2019 ENVIRONMENTAL SCANNING REPORT › uploads › 2 › 9 › 4 › 5 › 29454775 › 2019... ·...

2019 ENVIRONMENTAL SCANNING REPORT

Megatrends in Dentistry*Critical*Human Resources Challenges in Dentistry

ProminentGrowing Income Inequality Affecting Access to Dental CareEvolution of Alternative Dental Care Delivery ModelsEvolving Concepts of the Workplace and Benefits

ImportantIncreasing Global Mobility of Health ProfessionalsGrowing Commercial Nature of Oral Health CareThe Rise of Empowered Health Consumers

EmergingExpansion of Alternative Health ProvidersShifting Care Needs for an Aging PopulationTransformational Technologies Changing Everything

Resource 07.03

The profession needs to navigate new realities if it is to meet its ultimate goal of providing optimal oral health care to all Canadians and ensure that dentistry remains a valuable profession.

Table of

CONTENTSMegatrends ............................................................................................................... 3

Human Resources Challenges in Dentistry .............................................................. 4

Growing Income Inequality Affecting Access to Dental Care ................................... 8

Evolution of Alternative Dental Care Delivery Models ........................................... 10

Evolving Concepts of the Workplace and Benefits ............................................... 12

Increasing Global Mobility of Health Professionals................................................ 14

Growing Commercial Nature of Oral Health Care ................................................. 16

The Rise of Empowered Health Consumers .......................................................... 18

Expansion of Alternative Health Providers ............................................................ 20

Shifting Care Needs for an Aging Population ........................................................ 22

Transformational Technologies Changing Everything ............................................. 24

PEST Scan ................................................................................................................ 26

Political ............................................................................................................... 27

Economic ........................................................................................................... 30

Social .................................................................................................................. 34

Technological ...................................................................................................... 37

Health Scan .............................................................................................................. 42

Dentistry Scan .......................................................................................................... 61

2

1.2019 Environmental Scan

The purpose of environmental scanning is to identify key information and trends as well as changes and emerging issues to assess how they may impact the profession, either positively or negatively. Ultimately, the process tries to answer two questions, What? and So What? to help the profession decide how to react (Now What?).

To support the CDA board as it sets its priorities, the report looks at the environment at three levels:

» The external environment where political, economic, social and technological (PEST) dimensions are considered, particularly factors that can relate to and can impact dentistry and demand for oral health care.

» The health environment where pertinent information, trends and factors are explored from both the provider and patient perspectives and in the context of potentially having an impact on oral health care delivery.

» The dentistry environment where data and trends across the dental spectrum are examined including demographics, practice settings, economics, education, workforce, oral health status, regulation and models of care.

Given the volume of information presented, in order to bring attention to and highlight the most relevant information for dentistry in Canada, the environmental scanning report features a megatrends section- the first section of the report- which serves as an overview of the key major trends. It ranks the importance of ten identified megatrends based on their potential impact on dentistry as well as the timeframe in which the megatrend is expected to have an effect. Megatrends that are expected to have the biggest impact in many areas within a 5-year time frame are identified as prominent (red). Megatrends that are expected to have a lesser impact and in a longer time frame (more than 5 years) are identified as emerging (blue).

A megatrend results from the convergence of several issues identified in the environmental scan. A megatrend has the potential to lead to major changes in the dental profession. This section answers three questions: What? So What? and Now What?

Now What

So What

What Highlights key emerging trends identified in the environmental scan that contribute to the megatrend.

Summarizes the potential impact of the megatrend on dentistry.

Outlines options that organized dentistry can consider in response to the megatrend.

3

1.MegatrendsWe are in an age of disruption. Nimbleness, resiliency, and strong connections to stakeholders are important to successfully navigate the forces shaping the future.

2019 Environmental Scan

4

Human Resources Challenges in Dentistry

What

Growing supply of dentists relative to population

» Population to dentist ratios have been decreasing across all of Canada and provinces/territories for many years and this trend continues

» Canadian population has grown 12% between 2008 and 2018 whereas the number of licensed dentists has grown by 18%

» Larger urban centres in Canada are experiencing even lower population to dentist ratios and decreasing levels of “busyness”

» Increasing supply pool primarily due to increasing sources of new dentists, postponement of retirement

Shortage of dental assistants developing across country

» Increase in the number of new dentists practicing is outpacing the number of new dental assistants registering in most jurisdictions

» Greatest decline in Certified Dental Assistants (CDAs) is in younger age cohort, indicating a problem of retention: CDAs change careers for more money or growth opportunities

» Decreasing interest in dental assisting as a career and thus in applications to schools

» In certain regions, certified dental assistant wages have grown less compared to wages in other industries

» Highest dental assistant:dentist median income ratio in British Columbia- signifying potentially most challenging region for shortage of dental assistants

Distribution imbalances in many regions

» Recent study in Quebec concluded there is a strong relationship between degree of urbanization and highest concentration of dental professionals; lack of dental workforce availability in rural areas

» Workforce to population ratio of 1:3300 in rural areas compared to 1:2283 in urban areas; approximately 90% of dental workforce located in urban census subdivisions

» According to 2016 census data from Statistics Canada, wide variation in average dentist income trends over the last 5 year period; greatest increases observed in Manitoba and Newfoundland/Labrador, whereas greatest decreases in Ontario, Saskatchewan and Quebec- could be result of decrease in manufacturing sector jobs in those regions

» Dental schools’ producing new dentists at a faster rate than the growth in the population

Megatrend #1: Human Resources Challenges in Dentistry

20671906 1937

17371631

1771

664 722 809 825 739

1026 1008

2010 2011 2012 2013 2014 2015 2016

Newly certified dental assistantsNewly certified dentists

2000

1500

1000

500

Annual trends of newly certified dentists vs. newly certified dental assistants in Canada

2129

1.5

2.0

2.5

3.0

2010 2011 2012 2013 2014 2015 2016

1.76

2.86

2.352.36 2.35

3.21

1.591.76

2.86

2.352.36 2.35

3.21

1.59

Decreasing Canada-wide ratio of new dental assistant per new dentist

5

Various evolving demand trends influencing need for dentists

» Reduction in the prevalence of oral diseases in the general population due to success of dental profession providing effective preventive therapy, benefits from public water fluoridation, education and motivating patients about practicing good oral health habits

» Digitization of supply and buyers chain allows players outside dental space to enter dental care and deliver services directly to patients

» Quantified-self/wellness and virtual access tools encourage some dental consumers to better manage their own oral health, which has the potential to reduce the need for some preventive oral health services

» A recent US study found that if such trends continue there is likely to be a dentist surplus of between 32% and 110% by 2040

» Foreign trained dentists establish their practices in certain regions in Canada more than others

Megatrend #1: Human Resources Challenges in Dentistry22

134

2266

5

2326

1

1903

7

1908

6 2077

1

2790

0

2856

4

2924

6

10000

15000

20000

25000

30000

2014 2015 2016

Dentists Dental assistants Dental hygienists

Dentists/ Dental hygienists/ Dental assistants: Trend in total licensed numbers in Canada

0

0.1

0.2

0.3

0.4

CAN BC SK AB ON NT NS PE YK NB QU MB NL

Dental assistant : Dentist median income ratio 2015

Source Statistics Canada, Custom Tabulations. 2016 Census data.

-18%

-16%

-14%

-12%

-10%

-8%

-6%

-4%

-2%

0% CANADA NL QU SK ON AB BC NB PE NS MB

Population to dentist ratio change 2010 to 2018

Source: Canadian Dental Association membership database, Statistics Canada population estimates, 2018.

6Megatrend #1: Human Resources Challenges in Dentistry

So What

» Decreasing supply of dental assistants is leading to increasing labor costs and other staffing challenges for dental practices; can be further exacerbated if trend continues and if shortages materialize in supply of dental hygienists as well.

» Lower expenditures per patient per year, giving dentists the incentive to treat more patients to maintain incomes that justify their investment in dental education and practice.

» Consideration of a framework for oral health workforce planning and a dental health workforce study could be useful in anticipating supply and distribution challenges.

» Through rapid technological and business innovation, potential dental patients are having direct access to self-care, hence avoid what usually required a dental visit. Additionally, new technologies and outside players providing dental services and products further compounds human resource challenges as the supply of oral care services expands outside the traditional office space environments.

» Monitoring the distribution of health care workforce has the potential to assist in planning effective strategies to improve access to dental care, and to implement strategies that encourage dental workforce to benefit from the advantages of living and working in underserviced areas, thus improving economics of practice.

» Changing oral disease demographics potentially a threat to dentists and their increasing numbers if they can’t adapt their practice; with decreasing prevalence of these diseases in the younger population, can expect need for this level of care to shift gradually and human resource mix will need to reflect this.

» Opportunities exist for dentistry to expand services, since many medical conditions can be first observed intraorally, providing a venue through increased scope of practice for early diagnosis, prevention, treatment by dentists.

-40%

-20%

0%

20%

40%

60%

80%

CANADA BC AB SK MB ON QU NB NS PE NL

Dentists Dental HygienistsDental Assistants

Change in median i ncome 2010-2015

Source: 2016 Census Survey, Statistics Canada, Custom tabulations. Source Canadian Dental Association membership database, 2016.

0% 5% 10% 15% 20% 25% 30%

NB

NS

QC

PE

YT

SK

MB

BC

NL

Canada

AB

ON

NU

NT

Internationally trained dentists- location preferences

7Megatrend #1: Human Resources Challenges in Dentistry

Now What

» The Canadian dental profession should ensure that all dentists licensed to practice have an excellent grounding in the principles of professionalism, ethics and empathic communication.

» The Canadian dental profession should facilitate the provision of business education and resources for dentists that are appropriate for their chosen model of practice.

» The Canadian dental profession should research and facilitate the awareness and understanding of new alternative and integrated practice models, and assess their viability and sustainability.

» The CDA is undertaking a survey with the Canadian Dental Assistants Association (CDAA) of dentists and dental assistants across Canada to better understand the issues leading to lower recruitment and retention of dental assistants.

» Need to shift focus to needs-based planning, which is a move away from how many do we need, to what services do we need to what skills do we need to provide services.

Problems with Current Health Workforce Planning in Canada

» Distribution issues are often misinterpreted as supply issues

» Lack of focus on the impact of Artificial Intelligence, innovation and technology

» Disparate strategies based on incomplete picture of population health needs

» Planning not interconnected with regulatory system changes

» Evidence and data not aligned to planning needs

» Lacking analytics to determine competencies required to deliver services patients need

» Expand modelling beyond physicians

Why Health Workforce Planning Matters

» The concept of quadruple aim

» Complexity of shifting patient needs, preferences and technological advances

» Changing models of care

» Rapidly aging population

» Challenge of providing care in rural and remote locations

HealthWorkforcePlanning

Scope of Practice

Population Need

Labor Market

Models of Care

Education

Equitable Access to Care

Innovation

Funding

Legislation/Policy

Framework for Health Workforce Planning

8

Growing Income Inequality Affecting Access to Dental Care

What

Persistent income inequality in Canada

» The top 20% income-earning households earned 41.4% of all household disposable income in 2017, while the bottom 20% earned 6.7% of total household disposable income

» Wealth for households in the highest income quintile is 2.5 times higher than the overall average; the top 20% of income earners had a net worth of $1.8 million per household in 2017, compared with about $214,000 for the bottom 20%

» House of Commons report on poverty identified 10 groups most at risk of experiencing low income: children, lone-parent, women, unattached individuals, seniors, Aboriginal people, people with disabilities, immigrants, visible minorities, and low-wage workers

» According to the Conference Board of Canada, income inequality is a critical issue in Canada which ranked 21st among 34 OECD countries, as measured by the gap between the top 10% of income earners and the rest of the population

Inequality affects many health measures

» In Canada, social and economic conditions account for half of population health outcomes, according to a study by the Standing Senate Committee on Social Affairs, Science and Technology; virtually every measure of population health is worse in deprived areas than in wealthier ones

» Income, childhood environments, access to food and housing, education, and employment conditions influence health

» Large life expectancy gaps of 15 years for men and 17 years for women exist between those living in the highest and lowest income areas in many regions of Canada

» Recent CIHI report indicates that inequalities are persistent in Canada, and little has been made in reducing them by measuring 16 indicators including factors influencing health such as access to housing and food, smoking and obesity

Inadequate funding for public dental programs

» Expanded public dental funding has become a hot issue in recent elections and campaigns in Ontario and Quebec

» Growing income disparities are resulting in more Canadians of low and middle classes needing to use public dental programs

» For many years, provincial governments have been underfunding dental programs while increasing the number of those eligible

» Economically challenged provinces have reimbursement rates for public dental programs that are significantly reduced from provincial fee guides

Increasing price elasticity of dental care

» A quarter of Canadians do not currently have a dentist that they see on a regular basis, and 37% of those say it is primarily due to cost

» Most Canadians would not make an extra appointment with their dentist if it wasn’t covered by their plan

» Middle income earners reported the greatest increase in cost-barriers from 1996 to 2009; also had the largest rise in out-of-pocket expenditures for dental care since 1978 and the lowest levels of dental insurance coverage

» Dental care utilization is associated with relinquishing spending on other goods and services

Megatrend #2: Growing Income Inequality Affecting Access to Dental Care

0 10% 20% 30% 40% 50% 60% 70%

Lowest

2nd

3rd

4th

Highest

Inco

me

Qui

ntile

Avoiding dental professional because of cost Emergency pattern of dental visit

Impact of family income on dental care access

Source: Improving Access to Oral Health Care, Canadian Academy of Health Sciences. 2014

9

So What

» As income inequality increases, it leads to greater shortfalls in government tax revenues. Only by addressing issues of poverty across Canada will it be possible to reduce socio-economic gradients in all aspects of health care, including oral health care.

» The oral health status of the population will be greatly affected as the low and lower-middle income class in society continues to grow; dental public health programs may not have a significant impact at that point.

» Dentists cannot sustain their practices by seeing more public program patients, further exacerbating access wait times.

» Ongoing increases in provincial health budgets results in provinces not prioritizing an adequate level of funding for public dental care.

» More people will not be able to afford dental care creating pressure for the acceleration of new care delivery models.

» Lack of affordability decreases dental visitation rates which impacts dental incomes, creating opportunities and a market for practice management organizations.

» Provincial governments will continue to explore, propose dental care as part of medicare as an election platform, especially as greater population pools experience income inequities.

» Increasing visits to emergency rooms for dental care will further politicize the dentacare platform and increase pressure to include preventive dentistry under provincial medical service plans, provided by non-dentists.

» Organized dentistry needs to join coalitions to find solutions for reducing poverty and reducing income inequities.

Now What

» The Canadian dental profession should collaborate and create coalitions with health care and other professional groups as well as civil society groups interested in improving the oral health, overall health and social and living conditions of people in Canada.

» The Canadian dental profession should take all possible steps to ensure that the basic oral health needs of the entire population are met, regardless of geography or individual socioeconomic circumstances.

» The Canadian dental profession should encourage the delivery of oral health care to vulnerable patient groups in locations and by delivery methods that are most appropriate for these groups.

» The Canadian dental profession needs to look beyond the private practice model, perhaps to some sort of blended approach to funding. There is a need to find affordable, sustainable ways of providing dental care and to experiment with new payment models.

Megatrend #2: Growing Income Inequality Affecting Access to Dental Care

The World Health Organization explains prevalence of health inequity as “unequal distribution of health-damaging experiences that is not a ‘natural’ phenomenon but the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics.” 0% 10% 20% 30% 40% 50% 60%

Highest quintile

Fourth quintile

Third quintile

Second quintile

Lowest quintile

2017 2010

Distribution of household wealth by equivalized disposable income quintile Canada- 2010 vs 2017

10

Evolution of Alternative Dental Care Delivery Models

What

Paradigm shift in the delivery of oral health care

» The type of treatments provided in dental offices is evolving; from the treatment of disease (therapeutic procedures) occupying the major portion of a dentist’s time to an increasing focus on prevention of disease and the maintenance of good health overall

» Dentistry is facing increasing societal expectations; person-centered care is becoming an expectation of the cultural transformation that health care is moving towards; redefining the interactions between dentists and the population

» Ongoing technological advances are increasingly changing the current model of treating all dental patients the same- one size fits all, without taking into consideration their risk profile or probabilities of responding to various treatments or interventions

» Precision-medicine, use of diagnostic innovations such as the use of saliva and biomarkers and the use of big data will target and optimize the type of surgical care needed for patients thus requiring changes to how dentists’ practice

» An emphasis on quality and value is driving further changes in the healthcare delivery model for dentists

Socio- economic practice realities faced by the dental workforce

» Highest post-secondary tuition fees of all professional degrees in Canada; results in debt reduction and guaranteed income a priority upon graduating

» Increasing practice set-up costs, ongoing investment in cutting-edge equipment and technology, and rising costs of professional regulations and extra-professional issues

» Need for reconciliation of work/family life heightened because of the feminization of the profession which influences workplace priorities

» Oversaturation of urban areas and general oversupply trends make it difficult to open profitable practices in cities; suboptimal investment returns and depressed resale value of dental practices is resulting in extended careers

Changing practice environments

» Proportion of solo and partnership dental practices (small practices of 1 to 4 employees) are steadily decreasing in Canada; proportion of associates increasing rapidly

» In the US, corporate interests own 30-40% of all dental offices; the figure is 2% in Canada and rising; increasing private equity investments in dental corporations worldwide

» Growth in dental management service companies and dental support organizations- providing business services and centralized outsourcing of most business functions such as accounting, human resources, marketing, legal and practice management

» Non- traditional settings such as walk-in dental clinics, tele dentistry, mobile dentistry, and overseas dental tourism becoming more commonplace and accepted

Increasing integration of oral health into primary care

» Growing research on correlation between aspects of oral health and general health; evidence that dentists can play significant role in the systemic health of their patients beyond stabilization and prevention of oral disease

» Periodontal diseases share many risk factors with other non-communicable diseases

» Use of screening processes to identify systemic disease indicators during the dental care encounter has grown over the last decade and there are several disruptive technological advances close to the clinical application stage

» Oral cancer screening is being offered in pharmacies in some regions of Canada, and interest in other areas is picking up; pharmacists are also looking to make more preventive caries services (such as fluoride varnishes) available to the population

» American Academy of Family Physicians supports a new model for delivering preventive oral health care as a component of routine medical care and enhancing partnerships between primary care and dentistry (Oral Health Delivery Framework)

Megatrend #3: Evolution of Alternative Dental Care Delivery Models

Intensified scrutiny of benefits administration, benefits strategy, and drug pricing is already occurring. Pharmaceutical pricing in the supply chain has taken center stage as a main driver of increasing healthcare costs. There will continue to be a concerted effort by all stakeholders to share the higher costs while increasing the use of industry-wide cost-sharing initiatives, such as value-based purchasing or direct contracting with manufacturers to manage cost trends while balancing outcomes for population health.

11

So What

» Oral health professionals represent an underutilized group of health care providers that can contribute to improved health of populations living with chronic diseases by broadening their scope of practice to include primary health screenings and tailored health promotion activities.

» Focus will shift to individual risk assessment and prevention for cost-effective treatment plans; will lead to more incentives to develop payment schemes that put ceilings on dental costs and reward prevention.

» Dentistry can anticipate potential payment reforms and approaches tied to performance metrics by observing changes already under way in medicine.

» Further integration into primary care models will require dentistry to fully embrace and incorporate health care system elements such as electronic health records, participating in effectiveness research and interdisciplinary oral health preventive interventions.

» A holistic model of care, like those at Community Health Centres, can help some patients with many aspects of health. Different models may be required to address the needs of a variety of patient population groups.

» The development of inter-professional practice models (IPPMs) is one option for dentistry to explore. Improved collaboration between oral and general health care teams will be required to overcome dentistry’s previous isolation from medical care.

» Dentistry must consider alternatives to the traditional fee-for-service private practice model, including a public/private blended approach.

» The trend towards larger, multi-site practices will continue. Dental associations will need to maintain their relevance to individual practitioners while showing value for large, potentially corporate practice owners.

» New private delivery models may potentially create barriers to patient centered care, as there may be an impact on care decisions being based on economic or management criteria rather than the clinical needs of patients.

Now What

» The Canadian dental profession should articulate and promote a clear definition of oral health that enables the measurement of oral health and systemic health outcomes, and that helps to demonstrate the value of oral health care.

» The Canadian dental profession should embrace the inclusion of dentistry in national electronic health records (EHR) and include the collection of oral health diagnostic data that facilitate the development of comprehensive and value-based outcomes for both dental care and medical care.

» Organized dentistry must advocate for oral health care to be integrated in the public system EHR, to tap in to a large pool of valuable diagnostic and treatment data.

» The Canadian dental profession should ensure that graduates are aware of the full range of career options available to them, including alternative practice models.

» The Canadian dental profession should advocate for funding of clinical research that examines the relationship between oral and systemic health, along with health services research into collaborative models of dental and medical care.


Megatrend #3: Evolution of Alternative Dental Care Delivery Models

Core elements of oral health

Disease and condition status

Physiologicalfunction

Psycho-socialfunction

Driving determinants

Overall health and well-being

Mod

erat

ing

fact

ors

Source: Glick et al, JADA. A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition of oral health

12

Evolving Concepts of the Workplace and Benefits

What

Proportion of Canadians with employer benefits decreasing

» As government slowly reacts to current trends – there is continued shift of costs between the public system and employer-sponsored plans

» One third of employees receive no medical/dental benefits through their workplace; low-income workers and women most excluded

» Clear majority of workers in low-wage jobs do not have employer-provided health benefit plans

» Tomorrow’s typical employee will be a free agent, well paid, under contract, better paid than permanent counterparts and have personalized healthcare on an exchange

» By the year 2025, it is estimated that health benefits costs will rise by over 130% forcing employers to seek better services and choices

Healthcare landscape embarking on a fundamental transformation

» Currently, a significant shift in the health benefits landscape is underway: the health care environment is at a tipping point with more of the burden poised to shift to the private sector

» The workplace now encompasses multiple generations representing a wide variation in skills, life experiences, technical training, and college education; such a diverse workforce environment also creates challenges for healthcare

» There are five generations in the workforce with rapidly evolving expectations and an aging population driving rising costs

» Government’s public promise in relation to health care coverage will continuously change- resulting in cost shifts between the public system and employer-sponsored plans

» For the past 25 years the health benefits industry has survived under paternalistic insurance model- however within a decade the industry will become completely disrupted by specialty vendors and their innovations

» By 2025 employers will work with dozens of specialty healthcare providers, focusing on improving costs, efficiency, health outcomes and customer service

Initiatives by carriers trying to contain the “dental spend”

» De-listing of dentists by insurance providers with no transparent process in place

» More demanding documentation requirements for some dental procedures, increased number and invasiveness of audits

» New adjudication rules such as automated recoding of certain service combinations

» Making investments to accept more types of claims and documentation electronically

» Carriers raising the bar in terms of collecting data, using technology to profile providers and notifying consultants and employers when they find fraud

» Carrier collaboration in dealing with dentists and fraud, and use of sophisticated artificial intelligence software to analyse aggregate data from all carriers jointly

Expanding consumer choice in selection of health benefits

» Millennials are more interested and expect more choice in their benefits; more want flexibility in their health benefit plan and the ability to choose what’s covered and how much is covered, compared with baby boomers

» Employees with access to workplace wellness programs (63%) and health-care spending accounts (60%) are more likely to be satisfied with their health benefits plan compared to those without those benefits

» Companies and insurers are altering their offerings to appeal to a new generation of employees and health benefit offerings will need to be even more portable in the future

» Promotion of flexible plans that no longer earmark amounts for specific health services

» Growth of health spending accounts that motivate plan members to be more price-conscious, leading to value-based benefit choices; hence more scrutiny for dental care

» Employers are now adding a wider variety of optional voluntary benefits, such as identity theft protection, critical illness insurance, and pet insurance, which appeal to younger employees

» Employers are increasing access to mobile virtual medical care and access to centers of excellence. which saves time and money and increases the quality of care and employee productivity while improving employee health outcomes

Megatrend #4: Evolving Concepts of the Workplace and Benefits

13

So What

» A decreasing number of Canadians with dental benefits coupled with less generous benefits that no longer earmark money for oral health care mean fewer dental visits and decreased patient willingness to accept treatment plans.

