Sources Media Release

The Crisis in Health Care
A Brief by the Medical Reform Group of Ontario

Presented to:
Mr. Justice Emmett Hall
Health Services Review '79
Toronto, Ontario
April 1, 1980.


TABLE OF CONTENTS

INTRODUCTION

PART I; SOME OF THE REASONS FOR THE FAILURE OF "REA-SONABLE ACCESS" TO AND "UNIVERSAL COVERAGE" FOR HEALTH CARE
A. Income and Social Class
B. The Premium System of Payment
C. Opting-out
D. Cutbacks in Health Care Services

PART II; SOME SOLUTIONS TO THE CRISIS IN HEALTH CARE SERVICES
A. Alternatives to the Premium System of Payment
B. Methods to Alleviate Physician Discontent
C. Means of Insuring Physician Participa-tion in Government Health Insurance Programs
D. Alternatives to Fee-for-Service as a Method of Physician Payment

PART III: BEYOND THE ECONOMIC ISSUES
Health- What Are Its Boundaries?

REFERENCES

APPENDICES: Appendix A Statement of Principles of the Medical Reform Group of Ontario
Appendix B Opting Out of OHIP, a resolution passed by the MRG
Appendix C Funding of Health Care, a resolution passed by the MRG

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INTRODUCTION

The Medical Reform Group of Ontario is a newly-established organization of almost two hundred Canadian physicians and medical students; two-thirds of our members are from Ontario. We formed in the midst of mounting public concern about the future of health care in Canada, uniting around three principles:

1. Health care is a right that must be guaranteed without financial or other deterrents.
2. As physicians, we must turn our attention to the causes of ill health in social, occupational, and environ-mental conditions, and work to change these.
3. The health care system must be changed to provide a more significant role for other health care workers, and for the public.

As physicians and medical students we are vitally concerned with what we see as the crisis threatening the health care of the people of Ontario and of Canada as a whole. The Charter of Health for Canadians proposed by the Royal Commission on Health Services in 1964 states:

"...the achievement of the highest possible health standards for all our people must become a primary objective of national policy... This objective can best be achieved through a comprehensive, universal Health Services Program for the Canadian people... to attain the highest possible levels of physical and mental well-being."

We believe that the goals of the Charter of Health for Canadians have not been met.

In this brief, we examine some of the reasons for the failure in Ontario to achieve the principles of "reasonable access" to and "universal coverage" for health care. Specifically, we look at the following areas which affect the use of health care services:
(a) income and social class
(b) the premium system of payment
(c) opting-out
(d) cutbacks in health care services.

We then consider possible solutions to the problems of health care delivery in Ontario:
(a) alternatives to the premium system of payment
(b) methods to alleviate physician discontent
(c) means of ensuring physician participation in government health insurance programs
(d) alternatives to fee-for-service as a method of payment to physicians.

We conclude with an exploration of other factors which affect the health status of Canadians, but which lie beyond the economics and organization of medical care delivery.


PART I: SOME OF THE REASONS FOR THE FAILURE OF "REASONABLE ACCESS" TO AND "UNIVERSAL COVERAGE" FOR HEALTH CARE

A. Income and Social Class

Hospital and medical insurance programs were introduced in an attempt to correct inequalities in the access to medical care by eliminating direct costs to patients. However, their introduction did nothing to alter the way in which health care is delivered, nor to change the power structure within the health care system.

Indirect evidence indicates that health insurance has not eliminated differences in the health status of differing income groups. For example, a Toronto survey compared public health indices- death rate, tuberculosis rate, infant death rate, and still-birth rate- for two public health districts in Toronto, one in a middle and upper class district and the other in a working class and welfare area. Prior to the introduction of health insurance, all four indices were higher in the working class and welfare area. For the first seven years after the start of the provincial medical scheme (QMSIP), the decline in three of the four indices was greater in the middle and upper class area.

If medicare did not equalize the health status of differing income groups, did it result in equal access to health care facilities? Three studies1,2,3 examined this question using data collected before and after the introduction of Medicare and another looked at the distribution of health care after Medicare.4 Although
the findings are not uniform, they generally show that Medicare did not result in equal use of health facilities. When doctor-initiated services, such as referrals to specialists, were examined, the
increase in use was greater among the highest income earners than among the lowest.3,4 These studies reach the same conclusion: given the same needs, people with differing incomes do not receive equal amounts of care -- high income earners receive more care than do low income earners.

