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News Release

A Brief from the Medical Reform Group of Ontario
to the Legislature Standing Committee on Social Development on Bill 94

March 4, 1986

The Medical Reform Group was constituted in the fall of 1979 to provide a voice for physicians who believe:
1. Health care is a right that must be guaranteed without financial or other deterrents.
2. Social, economic, environmental, and occupational conditions mast be recognized as causes of ill health.
3. The health care system must be changed to provide a more significant decision-making role for other health care workers and the public.
Voting membership in the Medical Reform Group is open to any physician or medical student who agrees with the organization's statement of principles. Since its establishment, the group has actively campaigned to preserve and improve medicare. It has lobbied the federal and provincial governments for a ban on extra-billing. The group has made presentations to the Hall Review of Medicare, the Parliamentary Task Force on the Established Program Financing Act, and the House of Commons Committee on Health and Welfare.

The Need for the Health Care Accessibility Act
Most of the members of the Medical Reform Group are family physicians. We are reminded on a regular basis of the need for a ban on extra-billing. While we recognize that some of our opted-out colleagues have been conscientious in their billing practices, there have been far too many instances where people have been hurt. We have seen patients on welfare extra-billed. We have seen senior citizens on fixed incomes who have been extra-billed. There are also surveys that show indiscriminate billing practices. Professors Chris Woodward and Greg Stoddart of McMaster University conducted a study for the Hall Review in 1980 in counties of Ontario where there were high rates of opting-out. They found that over one-third of poor people had been extra-billed. They also discovered that nearly 20% of people had reduced their use of medical services because of fear of an extra bill and that nearly 5% of people said they had not sought medical attention for a sick child because of such concerns.

There are more comprehensive data from Alberta which show the same trend. The Alberta medicare plan has data on the dollar amounts of extra-billing by medicare registration category. Professor Richard Plain of the University of Alberta found that poor people (those receiving full or partial subsidy for their medicare premiums) paid nearly the same in extra-billing as those receiving no subsidy. Senior citizens were charged more than those receiving no subsidy. This may reflect the fact that the poor and elderly have more needs for medical services.

It must be admitted that it is very rare for a physician to refuse to see a patient who will not pay an extra-bill. More commonly an opted-out physician will refer such a patient to his or her outpatient clinic. Since 1978 all Ontario physicians have been permitted to be opted-out in their private offices while billing CHIP directly from hospital outpatient departments. This enables them to reduce their bad debts by so-called "practice streaming". Economists refer to this as price discrimination. It should be added at this point that this partly explains why only 5 or 6% of services are billed to patients directly even though 12% of physicians are opted-out.
It is acknowledged that the care in some outpatient clinics is indistinguishable from the care in a physicians private office. However, in many teaching hospitals this is not the case. The patient is seen by a clinical clerk (fourth year medical student) or intern under the direct supervision of a resident (specialist in training). The staff doctor may or may not see the patient and his or her involvement may be quite minimal. The housestaff
turn over frequently so there is poor continuity of care. This may be the most ominous aspect of extra-billing. It leads naturally to the two-tiered system of medicine Canadians rejected with the adoption of medicare.
Political and economic rationale for the legislation

The Ontario Medical Association and the Association of Independent Physicians have raised a number of objections to the proposed Health Care Accessibility Act. Many of them seem plausible at first glance but do not hold up to closer examination. Some of the criticisms levelled at the proposed legislation include:

1. The OHIP fee schedule provides no bonus for experience or expertise with junior doctors billing the same for particular services as their more senior colleagues.
2. Opted-out doctors are better doctors.
3. Opted-out doctors can provide a better service to their clientele by spending more time with than and having shorter waiting times for appointments.
4. Many of Ontario's doctors will leave the province if they are forbidden to extra-bill.
5. Ontario's doctors will became civil servants and lose the freedom to practice medicine as they see fit.
6. Public opinion supports a continuation of extra-billing.
7. Legislation on extra-billing will inevitably lead to capping of incomes, restrictions of OHIP billing numbers, and other curbs on the traditional privileges of the medical profession.
8. Physicians will lose a "bargaining lever" for fee negotiations.

We should like to deal with these arguments in their turn.