» As consumers look at the relative value of various parts of their health care plans those who are the lower utilizers of dental benefits are more likely to opt for other elements of their health care package.

» Changes in the labour market conditions as well as mindset of new generations result in an increasing need to promote and explain the value of preventive and therapeutic dental care directly to consumers. Education is increasingly important for the new generation of workers who place much more emphasis on choice and flexibility.

» Workforce of tomorrow will be looking for portable dental benefits that can move with the individual as they move through their careers.

» Increased vigilance of carriers results in an increased administrative burden on dental offices.

» Carriers will try to continue to increase their involvement in treatment planning decisions. Corporate oral health providers may be open to negotiating preferred provider plans resulting in increased competition for traditional dental offices.

» Organizations will continue to invest in health and wellness programs. At the same time organizations are shifting the burden of the healthcare benefits to the employees and demanding increased vigilance of carriers to control costs.

» Personalized medicine, specifically pharmacogenetics, will allow employees to receive the right care, the first time, based on their unique genetic make-up. More relevant for dentistry, predictive benefits will become commonplace, relying on claims and personal health data as well as measured behavior.

Now What

» The Canadian dental profession should advocate for funding of health care technology assessment research that will help practicing dentists make wise choices when considering incorporating new technologies into practice.


» There is a need to build a consortium to guide the pending changes to dental insurance. Led by the Canadian dental profession, it should include provider groups, plan sponsors, insurance providers and government. Changes need to be supported by an information technology platform that is patient-centred and encompasses various types of data.

» The Canadian dental profession needs to build the infrastructure to analyse and build knowledge based on dental claims data across Canada, to be able to show leadership in value based care.

0%

20%

40%

60%

80%

100%

2016 2025

Permanent Employees Temporary Employees

Changing Canadian employment landscape

Megatrend #4: Evolving Concepts of the Workplace and Benefits

0 5% 10% 15% 20% 25% 30% 35% 40% 45%

Help with childcare costs

Contributions to registered education savings plans

Assistance with student loans

Providing pet insurance

Support to pay down mortgages

When asked to identify benefits that will be offered in the future, Canadian executives cited:

14

Increasing Global Mobility of Health Professionals

What

Health human resources workforce planning prioritized by governments

» World Health Organization’s Global Strategy on Human Resources for Health: Workforce 2030 calling for global strategies and cooperation for health worker mobility

» Calls for the establishment of a dedicated health workforce agency in Canada to effectively manage the health worker supply and workforce distribution

» The Pan-Canadian Health Human Resources Network (CHHRN) recently established through funds from Health Canada, involved in health human resource research, policy and/or planning

» Initiatives by most provincial governments to develop databases and strategies for sound health human resources planning; Health Care Innovation Group and other think tanks have identified health human resource management as priority area

Evolving position of federal government on foreign trained professionals

» Federal government launched a new project that will help internationally trained health care professionals get their credentials recognized faster

» Career Accelerator for Internationally Trained Health Professionals project- to assist highly skilled newcomers with experience and education plan for and secure equivalent career levels, overcome barriers, and gain Canadian professional work experience in order to reach their full labour market potential

» Pan-Canadian Framework for the Assessment & Recognition of Foreign Qualifications had targeted dentists as an occupation starting December 31, 2012; however dentistry is no longer an eligible occupation on the list of the Federal Skilled Workers Program

» As of 2013 licensed foreign professionals undergo a pre-assessment prior to immigration to ensure that their education and their experience in their field of practice meet Canadian standards

Increasing number of internationally trained dentists certified annually

» From 2010 to 2016 there were 8273 applicants from over 120 countries for the National Dental Examining Board of Canada (NDEB) equivalency process, most recently over 1300 in 2017

» The greatest numbers of applicants to the equivalency process come are from India, Iran, the Philippines and Egypt

» In 2017, 56% of new dentists certified in Canada had completed an accredited qualifying, degree completion program or the NBED equivalency process- up from 17% in 2011 (significant increase in international trained dentists)

» Digital exam platform is being implemented by NDEB, making it more affordable and easier for a non-Canadian individual to take the exam from their location; digital platform will facilitate an increased number of examinees

» The NDEB is exploring alternative ways to address competencies which ultimately affect the quality of services offered by dentists in Canada, such as language competency and professionalism

International mutual recognition agreements

» Recent World Health Organization (WHO) report concluded that the international migration of health workers is increasing; there has been a 60% rise in the number of migrant doctors and nurses working in Organization for Economic Cooperation and Development (OECD) countries over the last decade

» Future projections point to a continuing acceleration in the international migration of health workers, and international global workforce mobility agreements under increasing development according to international health workforce experts

» Commission on Dental Accreditation of Canada (CDAC) signs mutual recognition agreements for general dentistry programs, Australia 2010, New Zealand 2011, Ireland 2012

» Potential impact of Trans-Pacific Partnership and new NAFTA agreement not yet fully understood

» Immigration laws in the United States becoming more inflexible making Canada a more viable alternative for many

Megatrend #5: Increasing Global Mobility of Health Professionals

Newly certfied dentists in Canada 2017

Canadian DDS graduates

Internationally trained graduates

56%44%

15

So What

» A continued trend toward greater global mobility suggests that the demand for individuals looking to practice dentistry in Canada will increase.

» The number of new dentists is no longer driven by dental school capacity but by the number of qualified applicants. As a result, it will be much more difficult to make forecasts and influence numbers.

» This is further compounded by the globalization of health care and anticipated international mobility agreements impacting the influx of foreign trained and outflux of Canadian trained dentists.

» The provenance and number of new dentists is expected to have an impact on accessibility and quality of care, but available evidence does not allow forecasting if this impact will be positive or negative.

» Triggers that would drive governments to get involved in health human resources management initiatives are not well understood and as a result difficult to influence.

» Canadian and other countries’ government policies on multinational agreements may impact mobility of health workforce including dentists, which could result in an escalating mismatch between the supply of and economic demand for health workers.

» There is an expansion of bridging programs across several universities in Canada that assist internationally trained dentists to transition from their international experience and training to the Canadian workplace.

Now What


» Organized dentistry in Canada should advocate that internationally-trained dentists coming into practice through the NDEB equivalency program undergo a comprehensive course on professionalism, ethics and communication skills and that they be assessed on their competency in these topics.

» The Canadian dental profession should ensure that graduates are aware of the full range of career options available to them, including alternative practice models.

» The Canadian dental profession should establish a formalized mentorship program for new graduates to facilitate the transition into professional practice and to encourage lifelong learning.

Megatrend #5: Increasing Global Mobility of Health Professionals

0 100 200 300 400 500

Graduates of Canadian DDS programs

Individuals successfully completed equivalency process

Graduates of reciprocal accredited programs

Graduates of accredited Qualifying/Degree Comple�on programs

Breakdown of newly certified dentists in 2017 (1101 total new dentists)

75

483

307

235

Source: National Dental Examining Board of Canada 018

20%

0

40%

60%

80%

100%

Pharmacist Medical Doctor

Physiotherapist Dentist Registered Nurse

Occupational Therapist

Registerd Psychiatric

Nurse

Licensed Practical Nurse

Health care providers employed in direct care Canada, 2016

Internationally educated Canadian educatedSource: Canadian Institute for Health Information, 2018.

16 Megatrend #6: Growing Commercial Nature of Oral Health Care

Growing Commercial Nature of Oral Health Care

What

Behavior of dentists due to economic drivers

» Dentists offering more purely cosmetic services in relation to traditional dental care; as well as an increasing trend of promotional materials on cosmetic dentistry and luxury service dental centres (i.e., spa dentistry) and street corner advertising

» Number of dentists who claimed to be “busy” during the last decade has declined, and increasing enrolment in marketing seminars aimed at up-selling patients

» One third of Canadians feel dentists are focused on making money and patients are wary of dentists promoting cosmetic dentistry

» Surveys suggest that dentists are frequently viewed by patients as business people making treatment recommendations motivated more by profit than by the health needs of individual patients, and many feeling that dentists sometimes recommend unnecessary treatment

» Recent study finding some association between an increase in density of dentists and the occurrence of misconduct

» Oversupply of dentists in urban areas reinforcing the above behaviours by dentists

Proliferation of marketing of oral care services

» Internet discount sites that include oral hygiene services increase public’s perception of dentistry as a commercial or cosmetic service

» Billboards and mall advertisements for exclusive deals in hygiene centres being seen by the public regularly

» Dentists joining online preferred provider’s registries to compete on price and offer rebates; on-line referrals provide information about location, cost, quality which gives patients more bargaining power

» Trend towards increasing direct-to-consumer marketing by manufacturers, encouraging consumers to ask for specific products when they go to their practitioners, because of demonstrated results by the pharmaceutical industry there is a return on such an investment

Competition from non-traditional sources for certain aspects of dental care

» Dental care is increasingly being accessed in non-traditional locations such as grocery and department stores throughout the United States and increasingly in Canada; mobile units such as mobile dental vans bringing dental care to large companies and communities

» Dental tourism offering cheaper dental care is getting increased media and internet coverage, and tens of thousands of Canadians are now estimated to go abroad for dental surgeries, to places such as Los Lagoons, Mexico, billed as having the most dentists per capita on earth

» Increased competition from retailers, hygiene centres, and now pharmacies for oral health screenings; dentists increasingly promoting free services such as “free cleaning” and “free examination” prominently displayed at dental office locations to compete

» Potential ownership of larger dental clinics by business people motivated by maximizing profit

Growing presence of direct-to-consumer dental services

» Also known as do-it-yourself (DIY) dentistry, patients are instructed how to independently take their own impressions and order products such as mouth guards, snoring appliances, teeth whitening trays and bleaching products, partial dentures, veneers and aligners

» In the United Kingdom pharmacies stock first-aid kits that temporarily replace fillings and lost or broken crowns; some estimates have a quarter million kits being sold annually

» According to a 2017 survey by the American Association of Orthodontics, about 13 percent of its member orthodontists are seeing patients who have tried do-it-yourself teeth straightening, with some of those attempts causing irreparable damage

» The DIY trend is primarily linked to social media; and 70 percent of DIY patients were between the ages of 10 and 34

» Online marketplaces such as Amazon sell many products such as dental permanent filling tooth restoration material kits

» Growing number of online health media outlets promote to readers that they could save money by do-it-yourself dentistry making the practice more acceptable

» Health Canada regulates the sale, advertising and importation of these devices however classifies most of these products as Class II medical devices, representing a lower level of risk to the public- and can be sold as long as there is no significant documented harm to public

17

So What

» Difficult to explain to the public why general health care is public while oral care is private, and the lack of interest for change by the profession. Without answers for this the perception of dentistry as a commercial enterprise continues to grow.

» With increased competition from a variety of non-traditional sources, there is pressure on dentists to discount prices from fee guides and promote cosmetic services.

» To cope with increasing competition, dentists may adopt business strategies, such as marketing and advertising, to attract patients or retain their patient base. Competitive pricing, up-selling and marketing for cosmetic oral services renders dentistry as more business, and less a health care profession in the public’s eye.

» As trend continues, could result in split between oral health care provided by regulated health professionals and cosmetic services provided by unregulated providers.

» Through rapid technological and business innovation, potential dental patients have direct access to self-care and will be able to avoid what usually required a dental visit. The potential for harm and appropriateness or value of treatment needs to be explored and pursued.

» Dental graduates and practitioners need to firmly understand that there is a social contract between dentistry and society, whereby individual dentists promise to put the oral health care needs of their patients above other considerations.

» Learning how to communicate well and develop strong relationships with patients is an essential part of dental education. Students must learn the important role that patient trust plays in the dentist–patient relationship.

» Mechanisms must be in place throughout the professional cycle to ensure that dentists are regulated in such a manner that benefits society by maintaining competency and acting ethically throughout their lifespan as professionals.

» Increasing numbers of consumers, empowered through online information, believe that dentists are not really needed for certain procedures (like treating caries, orthodontic alignment).

Now What


» The Canadian dental profession should establish a formalized mentorship program for new graduates to facilitate the transition into professional practice and to encourage lifelong learning.

» The Canadian dental profession should establish a national certification body for continuing dental education that assesses courses, to ensure that they are based on sound scientific evidence and free of funding bias and conflicts of interest.

» The Canadian dental profession should advocate for funding of education research that examines the best ways to teach and assess professionalism, ethics and communication skills, and encourage the development of learning modules for all dentists entering practice.

» The profession needs to focus on broader societal issues that impact on vulnerable groups and become engaged in addressing the social determinants of health. This is an effective way to foster public trust in the profession and enhance the perceived value of oral health.

» Dental Associations are launching public awareness campaign discouraging DIY dentistry as well as providing information on what to know before ordering such products.

Over 1 million Canadians have sought medical or dental treatment outside country in one-year period, and is expected to grow; over a fifth of Canadians consider going abroad for dental work, if too expensive here - Conference Board of Canada

Megatrend #6: Growing Commercial Nature of Oral Health Care

Given that 40% of the population either has no dental benefits at all, or are beneficiaries of increasingly dysfunctional publicly funded plans, there is an opportunity to create entirely new dental benefits products.

18

The Rise of Empowered Health Consumers

What

Increasingly knowledgeable Canadian health care consumers

» The largest reason for the “shopper” culture is the rise of the Internet; people now actively engaging online communities and advice through crowdsourcing for peer support with people experiencing similar therapeutic decisions

» 60% of Canadians pro-actively seek out health information on their overall health and well-being, majority look to the internet, magazines, television before seeking health professional advice

» A majority of Canadian adults (66%) regularly track one or more aspects of their health or wellbeing, such as their weight, blood sugar, blood pressure, level of physical activity, physical workout performance or sleep quality

» Half of Canadians agree with environmentalism and social responsibility and three-quarters feel that companies and brands should be environmentally responsible

» Community water fluoridation has become a major issue of debate across many municipalities across Canada

» Levels of education and income (both of which are higher for dental patients) increase the probability of having chosen or boycotted a product for ethical reasons

Decreasing patient provider information asymmetry

» There are thousands of health apps available today that allow consumers to track all aspects of their lives – including health statistics, emotional states, behavior and social environment – empowering individuals to take more control over their own health and data

» In 2018, 32% of Canadian adults reported using one or more mobile apps to monitor aspects of their health in the previous three months

» Approximately one in four Canadian adults (24%) currently owns at least one smart device for health and well-being

» On-line referrals and apps provide information about location, cost, quality which gives patients more bargaining power

» Through increased information availability, many consumers believe that dentists are not really needed for certain procedures such as application of fluoride varnish, caries detection, treating open caries lesions, orthodontic alignment

Millennials redefining health and wellness approaches

» Less than half of millennials consider regular medical (46%) and dental (44%) checkups as part of maintaining overall health

» Millennials are far more likely than other generations to rely on mobile and online tools to monitor and maintain their health

» Most consider maintaining a work/life balance as part of staying healthy, ranking it higher than regular dental or physical exams

» Millennials are less committed to traditional institutions to receive care- healthcare is no longer confined to the hospital, physicians’ and dentists’ offices and services they receive need to reflect that

» Social media becoming an increasingly significant channel of communication between dentists and patients

Drive towards patient’s rights and the personalization of care

» As part of the movement toward patient-centred care, several countries have adopted charters of rights for patients, although this has not happened yet in Canada

» People naturally strive for self-determination and whereas health systems have traditionally been structured in top-down approach, people are now more aggressively seeking ways to become active participants in their personal health journey

» Increasing patient demand for a greater role in decisions affecting their care and treatment to ensure the best available care is offered according to their needs and budget

» Empowered with access to information, consumers are striving to create more dialogue with their health providers and tailor care to their desires and their unique and personalized needs, not the providers’

» Shift towards “person-centred care,” rather than traditional, paternalistic models of care, a sign of the cultural transformation currently occurring in health care; it redefines the interactions between dentists and those who come to them for care

Megatrend #7: The Rise of Empowered Health Consumers

19

So What

» Dentists need mind-set change; no longer have the monopoly on knowledge, patients are now better “informed”, and have greater bargaining power.

» Communication is paramount - dentists must be able to transfer their knowledge in the correct perspective and to the individual case and will require innovative approaches to care, allowing patients to gain control over care in all aspects.

» With employers shifting the burden of health care benefits to employees as a cost reduction strategy, patients are often responsible for more out-of-pocket expenses, leading them to evaluate dental services extensively.

» Growing consumerism trend means dentists will need to manage the beliefs of their patients and face increasing difficulties in getting them to accept guidance based on scientific evidence.

» Dentists will need to use social media to build relationships with, and educate, members of the public. However, any efficient and relevant social media presence will require financial and labour investments along with the development of proper protocols.

» Dentists of the future will have to be more culturally sensitive and competent to better assess, treat, and deliver health care to patients. Each patient is unique and will respond differently to care based on factors such as physiology, genetics and culture.

» Dentists are becoming facilitators of knowledge but ultimately, patients chose the diagnosis and treatment options.

» In the absence of alternatives to mercury, BPA derived materials and fluoride, biased reporting will continue to harm image of dentistry. Complete disclosure of potential impact of dental materials on the environment will be expected and will have to be built into the informed consent process.

» Greater onus on the practitioner to demonstrate transparency highlights the importance of having excellent relationship-building skills.

Now What

» The Canadian dental profession should articulate and promote a clear definition of oral health that enables the measurement of oral health and systemic health outcomes, and that helps to demonstrate the value of oral health care.


» The Canadian dental profession should embrace the principle of person-centred care and encourage the delivery of oral health care to vulnerable patient groups in locations and by delivery methods that are most appropriate for these groups.


In 2017, 73% of Canadian adults owned a smartphone and 52% owned a tablet, and 86% owned at least one digital device North American market for wearable healthcare electronic devices was $3.1 billion in 2014 and expected to rise to $8.5 billion by 2019

Megatrend #7: The Rise of Empowered Health Consumers

88%

21%

13%

8%

7%

5%

4%

0% 20% 40% 60% 80% 100%

Bracelet, wristband, watch

Bathroom scale

Pedometer

Blood pressure monitor

Toothbrush

Thermometer

Glucose monitor

Types of smart devices used for health tracking by Canadians in 2018

Source: Canada health Infoway: Diffusion of Smart Devices for Health in Canada 2017.

20

Expansion of Alternative Health Providers

What

Growing number of providers substituting for and assisting physicians in Canada

» Number of nurse practitioners has more than doubled in the last 5 years nationally, physician assistants playing a growing role in Canada and supported by the Canadian Medical Association (CMA)

» Pharmacists are taking on expanded roles and are increasingly being recognized as the medication management experts of the health care team, more therapeutic roles such as allowing to administer vaccines, review patient records and order and interpret diagnostic tests

» Regulatory reviews across the country exploring scope of practice of paramedical professions and governments are legislating new scopes

» Expanded scopes allowing nurses to discharge in specific circumstances and pharmacists to order tests; medical clinics established in some communities, staffed by nurse practitioners and primary care nurses with no physicians

Alternative models of oral care delivery implemented internationally

» In the UK, increasing numbers of hygienist-therapists that perform restorative procedures are in dental teams; recent study finds they should be used to screen for dental caries and periodontal disease

» Oral health therapists (combined hygienist/therapist) are expanding in Australia to improve access to care and are expected to increase by 460% by 2025

» New Zealand dental therapists provide majority of oral care to children under 18 years of age, to more than 95% of children under age 13, and to 56% of preschoolers in the School Dental Service

» The amount of preventive and maintenance oral health care provided by non-dentists is increasing internationally, also by those outside the dental field such as physicians, pediatricians and pharmacists providing some basic oral preventive services for young children

Oral health models of care in the USA with expanded roles for mid-level providers

» Kellogg report in the USA concludes the current dental delivery system fails one-third of the U.S. population, nearly 45 million people live in federally designated dental shortage areas, where there are not enough dentists to provide needed care and millions more can’t afford dental care

» PEW foundation calls for expansion of qualified dental providers who can fill the unmet needs of children

» Maine, Minnesota and Vermont, as well as tribal lands in Alaska, Oregon and Washington, have moved forward to address their access to care challenges and now recognize dental therapy as a viable model; states pursuing dental therapist legislation include Arizona, Florida, Kansas, Massachusetts, Michigan, Mississippi, Ohio, Wisconsin

» States pursuing advanced dental hygienist legislation include Connecticut, Maryland and Washington (to allow qualified dental hygienists to perform some tooth extractions and other procedures and creating the designation of an advanced dental hygiene practitioner)

Access to care issues fueling discussions of mid-level oral providers in Canada

» A concern of the First Nations and Inuit Health Branch (FNIHB) is that there are a number of therapists in northern and remote communities who are retiring, and because there are no new graduates, there are few candidates to replace them in these roles

» Recommendation from House of Commons Standing Committee on Health that Health Canada review roles of dental hygienists within the Non-Insured Health Benefits (NIHB) program to improve ability to provide needed health services in rural/ remote communities

» The Canadian Dental Hygienist Association (CDHA) position paper “Filling the Gap in Oral Health Care” – proposes dental hygiene can be more fully utilized to improve access to care and identifies options for dental therapy education in Canada putting forward options that would allow hygienists to develop dental therapy abilities

» The Federal government has provided funding to commission studies on the proposed solutions by CDHA and to develop a pilot curriculum with two dental schools

Megatrend #8: Expansion of Alternative Health Providers

The global literature indicates that dental therapists practice in 54 countries and territories, including highly developed, industrialized ones as well as developing countries

21

So What

» Physicians must learn to embrace and work with alternative providers; the same will likely happen in dentistry. This will have an impact on the prestige, control and income of dentists.

» International models using alternative oral care providers have shown positive outcomes (access and cost effectiveness) that may be difficult to advocate against without a more viable solution.

» Active efforts to expand the number of jurisdictions where non dentists can provide simple restorative and minor surgical procedures under differing supervision requirements will continue.

» Alternative oral health providers will continue to use access issues to justify demands for increased scope of practice and it will be difficult to challenge without being seen as self-serving.

