.efourcountriesanalyzedinthisreporthavemadeamajorshiꢀtowardshomecareinthelastfewdecades.Accesstoinstitutionalcareinnursinghomesisnowreservedtopeopleinneedofpermanentsupervisionorintensivecareandtreatments.eseaging-in-placepoliciesnotonlycoincidedwithpopulationpreferencesbutalsocontributedtosoꢀeningtheimpactofthepopulation’sagingonlong-termcareexpendituresinthesecountries.InGermanyandtheNetherlands,inparticular,asystemofcashbenefitshasbeensetuptogivemoreoptionstopatientsandtopromotecaredeliveredathomeorinthecommunity.Seniorscanevenhirefamilymembersorrelativesandpayforthedomestichelporhomecarewiththepersonalallowancetheyreceive.esecash-for-careschemeshaveproventobemorecost-efficientthantraditionalgovernment-directedprograms.Mostimportantly,theseschemeshavebroughtbenefitstousersintheformofincreasedautonomyandcaresolutionsmoresuitedtotheirneedsandpreferences.Inrecentyears,severalCanadianprovinceshaveadoptedgovernancereforms,mergingregionalhealthauthorities,whichweremeanttobeautonomousintermedi-arybodiesresponsibleforliaisingbetweenserviceprovidersandthepopulation.Byremovinggovernanceanddecision-makingpowerfromregionalhealthauthoritiesandhealthinstitutions—fromhospitalstonursinghomes—,thesereformshaveledtogreatercentralization.iscentralizedapproachgoesagainstthetrendobservedinthefourhigh-performingcountriesexaminedhere,thathavedecentralizedthedecision-makingpowerstolocalauthorities.ispolicyorientationisbasedonthenotionthatlocalmanagersandotheractorsinthefieldarebetterabletounder-standthespecificneedsandpreferencesofpatientsandthebestmeanstoaddressthem.Canadianpolicymakersshouldconsiderthebenefitsofsuchdecentralizedapproacheswhenattemptingtoreformthelong-termcaresectorandcoordinatetheactionsofmillionsofpeoplewithvaryingpreferencesandknowledgeinincreasinglycomplexhealth-caresystems.fraserinstitute.orgLabrie•RethinkingLong-TermCareinCanada•1IntroductioneCOVID-19pandemicthatspreadgloballyin2020hadtragicconsequencesthatparticularlyaffectedseniors(Kain,McCreight,Mazzulli,Gubbay,Rea,andJohnstone,2021).epandemichasonceagainshedlightonthepoorcareconditionsinseveralpublicandprivatenursinghomes,themagnitudeoftheneedsofelderlypeopleinCanada,andtheinabilityofourcurrentpublichealth-caresystemstoadequatelyaddressthem.Giventheacceleratedagingofthepopulationandtheincreasingprevalenceofchronicdiseases,theprovincialhealthsystemswillhavetocopewithevengreaterhome-andlong-termcareneedsinthefuture(Nuernberger,Atkinson,andMacDonald,2018).Ofcourse,someeffortshavebeenmadetoimprovethesituationofeldersinmostCanadianprovincesinrecentyears.Provincialgovernmentshavenotablyiniti-atedvariousstrategiesaimedatallowingseniorstolivehealthierlivesandremainintheirownhomesaslongaspossible(MSSS,2012;Peckham,Rudoler,Li,andd’Souza,2018).efederalgovernmentalsorecentlyincreasedandtargeteditstransferstotheprovincesinordertoaddresssomeoftheshortcomingsobservedinhomeandcommunitycare.enewHealthAccord,ratifiedinAugust2017,wasaccompaniedbyacommitmentfromOttawatotransferanadditional$11billionoverthefollow-ing10years(Roberts,Bartram,Kalenteridis,andQuesnel-Vallée,2021).Asaresult,Canadawasinthetopthirdofcountriesthatspendthemostonlong-