Ease of access to doctors' offices influences who goes to see doctors. People in low income areas rate proximity as a very important factor in choosing a doctor.5 If they have to travel a long distance and spend money for public transit and babysitters, they are just as likely to use their time and money on problems they may perceive as more pressing.6 And in 1968, of 769 paedia-tricians in Canada, only twelve percent were located in lower income areas.7

Even if there were equal access, there still would not be equal care. Most doctors either have middle class origins, or have acquired middle class values during their training. It has been shown that physicians report less interest, more frustration, and less satisfaction dealing with lower class patients.8 For the same problem, doctors will spend up to fifty percent more time with patients from the highest social class than with those from the lowest.9 The amount of information that a doctor gives out seems to be influenced by his or her perception of the patient's economic status.10 As noted above, the wealthy receive a larger proportion of doctor-initiated services than do the poor. Although specialists' services may not result in better care, referrals are made on the assumption they will. Similarly, at a time when it was believed that extra time in hospital was beneficial, wealthy women were kept in hospital longer after giving birth than were poorer women.11

These class differences create tension between middle class doctors and their working class patients. A study of senior citizens covered by Medicare in an eastern U.S. city, found a strong negative correlation between economic status and discontent with medical services in the clinic these people were attending.12

Another study done in a downtown Toronto public housing community found that 47 percent of the population felt that they understood their own health better than most doctors.13

Income and social class restrict equality of access to health care. Medicare itself has not corrected the inequities of health care delivery to different social classes; the premium system, opting-out, and cutbacks exaggerate these problems.


B. The Premium System of Payment

Three provinces, including Ontario, still collect premiums for health insurance. The rate in Ontario of twenty dollars per month for a single person and forty dollars per month for two or more in a family , is the highest in Canada, more than twice that of any other province. The other provinces finance health services from general revenues; some provinces add on regular user charges, at least for certain services.

It is often argued that some people are wholly or partially exempt from paying premiums. For example, in Ontario, those over the age of 65 and families with taxable incomes of less that $3500 pay no premiums. Single people are exempt if their taxable income is below $3000. Families with taxable incomes between $3500 and $50 and singles with incomes between $3000 and $4000 pay only half of their premiums. There are two flaws with such premium assistance plans.

First, a family on partial premium assistance will be paying between 4.8 and 6.9 percent of its taxable income on health insurance, and a family with a taxable income of $5000 will pay 9.6 percent. Meanwhile, a 'typical' urban family with an income of $18000 will pay only 3.3 percent of its taxable income for health insurance. The premium system of payment is clearly a regressive form of taxation.

Secondly, the premium assistance program does not work. The Ontario Select Committee on Health Care Financing and Costs (1978) found that only about one-third of those eligible for full premium assistance (162,000 of 487,000), and almost none of those eligible for partial assistance (fewer than 1000 of 160,000) were receiving it.

Yet another obstacle to complete coverage for low-income families is that the OHIP administration demands a full three months' payment at one time. These payments must be made two to three months before the insured period. Many individuals and families on low incomes find it difficult to budget for the $60 or $120 every three months, and instead spend their money on more immediate needs such as food or clothing.

The Medical Reform Group is concerned about the substantial numbers of Ontario residents without OHIP coverage. Data from nine community health centres in Ottawa and Toronto indicate that in October 1979, of 44,000 regular patients who had originally presented with an OHIP number, approximately 6,000 were uninsured. These centres are in areas with large numbers of the so-called 'working poor': people who earn too much to be eligible for premium assistance and yet who do not have a job-benefit package which includes payment of health insurance premiums.

The percentage of people from lower income groups without OHIP coverage is undoubtedly higher than that from higher income groups. Unfortunately, the Ministry of Health in Ontario does not publish data on the breakdown of insurance coverage by income group. Our experience strongly suggests that the coverage is less than 95 percent among significant groups of the population, and thus a far cry from "universal".


C. Opting-out

Nearly twenty percent of Ontario's physicians, and up to seventy-five percent of those in certain specialties, have opted out of OHIP and charge patients directly.15 It is important, there-fore, to review the effects of 'user charges' as revealed in other Canadian settings and as accepted by various official inquiries in to such matters.

Decreased Services to the Poor. Studies of the Saskatchewan attempt to collect 'deterrent' or user fees for health services from 1968 to 1971 and the 1977 OHIP experience of patients in opted-in and opted-out practices, reached similar conclusions:

"While the source of information regarding how Ontario residents used medical services in 1977 differs from the methods used in other studies, the general conclusions about the impact of user charges remain the same... the volume of services provided decreased and the groups who were the most affected were the poor, in this instance public assistance beneficiaries and the elderly."17

Inflationary Effect on Health Care Costs. The above studies also challenge the claim that user charges result in cost reduc-tions to the health care system. The 1977 Ontario figures, for example, showed that "in addition to whatever additional charges may have been involved for the patients of opted-out physicians, these doctors provided on average more expensive services to their patients."18 This finding reflects in part the 'physician feedback effect' which occurs when physicians try to maintain their incomes in the face of lower volume (as some patients are deterred by user fees); doctors generate demand by doing more 'optional' services or even over-servicing. To quote the Saskatchewan conclusions, "the evidence of a greater volume of complete examinations provided during the co-payment period suggests that physicians may have engaged in some substitution of higher-priced for lower-priced services."19

Such physician behaviour reflects the potential in the present system of physician remuneration for 'physician abuse', leading to cost inflation. In fact, most authorities in this field find little evidence of the 'patient abuse' so often cited by medical associa-tions as a major cause of unnecessary costs for unnecessary services. Wolfson, in his review of the 1974-1975 OHIP records, states that "to the extent that abuse does exist in the system, these results indicate that it is more likely to originate with the physician through over-servicing than with patients through over-utili-zation."20

In addition, as Barer, Evans, and Stoddart,21 point out, extra-billing and add-on fees unilaterally and arbitrarily determined by physicians can only inflate total health care costs to society because government-physician negotiation of total costs for physician services is by-passed, and doctors alone are in control.