» Independent and advanced hygiene, medicine, pharmacy and nursing will be competitive substitutes to dental practice and the provision of publicly funded preventive oral care by non-dentists may be included under medical service plans. With demonstrated success of prevention to decrease oral disease, governments are more willing to pay for this type of care.

» Independent hygiene, medicine, and pharmacy models will be competitive substitutes to dental practice and “mid-level” providers in US (advanced hygienists, therapists, nurses, etc.) can become substitutes to dentists in certain procedures.

» An essential aspect of any model put forward by the dental profession would need to include “continuity of care”. The belief from government officials is that this is the added value that therapists in northern and remote communities provide. Itinerant dentists who rotate in for short and inconsistent periods would not be seen as a viable substitute for an in-community professional resource.

Now What

» The Canadian dental profession should promote the intrinsic importance of oral health and highlight the relationship between oral health and systemic health. It is the responsibility of the dentist to lead interdisciplinary teams in the collaborative management of oral diseases and conditions.

» The Canadian dental profession should take all possible steps to ensure that the basic oral health needs of the entire Canadian population are met, regardless of geography or individual socioeconomic circumstances.

» The Canadian dental profession should embrace the principle of person-centred care, and encourage the delivery of oral health care to vulnerable patient groups in locations and by delivery methods that are most appropriate for these groups.

» As a profession, dentistry needs to demonstrate to governments and other stakeholders that the profession has an open mind about discussing solutions. In the context of those discussions, the profession should be able to offer viable alternative solutions to addressing the access problem in remote areas.

Megatrend #8: Expansion of Alternative Health Providers

Dental Hygiene legislative summary - by province

Self-Regulation

Self Initiation

Expanded, restorative scope*

BC YES (1993) YES (1995) YES

AB YES (1990) YES (2006) YES

SK YES (1998) NO NO

MB YES (2005) YES (2008) YES

ON YES (1993) YES (2007) YES

QU YES (1975) NO NO

NB YES (2009) YES (2013) YES

NS YES (2009) YES (2009) YES

NL YES (2010) YES YES

PE NO NO NO

*Restorative procedures with or without additional training, independent of a dentist

22

Shifting Care Needs for an Aging Population

What

Pressure builds on governments to develop health care strategies

» The Canadian Medical Association (CMA) with support of many organizations is calling on governments to make the development of a national seniors’ strategy an immediate priority

» The Canadian Institute for Health Information (CIHI) reports that seniors account for less than 15% of the population, but consume 45% of public health spending; the proportion of spending on care for seniors will grow by over 15% to almost 62% of health budgets by 2036

» CMA estimates that Canada is over-spending by $2.3 billion in health care because seniors are taking up hospital beds

» A 2015 report from the Conference Board of Canada estimates that 2.4 million Canadians over 65 will require continuing care support, both paid and unpaid, by 2026. By 2046, that number will reach nearly 3.3 million

» Federal Government has identified seniors’ health as a priority area and renewed investments in research on dementia and related illnesses; changing its funding system so that provinces caring for a larger share of the country’s seniors get more money

Aging Canadian population

» Number of senior citizens (age 65+) expected to double by 2031, outnumbering children for the first time; by 2051, about one in four Canadians is expected to be 65 or over

» Ratio of the number of people aged 20 to 64 to those aged 65 and over expected to fall from about 3.7 in 2018 to 2.0 in 2060

» The number of beneficiaries of the Old Age Security (OAS) basic pension is expected to increase by 61% over fourteen years, growing from 5.8 million in 2016 to 9.3 million by 2030

» Number of individuals living with complex medical conditions, including dementia, expected to grow significantly

Oral care delivery for seniors in non-traditional settings

» Over 90% of Canadians believe in the need for a national strategy for seniors’ health, including support in home, hospice, hospital and long-term care facilities

» Nationally 1 in 6 seniors receives home care and this number is expected to grow significantly

» Dentists have no presence in homes and minimal presence in complex care institutions although governments are restructuring funding strategies towards home care

» Potential physical, sensory, and cognitive impairments associated with aging may make oral health self-care and patient education/communications challenging; dementia and other comorbidity concerns leading to seniors being treated by more geriatric specialists

» Gerontological Society of America recently produced white paper on inter professional solutions for improving oral health in older adults- calling for a team approach to care with medicine, nursing, pharmacy, social work and focus on the connection between oral and systemic health

Increasing calls for public health funding for oral care of seniors

» Seniors are vying for appointments in municipal public health clinics, and waits are up to three years to receive simple dental services such as a checkup or cleaning

» Municipal public health officials proposing city-run dental programs for low-income seniors using money no longer required for children’s dental care- including basic care, cleaning, fillings and extracts

» Canadian Academy of Health Sciences (CAHS) report recommends publicly funded dental care programs need to be broader and more coherent and provide essential care to those most in need, including seniors living in institutional care

» Nursing associations have joined alliances calling on governments to expedite the expansion of public dental programs to low-income adults and seniors

Megatrend #9: Shifting Care Needs for an Aging Population

Canada’s health care system was not built to meet the challenges of our aging population. Canada’s Medicare system was established to deal largely with acute, episodic care for a relatively young population. -Canadian Medical Association

23

So What

» There are opportunities for dentistry to address access to oral health care for seniors as part of national strategy initiatives and with other stakeholders. There may be more funds available for research into new models of oral care.

» Legislation may expand scope of physicians, nurses and others with advanced geriatrics training to provide basic oral care services, particularly for seniors in home care, LTC facilities, hospitals, community and other non-office settings.

» Need for organized dentistry to propose solutions and innovative models of care for prompt access to oral care for seniors, so that governments do not impose their own unilaterally. Could lead to calls for more advanced training in geriatric dentistry, to deal with the large dentate seniors’ population.

» The inclusion of oral health care provision needs to be part of the development of innovative and alternative models/partnerships that can provide services and resources for patients’ seamless transition through the continuum of care.

» Health-care system is very hospital-centric and Canadians are traditionally big users of emergency departments- this needs to be redirected towards improving home care and community-based services for seniors and dentistry needs to have a place in this transformative process.

» Canada is ill-prepared for the impact an aging population will have on the health care system, social services and the economy.

» Poverty rates of seniors, particularly those not in economic families, has been increasing- these will be the hardest to reach for oral health care needs.

Now What

» The Canadian dental profession should take all possible steps to ensure that the basic oral health needs of the entire Canadian population are met, regardless of geography or individual socioeconomic circumstances.

» The Canadian dental profession should collaborate and create coalitions with health care and other professional groups as well as civil society groups interested in improving the oral health, overall health and social and living conditions of people in Canada.

» The Canadian dental profession should embrace the principle of person-centred care, and encourage the delivery of oral health care to vulnerable patient groups in locations and by delivery methods that are most appropriate for these groups.

» The Canadian dental profession should promote the intrinsic importance of oral health and highlight the relationship between oral health and systemic health. It is the responsibility of the dentist to lead interdisciplinary teams in the collaborative management of oral diseases and conditions.

» The Canadian Dental Association’s National Coordinating Group on Access to Care produced an advocacy toolkit that can be used by dentists who advocate for improving dental conditions for seniors in long-term care facilities. The kit contains sample draft legislation, a guide on conducting political meetings, a sample op-ed for newspapers and leave-behind documents for meetings.

Megatrend #9: Shifting Care Needs for an Aging Population

0%

20%

40%

60%

80%

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

2016

Trends in poverty rates of seniors in Canada

Persons 65 years and over Elderly persons in economic families Elderly persons not in an economic family

Statistics Canada. Table 11-10-0135-01 Low income statistics by age, sex and economic family type

24

Transformational Technologies Changing Everything

What

Artificial Intelligence’s time has arrived

» While the core concepts of deep learning and artificial intelligence (AI) have been around for a few decades, they didn’t gain a lot of traction because of technological barriers such as low computing power

» Development of affordable sophisticated hardware to handle the processing of vast sums of data and evolving algorithms that benefit from the richness of information and computing power

» The emergence of AI as a technology that is on the brink of becoming ingrained within business products and services is primarily due to new, abundant and high-quality data - 90% of the world’s data has been created in the past 24 months

» Automation has the potential to transform work processes, by replacing humans with machines and software; examples include shopping assistants that are changing the way we shop or look for services such as health care

» Companies, across the wide business spectrum, are investing heftily in AI so quickly for fear of being left behind; it is estimated that by 2023, AI will be a 14- billion-dollar industry

» “Robot Dentists” have already successfully operated on human patients and the first robotic dentistry system has been cleared by the FDA

‘Uberization’ of health care

» Increasing use of innovative practice management software is revolutionizing how practices are run; equipped with capabilities that introduce practice efficiencies, allow voice commands and recognition in the clinical setting, aid in clinical diagnosis, schedule patient appointments and recalls

» Virtual health care provider offices that manages practices and patients online already exist in a few large Canadian urban centres

» This “Uber for health care” approach, claiming to provide 24/7 virtual doctors’ offices, offers patients online access to register, provide a description of their symptoms, and request a doctor’s consultation

» A new breed of specialized companies is taking over this space, offering advice and to providers and managing procurement

Teledentistry going mainstream

» Teledentistry has been demonstrated to be a practical and cost-effective way to improve oral health care for rural and disadvantaged children in New York state

» Research from university models in New York show that teledentistry reduces costs and barriers to care, and most importantly leads to the establishment of a dental home for underserved children

» California teledentistry Bill was signed into law in 2015, permanently expanding government funding to pay for dental services provided by hygienists and dentists using the Internet

» The American Dental Association recently created reimbursement codes for teledentistry services that went into effect in January 2018

» American Teledentistry Association was recently established; objective is to position the practice of teledentistry as a tool that increases access to oral care for millions of Americans through innovative technological advancements

Incorporation of emerging technologies

» Most clinicians have little knowledge about the full range of uses that these technologies could be applied to, their effectiveness in enhancing their practices, and how to assess the risks and benefits of these technologies

» Emerging technologies are enabling additional preventive restorative approaches which in turn avail more affordable and responsive services to public needs

» Seeing the disparity between dentists in justifiably using new screening tools, patients question dentists’ motives, particularly as some providers employ these tools and communicate with their patients about them

Megatrend #10: Transformational Technologies Changing Everything

$2

$6

$10

$14

2015 2023

2023, AI will be a 14- billion-dollar industry, 27 times larger than 2015

25Megatrend #10: Transformational Technologies Changing Everything

So What

» Dentistry will face increasing societal expectations, with a greater emphasis on social determinants of health that foster wellness. It is important to shift dental education towards a model that emphasizes prevention, diagnosis, and non-surgical treatment using modern technologies, to better prepare dentists for the future demands of the oral health care market.

» The ‘uberization’ and virtualization of health care services to replace face-to-face medical visits are increasing at high speed. They are fast becoming viable and efficient models for the delivery of care.

» The risk of interposition of commercial enterprises dedicated to the appropriateness of care is real and could have a significant impact on the practice of dentistry and the patient-dentist relationship.

» New graduates will likely be the drivers of technology uptake in dental offices. They are more likely to be “tech savvy” than their predecessors to the digital dentistry era.

» Another key driver of technology adoption will be the proliferation of dental corporate entities with access to larger capital and search for greater ROI.

» Teledentistry’s rapid establishment calls for its integration with local, regional, and national Canadian telehealth programs and within the overarching Canadian health care system.

» The advent of new technologies and their impact on the dentist-patient relationship will mandate the constant collaboration between dentists and among interdisciplinary health professional teams.

» Practice management software will be used to enhance marketing efforts and patient recruitment, and for the existing patient roster it will be used to improve the response to patient care needs.

» AI will begin to define the establishment of the relationship between systemic and oral health including diagnostic tools, genetic diagnosis and treatment-based care, imaging, data extrapolation, algorithm-based research.

» AI will have a huge impact on dental insurance; change of service delivery models and benefit packages, automated payments, identification of insurance services based on population studies and patients’ needs, denial of care based on data on lifestyles.

Now What


» The Canadian dental profession should ensure that graduates are aware of the full range of career options available to them, including alternative practice models. Dental schools need to become prepared for the use and deployment of AI in the academic curricula and into practice.


» The Canadian dental profession should establish a national certification body for continuing dental education that assesses courses, to ensure that they are based on sound scientific evidence and free of funding bias and conflicts of interest. This needs to include the proper use of transformational technologies such as AI.

» Dentistry needs to invest towards the demonstration of value of dental care and commit to the discontinuation of the delivery of services that are shown to be of low value.

» Organized dentistry should focus on harnessing the new technologies to enable, ease, and efficiently connect professionals and improve the value of care.

The ‘combinatorial’ effects of technologies – mobile, cloud, artificial intelligence, sensors and analytics among others – are accelerating progress exponentially; once physical and chemical limitations that are inhibiting exponential gains in mass-market technologies such as battery storage and wireless charging are overcome, it is likely that the pace of change will accelerate even faster. -World Economic Forum

26

2.PEST ScanConsumption-led growth in Canada is coming to an end, cooling economic growth to a sustainable pace, but headwinds loom.

27

Political

2018 Federal Budget

Deficit $17.8 Billion

Despite a relatively strong economy, the government is projecting sizeable deficits stretching to 2023.

Personal Tax Rates: No new personal income tax rate or tax bracket changes were announced in this year’s Budget.

Tax on Split Income: The government confirmed that it will proceed with the proposed tax on split income measures announced on December 2017. These measures have been greatly simplified however a fair amount of complexity remains.

The changes will automatically exclude individual members of a business owner’s family who fall into the following category.

The business owner’s spouse, provided that the owner meaningfully contributed to the business and is aged 65 or over. In recognition of the special challenges associated with planning for retirement and managing retirement income, the new approach to income sprinkling will be better aligned with the existing pension income splitting rules. This also reflects the fact that a business can play an important part in supporting its owner in retirement.

Pharmacare: National pharmacare could represent significant savings for both patients and the government. A 2016 Parliamentary Budget Office analysis estimated that of the $28.5-billion spent on prescription drugs in

2015, $24.6-billion would be eligible for coverage under a national pharmacare program and that a true national prescription drug program would cost $20.2-billion. In other words, national pharmacare could represent a savings of roughly $4.2-billion annually, in large part because governments would have a stronger position in price negotiations.

Gender Equality: The budget proposes pay-equity legislation for employees in the federal government and federal-regulated sectors but fails to put a dollar amount on that plan. The legislation, which will draw on models from Ontario and Quebec, will ensure that men and women receive the same pay for equal work.

Parental Leave: The government is proposing $1.2-billion over five years to create a new five-week “use-it-or-lose-it” incentive for new fathers to take parental leave. The benefit covers 55 per cent of the second parent’s income for as much as 12 months.

Indigenous Issues: The government is proposing to invest $447-million over five years to create a new Indigenous Skills and Employment Training Program. The program, which will replace the Aboriginal Skills and Employment Training Strategy, will help close the employment and pay gap between Indigenous and non-Indigenous people by focusing on training for higher-quality, better-paying jobs.

Research and Innovation: In total, the budget commits $3.8-billion more over the next five years to support science. A large share of this will be aimed at stepping up funding in physical and life sciences, social sciences and health for fundamental research at universities and other institutions. By 2023, scientists will have roughly half a billion more for fundamental research than they do today.

Cybersecurity: The 2018 budget has allocated $508-million, spread out until 2022-23. The funds will be used primarily by the Communications Security Establishment to create a new Canadian Centre for Cyber Security, as well as a National Cybercrime Coordination Unit for the RCMP.

Cannabis: With legalization of cannabis set for late summer, Ottawa is spending another $62.5-million on public education campaigns on the dangers of drug use and $10-million on research, including assessing the impact of legalization on mental health. The new funding for public education – on top of a previously announced investment of $46-million – will target communities at risk and Indigenous organizations.

The Government of Canada’s plan to invest in the middle class is delivering growth that works for everyone, according to the Organisation for Economic Co-operation and Development (OECD) Economic Survey of Canada.

66%

17%

8%

9%

Income tax

Excise taxes/ duties

EI premiums

Other revenues

Revenues $293.5 Billion Expenses $311.3 Billion

41%

8%22%

29%

Direct program expenses

Public debt charges

Major transfers to other levels of govt

Major transfers to persons

28

The OECD report also assessed economic developments that may pose a risk to Canada’s economic outlook, and found that the greatest uncertainty relates to the ongoing renegotiation of the North American Free Trade Agreement, as well as the imposition of other restrictions on trade, notably by the United States. An unexpected correction in the housing market also presents a risk, but is of lesser concern. The Government continues to monitor these issues and its aim is to ensure that any actions it takes will strengthen and grow the middle class, help people working hard to join the middle class, and grow the economy over the long term.

Government has helped secure new, separate and voluntary commitments from three payment card networks (Visa, Mastercard, and AmEx) that will lead to lower costs for small and medium-sized businesses. The reduction in interchange fees is expected to save small and medium-sized businesses in Canada $250 million per year, based on credit card sales of roughly $250 billion per year.

Federal 2018 Budget Changes to Impact Dental Professionals- CDSPI

While the tax on split income rules released in December of 2017 will proceed as drafted, a more practical approach to the passive investment proposals was introduced. No new rules or modifications to proposed rules concerning the conversion of a private corporation’s regular income into capital gains were announced.

CORPORATE TAX RATES- Effective January 1, 2018, the small business tax rate is proposed to be reduced to 10 per cent, as a first step toward lowering it to 9 per cent in 2019. This intended reduction will provide a small business with up to $7,500 in federal tax savings per year.

Budget 2018 proposes two measures, applicable to taxation years beginning after 2018, to limit the tax deferral advantages on passive investment income earned inside a CCPC.

Business Limit Reduction- Budget 2018 proposes to reduce the business limit for CCPCs (and their associated corporations) that have significant income from passive investments or non-practice assets. Under this measure, the business limit will be reduced by $5 for every $1 of investment income more than $50,000 such that the business limit will be eliminated when $150,000 of investment income is earned.Source: CDSPI

2018 Federal Government Priorities » Increasing Canada’s Competitiveness and support

for middle class.

» November 21st Fall Economic Statement to combat US tax changes.

» The Prime Minister continues to communicate focus on “the middle class and those working hard to join it.”

Budget Implementation Act, No. 2

» Priority legislation

Immigration

» Expanding levels to 350,000 by 2021

Trade and Investment

» USMCA, CPTPP, Trade Diversification

Pharmacare

» National Consultation on Pharmacare Strategy

Carbon Tax

» Backstop supports announced

Handguns and Crime

» Possible Handgun ban

Bloc Québécois 10

Conservative 96Liberal 181

New Democratic41

Other 7

Vacant 3

Parliamentary overview – House of Commons seat standings- December 12, 2018

29

Big hurdles in Liberals’ agenda to complete:

» USMCA deal

» Cannabis legalization

Implications for Dentistry:

» Continue to establish dentists as important community health care providers.

» Government still working on Healthy Eating Strategy, competitiveness of small businesses and pharmacare.

» Platform planning has begun for 2019 election.

» Influencing political party platforms is essential. Timing is everything and it’s important to start using relationships within the government and opposition parties to influence campaign priorities.

» Task is to communicate benefits of increased access to preventative care, position how current tax benefits help Canadians keep healthy. As has been demonstrated with the earlier tax proposals, this government is generally less focused on small business as the previous Government.

» Government focus is on helping middle class.

Healthy Eating

CDA supports measures to restrict marketing of food and beverages to children, especially through participation and collaboration with the Stop Marketing to Kids Coalition, of which CDA is a Supporting Member.

To this end, the CDA and the Coalition have supported Bill S-228, An Act to amend the Food and Drugs Act (prohibiting food and beverage marketing directed at children). This Bill, which would restrict food and beverage marketing to Canadian children age 13 and under, has passed through the Senate, and is approaching final reading in the House of Commons.

In addition, CDA has consulted extensively with Health Canada’s Office of Nutrition Policy and Promotion over those two years on several fronts. This includes:

» The Healthy Eating strategy

» The revision of Canada’s Food Guide

» Front of package labeling, to provide warnings for high levels of salt, fat and sugar

» Sugar-Sweetened Beverage (SSB) Reduction Campaign

Next Federal Election

Monday October 21, 2019

Early election has been ruled out.

Survey respondents asked to choose their top three issues:

» 35 per cent picked health care

» 28 per cent picked taxes

» 27 per cent picked the economy

» Climate change was the fifth-most frequently picked at 18 per cent

» Indigenous issues and women’s issues were the choices of just 5 per cent

Source: IPSOS Reid

36.4

33.6

16.8

6.2

3.81.9 1.2

Lib Con NDP Green BQ Other PPC

10

20

30

Federal election polling voter intentions averages (%) as of December 21, 2018

Compiled by CBC polls analyst Éric Grenier

Seat projections for 2019 federal election

Party Seats

NDP 27

Liberals 175

Greens 1

Conservatives 132

Bloc Québécois 3

Compiled by CBC polls analyst Éric Grenier

30

Economic

Economic Outlook » Population aging holding back economic growth in

Canada.

» Canada’s economic growth (real GDP) grew by a strong 3 percent in 2017, is projected to sink back below 2 per cent in 2018. Growth is expected to be 1.8 per cent in 2019 and unlikely to exceed 2 per cent again within the foreseeable future.

» After falling almost 20 per cent over the last two years, business investment eked out a small increase in 2017. Further increases will likely be moderate. As such, total business investment is unlikely to return to its 2014 highs until the middle of the next decade.

» Household consumption has been driving the economy’s recent strong performance, but consumers’ ability to spend will lessen over the next several years due to high consumer debt levels, a cooling housing market, and slowing employment growth.

» Job creation reached a 10-year high of 329,800 in 2017; more moderate but still healthy gains still expected in 2018 and 2019.

» The withdrawal of the baby boomers from the workforce over the forecast will increase the retirement rate, put downward pressure on the participation rate, and result in slower potential output growth.

» Housing starts are forecast to fall over near term, though will remain above 200,000 units in 2018.

Employment Rates and Wages

Real median hourly wage change between 2000 and 2017, workers 25 to 54 without bachelor’s degree

Women Men

British Columbia 2.5% -1.2%

Prairies 26.1% 22.6%

Ontario 1.9% 1.7%

Quebec 14.3% 7.9%

Atlantic Canada 21.2% 10.0%

Source: Statistics Canada, Labour Force Survey

Between 2000 and 2017, real wages (without a bachelor’s degree) increased in Canada but decreased in the USA.

Median Hourly Wage Change

Canada Women= 9.3% Men=4.3%

USA Women=1.1% Men=-5.5%

Unemployment Rate in Canada in 2017

Age Group Men Women

15-24 13.3% 11.5%

25-54 5.6% 5.2%

55+ 6.1% 5.1%

Source: Labour Force Survey, Job Vacancy and Wage Survey, Statistics Canada

Income of Canadians

Persons in low income (after tax low income measure in 2016):

» All persons= 13%

» Persons under 18 years old= 14%

» Persons 18 to 64 years old= 12.4%

» Persons 65 years and older= 14.2%

Percent change in median total household income, 2005 to 2015

» Median total household income rose from $63,457 in 2005 to $70,336 in 2015, 10.8% increase.