termcareasapercentageofGDPin2018(HughesTuohy,2021).eseeffortsseemnolongersufficient,however,andtherearemanyvoicescallingforamajoroverhaulofthesystem,theestablishmentofnationalstandardsforlong-termcareacrossthecountry,andtheinjectionofadditionalpublicfundstoimprovethedeliveryofeldercare(Roman,2021).Notably,therehavebeenincreasingcallstointegratelong-termcareintoCanada’spublichealth-caresystem(MarchildonandTuohy,2021;McGregor,2020).Someevensuggestthatweshouldrelysolelyonpublicornon-profitorganizationsfortheprovisionoflong-termcaretoseniors(Patel,2020;ReynoldsandLoriggio,2021).esecallsarebasedontherealityofanagingpopulation,coupledwithmisconceptionsofhowotheruniversalhealth-caresystemsincludesuchcareaspartoftheirsystem.isstudyexamineshowfourcountries—Germany,Japan,theNetherlandsandSweden—haveeitheruniversalizedormeaningfullyreformedtheiruniversallong-termcaresystemovertime.esesystemshaveallatonetimeoranotherbeenpraisedasmodelstoemulatebyopinionleadersandpunditsinCanada(BlomqvistandBusby,2016;Szehehely,2016;Peng,2020;Flood,DeJean,Doetter,Quesnel-Vallée,fraserinstitute.org2•RethinkingLong-TermCareinCanada•LabrieandSchut,2021).Canadahasalottolearnfromtheexperienceofthesecountries.eyallprovideuniversalaccesstolong-termcaretotheircitizensandgivethemmanymoreoptionsaboutwhereandhowtogetthecareandservicestheyneed.eirapproachcontrastswiththoseoftheCanadianprovinces,wheremostpatientshaveverylittlecontroloverthebasketofservicesofferedtothem.isstudyisorganizedasfollows.efirstsectionpresentsabriefdescrip-tionofthelong-termcaresysteminCanadaandthemainchallengestobeover-come.efollowingsectionsexaminehowGermany,Japan,theNetherlands,andSwedenintegratelong-termcareintotheirhealthsystems,andlookparticularlyatthepublic-privatepartnershipsthathaveemergedovertimetorespondtothechal-lengesposedbytheagingofthepopulationandtheincreasingneedsofseniorcit-izens.ereportconcludeswithadiscussionofkeyfindingsfromforeignpracticeandpolicylessonsforCanada.fraserinstitute.orgLabrie•RethinkingLong-TermCareinCanada•3TheManyChallengesFacedbytheCanadianLong-TermCareSectorLong-termcare(LTC)referstothehealth-careservicesgenerallyprovidedtopeoplewithareduceddegreeoffunctionalcapacityrequiringcomprehensiveaccommoda-tionandsupportsinnursinghomesorresidentialcarefacilities,andtopeoplewithlimitationsontheactivitiesofdailylivingintheirownhome(Marchildon,Allin,andMerkur,2020:119).WhiletheCanadaHealthActspecifiesthesetofcriteriaunderwhichphysicianandhospitalservicesdeemedmedicallynecessarymustbecoveredbytheprovincialhealth-insuranceprograms,itexcludeslong-termcare.Rather,LTCinCanadaisconsideredanextendedhealth-careservicethatcanbeprovidedatthediscretionofprovincesandterritories(Norris,2020).