The Ontario Medical Association is itself largely responsible for the OHIP fee schedules failure to reward excellence. The OHIP fee schedule was adopted directly from the OMA schedule in 1971 and set at 90% of its value. This was because both the profession and the government estimated that 10% of doctors fees went uncollected prior to medicare. The OMA list of fees, which has existed since 1922, has never had special bonuses for expertise or experience. Officials within the ministry of health have said privately for many years that they would be prepared to consider any system of merit pay for physicians as long as the total bill for physician services were not increased.

The evidence shows little difference in practice styles between opted-out and opted-in doctors. Professors Alan Wolfson and Carolyn Tuohy of the University of Toronto conducted an exhaustive survey of opting out which was published by the Ontario Economic Council in 1980. They found no difference between opted-out and opted-in doctors practices in patient loads, hours of work, or waiting times for appointments. There is no good evidence that on average opted-out doctors spend more time with their patients.

There is no evidence that opted out doctors are more skilled than their colleagues. Few doctors are opted out in northern or eastern Ontario. Few general practitioners, pediatricians, or internists are opted out. Opting out is concentrated in a few specialties (anesthesia, obstetrics, psychiatry) and geographical locations (Toronto and the golden horseshoe). To say that better doctors opt out is to say few g.p.'s or northern physicians are superior.

There is little fear that doctors will flee Ontario when the Health Care Accessibility Act is made law. All provinces except New Brunswick and Alberta already have some prohibitions against extra-billing. The United States has more doctors per capita than Canada and all the desirable practice locations are occupied. It is also extremely unlikely that many highly skilled specialists will leave. These doctors could have left Ontario years ago and made at least three times as much money in the United States. They are not likely to leave Ontario now despite their protestations. They are likely to stay for the same reasons we all live here. We have our families, our friends, our communities, and a quality of life that is unmatched anywhere.

Additionally, medical practice is becoming problematic for many physicians in the United States. With the explosive development of health maintenance organizations in the U.S. over 25% of doctors are currently employees and an article in a recent Canadian Medical Association Journal estimated that by the year 2000 over 50% of doctors will be employed by others. In some of these work situations physicians are asked to treat patients by protocol. They are told when their patients should leave hospital and what lab tests to order. Physicians within OHIP have nearly complete freedom to treat their patients as they see fit.

Physicians will not become civil servants with the passage of the Health Care Accessibility Act. Doctors within OHIP have no conditions imposed on their work. They can set their hours, take as much or as little vacation as they wish, and work with whom they wish. They cannot be considered to be Employees by any definition of the word. They may lack benfits packages but they are able to take advantage of many income tax provisions not available to employees. When one includes the new registered retirement savings plan limits (which move upwards to $15,500 over the next five years) individual doctors may well be better off as self-employed than as employees with excellent benefits.

There is no doubt that the majority of people in Ontario support a ban on extra-billing. Fair worded polls by Goldfarb associates, the Kingston Whig-Standard, and the Gallup organization have shown that 70 to 80% of Ontarioans are opposed to the practice.

Representatives of the Ontario Medical Association have pointed to actions in other provinces which they claim will immediately follow from a ban on extra billing. The government of British Columbia is attempting to restrict the number of medicare billing numbers available in that province. New graduates in the Province of Quebec may bill that province's medicare plan for only 70% of the normal tariff if they practice in well-doctored urban regions. The view that these actions are either automatic complements to legislation on extra billing or impossible without such legislation is politically naive. In Ontario the population of physicians is increasing at a more rapid rate than the population as a whole. There are still severe problems in distribution with some northern and remote areas chronically short of physicians while Toronto and other urban areas in the south continue to see their numbers of doctors increase. The OMA cannot prevent government action for these problems by fighting legislation controlling extra billing. Instead physician organizations should respond in a meaningful fashion to these problems if they wish to prevent what they regard as infringements on their freedom.

While it is true that doctors did achieve better increases in the OHIP fee schedule in the early 1980"s after opting out increased in 1979, there is no particular reason to believe these two events are causally linked. Doctors did well because the rate of inflation fell, unexpectedly, after the 1982 settlement. This was quite a chance event much as the high inflation and subsequent wage and price controls of the mid-1970"s which decreased doctors relative incomes. Doctors in Alberta have done very poorly the past 3 years despite their ability to extra bill. Doctors still have many "bargaining levers" without the recourse to extra billing. They provide the most essential of services and, in public opinion surveys, are consistently at the top in the rankings of occupations.