» Growth led by resource-rich provinces, led by Nunavut, Saskatchewan, Alberta and Newfoundland and Labrador.

» Slowest growth in Ontario and Quebec, having highest manufacturing activity.

» Metropolitan areas within regions follow provincial patterns. Almost every metropolitan area in Ontario had below average income growth, and prairie metropolitan areas had higher growth.

» Newfoundland and Labrador had the third fastest income growth amongst provinces/territories, lifting it from lowest to highest region in Atlantic/Quebec region over last 10 years.

83.8% 75.2%81.8% 66.6%

Canada U.S.A.

Employment rate in 2017, people aged 25 to 54 without a bachelor’s Degree

31

Debt » The ratio of Canadian household debt relative to

income edged down slightly, raising speculation that the growth in debt may have turned a corner.

» Household credit market debt as a proportion of household disposable income was 170.4 per cent in the fourth quarter. In other words, there was $1.70 in credit market debt for every dollar of household disposable income.

» The average Canadian owes $8,500 in consumer debt, excluding their mortgage.

» 12 per cent of Canadians report consumer debts above $25,000, while 14 per cent have debts between $10,000 and $24,999. Nearly half of respondents (46 per cent) said they have no consumer debt whatsoever.

Economic Conditions » More than a quarter of Canadians are already facing

serious financial hardship, according to the findings of a new study as part of an examination of poverty in Canada.

» According to the report from the Angus Reid Institute, 21 per cent of respondents said they can’t afford to go for dental care, while one quarter reported they have recently had to borrow money to buy groceries.

» Almost one-in-three Canadians (31%) feel “very stressed about money” on a regular basis – either “often” or “all the time”.

» More than half of Canadians (52%) believe poverty has been increasing where they live in recent years.

» Three-in-ten Canadians (30%) are pessimistic about their personal financial situation over the next few years.

» More Canadians believe their children’s generation will be worse off (43% do) than themselves than believe they will be better off (32%).

Who are the struggling?

» The one-in-six Canadian adults who qualify as Struggling according to this measure have a lot in common with those who fit the traditional characteristics of poverty in Canada.

» Like those who might be called “poor” based on income alone, the Struggling group tends to include larger numbers of Indigenous people, visible minorities, people with disabilities, LGBTQ people, women, and people with high school education or less.

» An unusual hallmark of the Struggling group that makes them distinct from strictly income-based segments of the population that could be called “poor” is their age.

» Those who are Struggling are overwhelmingly under age 55 (85% of them are).

» Those aged 55 and older are overrepresented among the Always Comfortable group, suggesting that – though many of them may be on fixed incomes in retirement – they are able to make ends meet in most situations.

» This differs significantly from income-based measures of poverty, which typically find older people more likely to have lower incomes.

» Fully one-third (34%) of both the 18-34 and 35-54 age groups find themselves in either the Struggling or On the Edge groups, while among those aged 55 and older, the percentage in these two groups totals just 15 per cent.

» This significant age gap is likely correlated with a couple of things: First, most of those in the 55-plus group are members of the Baby Boom generation,

who benefitted significantly from post-war prosperity in the mid-to-late 20th Century. Second, poverty and life-expectancy are highly correlated: People who experience significant economic hardship in their lives are simply less likely to live to old age.

-Angus Reid Survey, 2018.

Household Spending » Average annual household expenditure on goods

and services per household in 2016 = $62,183

» Shelter= 29%

» Transportation= 19%

» Food= 14%

» Household operations and furnishings= 11%

» Recreation= 6%

» Health and personal care=6%

» Clothing and accessories= 5%

» Other= 9%

0%

20%

40%

60%

Total Struggling On the edge

Recently comfortable

Always comfortable

< $50,000 $50,000-$99,999 > $100,000

Household income within economic segments in 2018

32

Median after-tax income of families and unattached individuals, 2016

» Canada $57,000

» British Columbia $56,800

» Alberta $70,200

» Saskatchewan $59,700

» Manitoba $57,000

» Ontario $59,400

» Quebec $49,500

» New Brunswick $50,900

» Nova Scotia $49,700

» P.E.I. $51,600

» N.L. $55,800

Warnings of Looming Global Recession

The International Monetary Fund (IMF) has stated governments and global institutions remain woefully underprepared for the next financial crisis.

There is a pressing need to work towards limiting the next, inevitable downturn to a “garden variety recession,” as the risks of another 2008-style global meltdown remain high.

World leaders have fewer tools in their emergency kits than they did a decade ago after years of deficit spending and soaring national debt levels.

BlackRock, the world’s largest money management firm, in its annual Global Investment outlook put the risk of

the world slipping into a recession in 2019 at a very scientific-sounding 19 per cent. By 2020, the company predicts a 38 per cent chance of a major downturn, rising to 54 per cent in 2021.

Recent drops in world markets have many analysts and economists cautioning about potential meltdown triggers, like a US trade war with China or a no-deal Brexit.

The governor of the Bank of England, sketched out the worst-case scenario for the U.K.’s impending divorce from Europe, including:

» an economy that could shrink by eight per cent

» the value of commercial property tumbling by almost half

» 7.5 per cent unemployment

» the British pound trading 25 per cent below the U.S. dollar

The outlook from Canada’s central bank is more bullish. The low oil prices that are causing hardship in Alberta and Saskatchewan will reverberate across the country, but the bank doesn’t anticipate a national downturn. Prime worry remains inflation, signalling more interest rate hikes in coming months.

Economists at UBS Securities recently charted 120 downturns in 40 different countries over the past four decades, and concluded that the current atmosphere is more consistent with a “sharp slowdown” than a depression. Especially since consumer spending, employment and productivity all seem to still be on the upswing.

Comparison of household spending trends select indicators 2012- 2016 - Average spent per household

Source: Statistics Canada, Survey of Household Spending 2018

0

$100

$200

$300

$400

$500

$600

$700

$800

2012 2013 2014 2015 2016

Health care services Eye-care goods and services Dental services

Private health insurance plan premiums Private health care plan premiums Dental plan premiums

33

Blockchain and the End of Banks?

Blockchain technology provides a way for untrusted parties to come to agreement on the state of a database, without using a middleman. By providing a ledger that nobody administers, a blockchain could provide specific financial services — like payments, or securitization — without using a middleman, like a bank.

Blockchain allows for the use of tools like “smart contracts,” which could potentially automate manual processes, from compliance and claims processing, to distributing the contents of a will.

For those cases that don’t need a high degree of decentralization — but could benefit from better coordination — “distributed ledger technology (DLT),” could help corporates establish better governance and standards around data sharing and collaboration.

With global banking currently a $134 Trillion industry, blockchain technology and DLT could disintermediate key services that banks provide, including:

1. Payments: By establishing a decentralized ledger for payments (e.g. Bitcoin), blockchain technology could facilitate faster payments at lower fees than banks.

2. Clearance and Settlement Systems: Distributed ledgers can reduce operational costs and bring us closer to real-time transactions between financial institutions.

3. Fundraising: Initial Coin Offerings (ICOs) are experimenting with a new model of financing that unbundles access to capital from traditional capital-raising services and firms.

4. Securities: By tokenizing traditional securities such as stocks, bonds, and alternative assets — and placing them on public blockchains — blockchain technology could create more efficient, interoperable capital markets.

5. Loans and Credit: By removing the need for gatekeepers in the loan and credit industry, blockchain technology can make it more secure to borrow money and provide lower interest rates.

6. Trade Finance: By replacing the cumbersome, paper-heavy bills of lading process in the trade finance industry, blockchain technology can create more transparency, security, and trust among trade parties globally.

Source: How Blockchain can disrupt banking. CBInsights 2018

58 per cent of homeowners in Canada say that an increase of more than $100 in their monthly debt payments would force them to change their spending habits to make ends meet.

Other Ongoing Key Relevant Economic Trends » Growing income inequality leading to declining

population health

» Stagnating incomes of the Canadian middle-class family

» Rising interest rates

» Declining retirement savings of Canadians

» Self-employment and underemployment on the rise

0% 5% 10% 15% 20% 25% 30% 35% 40%

NU

SK

NL

NT

AB

MB

YK

BC

PE

NB

NS

QU

ON

Change in median household income, 2005 to 2015

Source: Statistics Canada, Census of Population, 2016.

34

Social

Growing Income Inequality

Canada’s major cities turning into islands of wealth, poverty as middle class disappears

» Canada’s largest, most economically dynamic cities are becoming islands of cultural isolation, as economic inequality grows and the cities’ neighbourhoods become increasingly polarized.

» All four of Canada’s largest metro areas — Toronto, Montreal, Vancouver and Calgary — are seeing their middle-income neighbourhoods disappear, replaced by increasingly segregated high-income and low-income neighbourhoods.

» In 1980, 60 per cent of census tracts in Toronto were middle-income areas; by 2015, only 28 per cent were middle income.

» At the same time, rich and poor neighbourhoods exploded: wealthy areas rose from 12 per cent to 21 per cent of all tracts, while low-income areas exploded from 28 per cent to 51 per cent.

» More fractured, distrustful society where common ground between different groups can be hard to find.

» In line with the OECD average trend, the share of adults with at least an upper secondary level of education has increased from 85% in 2005 to 91% in 2016.

Education » In line with the OECD average trend, the share of

adults with at least an upper secondary level of education has increased from 85% in 2005 to 91% in 2016.

Level of education completed Women Men

Non-apprenticeship trades certificate

5% 7%

Apprenticeship certificate 2% 8%

College Diploma 25% 19%

Bachelor’s degree or higher 31% 26%

Source: Statistics Canada, 2016 Census

Households and Families » More Canadians are opting to live alone as the

country’s population ages and as women become better able to foot the household bills by themselves.

» For the first time in the country’s history, the number of one-person households has surpassed all other types of living situations. They account for 28.2 per cent of all households.

» 35% of young adults aged 20 to 24 live with their parents. Higher proportion in big cities like Toronto (50%).

» In private households, more seniors living as a couple in 2016 (63%) compared to 2011 (58%).

» 32% of people aged 85 and over living in collective dwelling.

Single Income Earner families are rare today- The Census data show that it takes two income earners for households to make it these days. According to Statistics Canada: In 2015, 96% of Canadian couples had both spouses reporting income, up significantly from about two-thirds in the mid-1970s.

Where people live

In Canada, most dwellings are single detached houses:

» 53.6%= single detached houses

» 18.0%= apartments in a building less than 5 stories

» 9.9%= apartments in building more than 5 stories

» 6.3%= row houses

» 5.6%= duplexes

» 5.0%= semi-detached houses

» 1.3%= mobile dwellings

However, in 3 largest cities (Vancouver, Toronto, Montreal) apartments are more common than single-detached houses.

In 10 large cities, single detached houses represented less than half of dwellings. These included Vancouver, Montreal, Toronto, Ottawa-Gatineau, Sherbrooke, and Halifax, but not Edmonton or Calgary.

One person household

Couple with children

Couple without children

Lone parent family

Other26%

26%

Portrait of Canadian households in 2018

11%28%

9%

35

Aging Population

According to newly released data from the 2016 census:

Thanks to the aging baby boomer population, Canadians who are 65-plus now outnumber children aged 14 and under for the first time.

» Canada saw its largest ever increase in the proportion of senior citizens in the five years ending in 2016, such that for the first time in history there are now more Canadians over 65 than under 15.

» Except in prairie provinces and territories, children under 15 years of age still surpass share of seniors.

» The proportion of senior citizens was up 20 per cent while Canada’s overall population was up five per cent.

» The population of children under 15 was up even less, 4.1 per cent, in line with a general trend of lower fertility over the last half century.

» Fertility now stands at 1.6 children per woman.

» The population of people 100 years of age or older rose more than 40 per cent, in line with a general increase in life expectancy.

» Since the early 1900s, Canadians’ life expectancy has now more than doubled to 82.

» Women’s life expectancy is higher, so aging population boosts the proportion of women, a trend that is likely to continue.

» Canadian women have outnumbered men for about 50 years, and in 2016 made up 50.9 per cent of the population.

» In the cohort older than 85 years, there are two women for every man.

» Geographically, the Atlantic provinces are considerably older than other provinces, and Alberta considerably younger.

» The three territories are the youngest, reflecting higher aboriginal fertility and lower life expectancy.

» At the local scale, some municipalities on Vancouver Island have more than 40 per cent senior citizens.

Disabilities » 1 in 7 Canadians aged 15 years and older reported a

disability= 3.8 million Canadians in 2016.

» 15% of disabilities are flexibility or mobility related.

» The average age of onset of disability is early 40’s.

» 49% of persons with disabilities compared to 79% of persons without disabilities reported being employed (aged 25 to 64 years old).

National Cannabis Use in 2018 » 14% of Canadians aged 15 and over have consumed

cannabis in the past 3 months.

» Highest rate Nova Scotia= 18%, lowest rate Quebec=10%

Canadians behavior once cannabis is legalized:

» 21% might try or increase consumption

» 24% might try new product

» 50% users may purchase from another source

Increasing Immigration and Multiculturalism » Approximately 1.2 million recent immigrants 2011

to 2016

» Top 10 countries of origin: Philippines, India, China, Iran, Pakistan, United States, Syria, United Kingdom, France, South Korea

» In 2016, 5.7 million immigrants settled in Canada between 1980 and 2016.

» In 2016, approximately 50% admitted as economic immigrants, 25% sponsored by families, and 25% as refugees.

Statistics Canada’s models suggest that in little more than a decade, nearly a quarter of Canada’s population will be senior citizens, and just 16 per cent children — a trend with clearly dire implications for future income tax revenue and health care spending.

Currently 21.9% of Canadians are immigrants, 17.7% are second generation

Percent of immigrants to Canada

Before 1981

1981 to 1990

1991 to 2000

2001 to 2005

2006 to 2010

2011 to 2016

16.1%

25.7%

12.1%

19.7%

12.3%

14%

Source: Statistics Canada 2016 Census of Population

36

Nutritional Information » When purchasing food product, 55% of women

and 40% of men consult nutritional information on packaging.

» Of those who consult information, 56% consult the nutrition facts table, 37% the list of ingredients, 6% front-of-package.

» Top reasons for not consulting: 45% don’t care, 20% do not need to, 6% do not know how to interpret it.

Nationwide healthy food strategy

Dietitians calling for a federal food program for kids to ensure more youngsters eat healthy food, after Canada was ranked close to the bottom of a UNICEF report for access to nutritious meals. UNICEF report published in June 2017 ranked Canada 37 out of 41 countries in terms of access to nutritious food for children.

Motion tabled in parliament that urged the federal government to initiate consultations with various groups to develop an adequately funded national cost-shared universal nutrition program.

Canada’s ban on artificial trans fats came into effect September 2018, one year after the federal government announced it would be ending the use of the artery-clogging fats.

Organizations including Diabetes Canada and the Childhood Obesity Foundation are continuing to call on the government to implement a soda levy.

Where You Live Affects Health

Where you live may affect your risk of major diseases like cardiovascular disease, diabetes and cancer, according to a recent Canadian study.

The study links regional trends in health to lifestyle factors, in an attempt to find the “causes of the causes.”

It explores the environmental factors that lead people to develop such conditions as high blood pressure, which can lead to further and more serious health complications.

Found significant differences in environmental factors that may contribute to health, with significant difference between urban and rural communities, as well as between eastern and western, and northern and southern communities.

Results show there are factors outside of a person’s control that influence the individual’s health, and these factors likely differ depending on where they live down to the level of postal code.

Some of the main factors highlighted by the study include:

» Access to public transportation

» The variety of fresh fruits and vegetables in stores

» The prices of popular foods

» The availability and prices of cigarettes and alcohol

» Advertising, or lack thereof, of healthy foods in restaurants

The environmental factor trends found align with health trends discovered in other studies, like that people living in rural environments tend to have poorer health than those in urban environments.

For example, rural communities face higher food prices – with a basket of food costing 7 per cent more on average than in an urban grocery store – that leads to rural households spending $249 more a year on a typical grocery basket than urban households. That, paired with a much more limited selection of produce at rural grocery stores may push residents to end up eating less healthy food options.Source: deSouza et al, Environmental health of communities across Canada, 2018.

Increasing Loneliness

The three periods when loneliness peaks: More people reported feeling moderate to severe loneliness during their late 20s, their mid-50s and their late 80s than in other life periods.

The general sense of isolation is more prevalent than expected. A full three-quarters of all participants in a recent study reported moderate to high levels of loneliness.

Many studies have concluded that the feeling of loneliness and social isolation significantly increase a wide variety of health conditions, as well as increase the risk of premature death. Isolation and loneliness could also have an effect on accessing dental care and oral health status.

1

3

5

7

1980 1990 2000 2010 2020

Canada Pension Plan - Growing monthly average of beneficiaries by year (millions)

37

Technological

Technological Revolution

We are entering a new era in which people will experience computing more naturally and seamlessly in the context of their lives, powered by intelligent assistance and the cloud. This transition is as significant as the move over the last decade from desktops to mobile devices.

How Canadians perceive technology

77%- helps to communicate with other people

66%- saves time

52%- helps to make more informed decisions

36%- helps to be more creative

Landscape-Changing Technological Shifts that will Occur by 2030:

Thoughts and insights about the near- term future of technology in the world – based on interviews of 800 executives from the technology sector.

World Economic Forum 2018.

80% of people on earth will have a digital presence online by 2023.

» More and more people will gain a digital identity as internet connectivity becomes more prevalent.

» By 2023, more than 80% of the global population will have a digital presence.

» In 2015, it was just over 40%.

» Digital life is becoming inextricably linked with a person’s physical life and will only continue to grow in importance.

» Companies like Facebook and Google are pushing this effort ahead with various projects to connect remote parts of the world to the internet, to shape a future in which everyone will be connected to the internet.

One trillion sensors will be connected to the internet by 2022.

» Companies will reach as many people as possible by raising the number of sensors connected to the internet- clothes, watches, glasses and in general many wearable technology tools.

» As the cost of sensors continues to decline and computing power increases, all kinds of devices will increasingly become connected to the internet.

» Everything will come online, even the ground we walk on will register our steps and collect data.

» Every physical product could be connected to ubiquitous communication infrastructure.

90% of the population will have unlimited and free data storage by 2018.

» We will never delete anything from our systems, since there will be almost unlimited room for codes and numbers storage systems. We are already seeing some companies offer cheap or completely free service.

» Hard drive cost per gigabyte continues to fall, and this has spurred more data to be created than ever before.

90% of the global population will have a supercomputer in their pocket by 2023.

» Around the world people are increasingly using their smartphones more than PCs, and in developing nations people are becoming connected to the internet for the first time via their mobile phone.

» As smartphones gain computing power and the price continues to fall, the speed of adoption will only accelerate.

» The number of global smartphone subscribers is estimated at 50% penetration in 2017, and by 2023, about 90% of the population will be connected via smartphone.

NEW INDUSTRIAL REVOLUTION Society is experiencing a new industrial revolution triggered by the arrival of ground-breaking technologies. This is already changing the world at a pace that has never been seen before in history. Dentistry, just as many other professions, is being impacted by this new industrial revolution. Modern technologies are going to increase income inequality and widen the gap between the wealthy and the poorer segments of the society. This will affect the purchase capacity of an even larger portion of the population hence influence the marketplace of the dental profession.

38

» Even in the most remote corner of the world, people will soon use mobile phones to surf the internet.

Driverless cars will account for 10% of all cars in the US by 2026.

» Autonomous cars bring numerous advantages to the drivers- they have an increased level of safety, a lower level of emissions and are changing models of transportation.

» Tech companies like Google and Uber are currently working on self-driving cars.

» Prediction is that by 2026, 10% of all cars are driverless in the US.

» By 2025, more rides taken globally will be via a car-sharing service, and not by a privately-owned car.

The first city with more than 50,000 people and no traffic lights will come into existence by 2026.

» Infrastructure will also become more connected in the future, giving way to more smart cities.

» Everything from the sidewalk and streets to the traffic lights and buildings will be connected to the internet.

» Smart cities, will be automated capable of managing their energy, logistics and traffic, bringing about the first city with a population of 50,000 people and no traffic lights by 2026.

The first AI machine will join a corporate board of directors 2026.

» Artificial intelligence will increasingly play a more important role in the business world as a decision-making tool.

» AI can learn from previous situations, it can provide insight and automate complex decision process based on data and past experiences.

» Enables robots to replace humans not only in low-wage, low-income jobs, but also doing white-collar jobs.

The first robotic pharmacist will arrive in 2021.

» Robots already have a big presence in the manufacturing industry, they are becoming more advanced and they will enter new service-oriented jobs.

» The first robot pharmacist will help to speed up the process of collecting and sharing medicines.

» With the help of 3D printers, robot machines will be able to help human doctors and researchers to grow usable artificial organs.

The first implantable mobile phone will become commercially available in 2025.

» The device will potentially be able to track a person’s health more accurately, while also allowing them to communicate thoughts via brainwaves or signals instead of verbally.

» Implantable health devices, like pacemakers and cochlear implants, have already become more mainstream.

» Will see more widespread adoption of implantable technologies emerge before 2025.

5% of consumer products will be 3D printed.

» 3D printing has already made a lot of inroads with designers and in the manufacturing industry.

» As the printers become less expensive, more powerful, and easier to use, consumers will also increasingly adopt the technology.

» This will enable them to print things at home on demand.

» In 2014, there were 133,000 3D printers sold worldwide, which is a 68% increase from 2013.

0%

10%

20%

30%

40%

50%

60%

70%

80%Smart phone

Laptop or netbook

Tablet or e-reader

Desktop or computer

Digital video camera

GPS device

Video game console

Internet enabled smart television

USB device for accessing Internet from television

Non-smart cell phone

The internet and digital technology- Percent of Canadians who own:

Source: 2016 General Social Survey, Statistics Canada

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Social media will pervade all facets of customer behaviour.

» Social media is playing a bigger role in every phase of the customer lifecycle: not just as a marketing tool, but for everything from sales to customer service, too.

» The surge of chatbots on platforms like Facebook Messenger shows just how scalable social customer service can be.

» CEOs and top leadership taking the lead in championing social media for their companies.

» This all points to a kind of emerging consciousness that social media is the best—and maybe the only—place to reach customers, employees and stakeholders right now.

Key Technological Trends

Wearables will integrate more seamlessly into daily life. Further pushing the boundaries of human-computer interaction bringing new technologies to market, closer to a vision of a more seamless future.

Big data to power an intelligent system. Data is something that all companies have, and their most important resource. Big data was created to analyze and manage the huge amount of digitally-available information, whose primary objective is to make smarter decisions and more accurate predictions for companies.

Machine learning will make great strides. Also known as automated learning, machine learning is expected to be consolidated as a tool that helps companies obtain a greater commercial value and benefit from the data they already own. In addition to ensuring the collection and storage of vast amounts of data, it's important to know how to use them, group them in clusters and create projective learning models by developing algorithms that make the interpretation and benefit from the available information possible. Machine

learning is reshaping the way businesses interact with their customers in a big way by helping them anticipate and meet customer needs more easily.