Unequal Geographic Distribution of Increased Health Care Costs.
Present rates of opting-out for some specialties vary from 0 to 100 percent within particular counties and regions of Ontario, resulting in geographic differences in health care costs. Recent Ministry of Health figures22, for example, showed that the following have opted out: all urologists in Peel, Halton, and Wellington counties and in the city of Peterborough, all obstetrician-gynecologists in Nipissing, and all anaesthetists in Middlesex county. In other areas, the remaining handful of opted-in specialists have long waiting times for office appointments. Perhaps more seriously, some rural areas now have no opted-in general practitioners. Thus patients in certain regions of Ontario must pay from their own pockets for services which CHIP pays for entirely in others.

Development of a Second Rate Health Care System for the Poor. The opting-out phenomenon in Ontario has already fostered a two-tiered system of health care via the reappearance of the 'private' and 'public' patient streams in many hospitals. Many university specialists are taking advantage of their long-standing privilege of being opted-out in their offices and opted-in in the teaching hospital outpatient clinics. In response to physician pressure, even specialists in non-teaching hospitals were recently given this privilege in a little-publicized ruling by the Ontario Ministry of Health. This phenomenon represents a move towards the return of that objectionable twin system of care which was wide-spread before Medicare: high continuity personalized care by the consultant in his private office versus low continuity 'public clinic' care in teaching hospitals by the house staff on duty, with or without the consultant's direct supervision. In areas where all the specialists are opted-out, the extra-billing for private office care forces some patients to attend the public clinics whether they wish to be educational cases or not. Of course, there must be 'teaching cases' in any health care system, but these should be determined on the basis of the nature of the case and informed patient consent, not by patient income.

Our view of the effects of opting-out in Ontario concurs with that of the Select Committee of the OntarioLegislative Assembly in its October 1978 Report on Health Care Financing and Costs:

"In summary, having weighed all the evidence presented to it very carefully (94 witnesses and 189 written Briefs -ed.), the Committee concludes that user charges for medical care are inappropriate at this time."23

In fact, the Medical Reform Group of Ontario would go further and say that the present opting-out situation is completely unacceptable. It is clearly contrary to the spirit of the Hall Commission Report of 1964 and the Medical Care Act passed in 1966, which guaranteed reasonable and fair access to care to residents of all provinces with public health insurance.24


D. Cutbacks in Health Care Services

The large number of cutbacks in health care services represents a fourth major obstacle to "reasonable access" to and "universal coverage" for health care in Ontario. While the inflation rate runs at 9.8 percent and is likely to increase further, the Ontario budget allowed only a 4.18 percent increase for health spending last year.

Although there have been many adverse effects of cutbacks, hospitals have taken much of the burden; constituting two-thirds of insured health costs, they are an obvious target. Extensive closures of active treatment beds have taken place across the province, based on the Government's revised bed/population ratios of 3.5/1000 in the south and 4.0/1000 in the north. Evidence relating these figures to community needs is meagre. The full effect of bed closures is difficult to quantify as the deficits these closures cause are largely qualitative. The evidence is anecdotal but nonetheless compelling.

As physicians, we have time and again been faced with the frustration of being unable to admit sick patients to hospital because there are no beds available. Long waiting lists have led not only to great inconveniences, but also to overtly dangerous situations. Overcrowding is but one manifestation of the effects of cutbacks. Patients are routinely placed in wards ill-equipped to handle their problems because of the shortage of beds in the appropriate wards, and the number of 'corridor admissions' has risen markedly. Other detrimental practices related to cutbacks include the rerouting of ambulances to more distant hospitals, and a move to discharge patients prematurely.

Chronic care patients are also not receiving the care they require. Many people who should be in a nursing home wait six months to a year for that service, and in the meantime cause a great strain to their families; their presence at home may mean that a wage-earner must give up a job in order to provide care. Other chronic care patients occupy active treatment beds inappropriately and at great cost to the taxpayer.

Staff reductions at hospitals have been another serious problem. Over the past three years, many jobs have been cut and the loss of more is expected. Cutbacks have thus meant not only deteriorating patient care, but also rising unemployment, restric-tions on wages, and demoralization of health care personnel.

These cutbacks in health care are not in the best interests of the people of Ontario. The percentage of the provincial budget allocated to health care continues to decline. The situation had become sufficiently serious by early 1979 that the Federal Minister of Health expressed concern that the increases of health care funding provided by federal block grants were not being fully transferred into health care by Ontario.

