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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.

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 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 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.

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 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>

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 Sources.

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.

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