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News Release
Tinkering with the non-system
November 12, 1993
The Medical Reform Group Steering Committee submitted the following
brief on Bill 50: An Act to Implement the Government's Expenditure
Control Plan, to the Ontario Legislature's Standing Committee on
Social Development, on November 12, 1993.
Introduction
The Medical Reform Group of Ontario is a voluntary organization
of 200 physicians, medical students and others concerned with the
health care system. The Medical Reform Group was founded in 1979
on the basis of the following principles: Health Care is a Right;
Health is Political and Social in Nature; and The Institutions of
the Health System should be Democratized (re-structured in a manner
in which equally valuable contributions of all health care workers
are recognised and decisions are democratized).
The Medical Reform Group (MRG) has repeatedly called on provincial
governments to reform the delivery of primary health care. We support
structures of payment and primary care provision which recognise
and address the social and economic roots of ill health, which are
based on rational planning, accountability, and monitoring and assessment
of results, which give a greater role to non-physicians, and which
favour capitation and salary as payment mechanisms. Over the past
fifteen years, the MRG has encouraged and supported the establishment
of non fee-for-service payment mechanisms, but always in the context
that their introduction would be followed by evaluation in a public
forum with the view to long-term health reform.
While we support the overall provincial initiatives to reform health
care, our criticisms of both the context and the content of Bill
50 are based on our disappointment that the Bill only tinkers with
the existing non-system, leaving the major flaws intact.
SECTION 5
Section 5 repeals Section 45 of the Health Insurance Act, allowing
the de-listing of insured services. We have been calling for a review
of the entire Fee Schedule, within the context of a health care
system where Primary Care providers are salaried or capitated. Thus,
the Fee Schedule would apply only to specialists, laboratories or
diagnostic imaging facilities.
Such a review would require development of explicit criteria to
judge whether a service is medically necessary and should therefore
be insured. It would also require open, public consultation with
health care workers and consumers.
We agree that the Ministry of Health should have the ability to
remove services with no diagnostic or therapeutic value, based on
a review of the scientific literature. We are also aware that there
are many services, such as cholesterol testing or circumcision,
which are medically indicated in only certain circumstances. The
development of criteria, with subsequent audit and feedback requires
physician "buy-in" and compliance. An effective monitoring
system is crucial. We do not promote the model of therapeutic committees,
such as the hospital abortion committees of the past, reviewing
and passing judgement on each case.
We caution government that delisting of services is simply the
first step in major reductions in the range of services that are
covered. This is truly an erosion of our comprehensive health care
system. Delisting can disproportionately affect poor or minority
groups. It can encourage the development of two-tiered medicine,
where ability to pay determines access to needed services. It can
facilitate the shift of physicians, trained with public funds, away
from the public system and into the private one, providing delisted
services to the wealthy or the privately insured.
When services become delisted, the government forfeits its ability
to set the price. We urge you to consider what has happened in cosmetic
surgery, where market forces of supply and demand set the price.
There is tremendous potential for profit if services are delisted
and providers can charge what the market will bear. Within the medical
profession, there is significant support for delisting as the opportunity
to increase incomes. To quote a Chief of Surgery: "If doctors
can set their own fees for these (delisted) services, and in a sense
work outside the system, why would they continue to treat trauma
patients? This way they make good money and don't have to get up
at 2 a.m." (Dr. Girotti, Ontario Medicine, September
20, 1993).
In addition to creating a two-tiered system, delisting services
and allowing third party payment for uninsured services, such as
notes for absenteeism, camp or school physicals, completion of welfare
forms or immunization records, allows physicians to offload charges
onto individuals and others. We are already aware of excessive charges
to patients for services such as transferring of records (e.g. patients
being charged $30.00 for a copy of an obstetrical ultrasound report)
and are aware of children being prevented from attending school
because parents could not afford to pay their doctor $40.00 to complete
a Tuberculosis Control form required by public health officials.
Is this what we hope to accomplish? The answer seems clear: true
health reform should promote and strengthen the health of all Ontarians.
The amendments proposed in Bill 50 present a narrowly focused attempt
to contain costs and restrict access while maintaining physician
incomes.
SECTION 6
Section 6 allows for regulations to stipulate different fees for
similar services, dependant on the provider, location or a combination
of the above. The OMA has interpreted this section as the legislation
necessary for government to pay new doctors differently than more
senior ones, specialists differently than general practitioners,
doctors setting up practice in over-serviced areas differently than
those establishing themselves in under-serviced areas.