The Medical Reform Group of Ontario has taken the position that health care spending be increased to at least keep pace with inflation; that until alternative facilities exist, bed cuts be stopped and wards reopened to alleviate waiting lists for care; and that the large numbers of layoffs of hospital workers be reversed. The extent to which the principles of "reasonable access" to "universal coverage" for health care for Ontario residents is being threatened by these cutbacks must not be minimized.

PART II: SOME SOLUTIONS TO THE CRISIS IN HEALTH CARE SERVICES

A. Alternatives to the Premium System of Payment

Canadian provinces have differing methods of financing health care insurance programs. Ontario funds its plan through a combination of premiums (the highest in Canada), general revenues, and per diem charges for some services (such as extendicare and chronic care). As discussed earlier, many people, particularly the 'working poor', are finding it difficult to provide themselves and their families with health insurance coverage because of its high cost in this province. Many of those who are eligible for premium assistance are not receiving it because of poor advertising of the plan. Some never make the initial application for OHIP coverage.

Some of the inequities of the present Ontario system could be easily remedied. The premium assistance program must be more widely advertised, or tied to the Income Tax Act. The three month advance payment could be eliminated. And the threshold for the premium assistance plan must be raised to reflect family finances in the 1980's. However the premium system goes against the spirit of universal accessibility embodied in the original Medical Care Act and Diagnostic Services Act.

A better method of financing the health insurance program might be to increase corporate and personal income tax levels in Ontario, with a system of tax credits for those least able to afford the increase. This scheme would ensure universal coverage with no need to advertise specific programs, eliminate the need for a separate bureaucracy for the collection of premiums, and most importantly, guarantee a progressive system of financing health care. It is worth noting, incidentally, that the percentage of tax income from the corporate sector has dropped dramatically: in 1962 it contributed 62 percent, in 1979, only 29 percent.

At present, one-third of health care funding in Ontario is derived from premiums. Nonetheless, this system is regressive in our analysis and our experience. It has led to a failure of the principle of "universal coverage". The Medical Reform Group believes that OHIP premiums must be abolished, and that funding for health care must come from progressive forms of taxation.

B. Methods to Alleviate Physician Discontent

The discontent with the OHIP system registered by many Ontario physicians stems from both economic and philosophical considerations. However, equally important as a cause of constant and loud complaint are a variety of OHIP practices and policies which appear, to some, designed to harass the physician. Many of these policies, furthermore, are detrimental to the practice of good medicine.

The Medical Reform Group advocates that OHIP support and experiment with other methods of paying physicians. While fee-for-service remains the major mode of payment in Ontario, however, we urge that improvements be made in the manner of its adminis-tration.

Paperwork: Each OHIP billing card must be completed by hand, with multiple details for each patient visit. Claims are processed slowly and cards are regularly rejected and returned to the physician if there are any errors or omissions, however minor. The long processing time on claims should be reduced: at present, it may take months to correct records or resolve disputes. The paperwork load could be further reduced if a plastic card were issued to all OHIP subscribers to be used on forms. Finally, doctors should be paid a paper-processing fee, similar to that now paid to labs.

Patient and Practice Profiles: Physicians can improve their methods of practice, undertake patient and practice research, and compare their practices with those of their colleagues using practice profiles. In Ontario, practice profiles are available only for a fee, and then only several months after the period to be studied has ended. A free profile service would aid in research and in modifying practice patterns to meet the needs of specific practices and patient populations.

Preventive Medicine: Although both physicians and governments pay lip-service to preventive medicine, fee schedules do not reflect this 'concern'. The physician is penalized for spending more than minimal amounts of time per patient. Preventive medicine involves counseling, teaching, and answering questions, and cannot be practiced without taking time. Under existing OHIP fee schedules, a physician must bill for psychotherapy or counseling (with a 'false' diagnosis) in order to be remunerated for spending time on these services. Broad categories under "Preventive Counseling" should be introduced, including areas known to produce stress and illness: poor diet, work-related stress, occupational hazards, child-rearing, family problems, immunization for travel, family planning, infertility, pregnancy and birth, etc.

Extended Care: Patients requiring chronic care, home care, nursing home care, or public health assessment may generate hours of unpaid time as the physician contacts agencies, social workers, and families in order to secure services. More money and effort should be expended on providing a variety of well co-ordinated levels of care for the patient in the community and in non-acute beds, in order to relieve pressure on doctors' time and to reduce the numbers of inappropriate placements.

Although many of these considerations may appear minor, their collective effect is not. The provincial government has not been responsive to practical administrative details that would avoid physician irritation and improve patient care. The adminis-tration of the system has been a significant factor in the increase in the numbers of physicians opting out and moving to sunnier climes.


C. Means of Ensuring Physician Participation in Government Health Insurance Programs

The Medical Reform Group of Ontario has resolved that the practice of opting-out be ended. In this section we examine the pros and cons of several methods of achieving this objective.