Artificial intelligence as the key to business breakthrough. The key tool of the New Age. Artificial intelligence aims to emulate human behavior (the ability to make decisions, learn, comprehend, develop language and communicate interpersonally), and even improve it (cognitive computing). Developing intelligent systems that can run independently and self-adapt will be an important goal for technology experts and suppliers. By 2025, AI systems could be involved in everything from population health management to digital avatars capable of answering specific patient queries.

The use of blockchain. The possibility of creating easily distributed, public, and resistant databases is gaining attention. Blockchain technology will transform the way we store and manage data, creating a database that will be lightyears ahead of the current centralized models.

Edge computing, the new cloud. Within this context, IT experts seek to create the most diverse and advanced artificial intelligence capacities in a platform environment on the open cloud. Edge computing was created to revolutionize the traditional idea behind the cloud. It refers to the power of data processing around a network, instead of handling it in a cloud or central data repository.

The Internet of things (IoT) will continue to take the lead. The Internet of things has been one of the most popular terms over the past few years in the technology industry. It refers to the networking of all kinds of things through the Internet. It aims to make devices communicate with each other and, as a result, become more intelligent and independent. The central idea that all technological devices can be connected to the internet and to each other to create

the perfect marriage between the physical and digital worlds. Flexible consumption models (also known as pay-per-use models) are going become increasingly more popular across all industries as new customer data becomes available.

Cybersecurity, increasing risks. Safeguarding a company's data and information has become an indisputable priority. Protecting information and keeping it far from any possible attack is very important. Cybersecurity is one of the fastest growing areas in the Information technology sector.

Virtual reality (VR). Virtual reality has been a popular component of video games for several years and this trend is continuing to expand. In addition to video games, VR is likely to affect companies across the board as they adopt the technology to help them engage customers more effectively and optimize their sales and marketing efforts. It’s also a potentially useful tool for learning and is increasingly being adopted- with recent improvements to both hardware and programming, the effects are going to be felt across almost every industry from retail to education to healthcare.

Touch commerce. The ability to buy anything with the touch of a finger. Merging touchscreen technology with one-click shopping, touch commerce allows consumers

Payment methods for personal spending by Canadians

76%

21%

3%

Debit, credit card, online banking

Cash or cheque

Other (rewards, gift cards)

40

to buy products easily from their phones. After linking their payment information to a general account and enabling the feature, customers can buy everything from clothes to furniture with just a fingerprint. Biggest thing to hit eCommerce in recent years with purchases of this type expected to increase by 150% annually and retailers in almost every industry anticipating an increase in sales directly related to this new technology.

Home of the Future: Smart Sensors Used to Enhance Home Care for Patients

Caring for seniors at home is going to get a whole lot smarter- with recent census data indicating one-person households surpass all other types of living situations in Canada, in part due to longer life expectancy, the need to help aging Canadians maintain independence and quality of life is stronger than ever.

AGE-WELL is a federally funded Networks of Centres of Excellence (NCE) program. Launched in 2015, the pan-Canadian network brings together researchers, non-profits, industry, government, care providers, older adults and caregivers to find innovative ways to support independent living and enhance wellness among seniors.

Many of their projects are examining how digital sensors can be used to collect and monitor health data, with a focus on finding non-invasive ways to install sensors in a home.

Examples:

Smart-matt: To embed a sensor between a patient’s mattress and box spring so clinicians could remotely monitor patient movements getting in and out of bed. A pressure sensitive foam pad that uses fibre optic light to measure pressure. As patients manoeuver in and out of bed, pressure sensors collect information related to

their movements, enabling researchers to use that data to remotely monitor things like how long it takes them and how many times they stand up and then sit back down again. Home-care providers could use the matt as a form of smart triage.

Stroke survivor rehab: Advanced telerobotics to design a system that will make it easier to deliver individualized therapy at home for older stroke survivors and seniors with age-related movement disorders. Remote rehabilitation platform combines force-enabled robotic technology, virtual reality and Internet communication and is similar to a virtual gaming experience. In a situation where a person has gone through therapy in the clinic and goes home, the goal is to continue the therapy as much as possible.

COPD monitoring: A wearable application to monitor chronic obstructive pulmonary disease (COPD) patients at home. The goal is to monitor their condition and detect early exacerbations – such as shortness of breath, worsening cough or a decrease in activity level – so that a timely intervention can occur before a trip to the emergency room is necessary.

Motion sensors: Used to monitor the activity and normal behaviour patterns of those living independently. The data collected is sent to a smart cloud and predictive analytics are applied to identify variations in behaviour so that clinicians, or even other smart technologies, can intervene. If someone gets up in the middle of the night and it is known from the last many days that their next step is the kitchen to get a glass of water, a light in the kitchen is turned on to try and prevent a fall in about one out of 1,000 times.

Digital health assistant: Similar to the way Amazon Alexa or Google Home function. Using natural language technology, the device becomes the interface to connect patients, family members, caregivers and the wider healthcare team. In addition to being used for passive

monitoring, it collects self-reported symptoms and can even be used to manage appointments.

Artificial Intelligence and Dramatic Shift in Worker Skills Over Next 20 Years

According to the McKinsey Global Institute about one in three Canadian workers will be pushed out of their professions in the next 15 years as artificial intelligence and robotics take on more jobs. They have road-mapped the long-expected labour revolution powered by increasingly robust automation technologies. They found it is theoretically possible to automate 50 per cent of what Canadians and Americans get paid to do.

Over the next 15 years, the skill shifts are going to be dramatic. About one-third of Canadians will have to switch occupations over the next 15 years.

Only about 10 per cent of jobs are projected to lose most of their functions to non-humans. Sixty per cent of workers are expected to have a third of their activities automated.

Manufacturing remains most vulnerable to disruption by non-human work followed by food service, accommodation, warehousing and transportation.

Jobs that require social and emotional skills such as psychiatrists, chief executives, legislators, and teachers are among the professions expected to hold out the longest against digital disruption.

Workers will be in and out of academic institutions to continuously upgrade their skills, just like how computers update software throughout their lifecycle. The model of where students educate themselves for the first 20 years of life, and go off and work for many decades, is no longer going to happen.

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According to Price Waterhouse, Artificial Intelligence (AI) and related technologies will generate as many jobs as they displace over the next 20 years.

The research found that while AI could displace roughly seven million jobs in England, it could also create 7.2 million roles, resulting in a modest net boost of around 200,000 jobs. It has also estimated that about 20 percent of jobs would be automated over the next 20 years and no sector would be unaffected.

Technologies such as robotics, drones and driverless vehicles would replace human workers in some areas, but also create many additional jobs as productivity and real incomes rise and new and better products are developed.

Cybercrime and Canadian Businesses, 2017

Businesses spent $14 billion to prevent, detect and recover from cyber security incidents:

» $8 billion on salaries for employees, consultants and contractors

» $4 billion on cyber security software and related hardware

» $2 billion on other cyber security measures

Reasons businesses invested in cyber security:

» 68% for protection of personal information

» 41% for prevention of fraud and theft

» 31% for prevention of loss of business operations

Cyber security incidents impacted 21% of all businesses and led to 23 hours of downtime on average

» Small businesses (10 to 49 employees): 19% impacted, resulted in 22 hours of downtime

Businesses experienced attempts by cyber criminals:

» to steal money or demand ransom payment= 38%

» to gain access to unauthorized areas= 26%

» to steal personal or financial information= 23%

» to disrupt or deface the business or web presence = 22%

Source: Canadian Survey of Cyber Security and Cybercrime, 2017.

Canadians Digital Use in 2018 » 26% of Canadians used online bulletin boards to sell

products (e.g. Ebay, Etsy, Kijiji)

» $722- average income from selling products on online bulletin boards

» $412- average Canadians spend on digital products annually

» 64%- used or purchased online streaming services (e.g. Netflix)

» 57%- used or purchased mobile apps and other online subscriptions

» 51%- used or purchased music downloads or music streaming subscriptions

» 33%- used or purchased eBooks, online magazines or podcasts

Source: Digital Economy Survey, Statistics Canada 2018

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3.Health ScanHealth care is a service industry that exists to meet the needs of patients. However, the system is still stuck in a model from the past, in which providers made the rules and controlled all decisions.

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And current methods of drug delivery, whether via a needle or pill, are similarly open to patient error and mismanagement.

On-skin monitoring/drug delivery platforms will free up physicians’ time and give more power to the patient.

Biotechnology

CAR-T cell therapy represents a fusion of major advances in genomics, engineering, and immunology. And the field is just getting started.

RNA technology on the brink of transformation

Access to RNA poised to solve decades old scientific problem.

Problem: Protein over/underexpression is a major cause of illnesses ranging from cancer to autoimmune diseases, but it has been difficult to control medically.

Solution: Since RNA is responsible for protein formation, therapies that target RNA may be able to prevent their formation.

Major Forces Reshaping Healthcare

Creating the right incentives and accountability for outcomes

Health care will put less emphasis on counting transactions and interventions and more on knowing whether these interventions make a difference in patients’ lives. Improving the quality of health care services and increasing value for money requires a fundamental transformation in the culture, incentives, and working practices of health care providers and administrators. This shift in culture and practice should be supported by measuring outcomes and establishing accountability frameworks tying these outcomes to performance targets.

Healthcare Trends to Watch

DIGITAL HEALTH

Intelligent Drug Design Skin-as-a-Platform Blockchain-enabled Hospitals

Automating drug designDermal/transdermal drug delivery and monitoring devices

Distributed networks advancing security and data sharing

BIOTECHNOLOGY

CAR-T Therapies RNA Therapies Anti-Aging Therapies

Re-engineering T cells to better attack cancer

Filling in therapeutic gaps with RNA-based medicines

Preventing, halting, reversing the aging process

MEDICAL DEVICES

Bio-Printing Neurotechnology Hand-held Diagnostics

Early-stage startups building organ printing machines

Enhanced human capabilities by integrating with nervous system

Condensing lab-grade diagnostics into hand-held devices

Source: CBinsights, 2017.

Health Scan

Healthcare is changing around the world. The very definition of medicine is now up for debate. Across digital health, biotechnology, and the medical device sector, startups are finally bringing medicine into the 21st century.

Disruptive Healthcare Innovations on the Horizon

Digital Health

Intelligent drug design refers to the use of automation tools, such as artificial intelligence, to speed up drug discovery. Startups are building computational platforms to better identify compounds likely to succeed in subsequent rounds of testing.

Current drug discovery takes 6 years. AI could shorten discovery timeline drastically, potentially saving years of research.

Skin-as-a-platform: Wearable everything refers to the use of wearable patches and other devices that sit on the skin to enable continuous biometric monitoring and drug delivery.

This is an important development because current methods of monitoring, whether blood pressure, glucose, or heart rate, are irregular and prone to human error.

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Preventive instead of reactive medicine

There is a fundamental shift to direct resources toward keeping people healthy rather than paying to treat the sick. These transformative changes stem from a need to curtail ever-increasing health care costs, which are not commensurate with the health outcomes achieved. These changes are currently underway in the health care system, and will impact the oral health care system soon.

Patients will not only have fast and easy access to medical information in the future, but they will have a lot of data about their own organism: trackers, wearables, and gamification-based sensors will guard their health in the future. This approach will shift healthcare from a reactive to a preventive approach, where data can

help in avoiding chronic diseases and keep up a healthy lifestyle.

Diagnostics at the point of care

Sensors, trackers, wearables not only allow to collect an unimaginable amount of data, but they also turn the patient into the point of care. Although the medical tricorder from Star Trek is far away at the moment, in the future we will see high-power microscopes with smartphones, for example, analyzing swab samples and photos of skin lesions. Sensors could pick up abnormalities in DNA, or detect antibodies and specific proteins. An electronic nose, an ultrasonic probe, or almost anything we have now could be linked to a smartphone and augment its features.

The latest developments in genomics and artificial intelligence can also revolutionize diagnostics. As the cost of genome sequencing is rapidly declining, it seems it can pave the way for precision medicine and DNA-based diagnostics. At the same time, smart algorithms and deep learning can become a significant player for example in radiology. It can help detect diseases on medical images, solve complex issues or supervise diagnostic processes.

High-tech therapy and follow-up

Robotics, 3D printing, telemedicine, artificial intelligence, nanotechnology and many more amazing innovations will support the fast and painless therapy and recovery of patients. Surgical robots and nanobots able to swim in bodily fluids will allow for minimally invasive procedures. 3D printing will have a role in replacing the traditional plaster cast or providing biomaterials such as artificial skin for burn patients. Tech giants, such as IBM, Google, or Microsoft are building artificial intelligence solutions to design personalized treatments for any cancer type or patient faster than any traditional healthcare service.

In the future, external skeleton-like devices will support and protect the human body from the outside. They let paralyzed people walk again, and help the rehabilitation of stroke or spinal cord injury patients.

As a consequence of digital technologies, patients will spend less time in hospitals, but they will be constantly wired through health sensors or wearables measuring vital signs. Moreover, hospitals will cease to exist in their current form, they might be reduced to emergency rooms, while recoveries will take place at home – through telemedicine, virtual and augmented reality services and with the help of humanoid robots.

0

$2000

$4000

$6000

$8000

$10000

$12000

$14000

$16000

$18000

Canada NT NU YK AB NL MB NS NB SK PE QU BC ON

Per person total health spending 2018

Source: CIHI National Health Expenditure Trends, 2018

45

Integrated care for population health

In a typical integrated network, the payers stipulate a framework whereby provider groups agree to care for a specific patient population with the goal of reaching or surpassing a predetermined set of quality and cost benchmarks. The integration model encourages healthcare organizations to deliver value to patients and reduce the overuse of treatments.

The Integrated Prevention Network establishes a framework whereby regional and/or local provider groups agree to care for a specific patient population, with the goal of reaching or surpassing a predetermined set of quality and cost benchmarks. The established framework is determined locally by the stakeholders, including the purchaser(s), the payers and administrators, and the clinical entities responsible for delivering on the stipulated care guidelines.

The use of innovative diagnostics and advanced blood and genetic protocols (recognized as the gateway to prevention) will be at the core of the standardized treatment guidelines. Standard “usual and customary” fee arrangements will be replaced by proprietary or commodity-driven reimbursement algorithms.

Increasing interprofessional collaboration in health care

The healthcare industry is also becoming more inter-professional. Interprofessional collaboration is defined as “when multiple health workers from different professional backgrounds work together with patients, families, caregivers, and communities to deliver the highest quality of care”. It is based on the concept that when providers consider each other’s perspective, including that of the patient, they can deliver better care. In addition to a trend towards preventative care delivered by non-dentists, there is a movement underway to more fully integrate dentistry and general health. The

profession must be prepared to promote both the oral health and overall health of the patient.

Health insurance sector transformation

For the past 25 years the health benefits industry has survived under a paternalistic insurance model- however within a decade the industry will become completely disrupted by specialty vendors and their innovations. By 2025 employers will work with dozens of specialty healthcare providers, focusing on improving costs, efficiency, health outcomes and customer service. With employers shifting the burden of health care benefits to employees as a cost reduction strategy, and with a tightening of insurance taking place, patients are often responsible for more out-of-pocket expenses, leading them to evaluate dental services extensively to choose more economically.

Consumerism and the expansion of direct-to-consumer retail insurance markets: By 2020, industry experts predict that the majority of health insurance purchases will shift from employer-sponsored group insurance to direct-to-consumer online marketplaces.

Business consolidation in healthcare- mergers and buyouts

Health Care System Expenditures

The following information is taken from the National Health Expenditure Trends, 1975 to 2018 — the Canadian Institute for Health Information’s 22nd annual health expenditure trends publication (provides detailed, updated information on health expenditure in Canada).

Key findings

Total health expenditure is expected to reach $253.5 billion or $6,839 per Canadian in 2018.

» It is anticipated that, overall, health expenditure will represent 11.3% of Canada’s gross domestic product in 2018. The trend over the last 40+ years shows that when there is economic growth, there is more health care spending.

In 2018, total health expenditure is expected to rise by 4.2%, a slight increase in the rate of growth compared with earlier in the decade.

» Between 2014 and 2018, health spending per capita is estimated to increase in real terms by an average of 1.7% per year. This reflects continuous economic growth and the prospects of higher government revenues in the next few years, which may lead to sustained health spending increases in the near future.

Provincial per capita health expenditures vary. In 2018, total health expenditure per capita is expected to range from $7,552 in Alberta and $7,443 in Newfoundland and Labrador to $6,597 in British Columbia and $6,584 in Ontario.

Drugs expenditure growth fastest among 3 largest health spending categories.

» Hospitals (28.3%), Drugs (15.7%) and Physicians (15.1%) are expected to continue to account for the largest shares of health dollars (close to 60% of total health spending) in 2018.

45 buyout deals

180buyout deals

2012 2017

Number of North American retail health buyout deals has been growing rapidly

46

» Over the last couple of years, the pace of drug spending growth has increased. Drug expenditures are expected to grow by an estimated 4.2% in 2018. Spending on hospitals in 2018 is estimated to grow by 4.0%, while physician spending growth is forecast at 3.1%.

Canada’s per capita health care spending among the highest internationally.

» Among 36 countries in the Organisation for Economic Co-operation and Development in 2017, the latest year for which comparable data is available, spending per person on health care remained highest in the United States (CA$12,865). Canada’s per capita spending on health care was among the highest internationally, at CA$6,082 — less than in the Netherlands (CA$6,786) and France (CA$6,177), and more than in Australia (CA$5,725) and the United Kingdom (CA$5,373).

About 70% of total health expenditure in 2018 will come from public-sector funding.

Both the public and private sectors finance Canada’s health systems. Public-sector funding includes payments by governments at the federal, provincial/territorial and municipal levels and by workers’ compensation boards and other social security schemes. Private-sector funding consists primarily of health expenditures by households and private insurance firms.

Provincial and territorial government spending on health is expected to account for 64.2% of total health expenditure in 2018. Another 4.8% will come from other parts of the public sector: federal direct government, municipal government and social security funds. Since 1997, the public-sector share of total health expenditure has remained relatively stable at around 70%.

Who is paying for services?

» 31%- Private (Out of pocket: 15.4%; Private insurance: 12.4%; Other: 3.3%).

» 69%- Public (Provincial and Territorial governments: 64.2%; Other: 4.8%).

Spending is highest on seniors; however, population aging is a modest cost driver

While Canadians age 65 and older account for about 17% of the Canadian population, they use almost 45% of all public-sector health care dollars spent by the provinces and territories. However, seniors are a diverse group. In 2016 (the latest available year for data broken down by age group), per-person spending for seniors increased considerably with age: $6,481 for those age 65 to 69, $8,348 for those 70 to 74, $11,081 for those 75 to 79, and $20,397 for those 80 and older.

Overall, population aging is a modest driver of increasing health care costs, estimated at 0.9% per year. The share of public-sector health care dollars spent on Canadian seniors has not changed significantly over the past decade — from 44.6% in 2006 to 44.8% in 2016.

During the same time period, the percentage of seniors in the population grew from 13.2% to 16.5%.

Assuming population aging continues to contribute approximately 1 percentage point per year to total health expenditure in the near future, aging alone will add around $2 billion per year to health spending in Canada. As the population continues to age, decision-makers will be faced with the challenge of determining the level of care (hospital, long-term institutional and community) for older Canadians that balances access to and quality and appropriateness of care with the cost of care.

More economic growth, more health care spending

There has been a positive relationship between economic growth and health care spending growth in Canada since the mid-1970s. In general, with more economic growth, and thus income, comes more spending on health care. The exception is the fiscal restraint periods from 1993 to 1996 and from 2011 to 2014, when governments attempted to reduce or eliminate budget deficits.

% of total health spending 2018

$ spending per person

% per person annual increase

Hospitals 28.30% $1,933 3.00%

Drugs 15.70% $1,074 3.20%

Physicians 15.10% $1,032 2.20%

Dental Services 6.70% $461 5.10%

Source: CIHI National Health Expenditure Trends, 2018.

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When viewing Canada’s health care spending trends in the larger global context, Canada’s experience parallels that of other countries in the OECD. The most obvious similarity is the positive correlation between growth in health care spending and growth in the economy between 2000 and 2010.

In the 2017 federal budget, the government confirmed an investment of $11 billion over 10 years, provided to the provinces and territories, specifically targeted at improving home and community care and mental health and addictions services. It also allocated $544 million over 5 years to federal and pan-Canadian health organizations to support health innovation and pharmaceutical initiatives.

Canadian Private Health Insurance

There are more than 150 life and health insurers operating in Canada (including 38 foreign-owned life insurers) providing a competitive Canadian marketplace with a wide range of financial security products for businesses and individuals. These products include employee benefits and individual plans that provide life and health insurance protection and retirement savings

solutions to ensure the financial security of almost 29 million Canadians.

» 25 million Canadians have supplementary health insurance.

» $12.5 Billion in Health insurance benefits- 11.3 for prescription drugs, about 35% of Canada’s total spending on prescription drugs.

» Government programs cover basic physician and hospital expenses for all Canadians and provide financial assistance to Canadians who are unable to work because of disability or illness. The majority of Canadians are also protected through extended health care (Ext. health), disability and other insurance provided by insurers.

» Extended Health Benefits- 25 Million Canadians covered with $29.2 Billion in premiums.

» Disability- 12 Million Canadians covered with $9.3 Billion in premiums.

How health insurance is purchased

Health insurance may be provided through group plans provided by employers, unions or professional associations, or individual plans that consumers purchase for themselves.

Percent of working Canadians and their families that are protected by private health insurance plans:

» 2018- 79%

» 2008- 71%

Specialty drugs

The development of specialized drugs has led to a steep rise in drug costs. These specialty drugs, while making up 2% of the total number of claims, accounted for 31% of prescription drug costs in 2017, and the costs are expected to rise further in future years. The cost of specialty drugs is anticipated to reach 40% of prescription drug costs by 2022.Source: Canadian Life and Health Insurance Facts. 2018 Edition.

$ 43 Billion in health premiums in 2017

Group 90%

Individual 10%

2017 Health benefits by coverage type

Other

Disability

Extended Health4%

21%

75%

$2

$4

$6

$8

$10

$12

Drugs Dental Paramedical& vision

Hospital Travel

Breakdown of extended health benefits paid in 2017(billions)

$25.5 Billion- spent on extended health benefits in 2017

$8.1 Billion or 31.8% of the total extended health benefits spent on dental benefits.

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Drugs and Prescribing Initiatives

Antimicrobial prescribing in Canada

» In 2016, there were 629 prescriptions dispensed per 1000 inhabitants in Canada.

» Majority (410.3 per 1000) prescribed by family and general practitioners.

» 8% (52.1 per 1000) prescribed by dentists.

» Over time (2013 to 2016), little change in prescribing volume by general and clinical specialists.

» 41% increase in prescriptions per laboratory specialists.

» 11% increase in prescriptions per dentist.Source: Conference Board of Canada; Understanding the Gap. A Pan-Canadian Analysis of Prescription Drug Insurance Coverage. 2017

Pan-Canadian analysis of prescription drug insurance coverage

» Currently, the proportion of uninsured Canadians in Canada is 5.2 per cent.

» The bulk of this population without access to prescription drug coverage lives in Ontario and Newfoundland and Labrador.

» As of January 1, 2018, with the introduction of OHIP+ in Ontario, this number will drop to an estimated 1.8 per cent in Canada.