Competing Rights
The Ontario Medical Association has claimed that the proposed Health Care Accessibility Act is an infringement on their economic rights. We physicians within the Medical Reform Group acknowledge this point but feel that the public also has a right to quality health care without financial deterrents. In attempting to adjudicate between these competing rights we should remember the following points:

* The government has given the medical profession a legislated monopoly on the delivery of medical services.

* One cannot consider the delivery of medical services as amenable to examination by traditional economic tools because the patient is almost never a fully-informed consumer. She relies upon the physician to act as her "agent" in "purchasing" various services.

* A physicians education is almost totally paid for by taxpayers. It is estimated that a physician's training costs well over $100,000. Although interns and residents work excessive hours, they now earn more than the average Canadian family.

* Physicians carry out much of their work in publicly-financed hospitals. They are provided with expensive equipment and skilled staff to assist with the care of their patients. This is particularly true of specialists who constitute approximately 75% of the opted-out group.

* The public guarantees payment to physicians through OHIP. Unlike other "small businesses" opted-in physicians do not have to worry about collecting bills.

* The College of Physicians and Surgeons forbids the advertising of medical services. One cannot have a true market if information regarding the "product" is suppressed.

* Finally, health care is not a commodity like any other. It is an essential service. Perhaps Justice Emmett Hall said it best in the report of the Royal Commission on Health Services (1965).

"The emphasis on the freedom to practice should not obscure the fact that the physician is not only a professional person but also a citizen. He has moral and social obligations, as well as self-interest to do well in his profession. The notion held by some that the physician has an absolute right to set his fees as he sees fit is incorrect and unrelated to the mores of our times. This nineteenth century laissez-faire concept has no validity in the twentieth century in its application of medicine, dentistry, law, or to any other organized group. Organized medicine is a statutory creation of legislatures and parliament. When the state grants a monopoly to an exclusive group to render an indispensable service it autcmatically becomes involved in whether those services are available and on what terms and conditions."

Bill 94
The government has chosen the so-called Nova Scotia model instead of the so-called Quebec model. Since these terms have been sometimes used rather loosely it may be advisable to clarify them.
Quebec passed legislation to eliminate extra-billing in 1970. The law allows three options to physicians.

1. The physician may elect to participate in the plan, bill the plan, and accept payment from the plan as payment in full.

2. The physician may elect to participate in the plan and bill the patient directly. The medicare plan reimburses the patient and the physician must accept this payment as payment in full.

3. The physician may elect to not participate in the plan at all and thereby become ineligible for any plan payment either to himself or to his patients for any of his services.
Nova Scotia passed legislation to eliminate extra-billing in 1985. Their legislation provides for options 1 and 2 of the Quebec legislation but not option 3. Ontario's proposed legislation is similar to Nova Scotia's. Manitoba has already passed this type of legislation while Saskatchewan aand British Columbia have passed legislation as in Quebec.

The Nova Scotia Style legislation is more restrictive than the Quebec one. We see some philosophical advantages to the Quebec "model" but we are sympathetic to the practical considerations which may have caused the government to abandon it. The Ontario Medical Association has refused to discuss the style of legislation. Dr. Myers, president of the OMA said to a television interviewer on January 20, 1986, that he didn't want "any model". It could certainly be anticipated that if the government passed Quebec style legislation the OMA or its local affiliates would organize mass non-participation. This would force the government to assess if accessibility was compromised and if it was to somehow force some doctors to participate with OHIP. Neither of these actions would be easy. The Medical Reform Group would support the Quebec model only if the OMA agreed not to use mass non-participation to defeat the intent of the legislation.

The Medical Reform Group does have some reservations about the option for physicians to opt out in the proposed legislation. It currently takes two to three weeks for OHIP to reimburse patients for services for which they were directly billed. If the OMA is successful in encouraging its membership to directly bill their patients, it may be anticipated that this period may be extended by several weeks. If a physician insists that the patient pay the bill before OHIP reimbursement, this could cause hardship for some patients. It may even deter some people from seeking care. Thus, the Medical Reform Group recommends that an amendment be made to the legislation to forbid an opted-out physician from asking for payment until the patient has been reimbursed from OHIP.