[1]Nonetheless,eachprovinceprovidesservicestoitselderlypopulationunderprogramsthatcoverpartofthecostsofinstitutionalcareandhomecare.erearevariationsinthegenerosityoftheseprograms,althoughthemodelsaresimilarfromprovincetoprovince.Careinnursinghomesisgenerallypubliclyfundedorsubsidized,whilethefinancingofaccommodationservicesistheresponsibilityofresidentsandmayvaryaccordingtoincome(Norris,2020).Withregardtohomecare,publicprogramscoverthecareportionoftheservicesinmostprovinces(uptoamaximum)but,ingeneral,otherservicesforlessacutepersonalneedsmustbebornefinanciallybytheusersthemselves(Zhang,Sun,andl’Heureux,forthcoming).Home-careservices(nursingcare,rehabilitationtherapy,nutritionalcounselling,andsoon)areneeds-basedandprovidedbyregulatedhealthprofessionalssuchasnursesandphysiotherapists,whilehomeassistanceservices(mealpreparation,eating,toileting,andsoon)aredeliveredmostlybypersonalsupportworkersandinformalcaregivers(Mery,Wodchis,andLaporte,2016).Inrecentyears,severalprovinceshaveadoptedgovernancereforms,mergingregionalhealthauthorities(RHA),whichweremeanttobeautonomousintermedi-arybodiesresponsibleforliaisingbetweenserviceprovidersandthepopulation.Byremovinggovernanceanddecision-makingpowerfromRHAsandhealthinstitu-tions(fromhospitalstonursinghomes),thesereformshaveinawayledtogreater[1]eCanadaHealthAct(CHA)definesinsuredhealthservices,underasetofcriteria,asthosedeemedmedicallynecessary,especiallyphysicianandhospitalservices.CareinnursinghomescareandhomecarearementionedintheCHAas“extendedcareservices”;theyarenotinsuredhealthservicesbutcanbeprovidedatthediscretionofprovincesandterritories(GovernmentofCanada,1984:S.13).fraserinstitute.org4•RethinkingLong-TermCareinCanada•Labriecentralization(Picard,2017;Labrie,2017;Ragupathi,2020).InQuebec,thisincreasedcentralizationwasrecentlyidentifiedasafactorthathascontributedtoreducingtheaccountabilityofmanagers,underminingtheorganizationoflong-termcareandweakeningitsabilitytocopewiththeCOVID-19pandemic(CSBE,2021).Overall,Canadadevotes2%ofitsGDPtolong-termcare,whichincludesinsti-tutionalandhomecare(figure1).About78.4%offundingforlong-termcarecomesfromgovernments,3.3%fromprivateinsurers,and18.3%fromout-of-pocketspend-ingbyindividuals(OECD,2021).Amongthemainreasonsforthelowuptakeofpri-vatelong-termcareinsurance(LTCI)inCanadaarealimitedawarenessoftheLTCIproducts(Boyer,deDonder,Fluet,Leroux,andMichaud,2020)andtheperceptionthatgovernmentswillsomehowmeetthelong-termcareneedsofthepopulation(so-called“crowding-outeffectofgovernmentprograms”)(Boyer,deDonder,Fluet,Leroux,andMichaud,2019).Figure1:Expendituresforlong-termcareandotherhealth-careservicesasapercentageofGDP,selectedOECDcountries,2019Long-termcareOtherhealth-careservicesUnitedStatesGermanySwitzerlandFranceJapanSwedenCanadaBelgiumNorwayAustriaNetherlandsUnitedKingdomDenmarkFinlandSpainItalyIcelandCzechRepublicIreland0369121518PercentageNote:dataforJapanpertaintotheyear2018.Source:OECD,2021.fraserinstitute.orgLabrie•RethinkingLong-TermCareinCanada•5Adiversityofnursinghome-careproviders,butnorealcompetitionIntermsofservicedelivery,thereisadiversityofinstitutionalcareprovidersofdif-ferenttypesineachprovince.AccordingtodatacompiledbytheCanadianInstituteforHealthInformation(CIHI),therewere2,076nursinghomesinCanadain2021,46%ofwhicharepubliclyowned,29%areprivatefor-profit,and23%areprivatenot-for-profit.[2]However,privatefor-profitparticipationvariessignificantlyfromprovincetoprovince,beinghigherinOntario(57%)andPrinceEdwardIsland(47%),lowerinQuebec(12%)andalmostnon-existentinNewfoundland&Labrador(2%)(CIHI,2021a).Ingeneral,theparticipationoftheprivatesector(for-profitornot-for-profit)intheprovisionofnursinghomecareinCanadaislowerthaninmanyOECDcountries(figure2).Figure2:Provisionofnursing-homecare,byownershiptype,selectedOECDcountries,2021ormostrecentyearForprofitNotforprofitPublic33.0%56.0%23.0%31.0%11.0%AustraliaCanada29.0%24.0%43.0%13.9%12.2%19.2%80.0%69.3%46.0%45.0%France53.0%4.0%Germany79.1%87.8%7.0%JapanNetherlandsSweden0.9%