» Less than 1% of Canadians who received a prescription in the past six months cited cost as a reason for not taking their medication as prescribed.

» Of surveyed Canadians who did not take their medications as prescribed, 54% were not aware and 3 per cent were unsure if there were public drug programs to help pay for prescription drugs.

» Approximately 4.1 million Canadians (11.3%) who do not have private insurance and are eligible for public coverage do not enroll in the public plan.

Pan-Canadian survey published by Nanos Research on prescription drug use among Canadians. Some of the key survey findings include:

» 80% of Canadians reported having received a prescription in the past six months.

» 93% of those who reported having received a prescription in the past six months also reported that they took the medication as prescribed.

» 7% of those who reported receiving a prescription in the last six months did not take the medication as prescribed.

The reasons cited for non-adherence to medications among Canadians who reported not taking their medication as prescribed included:

» There was no longer a need for the medication (33%).

» There were side effects, an allergic reaction, or the medication was too strong (23%).

» The medication was too expensive or was unaffordable (7%).

» They forgot to take the medication (7%).

» Of Canadians who did not take their medications as prescribed, 54% were not aware, and 3 per cent were unsure if there were public drug programs to help pay for prescription drugs.

Source: Conference Board of Canada; Understanding the Gap. A Pan-Canadian Analysis of Prescription Drug Insurance Coverage. 2017

Clinical specialists19%

Dentists8%

Family and general medicine65%

Laboratory specialists

1%

Opt

omet

rists

/pha

rmac

ists

/nur

ses

3%Su

rgic

al s

peci

alis

ts4%

Proportion of antimicrobial prescriptions dispensed in Canadian ambulatory setting by prescriber group 2016

Source: Conference Board of Canada; Understanding the Gap. A Pan-Canadian Analysis of Prescription Drug Insurance Coverage. 2017

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Antibiotics prescribed more often in Canada than in other OECD countries

In 2015, more than 25 million courses of antibiotics were prescribed in the country — the equivalent of almost 1 prescription for every Canadian age 20 to 69. According to data from the Canadian Institute for Health Information (CIHI), antibiotics are prescribed more frequently in Canada than in other Organisation for Economic Co-operation and Development (OECD) countries.

Data highlights:

» Every day, about 20 out of 1,000 Canadians take a dose of antibiotics.

» Canadian clinicians prescribe 33% more antibiotics than clinicians in countries like the Netherlands, Sweden and Germany.

» In all OECD countries, 3 out of 5 antibiotic prescriptions were for diagnoses considered inappropriate such as common colds and related symptoms (e.g., sore throat, cough).

“Our data shows that there is overuse and misuse of antibiotics across the country. The unnecessary use of antibiotics can be harmful for vulnerable patients, decreases the effectiveness of antibiotics over time and puts us at larger risk of antibiotic resistance.”

Source: CIHI OECD Interactive Tool: International Comparisons

PrescribeIT- Canada Health Infoway

More than 600 million prescriptions are dispensed in Canada annually.

9% are for narcotics and other controlled drugs.

39% of prescribers are either never notified of a patient’s drug misuse, or notified after the patient picks up the prescription.

More than 40% of prescriptions are hand written.

4 million Canadians admit to losing or damaging a prescription.

» 415,000 prescriptions took a spin in the wash

» 140,000 were dropped in puddles

» 88,000 were eaten by dogs

Canada Health Infoway is working towards a national e-prescribing service as one of their 2 strategic goals.

Canada Health Infoway is also embarking on ACCESS 2022 (Digital Health) their other strategic goal.

Despite increased spending, Canada’s health care systems are fragmented and out-dated. Health care has not kept up with other sectors that are continually innovating to improve the customer experience.

Canadians want a digital health system that is easier to navigate and more patient-centric. The launch of ACCESS 2022 is a movement to inspire industry and all Canadians to work toward a new day in health care, to provide Canadians and their providers with access to personal information and digital health services.

Opioids Crisis

Opioid crisis having “significant” impact on Canada’s health care system.

» Information released by the Canadian Institute for Health Information (CIHI) shows that the quantity of opioids dispensed to Canadians declined between 2012 and 2016. The quantity of opioids is measured by the defined daily dose (DDD), which is the average

dose per day for a drug used in adults, according to the World Health Organization (WHO).

» The number of opioid prescriptions has increased over 5 years, but the quantity of opioids in each prescription has decreased. Prescribing lower quantities encourages more frequent interactions between health care providers and their patients, which allows providers to monitor the effectiveness of the drug and the need to continue therapy.

» In 2016, 21.5 million prescriptions for opioids were dispensed, an increase from 20.2 million prescriptions in 2012. Seniors had the highest rates of opioid prescriptions in Canada between 2012 and 2016, and more than 1 in 5 seniors received at least one opioid prescription last year. The data also shows that 1 in 8 seniors who were prescribed an opioid were prescribed a strong opioid for 90 days or more. A strong opioid is a drug with a higher potency, such as oxycodone, morphine or fentanyl.

» Seniors are at greater risk for opioid-related harms due to several factors, including age-related changes in drug absorption and metabolism that may increase the risk of accidental drug poisoning.

» 6 opioids — codeine, oxycodone, hydromorphone, morphine, tramadol and fentanyl — accounted for more than 96% of all opioids prescribed between 2012 and 2016. Of these, 4 are considered strong opioids (oxycodone, hydromorphone, morphine and fentanyl) and are usually prescribed for moderate to severe pain.

» Canadians are increasingly being prescribed strong opioids. In 2016, 57.3% of all opioids prescribed were strong opioids, an increase from 52.2% in 2012.

» Between 2007–2008 and 2016–2017, the rate of hospitalizations due to opioid poisoning increased 53%. More than 40% of the increase occurred over the past 3 years.

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» Hospitalization rates varied across the provinces and territories overall, with Northern and Western Canada having generally higher rates than Eastern Canada.

» Adults age 45 to 64 and seniors age 65 and older had the highest rates of hospitalizations due to opioid poisoning over the past 10 years, but the fastest-growing rates were for those age 15 to 24.

» The number of emergency department visits in Alberta related to heroin and for synthetic narcotic poisoning, which includes opioids, rose by almost 10 times over the past 5 years.

» In Ontario, emergency department visits related to heroin poisoning increased by almost 4 times, while visits for synthetic narcotic poisonings more than doubled.

» Purposely self-inflicted harm, which includes suicide attempts, led to 31% of opioid poisonings in Canada last year, while more than half of poisonings were considered accidental. Intentional poisonings were most prevalent for youth age 15 to 24, accounting for 44% of hospitalizations.

» 63% of opioid poisonings among Canadians age 65 and older in 2016–2017 were accidental, while 16% were intentional and 21% were of unknown reason.

Source: CIHI, June 2018

“While we are rightly paying close attention to overdose deaths, we need to be looking at a broader range of outcomes: emergency room visits, hospitalizations and prescribing across all age groups. If you put together the rates of prescribing with some of the hospitalization data, it shows we have a serious issue in Canada.”

In 2017 there were 3987 apparent opioid-related deaths in Canada

» About 11 lives lost per day related to opioids.

» 92% were accidental (unintentional).

» The number of accidental deaths involving fentanyl or analogues increased by 81% between 2016 and 2017.

» An average of 17 people were hospitalized due to opioid poisoning in Canada each day in 2017—an increase from 16 per day in 2016.

» Suspected opioid-related overdoses were most common among individuals between the ages of 20 and 29.

» Two-thirds of suspected opioid-related overdoses occurred among men.

» Highest rates in British Columbia –Rate of 20 and Higher per 100,000 population and Alberta/ Yukon- Rate of 15 to 19.9 per 100,000 population.

» Lowest rates in Quebec, Saskatchewan, New Brunswick and NWT- Rate of 0 to 4.9 per 100,000 population.

Source: Health Canada, June 2018

Opioids and dentistry

» Canadians are the second largest consumers per capita of prescription opioids in the world.

» Between 30 and 40% of opioid prescriptions are for dental procedures.

» Highest prescribing rate is adolescents.

» US data shows dentists leading prescribers of opioids to youth (age 10-19).

» Patients from dental clinics are more likely to non-medically use or divert prescription opioids than those in general population.

» On average, patients report having significant (54%) of opioids prescriptions “left over”.

» June 2016: Minister of Health announced an Opioid Action Plan.

» November 2016: Minister of Health Co-hosted Opioid Conference Summit-released Joint Statement of Action to Address the Opioid Crisis.

» Resulted in a Joint Statement of Action to Address the Opioid Crisis.

» Commitments from the Association of Canadian Faculties of Dentistry, the Royal College of Dental Surgeons of Ontario.

» Additional commitments to be made as part of update of Joint Statement.

» December 2016: Established FPT Special Advisory Committee to coordinate public health response to opioid overdoses.

» December 2016 – Introduced legislative changes (C-37) that support enforcement and public health response.

» February 2017 – Established FPT Opioid Overdose Surveillance Task Group.

Opioid prescriptions by dentists increase risk of addiction

December 2018 study in JAMA concluded that opioid prescriptions by dentists and oral surgeons may lead to a statistically significant increased risk of persistent opioid use and abuse for adolescents and young adults.

Patients who received an opioid prescription from a dental practitioner were at a statistically significant risk for persistent opioid use and a subsequent diagnosis of opioid abuse, the research found.

Based on study findings, conclusion is that exposure to opioids from dental practitioners may be associated with

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an increased risk of opioid abuse and that more scrutiny of third-molar extractions and opioid prescriptions associated with postoperative care is needed.

“The overall quantity of opioids dispensed in Canada is dropping, but people are being prescribed strong opioids more often. Opioids can be an effective way to treat moderate to severe pain, and the risks and benefits should be weighed when prescribing. It is important that we continue to monitor prescribing trends and opioid-related harms as part of our work to help inform public health policy.”

Increasing Complexity of Regulatory Environment

Ideology, promoted by vested interests, is preventing real transformation. - Conference Board of Canada

Common themes exist across international regulatory reforms

» Regulatory bodies have basically grown out of a 19th century structure that is not fit for purpose in the 21st century.

» A shift in each jurisdiction towards a more overt primacy of the public interest over professional interests.

» Greater independence of regulation from the professions.

» Push towards collaboration and consistency between professional regulators.

» Focus on articulating principles to aid in assessing regulatory quality.

» The UK’s regulatory system has undergone significant reform over the last two decades, largely in response to a number of scandals. Professions essentially lost the authority to self-regulate, the number of regulatory bodies was cut, and the Professional Standards Authority (PSA) was created as an independent body

Acting in the Public Interest

19th to mid-20th Century Perspective

1960s to 1990s Perspective 21st Century Perspective

Dimensions of Considering and Acting in the Public Interest Argument

» Standards of practice

» Standards of qualification

» Elevating the profession

» Addressing public information deficit

» Entry barriers

» Competence of practitioner

» Access to services

» Service quality

» Practitioner competence

» Efficiency of the system

» Cost effectiveness

» Nest for the patient and the public

» Better coordination of services

» More flexible to patient need

» Increased patient choice

» Lay representation on boards

» Oversight by government

» Equity of access

» Costs of regulation

» Increased efficiency

» Increased cost effectiveness

» Reduction in entry barriers to mobility

» Promoting competition

» Regulation proportionate to risk

» Promoting alternatives to the licensing model

Synopsis » Benefits both the profession and the public. Quality to the forefront but some concerns over access, choice and entry barriers.

» Professions cannot be trusted to act in the public interest and therefore need oversight. Balance between quality, cost and access.

» Public interest tied to efficient provision of services through minimum regulatory intervention

Source: Benton et al, 2018.

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accountable to the UK parliament. In overseeing regulators, it assesses their performance, holds them to standards, conducts audits, scrutinizes disciplinary decisions and reports to government. The PSA also oversees the recruitment and selection of individuals to serve on regulatory bodies.

Current shortcomings in Regulated Health Professions Act models in Canada

» Pioneering when passed more than a quarter of a century ago, but today its rigidness is holding back health-care transformation.

» If you embed regulatory rules into the law, you get stasis, you get stuck. It’s impossible to change things.

» The framework is a bad fit for a world of rapidly and continuously evolving technology, science and medicine.

» A reformed oversight system would ideally have flexibility to adapt to new innovations and new ways of delivering care.

» Legislation does not cover categories of health workers who play increasingly important roles, such as personal support workers and paramedics.

» Appetite for significant reform is growing, even among regulators, who are now looking at a “radical paradigm shift.” Ideas for change are also coming from experts in regulatory governance, critics of the existing system, patient advocates and a think-tank commissioned by the province to look into oversight modernization.

Physican regulatory trends

Many physicians are distressed as they look toward the future. A recent survey of physicians reported that 65% thought the quality of health care will deteriorate in the future. Part of this malaise is driven by concerns that reforms contained in the Affordable Care Act (ACA) will further erode physicians’ autonomy.

As increased transparency reveals many aspects of medicine that have formerly been hidden from patients (such as conflicts of interest and costs of care), as more physicians are employed, as the economic stakes for patients and their families are greater, and as the belief that medicine should be more personalized becomes integrated into practice, it is incumbent on the leaders of medicine to re-examine the organizational, governance, and self-regulatory structure of the profession.

The World Medical Association, having explored the importance of professional autonomy and physician clinical independence, has adopted the following principles:

1. The central element of professional autonomy and clinical independence is the assurance that individual physicians have the freedom to exercise their professional judgment in the care and treatment of their patients without undue influence by outside parties or individuals.

2. Medicine is a highly complex art and science. Through lengthy training and experience, physicians become medical experts and healers. Whereas patients have the right to decide to a large extent which medical interventions they will undergo, they expect their physicians to be free to make clinically appropriate recommendations.

3. Although physicians recognize that they must take into account the structure of the health system and available resources, unreasonable restraints on clinical independence imposed by governments and administrators are not in the best interests of patients, not least because they can damage the trust which is an essential component of the patient-physician relationship.

4. Hospital administrators and third-party payers may consider physician professional autonomy to be incompatible with prudent management of health care costs. However, the restraints that administrators

and third-party payers attempt to place on clinical independence may not be in the best interests of patients. Furthermore, restraints on the ability of physicians to refuse demands by patients or their families for inappropriate medical services are not in the best interests of either patients or society.

5. The World Medical Association reaffirms the importance of professional autonomy and clinical independence not only as an essential component of high quality medical care and therefore a benefit to the patient that must be preserved, but also as an essential principle of medical professionalism. The World Medical Association therefore re-dedicates itself to maintaining and assuring the continuation of professional autonomy and clinical independence in the care of patients.

Source: World Health Professions Regulation Conference 2018

Patient Expectations in Healthcare Radically Changing

The health care “system” Is locked into a model from the 1960s

New generations’ expectations for technologies

Empowerment and communication are considered the primary drivers of improved patient engagement. With the growth in smartphone usage, patient expectations for instant access to services and health technology adoption are on the rise.

Findings from various recent patient surveys:

» 72% of patients said the use of technology is important when it comes to managing their health.

» 54% of patients want to use their smartphones to communicate with healthcare providers.

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» 78% of patients want better access to mHealth and telehealth tools.

» 66% of patients are ready to adopt mHealth and technology into their treatment plan.

» 79% of respondents were more likely to select a provider who allows them to conduct healthcare interactions online or on a mobile device.

» 60% of Millennials prefer telehealth to in-person doctor’s office interactions and 71% would like their providers to use an app to book appointments, share health data and manage preventive care.

Healthcare providers are now enhancing patient engagement and satisfaction by leveraging the benefits of patient-facing technology.

Increasing the communication and interaction with patients not only leads to higher engagement and healthcare quality but also reduces the costs associated with care.

Consumers’ changing expectations for health benefits plans

» Plan members say the following plan enhancements could make their group benefits plans more relevant: increase in allowed visits to preferred practitioners (32%), personal financial planning (29%), increased psychological services coverage (28%), nutritionist coverage (24%), homeopathy coverage (18%), and digital solutions to interact with coverage (14%).

Source: Sunlife 2018

» Plan members are interested in receiving information about managing their personal health conditions (65%), general health (57%), their medications (55%), and contact information for nearby health-care professionals (54%).

» Among employees that anticipate changing their plans in the next two years, the top change would be a restructuring of the plan design (39%), new or

increased benefits (38%), and adding more benefits tied to wellness or illness prevention (36%).

» A preventative benefit in which employees are showing interest is coaching for nutrition (63%), personal health goals (61%) and managing chronic conditions (73%).

Source: Sanofi 2018

» The top five challenges encountered by plan sponsors around their benefits plans include costs/affordability/return on investment (41%), meeting and managing employee expectations and needs (19%), having employees maximize use and understanding of the value of benefits (7%), the economy and lower interest rates (7%), and flexibility (6%).

» 51% of Canadian executives expect benefits plans to be more generous by 2037.

Source: Benefits Canada 2018

Senior’s Health Care an Ongoing Pressing Issue

The population of seniors is growing exponentially, and Canada is not ready. The number of seniors expected to need help or care will double in the next 30 years. When publicly funded health care was created about 50 years ago, Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 36 million and the average life expectancy is 10 years longer. The health care system has not kept pace with the advancements in medicine.

Physicians report they are challenged by the complex medical needs of their senior patients, as many seniors have multiple illnesses and health conditions requiring treatment.

Canadian Medical Association recommendations to Government

» Federal government include capital investment in residential care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure.

» Federal government take steps to provide adequate income support for older Canadians, as well as education and protection from financial abuse.

» Federal government provide targeted funding to support the development of a pan-Canadian seniors strategy to address the needs of the aging population.

» Governments work with the health and social services sectors, and with private insurers, to develop a framework for the funding and delivery of

“Health care is a service industry that exists to meet the needs of patients. However, the system is still stuck in a model from the past, in which providers made the rules and controlled all decisions. As societies evolve, citizens increasingly demand transparency and participation in decision-making. They also expect the system to respect their values and preferences and to facilitate access to health care services. Patients don’t care about silos within the system; they want to have access to seamless services that meet their physical and emotional needs. To achieve this, we need to halt the paternalistic approach that assumes we know what patients need and shift to involving them as active participants in the redesign process.”

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accessible and sustainable home care and long-term care services.

» Federal government and other stakeholders work together to develop and implement a pan-Canadian caregiver strategy, and expand the support programs currently offered to informal caregivers.

» Federal government improve awareness of the new Canada Caregiver Credit and amend it to make it a refundable tax credit for caregivers.

» Federal government develop explicit operating principles for the home care funding that has been negotiated with the provinces and territories to recognize funding for caregivers and respite care as eligible areas of investment.

» Federal government convene an all-party parliamentary international study that includes stakeholders to examine the approaches taken to mitigate the inappropriate use of acute care for elderly persons and provide support for caregivers.

» Governments at all levels support programs to promote physical activity, nutrition, injury prevention, and mental health among older Canadians.

» Governments and other stakeholders work together to develop and implement models of integrated, interdisciplinary health service delivery for older Canadians.

» Governments continue efforts to ensure that older Canadians have access to a family physician, supported by specialized geriatric services as appropriate.

» Governments and other stakeholders work together to develop and implement a pan-Canadian pharmaceutical strategy that addresses both comprehensive coverage of essential medicines for all Canadians, and programs to encourage optimal prescribing and drug therapy.

» Governments and other stakeholders support ongoing research to identify best practices in the care of seniors, and monitor the impact of various interventions on health outcomes and costs.

» Governments at all levels and other partners give older Canadians access to opportunities for meaningful employment if they desire.

» Governments and communities take the needs of older Canadians into account when designing buildings, walkways, transportation systems, and other aspects of the built environment.

Projected number of centenarians in Canada:

» 2021: 11,100

» 2026: 14,800

» 2036: 20,300

Growing Demand:

» 20%- Seniors as portion of total population by 2024

» 127%- Growth in people 85 years and over from 1993 to 2013

» 80%- Portion of seniors with chronic conditions

» 71%- Growth in seniors needing continuing care from 2011 to 2026

» Informal caregivers for seniors provide $25 billion worth of unpaid labour annually

Source: Advancing Inclusion and Quality of Life for Seniors. CMA submission to the House of Commons Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities. 2017.

Five key seniors care recommendations by CMA in 2018

» Provide targeted funding to support a pan-Canadian seniors strategy.

» Improve capital investment in residential care infrastructure.

» Amend and improve awareness of the Canada Caregiver Credit.

» Develop explicit operating principles for home care funding.

» Convene a study on appropriate use of acute care for elderly persons.

Canadian Association of Retired Persons (CARP) advocating for a national seniors strategy

CARP members represent 300,000 of Canada’s seniors and has identified 5 key areas for action that reflect the experiences of seniors across Canada.

The FACES of Canada’s Seniors: Financial Security Abuse Prevention Caregiving and Housing Supports Exceptional Healthcare Social Inclusion

Some facts:

» 64% of CARP members are concerned about having enough money to last through retirement

» Most seniors are at risk of outliving their tax-deferred savings

» 12.5% of Canadian seniors now live in poverty and between 2014 and 2015, 75,000 more seniors became low-income

» 1 in 3 CARP members know an older Canadian who has been abused

» 85% are concerned about supports for older adults experiencing abuse

» More than 1 million Canadian caregivers are over 65

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» Women spend on average 5.8 years of their life providing care to family/friends compared to 3.4 years for men

» 41% of CARP members surveyed are caregivers

» By 2038 demand for long-term care will increase tenfold

» By 2038 1.125 million Canadians will have dementia

» By 2038 62% of Canadians with dementia will be living in their own homes

» The total number of informal caregiving hours will triple to 756 million hours from 231 million hours in 2008

» 76% of CARP members agree the federal government should fully fund a National Dementia Strategy

» 82% of CARP members agree the federal government should implement a national pharmacare strategy that ensures equal access to medications for all Canadians, regardless of where they live

» At retirement, 76% lost or had a reduction in their prescription drug benefits

» 66% of CARP members are concerned about dementia or loss of cognitive abilities

» 86% of CARP members worry about their ability to access dementia supports

» 90% of CARP members are concerned about the time it takes to access medical specialists

» 81% of CARP members are concerned about the time to access diagnostic procedures like MRIs and CTs

» 75% of CARP members agree governments should increase funding and access to vision, auditory and dental care

» 88% of CARP members believe governments should increase the number of long-term care beds

» 68% of CARP members are concerned about their ability to access publicly funded home care and community support services

» Socially isolated seniors are 4 to 5 times more likely to be hospitalized and have a higher likelihood of falls

» Lack of a supportive social network is linked to a 60% increase in the risk of dementia and cognitive decline

Source: The Faces of Canada’s Seniors: Making Canada the Best Place to Age. CARP, 2018.

Focus on home care needs in Canada

Home care services allow people of all ages to receive care at home rather than in a hospital or long-term care facility. Home care services include short-term care for recovery, long-term care for disabilities, chronic conditions or age limitations, and end-of-life care. Care provided by family or friends is not included.

In 2017 about 1.2 million Canadian adults needed home care services.

26% of these had their needs partially met, 10% had their needs unmet.

