The impact of reimbursement systems on occupational therapy practice in Canada and the United States of America.

Different funding and cost-control mechanisms in Canada and the United States of America (USA) have a powerful influence on occupational therapy practice in each country. Canada's public health insurance system emphasizes access to health care services based on medical need. Costs are controlled at the provincial government level by limiting the capacity of facilities and personnel. Occupational therapists in publicly-funded settings have considerable professional autonomy to use occupational therapy theoretical models and to be client-centred. The measurement of outcomes is not always required and the interventions of individual occupational therapists are infrequently scrutinized. The USA has no universal, publicly-funded, comprehensive health insurance. Health care policies are driven by financial priorities and cost control occurs at the service delivery level. Insurance companies define the scope of occupational therapy practice by identifying what services they will pay for and they scrutinize occupational therapy interventions. The emphasis on effectiveness and efficiency leads to critical examination of interventions by therapists. Canadian occupational therapists can learn much from their colleagues in the USA in this area.