Option A: Raise the OHIP Benefits (Fees) to Physicians: If the main reason for doctors' opting out were financial, raising OHIP benefits would theoretically convince doctors to re-enter OHIP and stop extra-billing. But doctors also opt out for philosophical reasons. Wolfson in 1975 found that a major difference between opted-in and opted-out physicians was that the latter were likely to be "more individualistic and conservative in their attitudes toward the role of government in health services."25 Many recent statements by the Ontario Medical Association confirm that an important objective of opting-out is to re-establish the consumer-provider relationship that once characterized patient-physician interactions. A central component of this traditional relationship is the direct monetary transaction between patient and doctor, without government intervention. Physicians who advocate opting-out are in fact asking for provider control over the total price of physician services. Some seem to believe that they are simple entrepreneurs, offering services in a free market, much like the corner shoe repair man.

The vehement philosophical objections to OHIP voiced by some of our opted-out colleagues indicate that raising OHIP benefits alone wouldn't convince all physicians to opt back in.

Option B: Limiting the Use of Publicly Funded Hospitals to Doctors Who Are Opted-in: While the Medical Reform Group of Ontario believes that doctors should not be able to make uncontrolled private profits through their use of publicly-funded facilities in hospitals, limiting the use of such hospitals to opted-in physicians would be an indirect and awkward method of bringing doctors back into OHIP. First, it would apply pressure primarily on physicians who use hospitals extensively. A large number of urban general practitioners and some specialists make little use of hospitals, and the bulk of health care services are delivered outside of hospitals. Secondly, limiting hospital use could well lead to pressure for the construction of private hospitals along the lines of the American model. Finally, there is a practical problem in enforcing such an arrangement: group practices could leave only one physician opted-in to do hospital admissions for the entire group by referral; the group could share total incomes, thus circumventing the measure entirely.

Option C: The Quebec Option: The system currently employed in Quebec limits Medicare benefits to those who receive their care from opted-in doctors. Therefore, patients who see opted-out doctors are entirely responsible for the costs of any services rendered. Under this system, a physician must be either 'all in' or 'all out' of the plan.

This kind of legislation, while attractive as a direct attack on the problem, would almost certainly provoke a major confrontation with a small minority of physicians. Some of these doctors might be tempted to try practicing 'entirely out' of the OHIP system, at least as an initial strategic manoeuvre, in response to the legislation. Others would threaten to leave the country. In geographic areas where most or all of the available physicians in a given specialty might take either of these actions, serious hardship could result for all but the most wealthy patients.

Option D: Legislating All Doctors Into OHIP: This option would differ from the Quebec option in that 'entirely opted-out' physicians would not be allowed to practice at all. A physician could not bill a patient directly. Such legislation is most unlikely in Canada, given the fact that since the advent of Medicare, physicians have been free to practice entirely outside public health insurance plans. There may be no need for such restrictive legis-lation: after the introduction of the present system in Quebec, only a few physicians in the province chose to opt out completely.

No one of the above methods appears entirely satisfactory, and some combination of methods may be the best solution. For example, a politically feasible and reasonably acceptable solution might be a combination of legislation modeled on that currently used in Quebec, combined with substantial fee increases to doctors
to 'sweeten the pot', as was done in many provinces when medical insurance was introduced in the late 1960's.

This discussion has focussed on an acute problem of the present system of physician payment. The Medical Reform Group believes that it is also necessary for governments to more actively examine and implement alternative methods of physician remuneration, Only in this way can we eventually achieve a health care system which provides quality care for all in a setting which is satisfying for both doctors and patients.


D. Alternatives to Fee-for-Service as a Method of Physician Payment

Fee-for-service has been the major method of remunerating physicians' clinical services in Canada, while other systems of payment have been largely ignored. Yet the literature regarding the experiences of other countries with different payment systems does not validate the high esteem accorded to fee-for-service.27,28

The major alternatives to the fee-for-service method of payment are salary and captivation. In most countries some combi-nation of all three methods is used.

A salaried physician receives an annual wage and is expected to provide medical services during a specified period of time. Salary is a common method of payment throughout the world and is used in Canada to pay certain public health physicians, radiologists, anaesthetists, and pathologists. A salary system is easy to administer and paperwork is minimized. The patient is not deterred by financial barriers, and both physician income and the health budget expenditures for physician services are predictable.

Capitation systems are less common in other countries, but generally have worked well. Under these systems, the physician receives a single payment for each person on his or her roster. This payment covers services for an extended period of time. The physician provides all necessary care that he or she is qualified to provide for that person, and any additional services are referred. Capitation has been most frequently used to pay general practitioners, although in some countries it is also used to pay specialists. Like a salary system, capitation provides a predictable income for the physician, alleviating the worries of generating an adequate income. Capitation is somewhat less easy to administer than salary, but less burdensome than fee-for-service. Capitation, moreover, encourages continuity of care. Since it is to the physician's advantage to maintain a healthy population, preventive medicine is encouraged.