Top barriers to obtaining home care:

» Availability of services

» Personal characteristics

» Costs

» Ineligibility, doctor does not think necessary

Factors associated with unmet home care needs:

» Age 35 to 49 (more likely have unmet needs)

» Not having long term care insurance

» Fair or poor self-perceived health

» Living alone

Source of payment for home care services (by household):

» 52% paid solely by government

» 27% paid solely out-of-pocket

» 8% paid in part by government and/or insurance

» 7% paid solely by private insurance

» 6% paid by other sourcesSource: Gilmour, H. 2018. Formal home care use in Canada. Health Reports 29. Statistics Canada 2018

Buurtzorg Method- Example of an innovative approach for seniors’ care in the Netherlands that’s going global

Founded in 2006, the Buurtzorg method has evolved into an operation that deploys units of up to 12 nurses, who are responsible for between 40 and 60 people within a particular area. There are an estimated 900 teams in the Netherlands, supported by about 50 administrators and 20 trainers. Buurtzorg differs from other health care approaches in the scope it allows the nurses who are administering care. The main requirement is that they must spend at least 61 per cent of their time with patients.

Administrative tasks are considered a secondary concern. To achieve this goal, nurses are supported by an IT operation that provides real time information, which is directly connected to the care process. The innovative use of self-governing nurse teams has attracted great interest. While traditional approaches rely on different types of personnel such as nurses, homemakers, and attendant care workers to provide individual services, Buurtzorg expects its nurses to deliver the full range of health-related and support services. There is no specialization within nursing teams. A Buurtzorg nurse might administer wound care but may also help someone eat, bathe, or get dressed.

The preventive focus and innovative delivery have enabled the Dutch health care system to reduce costs

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by around 40 per cent. The time it takes to administer care has dropped by 50 per cent. While actual costs per hour are higher, they are offset by fewer hours required to provide care. These results have encouraged other countries to consider a similar style of community care. Buurtzorg is being trialled in the UK and Sweden, with Germany, Austria, US, Japan, China, Taiwan, and South Korea slated to follow. Source: Brindle 2017.

Growing Prominence of Key Health Conditions in Canada

Focus on diabetes

» Diabetes experts say Canada could prevent another million type 2 diabetes diagnoses in the next decade if the federal government helps to fund a national diabetes strategy.

» Diabetes 360 strategy, modelled after HIV/AIDS targets, would establish clear milestones to prevent and manage the disease, which affects about five million Canadians.

» The strategy would focus on factors contributing to the disease’s rise in Canada, such as poverty, poor food security and unhealthy living.

» Canada is facing a diabetes epidemic. Since 2000, the number of Canadians with diabetes has doubled.

» A 20-year old in Canada now faces a 50/50 risk of developing diabetes. For First Nations people, that risk is 80 per cent.

» Diabetes 360 could prevent more than a million Canadians from receiving a diagnosis of type 2 diabetes in the next decade. It could also mean 50,000 lower limb amputations avoided. It could reduce 350,000 hospitalizations.

Source Diabetes Canada 2018

Obesity on the rise

» The prevalence of obesity in Canada is higher than most other OECD countries.

» In 2015, 61.0 per cent of Canadian adults were classified as overweight or obese, up from 59.0 per cent in 2004.

» Excess weight can negatively impact every aspect of health, from reproductive and respiratory function, to memory and mood. It also increases the risk of diabetes, cardiovascular disease, and some cancers. Some 65 to 75 per cent of the prevalence of hypertension can be directly attributed to obesity.

World Health Organization -Strategic Initiatives for Healthy Aging

Strategic objective 1: Commitment to action on Healthy Aging in every country

» 1.1 Establish national frameworks for action on Healthy Aging

» 1.2 Strengthen national capacities to formulate evidence-based policies

» 1.3 Combat ageism and transform understanding of aging and health

Strategic objective 2: Developing age-friendly environments

» 2.1 Foster older people’s autonomy

» 2.2 Enable older people’s engagement

» 2.3 Promote multi-sectoral action

Strategic objective 3: Aligning health systems to the needs of older populations

» 3.1 Orient health systems around intrinsic capacity and functional ability

» 3.2 Develop and ensure affordable access to quality, older person-centred and integrated clinical care

» 3.3 Ensure a sustainable and appropriately trained, deployed and managed health workforce

Strategic objective 4: Developing sustainable and equitable systems for providing long-term care (home, communities, institutions)

» 4.1 Establish and continually improve the foundations for a sustainable and equitable long-term care system

» 4.2 Build workforce capacity and support caregivers

» 4.3 Ensure the quality of person-centred and integrated long-term care

Strategic objective 5: Improving measurement, monitoring and research on Healthy Aging

» 5.1 Agree on ways to measure, analyze, describe and monitor Healthy Aging

» 5.2 Strengthen research capacities and incentives for innovation

» 5.3 Research and synthesize evidence on Healthy Aging

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» Obesity is expected to keep rising in Canada until at least 2030, cardiovascular disease is likely to remain the leading cause of death, and increasing numbers of Canadians are expected to suffer from diabetes/pre-diabetes.

» The growing prevalence of obesity and associated lifestyle diseases could have serious implications for the cost of health care, workplace absenteeism, and people’s quality of life.

» Obesity and associated lifestyle diseases are expected to keep rising in Canada, and cardiovascular disease is likely to remain the leading cause of death.

» As we look toward 2030, we can expect to see Canadians adopting diets higher in local, organic, plant-based food.

» Businesses in the health, pharmaceutical, food, and agricultural sectors will be particularly impacted by changes to the nation’s health and diet.

The rising incidence and cost of mental illness

» Mental illness is costing the Canadian economy over $20 billion a year due to lost labour force participation, and by 2030 is forecast to reach $29.1 billion. These figures don’t include the costs of patient care, insurance for employers, services in communities, or the many intangible costs for those affected and their families.

» According to the Canadian Mental Health Association, one in five Canadians will experience a mental health problem in any given year. In the workplace, discrimination against those with mental health problems can contribute to reduced employment, missed career advancement opportunities, and job loss. Poor mental health is associated with substance abuse, addiction, other medical conditions, poverty, homelessness, crime, premature death, and suicide.

» Canada is likely to face many challenges associated with mental health as it looks to 2030. Employers

should consider the impact of mental health problems on their employees and business operations, and take steps to support those affected.

» Mental illness affects 1 in 5 Canadians in their lifetime.

» It is the number one cause of disability in Canada.

» 70% of mental illnesses first appear in childhood or adolescence.

» Mental illness affects people of all ages, education levels, incomes and cultures.

» 8% of adults will experience major depression during their lives.

» 5% of Canadians experience anxiety.

» 10-20% of Canadian youths suffer from mental illness.

» By age 40, about 50% of the population will have or have had a mental illness.

» Only 1 in 5 youths receive treatment for it.

» Almost one half (49%) of those who feel they have suffered from depression or anxiety have never gone to see a doctor about this problem.

» Mental illness can lead to suicidal thoughts and actions.

» The suicide rate for Canada’s aboriginal youth is 6 times the national average.

» Annual cost of mental illness in Canada is $51 billion.

» It’s estimated that in any given week, mental illness renders 500,000 Canadians unable to work.

Source: Canadian Mental Health Association, 2018

The expanding crisis of dementia

» The percentage of the Canadian Institutes of Health Research’s budget invested in dementia research: 5%

» The greater your risk of developing dementia if you smoke: 45%

» Those diagnosed with dementia over the age of 65 that are women: 65%

» The number of Canadians under the age of 65 living with dementia: 16,000

» The number of new cases of dementia diagnosed every year: 25,000

» The number of Canadians with dementia being cared for in hospitals even though this is not an ideal location for care: 56,000

» Canadians are currently living with dementia: 564,000

» The number of Canadians who will be living with the disease in 15 years: 937,000

» The number of Canadians affected directly or indirectly by the disease: 1.1 million

» The annual cost to Canadians to care for those living with dementia: $10.4 billion

Source: Alzeimer Society of Canada

Dealing with disability in Canada

22% of Canadians had at least one disability in 2017.

Represents 6.2 million people.

Disability defined as Canadians aged 15 and over whose everyday activities are limited because of a long-term condition or health-related problem.

By sex:

» Women 24%

» Men 20%

By age:

» Youth aged 15 to 24 years: 13%

» Working-age adults aged 25 to 64 years: 20%

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» Seniors aged 65 years and over: 38%

By disability type (4 most common):

» Pain related: 15%

» Flexibility:10%

» Mobility:10%

» Mental-health related:7%

Other disability types:

» Seeing: 5%

» Hearing: 5%

» Dexterity: 5%

» Learning: 4%

» Memory: 4%

» Developmental: 1%

1.6 million Canadians with disabilities were unable to afford required aids, devices, or prescription medication due to cost.

Among youth with disabilities, 60% had a mental health related disability.

Employment rates for working-age adults: 59% for persons with disabilities vs. 80% for persons without disabilities.Source: Statistics Canada, Canadian Survey on Disability, 2017

A surge in superbugs

Antimicrobial resistance is threatening the prevention and treatment of an ever-increasing range of infections caused by b acteria, parasites, viruses, and fungi. Growth of antimicrobial resistance has been attributed to the overuse of antimicrobial drugs in veterinary and human medicine. Weak micro-organisms are killed, but the survivors may be made stronger as they adapt to survive. As micro-organisms build up a resistance to antimicrobial drugs, they become ineffective.

And, currently treatable illnesses and infections become difficult to control or cure, creating an economic and emotional burden for families and Canada’s health care system. The World Health Organization states that 700,000 people worldwide die annually from infections caused by superbugs (antibiotic-resistant bacteria). In Canada, medical costs associated with antimicrobial resistance have been estimated at $1 billion. Without effective action, superbugs are predicted to cause 10 million deaths a year worldwide by 2050. Businesses working in the health, pharmaceutical, and agricultural sectors will have a big role to play in tackling antimicrobial resistance over the coming years.

Value Based Healthcare

There has been acknowledgment for many years that health is much more than just the provision of healthcare. The World Health Organization defines health as ‘a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity’.

Improving health includes broader aims, such as tackling the social determinants of health, allowing people the ‘freedom to lead lives they have reason to value’. The value-based care movement involves greater recognition of what patient’s value when defining health and care outcomes and allocating limited resources.

Value based health care is a term used to describe a model of health care that compensates providers based on patient outcomes. The current fee-for-service model is in direct opposition to a value-based model, as providers are compensated based on number of services provided.

» Canadian current system is similar to US Healthcare system – based on what providers can do rather than what the patient needs. Medical system in the US is chaotic, unreliable, inefficient and crushingly expensive.

» Current fee based system leads to potential for overtreatment, lowered quality of care.

» High debt loads following graduation equates to a need for high production.

» Change from present fee based system to a value based system will encounter resistance from providers. Clinicians will need to prioritize patients’ needs and patient value over the desire to maintain their traditional autonomy and practice patterns.

» Engaging key stakeholders, including healthcare providers, government agencies, insurance companies, and patients, to come together and work towards a system of health care reform. The very foundation of how health care is financed and delivered will change under a value-based system, and input from all sides will be required.

» Comprehensive reform will require simultaneous progress in all the components of a value-based care system because they are mutually reinforcing. However, a health care strategy will involve a sequence of small steps over an extended period rather than an attempt to change everything at once.

» Increasing focus on personalized medicine led by identification of biomarkers, health and wellness to derive value.

» The open health movement, patient-centered care, and value-based payments are inextricably linked.

Value-based health care is founded on the principle of improving the quality of care for patients. At its core is increasing the overall value for patients, that is, attaining the best possible health outcomes while maintaining the lowest possible costs. In this system, better health becomes the goal, not more treatment. Changing to a value-based healthcare system, will mean changing the way a patient receives care. Value-based healthcare puts what patients value at the center of healthcare. It helps ensure that they receive the care that can provide them

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with outcomes they think are important and that limited resources are focused on high-value interventions.

In order for value-based health to work, health care payers and providers must stop fighting the emergence of a competitive health care marketplace and make competing on value central to their strategy.

All stakeholders in the health care industry can catalyze change in five ways:

1. Put patients first

2. Create choice

3. Stop rewarding volume

4. Standardize methods to pay for value

5. Make data on outcomes transparent

To compete on value, providers must meet patients’ needs better or at a lower cost than their competitors do, or both. But this kind of competition has been slow to arrive, because four interrelated barriers have blocked the way.

Limited reimbursement-based incentives

For the most part, providers have not been rewarded financially for delivering value, nor have they been meaningfully penalized for failing to do so.

Limited market-share incentives

Even when providers have improved value, they have not been sufficiently rewarded with increased market share.

Inadequate data on value

Good data on outcomes and costs is essential to designing and optimizing value-based care; unfortunately, there’s very little of it available.

Inadequate know-how

In the absence of financial incentives to pursue value and without good data to guide leadership, the management skills necessary for transforming care delivery have not developed.Source: Dafny, LS and Lee, TH. Health care needs real competition. Harvard Business Review, December 2016.

Value-based health care is a model in which health care providers are paid according to the health outcomes they achieve, rather than the number of services they provide. To fully realize the improvements to value offered by these innovative processes, clinician engagement is required. Clinician engagement refers to the involvement of health care professionals in the procurement process for medical devices, pharmacy, services, and other treatments.Source: Value-Based Health Care Forum; The Conference Board of Canada.

Digital Health for Value-Based Health Care

The Canadian health care system is currently underperforming, impeding its ability to deliver effective and sustainable healthcare. Canada’s system will continue to face an aging population and complex changes. The shift to value-based care will improve

the current health care system using digital health technologies.

Data collection

Use of digital health technologies will require a significant increase in the collection and use of data. Data collection is necessary to encourage governments to change procurement models. Canadian health care has entered era where government is moving towards incremental investments in care.

Integrated system

Requires the development of proper funding and policy frameworks as well as changes in procurement models and elimination of silos. Requires health care providers to shift away from the fee-for-service model and to be willing to use digital technologies to streamline system.

Access to patient data

Government policy-makers need to focus on how they approach patient care and consider how current privacy laws prevent the broader use of data to deliver effective digital solutions. Until policy-makers find solutions

Health outcomes that matter to patients Costs of delivering those outcomes

Value=

What Is Value in Health Care?

Sources: Dafny, LS and Lee, TH. Health care needs real competition. Harvard Business Review, December 2016, Value-Based Health Care Forum; The Conference Board of Canada.

Innovations play a key role in the advancement of healthcare delivery, and as the use of technology continues to increase, ambulatory and outpatient care will also increase, supported by consumers who will find the growth of these services saves them money on their healthcare costs. Integral to achieving savings will be integrated models to deliver successful population health outcomes from the services provided.

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to these, patient voice will not be heard. Passive role of patients could only occur when changes are made to privacy laws surrounding data access. Current policy landscape presents a substantial barrier. Future policy development needs to look at ways to include stakeholders from both public and private sectors.

Reduce fragmentation and design with patient voice

Patients often use multiple portals to access their health records; the current digital health landscape is not patient-centric. None of current systems work together, and access is not available across provinces. Innovations must include ways to share information among different platforms and allowing online scheduling. Digital health landscape must include input from patients and informal caregivers. Innovators need to consider diversity of patient and caregiver groups.

Technological innovations

Use of digital technology in health care has endless possibilities. Developments in e-health services may include e-scheduling, e-visits, virtual visits, and e-renewal of prescriptions. ELIZZ is an example of and AI Chat Bot/ Caregiver Coach. The program uses artificial intelligence technology to provide patients with the ability to consult the chatbot as if it were a real clinician. Currently 18,000 users around the world consult it daily and it has accumulated 50 million visits in the last 10 years.

Funding and investment

Although data collection can empower the patient in multiple ways, the use of this data may not lead to immediate improvements in digital health technologies because funding is often only released when a program has demonstrated a significant return on investment.

Platform for collaboration

Increasing collaboration allows for technological diffusion. TELUS Health has partnered with Canada Health Infoway to digitize paper systems, which required several consultations with physicians who work for different organizations.

Reduce barriers to entry

If Canada wants to encourage the scale and spread of digital health technologies, barriers need to be reduced. InputHealth Systems has been able to successfully procure funding in the United States but not in Canada due to complex laws and regulations.Source: The Canadian Alliance for Sustainable Health Care and The Centre for the Future of Health Stakeholder Meetings 2018. Conference Board of Canada. 4.

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4.Dentistry ScanThe evolution of dental treatments towards an emphasis on quality and value will drive further changes in the healthcare delivery model for dentists and may not generate accustomed revenue.

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Dentistry Scan

Practice Environment

Fundamental shift in the make-up of the Canadian dental practice

There are now more dentists per practice on average.

» The number of hygiene days per practice is increasing overall (with more days being added by those who only had one or two per week previously).

» Growing percentage of respondents describing their location as Urban (now 62% as compared to 56% last year and 51% in 2016 and average of 53% over past ten years). Drop off is in Suburban locations (falling to 22% from 29% in 2017 and an average of 25% over the past 10 years).

DIAC Annual Survey 2018

Trend towards increasing numbers of dentists in the practice continues

» In 2018, 36% identified themselves as sole practitioners (similar to 36% in 2015 and the average of 40% the previous eight years).

» Dramatic increase in percentage of respondents (11%) with five or more dentists in their practice.

» This was 3.4% in 2016 and an average of 6.3% the last 14 years.

» The trend of those having more than five operatories in the practice (15.4% from 1997 to 2010) has levelled off over the last five years staying in a range of 20-25%.

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Age plot of Canadian dentists- June 2018 n= 21576

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Dentists by number of years in practice by province/ territories June 2018

1-10 11-20 21-30 31-40 41+ Unknown

Source : CDA Membership Database 2018

TT = Territories

0%

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» Increased to an all-time high of 30% in 2017 but returned to historical norms in 2018 at 26%.

Growth in corporate interest in dentistry

According to DIAC annual survey 2018:

» Corporate dentistry appears to be a continuously shifting environment, with numerous variations in practice models that are constantly evolving.

» Majority (63%) of dentists stated they were in a solo practice environment.

» More than a third (34%) were in a group practice situation.

» Further 2% in Corporate dentistry.

» 94.6% of those currently in a solo practice intend to remain there.

Of those in Group Practice:

» 45% are an Owner of a multi-practice; 55% an Associate

» 89% consider their multi-practice Regional; 10% National, 1% International

» 76% had 2-4 separate Clinics/Locations; 24% had 5 or more

Source: DIAC annual survey, 2018

Key advantages of group practice/ corporate dentistry:

Have associate support 57%

Buying power 20%

Better hours for patients 12%

Reach more patients 6%

More schedule flexibility 3%

Increase in tuition fees for dental schools by province 2009 to 2019

87%

13%

163%

102%

81%

79%

44%

8%

20%

60%

100%

140%

180%

Canadaaverage

AB BC ON MN NS QC SK

0%

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SolePractitioner

One Two Three Four or more

Source: DIAC Annual Survey 2018

Number of additional dentists in practice Average number of patients treated per day by dentist

5% 62% 22% 12%

Five or Less 6-10 11-14 Over 14

0

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Number of graduates, Canadian dental schools, annual trend by gender 2007 - 2017

Male Female Total

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Stage of digitization of dental offices in 2018:

Fully paperless 32.7%

Not paperless 33.7%

In transition to paperless 33.7%

Top dental topics for patients in Canada in 2018:

1. Implants

2. Cosmetic Dentistry

3. Whitening

4. TMJ

5. X-ray RadiationDIAC Annual Survey 2018

Education and Research

Declining oral research capacity in Canada

» General practitioners and specialists are not prepared for the research role of a dental faculty member unless they invest in getting a PhD.

» Limited research time afforded to dental faculty to contribute to the university’s research mission (less than 1% of national research funding is for oral health).

» As government funding continues to fall, universities are finding it increasingly difficult to recruit and retain good dental teachers and researchers.

» US universities luring Canadian academics with higher salaries, offers to repay loans and superior research funding.

» Workforce shortfall in numbers choosing careers in oral health education/ research.

Dentist gender demographics Canada June 2018

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25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-85

FemaleMale

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AB BC MB NB NL NS NT NU ON PE QC SK YT CANADA

Gender mix of dentists in Canada 2018 by province

Female Male

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Oral Health Workforce Trends

The oral health workforce is an ongoing issue of increasing importance in Canada.

» There were 23,853 licensed dentists in Canada as of July 2018.

» Population to dentist ratio in Canada was 1554 in 2018. Six percent decrease in ratio from 2014.

» Indicates that the number of dentists is increasing faster than the general population.

» Wide variations across jurisdictions, from a low of 1385 in British Columbia (i.e. greatest concentration of dentists) to a high of 2604 in Newfoundland/ Labrador (i.e. lowest concentration of dentists).

» Approximately 20% of the Canadian population is in rural areas whereas only about 10% of dentists are practicing in rural regions.

» Specialists represent 12% of all dentists.

» There were 1008 new dentists entering practice in Canada in 2016.

» As of 2017, there were 29,246 licensed dental hygienists in Canada.

» Dental hygienists are self-regulated in all provinces except Prince Edward Island, and the three territories. They are the 6th largest regulated health profession in Canada.

» Hygienists can now self-initiate and have independent practice in 8 provinces, although the clear majority still work in dental offices.

» The dental hygienist to dentist ratio in Canada is currently 1.2.

» There are between 26,000 to 29,000 dental assistants in Canada and nearly 20,000 are registered with a provincial dental assisting association. Of those 20,000 dental assistants approximately 74% are certified /licensed, 99% are female and the average age is 38 years old.

» There are almost 2000 dental technologists, and approximately 2000 licensed denturists in Canada.

» Denturism is self-regulated in all provinces and the Yukon Territory.

» Of the less than 300 dental therapists currently in Canada- the majority (55%) work in private practices, primarily in Saskatchewan. The remainder work in First Nations and Inuit communities.

» There are no dental therapists in Ontario and Quebec since there is no enabling legislation in those provinces.

» There are currently 29 dental hygiene programs operating in Canada (outside of Québec); 21 are publicly and 8 are privately funded.

» There were 1,021 newly certified dental hygienists in 2017 in Canada.

» It is projected that approximately 1,250 candidates will write the National Dental Hygiene Certification Exam in 2018.

» Although there had been a rapid growth rate in hygienists being trained up until 2012, there has been a decrease from 1565 candidates who wrote the National Dental Hygiene Certification Board (NDHCB) exam in 2012 to 1,209 who wrote it in 2017.

» This decline is attributed to the introduction of new 6 semester programs in Ontario hygiene colleges and fewer enrollments in general because of the currently prevailing market conditions.

» It has become more challenging for dental hygienists to find employment in large urban centres which also contributes to the drop-off in numbers.

» Quebec dental hygiene graduates are not required to take the NDHCB exam to practice.

» There are currently 39 schools of dental assisting accredited by the commission on dental accreditation in Canada.

» Given the considerable number of schools and programs, it is difficult to determine the number of dental assistants currently training or graduating annually in Canada.

» Considering only certified dental assistants, their numbers in Canada have decreased substantially from 2,310 in 2007 to 1,771 in 2016 (24% decrease).

» This has resulted in a shortage of dental assistants developing across most jurisdictions, with significant potential ramifications for dental practices.