79.9%13.0%7.0%7.2%UnitedKingdomUnitedStates23.5%ꢀꢁꢀꢂꢀꢃꢀꢄꢀꢅꢀꢀPercentageNote:ForCanada,thebreakdownbetweenprivatefor-profitandnot-for-profitwasnotavailablefor2%ofthefacilities.Sources:Australia(2018/19):ACFA,2020;Canada(2021):CIHI,2021b;France(2020):Delanglade,2021;Germany(2019):GermanFederalHealthMonitoring,2021g;Japan(2017):MHWL,2019;Netherlands(2019):Bos,Kruse,andJeurissen,2020;Sweden(2020):NBHW,2021;UnitedKingdom(2016):Pujol,Hancock,Hviid,Morciano,andPudney,2021;UnitedStates(2016):CDCP,2019..[2]ebreakdownbetweenprivatefor-profitandnot-for-profitwasnotavailablefor2%ofthefacilities(CIHI,2021b).fraserinstitute.org6•RethinkingLong-TermCareinCanada•Labrieesectoristightlyregulatedandmonitoredinallprovinces.Nursinghomesmustobtainalicencetooperateandnewlicencesgrantedbyprovincialgovernmentsaregenerallyrestrictedbynumberorgeography(Roblin,Deber,Kuluski,andPannorSilver,2019).Inseveralprovinces,itisnotpossibleforlicensedprivateproviderstoturnaprofitfromthenursingcaredeliveredtoresidents.InOntarioandQuebec,forinstance,publicfundsdedicatedtonursingandpersonalcaremustbeusedforthissolepurpose,andanyunusedsurplusmustbereturnedtogovernments(Hsu,RohitDass,Berta,Coyte,andLaporte,2017;Déry,2018).[3]Inspectionvisitsarealsofrequentlycarriedoutinseveralprovincestoensurethatlicensedprovidersmeetestablishedstandardsofcare.ꢀ[4]EvidenceaccumulatedovertimeabouthowtheownershipstatusofnursinghomesaffectscareoutcomesinCanadaismixed.Forinstance,researchersshowedthatnon-profitnursinghomesattachedtoahospitaloraregionalhealthauthorityhaveloweradjustedratesofhospitalizationrelativetofor-profitfacilitiesinBritishColumbia(McGregor,Tate,McGrail,Ronald,Broemeling,andCohen,2006).[5]InOntario,Tanuseputroandcolleagues(2015)demonstratedthatresidentsofpubliclyfundedprivatenursinghomesweremorelikelytobeadmittedtoahospitalanddiethanresidentsofnot-for-profithomes.eseresultscontrastwiththoseobtainedbyothergroupsofresearchersusingdifferentstatisticaltoolsanddistinctpopula-tions.Wilkinsonandcolleagues(2019)forinstanceshowed,usingnineperformanceindicators,[6]thatprivatefor-profitprovidersperformaswellasprivatenon-profitprovidersandsignificantlybetterthanlaggingpublicproviders.eiranalysisalsorevealedthatthequalityofservicesinthelong-termcaresectorinOntarioimprovedsignificantlyfrom2012to2017.Similarly,otherresearchersfoundthatthequalityofcareinprivatefacilitiesisrelativelyhigherthanpubliconesinQuebecandthegapbetweenthemhaswidenedsignificantlyovertime.eiranalysisshowedthatalowershareofseniorsreceived[3]NursinghomesoperatinginOntarioalsohavetomaintainatleasta97%occupancyrateinordertoobtainthetotalityoftheiradjustedcase-mixperdiemfundingfromthegovernment(Hsu,RohitDass,Berta,Coyte,andLaporte,2017).