Under fee-for-service, a physician is paid for each medical procedure or visit. Many physicians have traditionally favoured this system because it allows the greatest measure of control over the amount of income that can be generated. A physician can increase his or her income in one of two ways under this system: by increasing the number of services provided or by increasing the fee charged for each service. With the advent of public health insurance, the option of increasing the fee per service was limited, leaving physicians who wanted to substantially increase their incomes with the alternatives of opting-out or increasing the number of services provided. Either of these options creates problems for the patient.

Fee-for-service is a difficult system to administer and the total expenditures for physicians' services are less predictable; planning is more difficult. Preventive medicine is not encouraged: a healthy population generates fewer patient visits, and the physician's income is therefore decreased. Fee-for-service encourages unnecessary rechecks and office visits for problems that could readily be managed over the telephone. Besides adding an extra cost to the health care budget, an extra cost to society is incurred through the loss of patients' working time.

Opponents of salary and capitation argue that without the financial incentive provided by fee-for-service, physicians would be encouraged to underservice and to minimize their work load. There has never been convincing evidence to substantiate this idea; the available evidence in fact seems to refute it.31,32

No system of payment is ideal and any system is open to abuse. Nonetheless, the predominance of fee-for-service as a method of paying Canadian physicians can no longer be construed as in the best interests of patients and physicians. There are, at present, few opportunities to practice under an alternate payment system in this country, and none of these are adequately publicized, promoted, or funded. The Medical Reform Group of Ontario believes that combinations of the above three systems should be actively encouraged: many physicians would welcome the opportunity to practice under a salary or a capitation system. We urge the creation of such opportunities.


PART III: BEYOND THE ECONOMIC ISSUES

We have concentrated thus far on what we see as the imme-diate problems facing health care delivery in Ontario. But the roots of these problems lie deeper, in many widely-spread areas. We are convinced that the solutions to many of the problems that we are currently facing lie outside the realm of the delivery of medical care.

Education of the Public: Health and medical knowledge is too important to be left in the hands of the few who are fortunate enough to become physicians or other health care workers. Basic health and medicine should be a central part of public school education. The need for medical intervention in minor ailments could be obviated, and informed participation in ongoing medical treatment would be possible. Furthermore, a critical knowledge of the complex of factors which shape health, and of the economic, scientific, and philosophical forces that shape the treatment of disease, would have profound effects on health policy priorities in the future.

Education of Physicians: Medical education does not reflect the needs of the practitioner as much as it does the interests of academics and researchers. Common diseases- the daily run of colds, flu-, sprains, and bruises- receive little consideration in medical training, and the role of psychosocial factors in the causation of disease is virtually ignored. The cornerstones of preventive medicine- occupational and environmental health, nutrition, the role of social class or geography- rarely receive more than passing mention in medical school curricula.

Nor do doctors receive the education required to critically evaluate the barrage of new information they will face once they leave medical school. It is a disturbing truism that a physician's prescribing habits come to reflect more and more the claims of pharmaceutical company detail men, and less a critical scientific evaluation of the available methods of therapy. Mechanisms should be developed to ensure the continuing education of practicing physicians, with emphasis not only on the awareness of new advances in medical technology, but also on the critical appraisal of these advances.

Intimately linked with the content of medical training is the selection of trainees: admission policies must be modified so that medical school classes more accurately reflect the cultural, racial, class, and sex composition of society. Even the mechanisms for the selection of medical students should be reassessed.

The Role of Other Health Workers: More use must be made of the experience, skills, and commitment of other health workers. There is a need for innovative methods designed to break down the rigid hierarchy of authority that characterizes working relationships within the health care system, and to promote the ideal of a team approach to patient care. The specialized skill and perceptions of all health care personnel, from physiotherapists to orderlies to nursing staff, should be more completely integrated into day-to-day patient care. Many of the tasks now performed by physicians could be at least equally well done by paramedical personnel.

Control of Health Care Institutions and Health Policy: The administration and policies of health care institutions must better reflect the wishes of those they serve and those they employ. Hospital boards or district health councils, for example, too often represent a sinecure for the privileged; they rarely reflect the composition of the community. Democracy and accountability must be introduced into the health care delivery system.

There is a need as well for mechanisms to be developed so that issues of health policy- research priorities or the planning of services, for example- could be opened to public input and scrutiny.

Funding of Preventive Programs: At present in Ontario, only 3.1 percent of the health budget is earmarked for "community health", and even much of this small sum does not go to preventive programs. In the face of mounting expenditures on technology-intensive, treatment-oriented facilities, there is a need for increased spending on preventive programs which might reduce the need for medical intervention. For example, widespread antenatal programs aimed at high-risk mothers could prevent some of the complications that neonatal intensive care units are designed to treat. More money must be channeled into programs to prevent ill health; all too often, sophisticated medical technology can do little to correct the consequences of problems which are readily amenable to preventive measures.


Health - What Are Its Boundaries?

Health care policy inevitably touches on areas as diverse as labour relations, foreign affairs, and natural resources. Just as silicosis is a problem of the foundry more than it is a disease of the lung, or diphtheria a disease of poverty as much as it is a bacterial infection, health care policy is often more a matter of social criticism than of clinical medicine.