» There are four schools training denturists in Canada, and in 2018 there were approximately 85 graduates in total. There are four accredited schools in Canada that provide training in dental technology. In total these accredited schools have graduated approximately 80 dental technologists annually in the last few years.

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» Traditional 4-year curriculum is stretched to the limit by the need to teach new treatment modalities while older ones remain part of the curriculum; this will worsen with the innovative technological discoveries coming to market.

» Budgetary constraints make it difficult to maintain infrastructure at the level needed.

Educational framework of dental programs undergoing major change

» Delivery of primary care is moving towards an integrated approach, with inter-professional education of health care providers including dentists.

» Many educational and health care facilities throughout North America have joined the departments of medicine and dentistry- for example amalgamating Faculties of Medicine, Pharmacy, and Nursing under a super faculty.

» The Association of Canadian Faculties of Dentistry has developed an educational framework for the development of competency in dental programs outlining core competencies a beginning general dentist must successfully integrate.

» Core competencies go well beyond clinical knowledge and skills and include patient-centered care, professionalism, communication and collaboration, practice and information management, and health promotion.

Licensure and Examination

Transition to electronic exam delivery

» The National Dental Examining Board (NDEB) is in the process of transitioning all paper-based tests to electronic delivery by 2024 in order to enhance relevancy, reliability, security, efficiency, consistency and accessibility.

Canada 74%

University of Toronto23%

Université de Montréal15%

University of Western Ontario12%

University of British Columbia

9%

University of Alberta9%

DalhousieUniversity

7%

UniversitéLaval 7%

McGill University

7%

University of Manitoba6%

University of Saskatchewan 5%

International 15%

USA8%

Unknown 3%

Canadian dentist by location of dental school of graduation 2018

Architecture$6881

Business/management

$7409

Dentistry$23474

Education$4538

Engineering$8466

Law$13332

Medicine$14780

Nursing$5788

Pharmacy$10746

Veterinary medicine

$7924

Average undergraduate tuition fees for Canadian full-time students, by field of study, 2018/2019, current dollars $

Source: Statistics Canada Table 37-10-0003-01.

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» NDEB investigating and implementing new developments in testing and evaluation.

Review of equivalency process

» The NDEB is evaluating the existing Equivalency Process and identifying strengths and weaknesses.

» Investigating alternative testing techniques and leveraging psychometric and related expertise to maintain validity and reliability of the process.

Continued evolution of assessment technologies

» The science of psychometrics and assessment continues to evolve as new testing approaches are implemented for evaluating competencies in the health professions.

» Competency-based assessment, in career assessment, compensatory vs conjunctive, and adaptive testing are examples of where the science of assessment is evolving.

Increased use of digital platforms

» Providing examinations at physical locations globally is very cost intensive and professions are seeking ways to enhance delivery and cut costs.

» Using digital platforms to test and score allows for greater scalability and reach.

» Due to scalability, the digital platform will result in an increased number of examinees, and make it significantly more affordable for individuals to take exams in their own location rather than traveling to testing site.

Emerging and Breakthrough Technologies

The rapid and changing development of modern technologies that aid in diagnosis and treatment of oral disease requires a dentist to increase capital investments to operate, thus driving expenses up.

Examples of dental wearables and swallowables

» The DentalGo app allows dentists to use Google Glass’ voice recognition for many functions. Without using their hands or moving away from the chair, dentists are able to speak to the headset and access a patient’s dental records, register new patients, view patients’ radiographs, set up or view appointments, and send information directly to or receive information from colleagues.

» Smart watches allow one to gather critical key performance within real time visibility. For instance, there is a product that indicates which procedure to perform next, offers details about the patient (eg. summary of medications, health alerts, and previous

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Alberta

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Canada

Northwest Territories

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Ontario

British Columbia

Population to dentist ratio July 2018 Canadian dentist by location of dental school of graduation 2018

Canadian

University of Toronto 23.25%

Université de Montréal 14.76%

University of Western Ontario 12.22%

University of British Columbia 9.23%

University of Alberta 8.62%

Dalhousie University 7.15%

Université Laval 6.99%

McGill University 6.77%

University of Manitoba 6.38%

University of Saskatchewan 4.63%

International (Top 10)

India 9.27%

Iran 6.30%

Australia 3.73%

Iraq 3.49%

Phillipines 3.28%

Egypt 2.80%

China 2.75%

Poland 2.03%

England 2.03%

Romania 1.83%

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appointments), includes real-time updates, and lists who is waiting in the next operatory. It also generates a list of patients, color-coded by procedure type, and notifies the dentist via a vibration as each patient checks in.

» Several sensor systems have been developed and evaluated in order to monitor chewing. Surface electromyography (EMG) can sense the activation of jaw muscles during mastication by placing electrodes over the skin surface. Sensors and strain gauge abutments can also be used to measure bite and checking forces.

» In the field of oral activity recognition, a miniature accelerometer has been designed that was inserted into a false tooth. Once inserted into the mouth, this wearable appliance functioned as a data-collecting device since it was taking notes and monitoring the g-force associated with each oral activity. The findings reported that individuals use their mouths in very different ways, even for activities like chewing. The accelerometer reported activity with a nearly 93% accuracy.

» Another trend in oral activity recognition is the tooth tattoo. This tattoo is a tiny oral sensor and serves as an intermediary between the bacteria and the sensor system, allowing the sensor to register the presence of gram-negative bacteria. In order to apply the sensor, the surface of the assembly has to be wet and then pressed onto the tooth. Once placed there, the silk backing dissolves within 15-20 minutes, leaving behind the sensor.

» Dentifrobots (nanorobotic dentifrices) can now be delivered either by mouthwash or toothpaste, and can cover all subgingival surfaces. These dentifrices function as a ‘swallowable’ device since they are purely mechanical devices that safely deactivate themselves when swallowed. The functions include removing plaque and calculus as well as metabolizing trapped organic matter. Properly configured dentifrobots can

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CANADA BC AB SK MB ON QU NB NS PE NL

Change in average income 2010-2015

Dentists Dental hygienists Dental assistants

Source Statistics Canada 2016 Census Survey, Custom tabulations

Trend in private sector dental expenditure by source (billions of dollars)

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Dental Services- private sector out-of-pocket Dental Services- private sector insurance

CIHI National Health Expenditure Trends 2018

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also identify and destroy pathogenic bacteria that exist in the plaque and elsewhere.

Other groundbreaking emerging technologies include:

» Vaccine to control oral disease.

» Artificial dentin, enamel in dentistry.

» Mini-robots to clean your teeth.

» pH will be measured regularly to know when to brush teeth, measure caries risk.

» Auto biosensors will be used (via oral cavity) to diagnose.

Examples of mobile technology applications for dental patients

» Patient advice is available through a range of software applications (apps), ranging from instructions on how to brush your teeth what to do if you have a toothache.

» Dentify and Brush DJ are both listed on the NHS app library and are recognized as ‘safe’ and ‘trusted’ apps that patients and practitioners can use.

» Other examples of apps include one that enables patients to face their fears and overcome any issues they have related to dental anxieties. Include dental support forums for patients with dental phobia.

» The American Dental Association has launched a ‘symptom checker app’ which allows patients to check their symptoms such as pain, discomfort and other symptoms so that they may be able to get a diagnosis. The app encourages patients to visit the dentist, if needed.

» CheckDent, Social Network for Dental Health- a dental health forum where patients can get answers from dentists and other users on popular topics like teeth bleaching, braces, wisdom teeth and root canal treatments. Extensive collection of dental video clips articles continuously updated and added by a team of experts. An interactive dentist directory with profile pages linked to the Checkdent social network and the option for verified patients to write detailed reviews and rate dentists in key areas such as chairside manner, patient information and average wait time.

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Dental services expenditures as percentage of total private health expenditures in 2018

Dental services expenditures

Other

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Saliva testing approaching status of a widespread diagnostic tool

» Using saliva as a diagnostic tool is not yet a reality. However, the first two tests are soon to enter the regulatory stage and are likely to become available in about two years.

» These are for Sjögren’s syndrome and one of the lung cancers.

» Some 1166 proteins have been identified in human saliva. In addition, there are genetic and micro-biome constituents.

» Every human cancer has genetic markers, this information is shed by the tumor cells.

» Point-of-care tools are emerging.

» Advancements in saliva tests could likely be done within a decade.

» Saliva as a “liquid biopsy”, with chairside tools will become a reality for diagnosis of and screening for a variety of both systemic and oral diseases.

» Over 90% of malignant tumors in the head and neck are originated from carcinomas of squamous cells that appear in superficial areas of the oral cavity. Their detection with salivary biomarkers can contribute to their early treatment, before they transform into tumors.

» While the collection of saliva for various diseases is a natural fit for dentistry, the process of collection is likely to be so simple that medicine is more likely to be the primary user of this technology. The link to dentistry is less tenuous for diseases of the oral cavity.

» Ongoing disease monitoring might at some stage in the future involve the attachment of items to teeth.

» Salivary biomarkers have recently been shown to indicate Alzheimer’s risk- demonstrates the potential for using metabolomics and saliva in the early diagnosis of Alzheimer’s disease.

Explosive growth of 3D printing in dentistry

» Although 3D printers are quite expensive as of now, and printing teeth still seems to be a far-fetched process, there is a big possibility that this would be a reality in the near future.

» To date, the 3D printing industry is busy developing resins and other materials that can help in the production of crowns, inlays, replacement teeth and veneers and so on. Additionally, 3D printing could also easily enable the production of retainers and custom aligners.

» The intra-oral dental 3D scanner market is predicted to reach a CAGR of 10.4% by value from 2016 to 2020. This market, estimated at US$ 189.1 million in 2015, is forecast to grow to US$ 310.4 million by 2020, thereby accelerating the demand for digital workflow in the dental field.

» More and more companies are getting involved in the dental 3D printing market. These include

Recent annual dental fee guide increases

PROVINCE 2015 2016 2017

Newfoundland 1.8% 1.5% 3.0%

Prince Edward Island 2.3% 2.5% 1.5%

Nova Scotia 2.2% 3.5% 1.8%

New Brunswick 2.0% 2.0% 2.0%

Quebec 2.1% 2.6% 2.5%

Ontario 1.5% 2.0% 1.7%

Manitoba 2.9% 2.4% 2.9%

Saskatchewan 2.0% 1.9% 2.2%

Alberta 3.2% 2.9% 1.8%

British Columbia 2.0% 3.2% 4.5%

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TT SK AB NB ON NL CA BC QU MB

NS PE

Percentage increase in number of dental offices 2014 to 2016

Source Statistics Canada Small Business Profile 2016

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prostheticians, dentists and laboratories who want to use 3D printing to manufacture their solutions.

» Today, in a laboratory environment, it is common to have both subtractive and additive solutions that coexist in a digital workflow strategy. This portrays the increased adoption of 3D printing.

» Additive manufacturing will play an important role in the dental sector, particularly in the production of metal implants. It is estimated that by 2024, 3D metal printing will grow to manufacture over $1 billion worth of implants.

Oral Health Delivery System

Increasing integration of oral health care into overall health care

The scope of practice for dentists could be reconceptualized and expanded. Many oral and systemic diseases have common risk factors such as tobacco use and poor diet. A broad number of primary health care activities may be conducted in the dental office, such as screening for hypertension, diabetes mellitus, and dermatopathology; smoking prevention and cessation activities; and obesity interventions. Early disease detection and initiation of treatment combined with lifestyle changes can contribute to a reduction in morbidity and mortality from chronic diseases.

Expanded provider roles for oral health prevention

» A great amount of preventive and maintenance oral health care is provided by non- dentists.

» In addition, non-dentists can provide simple restorative and minor surgical procedures under differing supervision requirements in some jurisdictions.

» Active efforts to expand the number of jurisdictions where these practices are allowed are increasing.

» This also includes traditional health system providers such as physicians, nurses, and pharmacists (i.e. more multidisciplinary care in the oral health field, potentially increases competition in the oral health care space).

Changing oral disease patterns and paradigm shift in oral health care

» Healthcare is undergoing significant changes; dentistry, although distinct from much of our healthcare system, is not immune from these trends. Today, there is increasing focus on prevention of disease and maintaining good health overall.

» There has been a significant reduction in the prevalence of oral diseases in the general population because of the success of the dental profession in providing effective and appropriate preventive therapy, public health initiatives such as water fluoridation, and health promotion about practicing good oral health habits.

» The type of treatment provided in dental offices is changing. In the past, the treatment of disease occupied the major portion of the dentist’s time, and therapeutic procedures dominated what dentists did (restoring damages of caries and periodontal disease).

» The level of therapeutic care need is decreasing steadily and along with it demand for the most common, traditional dental services.

Direct to consumer dentistry

Digitization of the supply and buyers chain will continue, which reduces the simultaneity of production and consumption in any procedure that requires a lab component, and all back-end operations in a dental office (booking, insurance, payments). This will allow

large corporate players outside of the dental space to enter a significant portion of dental services and deliver services directly to patients. The effect will be less revenues or increased costs or both for dental offices.

Rise of DIY dentistry

» According to a 2017 survey by the American Association of Orthodontics (AAO), about 13 percent of its member orthodontists are seeing patients who have tried do-it-yourself teeth straightening, with some of those attempts causing irreparable damage. AAO attributes the DIY trend primarily to social media, citing YouTube tutorial videos on how to straighten one’s own teeth. The AAO found that 70 percent of DIY patients seen by its members who took part in the study were between the ages of 10 and 34.

» While this phenomenon is most recently prevalent in orthodontics, it will only be a matter of time before it makes its way to other disciplines of dentistry.

» Accurate figures on the extent of DIY dentistry are hard to find.

» One of the biggest sellers of dental first aid packages in the UK sells more than 250,000 kits a year, but there is no research on how they are used. Research from the oral health charity, the British Dental Health Foundation, found that one in five Britons said they would remove a tooth themselves or ask a friend to do so if they could not afford dental treatment.

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Definition of Oral Health

FDI’s Definition of Oral Health Oral health is multi-faceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort and disease of the craniofacial complex.

Further attributes of oral health

Is a fundamental component of health and physical and mental well-being. It exists along a continuum influenced by the values and attitudes of individuals and communities.

Reflects the physiological, social and psychological attributes that are essential to quality of life.

Is influenced by the individual’s changing experiences, perceptions, expectations and ability to adapt to circumstances.

When drafting this position statement, the FDI Think Tank reviewed existing definitions of oral health, which for the most part relied on a biomedical perspective, but failed to account for patients’ values, perceptions and expectations. The present definition is an attempt to propose a universally applicable and acceptable definition of oral health in order to more clearly position oral health within health; demonstrate that oral health does not occur in isolation, but is an important part of overall health and well-being; raise awareness of the different dimensions of oral health as a dynamic construct; and to empower patients by acknowledging how individual’s values, perceptions and expectations impact oral health. Importantly, this definition lays the

foundation for the future development of standardized assessment and measurement tools.

Although different stakeholders may value the importance of the various elements that influence oral health differently, the definition is meant to be universally applicable in all geographical areas, for all populations, and by different stakeholders. They are meant to serve as enablers:

For individuals, who are encouraged to value their oral health and given an active role in evaluating it and assessing their needs, leading to greater empowerment.

For oral health practitioners, who are presented with a unique opportunity to work in a more patient focused way while joining the wider health community in acting on driving determinants, rather than solely treating existing disease; for other health professionals, who are offered the opportunity to better understand oral health, its importance, and its rightful place in any and all health conversations, and thus, policies related to health.

For National Dental Associations who now have a globally agreed upon definition that can be used to set priorities according to their own need and priorities, and who in the future, will have access to an accompanying measurement toolbox for use to assess individuals and population needs, and to be used as an advocacy tool for national policymakers.

For FDI who can drive this initiative further by providing standardized instruments to collect and collate standardized data, which will be fundamental in informing policies and priorities at the global level and serve as a powerful advocacy tool.

Internationally, work is underway to develop suitable instruments for measuring oral health. The International Consortium for Health Outcomes Management (ICHOM) is an independent, not-for-profit organization dedicated to supporting value-based health care by facilitating the

measurement and comparison of health care outcomes. The ICHOM has launched a project aimed at developing a standard set of oral health outcome measures.

Expenditures and Economics

Dental spending 2018 in Canada

» Total expenditures on dental services: $17,087 Billion.

» Percentage distribution of total health expenditures on dental services: 6.7%.

» Per capita expenditure on dental services: $461.

» Private sector health expenditure on dental services: $16,104 Billion.

» Total private sector health expenditures in Canada: $78,708 Billion.

» Percentage distribution of private-sector health expenditures on dental services: 20.5%.

» Public sector health expenditure on dental services: $984 Million.

» Percentage distribution of public-sector health expenditures on dental services: 0.6%.

» Out-of-pocket expenditures from 50% in 1988 to 43.6% in 2016.

» Private insurance expenditures from 50% in 1988 to 56.4% in 2016.

Source: CIHI National Health Expenditure Trends 2018

Canadian dental insurance statistics in 2017

» $1700- average dental claim per year for those aged 45-49.

» $500- average dental claim per year for those under 24.

» $1629- average annual maximum for basic dental services per insured adult.

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Financial Performance Data- Offices of Dentists NAICS 6212

» Distribution by Total Revenue / Value in Thousands of Dollars

» Revenue range: Annual revenues $30,000 - $5,000,000

» Incorporation status: All businesses

Whole industry (reliability)

Bottom quartile (25%)

Lower middle (25%)

Upper middle (25%)

Top quartile (25%)

Number of businesses 22813

Revenue range:

Low Value ($000) 30 30 140 395 938

High Value ($000) 5000 140 395 938 5000

Revenues and expenses (thousands of dollars) - Averages

Total revenue 647.0 79.10 237.80 646.50 1624.60

Cost of sales (direct expenses) 38.0 0.90 5.00 28.30 117.90

Wages and benefits 16.6 0.20 1.60 12.40 52.40

Purchases, materials and sub-contracts 21.4 0.80 3.40 15.90 65.40

Operating expenses (indirect expenses) 396.0 29.00 111.00 419.90 1024.10

Labour and commissions 184.0 6.30 44.20 197.90 487.50

Amortization and depletion 19.8 2.10 6.10 21.00 49.90

Rent 31.9 2.20 9.90 39.10 76.20

Professional and business fees 38.6 3.00 9.50 33.90 108.10

Total expenses 434.0 29.90 116.00 448.20 1142.00

Net profit/loss 213.0 49.20 121.80 198.30 482.60

Financial ratios Averages

Gross margin (%) 94.10 98.80 97.90 95.60 92.70

Source: Statistics Canada, Small business profiles, 2016

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» $1629- average annual maximum for basic dental services per insured adult.

» $1774- average annual maximum for major restorative dental services per insured adult.

» $515- average annual dental premiums for single coverage.

» 12%- of organizations require that employees pay a deductible for dental benefits.

» 63%- average reimbursement level for major restorative dental services offered by employers.

» 91%- average reimbursement level for basic dental services offered by employers in Canada.

Source: Benefits Benchmarking 2017, Conference Board of Canada

Oral health providers earnings trends

Earnings gap for internationally trained dentists.

Large earnings gap ($46,225 or approx. 30%) between Canadian/US-trained and foreign-trained dentists on average, and 40% ($18,537.06) of this gap still persists after controlling for characteristics such as mother tongue, potential Canadian work experience, visible minority, gender and geographical location. This 40% gap is the result of unobservable differences (location of training effects) rather than rates of return for characteristics.

Blockchain in dentistry

Dentacoin is an example of a platform that recently introduced various blockchain-based applications and a cryptocurrency specifically meant for dental industry. Dentacoin aims to make dental treatment readily and

easily available for all strata of society, irrespective of their financial status. With the Dentacoin Assurance program e.g., patients are only required to pay their dentists a monthly fee in the form of Dentacoins (the cryptocurrency issued by the platform) in order to receive lifelong, preventive care.

Dental services expenditure by province/territory, Canada, 2018 - current dollars (000’s)

NL $159,426

PE $48,765

NS $363,494

NB $253,941

QU $2,999,371

ON $7,083,939

MB $528,743

SK $475,910

AB $2,597,326

BC $2,525,243

YT $16,592

NT $21,329

NU $13,119

CANADA $17,087,200

Source: National Health Expenditure Database, Canadian Institute for Health Information.

0

$20000

$40000

$60000

$80000

$100000

$120000

$140000

$160000

$180000

Canada BC AB SK MB ON QU NB NS PE NF

Average income 2015

Dentists Dental hygienists Dental assistants

Source: Statistics Canada, 2016 Census Survey, Custom Tabulations.

Employment size category of dental offices in Canada

Micro (1-4)36%

Small (5-99)64%

Micro (1-4)

Small (5-99)

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Practice Metrics

Offices of Dentists in 2016:

» Establishments 25,077

» Average revenue $647.0 thousand

» Profitable 94.3%

Incorporated dental offices in Canada with revenues of $5 million +

» 2014= 54

» 2016=73

35% increase in 2 years

Dental Topics in the National Media » Rising cost of tuition for dentistry students.

» Oral health challenges faced by seniors in long-term care.

» Rising dental costs for benefits employees in Canada.

» TMJ, causes and treatments.

» Recommendations for fluoride for babies; fluoride drops .

» Tongue cleaning and its effects on oral health.

» How dentists can accommodate abuse survivors.

» Role of dentists in combating domestic violence.

» Nova Scotia reversal of cancelling children’s polishing and scaling coverage.

» NDP dental coverage plan for Ontarians.

» Dentists and the Canada Food Guide.

Number of offices of dentists in Canada by total and by incorporated by province- 2016 NAICS 6212 - offices of revenues $30,000 to $5 million

All OfficesIncorporated Offices

Percentage Incorprorated

British Columbia 3,471 2,811 81.0%

Alberta 2,724 2,219 81.5%

Saskatchewan 463 350 75.6%

Manitoba 687 454 66.1%

Ontario 9,725 6,177 63.5%

Quebec 4,544 1,978 43.5%

Nova Scotia 521 408 78.3%

New Brunswick 333 260 78.1%

Prince Edward Island 77 57 74.0%

Newfoundland Labrador 216 135 62.5%

Territories 52 26 50.0%

CANADA 22,813 14,875 65.2%

There are 73 incorporated dental offices in Canada with revenues of $5Million +

Source: Statistics Canada - Small business profiles, 2018

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Comments

To support the production of this report, an environment scanning database was set up to store information generated during CDA’s day-to-day activities and because of specific environmental scanning initiatives. This information provides a baseline against which the impact of CDA’s actions can be evaluated. It is also available to facilitate the study of issues that will be identified as worthy of a closer examination.

In addition to the need for updates (e.g., adding issues as they are identified and removing those that are no longer current), it is expected that because this report attempts to make predictions about the future, it will need to be adjusted as the assumptions presented are shown to have been either accurate or invalid. As a result, it will be modified in a continuous fashion and the most current version will be made available to relevant stakeholders on an as-needed basis. Ongoing issues and trends identified from previous environmental scans that are still relevant remain in the report.

While significant efforts went into the identification of as many issues of importance as possible, there is no doubt that some will have been missed. To help make this report more comprehensive, we encourage all readers to forward their observations by e-mail to: [email protected].

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