[4]InOntario,forinstance,thereistheLong-TermCareHomeQualityInspectionProgram,<.on.ca/en/public/programs/ltc/31_pr_inspections.aspx>.InQuebec,ministerialinspectionvisitsareconductedperiodicallyandevaluationreportsarepublishedonline,<https://www.msss.gouv.qc.ca/reseau/visites-evaluation/>.[5]Ofparticularnote,McGregorandcolleagues(2006)alsoshowedhigherhospitalizationratesinunattachednot-for-profitnursinghomescomparedtofor-profithomes,aꢁercontrollingforhomesize.[6]esenineindicators,collectedbytheCanadianInstituteforHealthInformation(CIHI),are:experiencingpain,experiencingworseningpain,fallsinthepast30days,improvedphysicalfunctioning,potentiallyinappropriateuseofantipsychotics,restraintuse,worseneddepressivemood,worsenedphysicalfunctioning,andworsenedpressureinjuries.fraserinstitute.orgLabrie•RethinkingLong-TermCareinCanada•7inadequatecareinprivatefacilities(7.9%),comparedtopublicinstitutions(33.2%)(Bravo,Dubois,Demers,Dubuc,Blanchette,Painter,etal.,2014).AnotherstudyfoundthatprivatefacilitiesonpubliclyfundedcontractsinQuebecofferedgreatercomfortandprivacyaswellasalessrestrictiveenvironmenttoresidentsthanpublicnursinghomes.On-siteevaluationsalsoshowedthatallneedsweresatisfiedinahigherpropor-tionofcasesforservicesdeliveredbyprivate(for-profitandnot-for-profit)providers,relativetopublicinstitutions(Dubuc,Dubois,Demers,Tourigny,Tousignant,Desrosiers,etal.,2014).QualityassessmentvisitsbytheQuebecMinistryofHealthandSocialServicesalsodemonstratedthatprivatefor-profitfacilitiesintegratedintothepublichealthsystemareproportionallymorelikely(64.4%ofthem)tohavelivingenviron-mentsdeemedentirelyadequatethanpublicnursinghomes(17.6%)(Déry,2019).For-profitprovisionoflong-termcarehasnonethelessbeencriticizedrecentlyinthecontextoftheCOVID-19pandemicforallegedlyreportingworseoutcomes,atleastinOntario(Tubb,Wallace,andKennedy,2021).However,severalindependentresearch-ers,notablyfromCIHIandStatisticsCanada,havecontestedthisconclusionandraiseddoubtsabouttheexistenceofadirectlinkbetweentheownershipstatusofnursinghomesandtheriskofoutbreakordeathfromthecoronavirus(BellandWodchis,2021;Clarke,2021;DamanioandTurcotte,2021;Fisman,Bogoch,Lapointe-Shaw,McCready,andTuite,2020).eolderdesignstandardsandthenumberofsharedroomsincertainfacilities(DamanioandTurcotte,2021;Stall,Jones,Brown,Rocha,andCosta,2020),aswellastheabsenceofrealcompetition(Pue,Westlake,andJansen,forthcoming)wouldbemuchmoreimportantfactorstoexplaintheobserveddifferencesinoutcomes.Lackofchoiceandcompetitionhamperaccessinthepublicnursing-homesectorExcesscapacitybeingvirtuallynilinmostprovinces,dissatisfiedusersarenotabletoturntosomeotherproviderwithavailableplaces.InOntario,forinstance,theoveralloccupancyrateisaround99%andjust40%ofresidentsawaitingplacementinpub-liclyfundednursinghomesin2020weregrantedtheirfirstchoiceofresidence,aꢀerseveralweeksofwaiting(MHLTC,2020).us,thereisnorealcompetitionbetweenprovidersanduserchoicemostlyexistsintheory.AdmissionstoLTCinstitutionsarecontrolledbygovernments,whichdeterminewhoiseligibleforpubliclyfundedservices.Mostprovidersoperateatfullcapacityandtheirrevenuesdonotdependonthequalityofserviceprovidednorontheireffectivenessinattractingclients.Asinmanyotheraspectsofthehealthsystems,provincesstruggletoprovideneededinstitutionalcarefortheelderlypopulationinatimelyfashion.ewaittimetoobtainaplaceinapubliclyfundednursinghomeinsomeprovincescandragonformanymonths.InOntario,thewaitlisttoobtainaplaceinalong-termcarefacil-ityhasalmostdoubledoverthelast10yearstoabout38,000peoplein2019/20(FAO,2019;OLTCA,2021).Halfofelderlypatientshadtowait145daysormorebeforebeingfraserinstitute.org8•RethinkingLong-TermCareinCanada•Labrieadmittedtoanursinghomein2019/20(HQO,2021).esituationisevenworseinQuebec,whereseniorsinneedofaplaceinapublicnursingfacility(CHSLD)hadtowait300daysonaverageduringthissameyear(MSSS,2021).Despiteincreasedgovernmentfunding,therehasbeennosignofimprovementinthisregardoverthelastdecadeineitheroftheseprovinces;quitetheopposite(FAO,2019;CSBE,2017).Someofthesepatientsareoccupyingbedsinhospitalsduringthetimetheywaitforaplaceinanursinghome.eseso-called“bedblockers”occupybedsandmobilizestafftimeandothermedicalresources,whichmakethemnotonlymoreexpensivetocareforrelativetothecostofcaringfortheminalong-termcarehome,butalsopreventotherpatientswithgreaterneedfromgainingaccesstorequiredhospitaltreatmentinamoretimelymanner.Someyearsago,Canadianresearchersestimatedthatthesepatientsconsumedtheequivalentof2.4millionhospitaldaysannually(SutherlandandTraffordCrump,2013).Difficultaccesstopubliclyfundedhome-careservicesIntheareaofhome-careservices,therearemarkedvariationsintheapproachesusedbytheprovinces.Ontariofavouredforsometime,intheearly2000s,amodelofcompetitiveprocurementprocessesinvolvingprivateproviders,withsomesuc-cessintermsofqualityofservice(Doran,Pickard,Harris,Coyte,McRaw,Laschinger,etal.,2007).Almosthalf(45.7%)ofhome-careprovidersinCanadaarenowlocatedinthisprovince,proportionallymorethanitsdemographicweightinthecountry(Koronios,2020).However,theapproachbasedoncompetitionamongprovidersforpubliclyfundedservicecontractswassuspendedin2008(OAGO,2017),sothattheexpectedpositiveeffectsfromcompetitionnolongerexist(WojtakandStark,2017).InQuebec,too,thereisnorealcompetition,sincegovernment-administeredservicesfacilities(CLSCs)remainboththeprincipalprovidersandthesingleentrypointforpeopleseekingcareathome(Firbank,2011).Mostofthelong-termcarebudgetinCanadaisspentoninstitutionalcare,unlikethesituationgenerallyprevailinginotherOECDcountries(figure3).Itisawell-knownfactthatmostseniorsinCanadaconsiderinstitutionalcarealastresortandwouldprefertoreceivecareservicesathomeifthesewereaccessibletothem(HomeCareOntario,2020).Onein10Canadianswaitmorethan35daysbeforeobtainingneededhome-careservices,accordingtothelatestfigurespublishedbyCIHI.ewaittimesforhome-careservicesareespeciallylonginAlbertaandBritishColumbia(CIHI,2021a).InQuebec,therewereover40,000peoplewaitingforhome-careser-vicesintheSpringof2020atthedawnoftheCOVID-19pandemic(MSSS,2021:41).Asaresult,manyseniorsfailtogetthecaretheyneedintheirownhomesandhavetobeadmittedtolong-termcarefacilitiesprematurely.In2018/19,aboutoneinnine(11%)newlyadmittedresidentsinalong-termcareinstitutionhadlowormod-eratehealthconditionsandcouldhavebeenbettercaredforathome(CIHI,2020).fraserinstitute.orgLabrie•RethinkingLong-TermCareinCanada•