The final quarter of the twentieth century is witnessing a profound transformation in our consciousness of the dimensions of health and disease. We are learning, for example, that 80 to 90 percent of cancer is environmentally-induced, and that perhaps a third of all cancer can be linked to substances in the workplace. We are learning that infant mortality is less a matter of bad genes than it is a problem of poverty, malnutrition, and inadequate antenatal care. At the other end of the scale, we are faced with the problems of providing the aged with humane care during life, and death with dignity. On all fronts we are being challenged to shift our focus beyond the individual and his or her problems, to the complex of factors that gives rise to these; health care is becoming less and less the private concern of the individual, and more the public concern of the whole society.

It is beyond the scope of this brief to explore in depth the policy implications of these issues. We believe, however, that in the coming decade, new mechanisms must be developed to respond to the many challenges facing health care.

As a young and rapidly-growing organization of physicians and medical students, the Medical Reform Group of Ontario wishes to add its voice to those of the many Canadians who believe that the ideal of publicly-funded, high-quality, accessible medical care for all must be preserved, and that as a society, we must seek new ways to make our health care system more responsive to the needs of all Canadians.

REFERENCES

1. P.E.Enterline, et al. The Distribution of Medical Services Before and After "Free" Medical Care - The Quebec Experience, New England Journal of Medicine, 289: 1174, 1973.
2. R.F.Badgley et al. The Impact of Medicare in Wheatville, Saskatchewan, 1960-1965, Canadian Journal of Public Health, 58: 101, 1967.
3. R.G.Beck. Economic Class and Access to Physician Services Under Medical Care Insurance, International Journal of Health Services, 3: 341, 1973.
4. P. Manga. The Income Distribution Effect of Medical Insurance in Ontario, Ontario Economic Council, Toronto (1978).
5. A.P.J.Finnegan and E.J.Monkman. Attitudes to Health Care: Student Research in a Downtown Core, Canadian Family Physician, 18: 94, 1972.
6. J.P.Acton. Non-Monetary Factors in the Demand for Medical Services: Some Empirical Evidence, Journal of Political Economy, 83: 595, 1975.
7. A.Crichton. The Community Health Centre in Canada, Vol.Ill -Community Health Centres: Health Organizations of the Future, Information Canada, Ottawa (1973), pp.6-12.
8. L.Dungal. Physicians' Responses to Patients: A Study of Factors Involved in the Office Interview, Journal of Family Practice, 6: 1065, 1978.
9. D.J.G.Bain. The Relationship Between Time and Clinical Management in Family Practice, Journal of Family Practice, 8: 551, 1979.
10. F.Davies. Passage Through Crisis, Bobbs-Merrill, Indianapolis (1963) .
11. Toronto Daily Star, January 22, 1972, p.13.
12. M.D.Hyman. Some Links Between Economic Status and Untreated Illness, Social Science and Medicine, 4: 387, 1970.
13. P.Finnegan et al. The Alexandra Park Health Study, Toronto (1971).
14. Ontario Ministry of Health List of Opted-In and Opted-Out Physicians. Released December 19, 1979.
15. E.G.Beck and J.M.Horne as cited in R.F.Badgley and R.D.Smith, User Charges for Health Services, Ontario Council of Health, Toronto (1979), pp.121-162.
16. Ibid.
17. R.F.Badgley and R.D.Smith, op. cit., p.194.
18. Ibid., p.183.
19. Ibid., p.135.
20. A.D.Wolfson. Patient Utilization Study, University of Toronto, Toronto (1978), mimeo, 37 pages.
21. M.L.Barer, R.G.Evans and G.L.Stoddart. Controlling Health Care Costs by Direct Charges to Patients - Snare or Delusion, Ontario Economic Council, Toronto (1979), pp.84-86.
22. Ontario Ministry of Health, op. cit.
23. Ontario Report of the Select Committee on Health Care Financing and Costs, Legislative Assembly, Toronto (1978).
24. Canada. Medical Care Act, R.S.C. 1970, Chapter M-8. 25. Ontario Medical Review, 45: 355 and 46: 20.
26. A.D.Wolfson, C.J.Tuohy and C.P.Shah. What Do Doctors Do? A Study of Fee-For-Service Practice in Ontario, University of Toronto, Toronto (1978).
27. W.A.Glaser. Paying the Doctor: Systems of Remuneration and Their Effects, Johns Hopkins Press, Baltimore (1970).
28. J.LeDou and J.Likens. Medicine and Money, Ballinger Publishers, Cambridge (1977).
29. J.E.F.Hastings, F.D.Mott, D.Hewitt et al. An Interim Report on the Sault Ste. Marie Study: A Comparison of Personal Health Services Utilization: A Joint Canada-World Health Organization Project, Canadian Journal of Public Health, 61: 289-296, 1970.
30. E.Vayda. A Comparison of Surgical Rates in Canada and in England and Wales, New England Journal of Medicine, 289: 1224-1229, 1973.
31. E.Vayda. Pre-Paid Group Practice in the United States, Canadian Family Physician, October, 1973.
32. W.A.Glaser, op.cit.