The current fee-for-service payment system has contributed to the
maldistribution of human, i.e. physician, resources. By capitating
general practitioners, and by requiring that all Ontario residents
register with a practice, physician distribution will be linked
to population distribution. The use of funding envelopes would facilitate
needs-based resource planning, and provide more resources to communities
where geography or social-demographics necessitate greater or different
modalities.
We agree that the government should have greater ability to determine
fees in a reformed system, particularly if, as anticipated, the
Regulated Health Professionals Act broadens the choice and availability
of health providers. We caution that it not be the exclusive or
even major strategy to solve problems of access or efficiency.
SECTION 7
This amendment gives government the ability to limit services to
a specific number within a prescribed amount of time, as in the
case of eye exams and psychotherapy. Services exceeding the ceiling
could be paid at reduced amounts, or not at all.
At first glance, this amendment appears desirable in that it would
allow for the implementation of evidence-based practice guidelines.
However, setting predetermined restrictions within a fee-for-service
context may only serve to create more bureaucracy and frustration
if it forces providers or consumers to complete more paper work
and undergo delays in accessing necessary services.
Physicians and other providers, practising outside the context
of fee-for-service would not experience a monetary incentive to
provide unnecessary services, such as additional eye examinations
or superfluous psychotherapy. On the other hand, if a client needed
more than average services, there would not be the hassle or delay
of seeking exemption, as currently exists with delisted products
in the Ontario Drug Benefits formulary.
We would then be able to focus on improving clinical decision making
based on scientific research and intellectual debate, rather than
pre-determined rates. Strategies such as academic detailing, audit
and feedback are probably more effective than the scenario created
by Section 7. We know how powerful monetary incentives are, and
they could be utilized to promote and reward effective and efficient
clinical practice once we have the information systems and outcome
measures to facilitate the proper use of clinical guidelines.
SECTION 8
Section 8 grants broad powers to the government to introduce regulations
to control expenditures and the supply and distribution of physicians,
practitioners and health facilities. The MRG supports informed and
democratic resource planning and allocation. We are not surprised
that despite years of discussion and a healthy bank account, the
medical profession has failed to address this longstanding issue
of human resource planning.
The MRG hopes that these amendments will not be ends to themselves,
but will facilitate opportunity for population based planning and
resource allocation based on reliable indicators of need and effective
strategies of demonstrated effectiveness. We support a more accountable
system than presently in place, with better monitoring and consistent
use of <%-2>outcome evaluation for decision-making.<%0>
CONCLUSION
The Expenditure Control Plan continues to support the present fee-for-service
structure of physician payment, which promotes volume and creates
incentives for the provision of unnecessary services. The Medical
Reform Group supports amendments to the Health Insurance Act which
allow for better resource planning and a diversification of providers,
such as Nurse-Practitioners, Midwives, Social Workers and others,
in a new model of primary health care delivery such as is currently
present in community health centres and some health service organizations.
By introducing expenditure controls without addressing fundamental
reform of the system, we worry that access will be seriously eroded
and that both real and perceived barriers and restrictions breed
further public discontent and disillusionment with the future of
a universal and comprehensive health plan. This would provide existing
proponents of privatized, two-tiered medicine, with the fuel to
further dismantle Medicare.
Subject Headings: Abortion
Rights – Community
Health – Community
Health Centres – Drug
Substitution – Epidemiology
– Epidemiology/Community
Medicine – Health
Administration – Health
Care Budgets – Health
Care Cost Containment – Health
Care Costs – Health
Care Delivery – Health
Care Finance & Fund-Raising – Health
Care in Canada – Health
Care in Ontario – Health
Care in the U.K. – Health
Care in the U.S. – Health
Care Myths – Health
Care Reform – Health
Care Resources – Health
Care Services – Health
Care Workers – Health
Clinics – Health
Determinants – Health
Economics – Health
Expenditures – Health
Issues – Health
Policy – Health
Policy/Seniors – Health
Service Organizations – Health/Social
Justice Issues – Health
Statistics – Health/Strategic
Planning – History
– Hospitals
– Labour
Medicine – Medical
Associations – Medical
Costs/Foreign – Medical
Education – Medical
Ethics – Medical
Human Resources – Medical
Personnel – Medical
Research Funding – Medicare
– Medication
Use – Medication
Use/Seniors – NAFTA/Health
– Occupational
Health & Safety – Patients'
Rights – Pharmaceuticals
– Physician
Compensation – Physician
Human Resources – Pro-Choice
Issues – Public
Health – Publications/Health
– Social
Policy – Women's
Health
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