Other issues
The Medical Reform Group is concerned that so much attention has been paid to the extra-billing issue at the expense of other issues which affect the health care system. However, we would like to re-emphasize its importance in terms of preserving medicare. Professor Robert Evans, of the University of British Columbia has said that when one is in a leaky boat in the middle of the ocean one must fix the leak before one can determine in which direction to sail. We believe that extra-billing and other user charges are the leak in the boat of medicare. After extra-billing is banned we must decide what direction our health care system should take.
The Ontario Medical Association has stated that the issue of extra-billing is a "smoke screen" for the real problem facing the health care system which is claimed to be underfunding. They have claimed that there should be no action taken on extra-billing until the whole health care system has been investigated. . The Canadian Medical Association made similar claims in 1983 when the federal government was developing the Canada Health Act. The CMA commissioned a task force to investigate the adequacy of funding of Canada's health care system. The formal name of the commission was The Task Force on the Allocation of Health Care Resources. Its chair was Ms. Joan Watson. The other members were Hon. Pauline McGibbon, Roy Rcmanow, Dr. O'Brien Bell, and Dr. Leon Richard.

The commission held hearings across Canada and received submissions from hundreds of individuals and organizations. The CMA paid all the expenses which were estimated at over one-quarter of a million dollars. The task force found Canada's institutionalization rate for its elderly to be nearly double that of the United States or Great Britain. They concluded:

"A major problem identified is that if we continue to put old people in institutions at the rate we do now, the costs will not only be prohibitive, we will perpetuate the callous practice of 'warehousing' the elderly. Old people do not want to live in institutions."

Considering that we are already so well endowed with institutional beds for our elderly in Canada and Ontario how do we, the committee, or the people of Ontario at large explain the fact that we continue to see news items about how we need more nursing home beds because acute care hospitals are "clogged" with chronic patients? The commission found that there would be no need for new hospital beds before 2006 if the rate of institutionalization of the elderly in Canada were reduced from 9.45% to 6.0%. The rates in the U.K. and the U.S. are 5.0 and 5.3% respectively.

The commission further noted that there are problems associated with much of the highly touted new technology. Some modern technologies can indeed achieve remarkable results, but some may be useless or even dangerous. The commission expressed concern for the inadequacy of present evaluation procedures.
Finally, when the task force attempted to answer their major question of the adequacy of funding for the system they said,

"We cannot assess the extent of existing inefficiencies, and because there is no guarantee that putting more money into the system is necessarily the best way to improve health, the Task Force cannot make a clear cut recommendation."

The Medical Reform Group feels it is important to consider the issues which the task force raises. Although other inquiries into the health system have arrived at similar conclusions, this study was financed by the medical profession. The Ontario Medical Association claims that the health care system is underfunded and has asked its members for additional money to fight medicare three times in the past six years. It has never distributed the CMA report. The CMA charges for copies.

The Medical Reform Group does agree with the OMA that it would be worthwhile to have a full investigation of Ontario's health care system. There have been previous studies and some might argue that we already have the answers. However, a quick look shows that the public and most health care workers are poorly informed on the issues. The time is ripe to educate the people of Ontario and involve them in the development of their health care system.

1. The government and the OMA should develop a fair fee negotiation process. This should involve a grievance procedure which would cover all issues related to physician remuneration including income capping and utilization restrictions. There should be provision for binding arbitration with a ban on a legislative veto.
2. The government should establish a Royal Commisssion on financing of the health care system. It should provide facilities and funds for the public and non-profit organizations to become involved in the process. The commission should investigate alternatives to traditional delivery systems such as community health centres and health service organizations. It should also examine the distribution of physicians and resources.
3. The government should take some simple steps to make medical practice easier. Plastic CHIP cards would facilitate the completion of forms. The Province of Quebec has provided these for a number of years. Better public information on Health Sources would make it easier for physicians who wish to pursue this alternative.
4. Bill 94 should be amended so that patients should not have to pay an opted out physician until he or she is reimbursed by OHIP.

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