APPENDIX A: STATEMENT OF PRINCIPLES OF THE MEDICAL REFORM GROUP OF ONTARIO
As physicians and medical students, we view with concern the lack of a forum to address the vital social issues facing health care in Canada today. While science tells us that the roots of the common causes of illness in Canada lie in correctable social, economic, occupational, and environmental conditions, as a profes-sion we have focussed on diagnosis and cure, ignoring the contri-bution we can make to the prevention of disease. While political economy tells us that there is a growing need to democratize the health care system, as a profession we cling to an archaic hierar-chy whose roots lie in the nineteenth century. While conscience tells us that health care is the right of all Canadians, the medical profession has increasingly involved itself in an attack on free universal accessibility to care.

We recognize that our concerns extend beyond the immediate issues, and that in seeking change, we must examine the intellec-tual, social, political, and economic underpinnings of the prevai-ling philosophy of medicine, particularly those which transform health care into a saleable commodity.

We have, therefore, joined together to publicly express our concerns. The Medical Reform Group of' Ontario is a democratic, non-sectarian organization of progressive physicians and medical students dedicated to the following principles:

1. Health care is a right.
The universal access of every person to high quality, appropriate health care must be guaranteed. The health care system must be administered in a manner which precludes any monetary or other deterrent to equal care.

2. Health is political and social in nature.
Health care workers, including physicians, should seek out and recognize the social, economic, occupational, and environmental causes of disease, and be directly involved in their eradication.

3. The institutions of the health system must be changed.
The health care system should be structured in a manner in which the equally valuable contribution of all health care workers is recognized. Both the public and health care workers should have a direct say in resource allocation and in determining the setting in which health care is provided.

The Medical Reform Group is committed to allying itself with the struggles of other health care workers on an independent fraternal basis.

The Medical Reform Group is not affiliated with any political party; our common base is our commitment to the above principles.

APPENDIX B OPTING OUT OF OHIP

Resolution adopted by the Medical Reform Group of Ontario October 14, 1979.

WHEREAS the Ontario Medical Association has actively encouraged opting out of OHIP by all physicians in the province, and the use of a fee schedule substantially higher than OHIP benefits,

WHEREAS, although the O.M.A. position is that opting out will result in better quality of patient care, the underlying reasons for the O.M.A. stand on opting out are as follows:
1) to increase physician income, by forcing patients to pay fee increases in excess of those established by government,
and/or 2) to increase physicians' financial and political control over the health care system by allowing them, through professional associations, to unilaterally determine fees,

WHEREAS opting out results in:
1) decreased access to care for lower income patients, who are the only ones significantly deterred by "deterrent fees",
2) a substantial unnecessary increase in total health care costs over time due to unopposed physician control over fees,
3) a geographically unfair distribution of increased health care costs to the consumer, since different communities experience different increases in fees according to local rates of opting out,
4) an accentuation of the traditional disparity between the health care received by the poor and that received by the wealthy, through encouragement of the two-tiered "public" and "private" patient models,
and thus 5) the destruction of the basic principles of Medicare.

THEREFORE, the Medical Reform Group
1) opposes opting out or extra billing by physicians; for the reasons given above, it is not an acceptable solution to doctors' dissatisfaction with the present OHIP system,
2. calls for immediate action by the provincial government to develop alternative systems of payment for physicians' services which will
a) end the practice of opting out
b) deal with physicians' and patients' dissatisfactions with the present OHIP system,
c) safeguard the right of Ontario citizens to quality health care with equal access for all,
3) calls for a public list of opted in and opted out physicians as an interim measure to aid health care consumers and to make the present situation a matter of public knowledge.

APPENDIX C FUNDING OF HEALTH CARE

Resolution adopted by the Medical Reform Group of Ontario October 14, 1979.

WHEREAS the percentage of the Ontario budget spent on health care continues to decrease,

WHEREAS many existing community projects are being cut, or forced to close,

WHEREAS there have been massive hospital bed closures which have not been compensated for by opening more appropriate facilities, and massive layoffs of hospital staff that have adversely affected the quality of care,

WHEREAS OHIP premiums constitute a form of regressive taxation, with lower income citizens paying a higher proportion of their incomes in premiums,

BE IT RESOLVED THAT
1) The health care cutbacks be reversed.
2) The health care budget be increased yearly to at least keep pace with inflation.
3) More money be allocated to the important areas of preventive medicine and community-based services, and this money not come from cutting other essential services such as education and social services.
4) Until alternate facilities exist, hospital bed cuts be stopped and wards re-opened to shorten waiting lists for care.
5) The important role of all health workers be recognized and cutbacks in staffing be reversed.
6) OHIP premiums be abolished and funding for health care come from progressive forms of taxation.

BE IT RESOLVED THAT the MRG pass the above resolution as statements of principle, and to serve a guidelines for future work in these areas.

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