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MRG critical of proposed delisting

The following brief was submitted by the Medical Reform Group to the Joint Management Committee Panel reviewing the schedule of benefits.

The Medical Reform Group is critical of the proposed delisting of 19 medical and surgical procedures from the OHIP fee schedule. When the original list of 14 was made public in 1992, we believed this approach to be a serious threat to medicare in the province. Even with the new and more rigorously defined categories, we are still convinced that any focus on delisting continues to risk the creation of a two-tiered system, with no guarantee of any significant decrease in health care costs.

The Medical Reform Group was established in 1979 out of a commitment, by its founders, to the principle of health care as a right, and a recognition of the basis of health as social and political in nature. We agree that the Ministry of Health should consider deletion of services for which there is no proven benefit and applaud their responsiveness to public participation in these discussions and decisions. But it is clear from the `qualifications' of the JMC list that almost every considered procedure has `medical' indications, if by that we mean that we understand health to have a broad definition which includes emotional well-being and quality of life, not just its prolongation. We are alarmed that the 'bureaucratization' of these distinctions will have several effects:

1. Delisted services will have no limit on the fee that the physician can charge. This was our initial fear of a two-tiered system for those who can pay and denial of services to those who can't, but for whom there may be a legitimate need.

2. Delisting encourages direct charges to patients. Third-party billing has essentially delisted the annual health examination (Item 12), which in the absence of any `diagnosis' is most often done at the request of an insurance company, school, summer camp, etc. Many of us in general practice know that `sick note' charges are rarely passed on to the employer, but are `out-of-pocket' expenses for the patient. We are also aware of excessive charges to patients for services such as the transferring of records (e.g. a patient was charged $30 for photocopying of an obstetrical ultrasound report: personal communication, Dr. Rosana Pellizzari). Mr. Bill Mindell, of the City of York Health Unit reported that children were prevented from attending school because parents could not afford to pay a $40 physician fee to complete a Tuberculosis Control form required by public health officials. These are clearly the equivalent of "user fees".

3. Physicians will use their "OHIP-allotted" billings to provide other insured services, challenging the argument that health care costs will, by this approach, be lowered in any significant way. In a fee-for-service system physicians have every opportunity to maintain their incomes.

4. The other possibility is that physicians will be tempted to provide more delisted services, for two reasons -- they are more lucrative and they promise an easier 'physician lifestyle'. 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 am." (Dr. Girotti, Ontario Medicine, 20/9/93).

5. The notion of patient responsibility lives on the borderland of victim-blaming for illness. If we consider travel malaria prophylaxis to be an expense to the traveller (Item 14) what do we do if the prophylaxis 'fails' and our patient returns to Canada with malaria? What about suspected displastic nevi - they are benign but potentially malignant - will they be 'covered'? (Item 9). We are very concerned that we will see a repetition of the 'therapeutic' abortion committees which presumed to judge the 'medical necessity' of a woman's choice.

What seems to be a benign plan on the first glance is not. It may be tempting to 'cut and slash' what appear to be the offending agents of our health care system, but our precious energy needs to be re-directed to substantial reform of a primary care system that has revealed its weaknesses. The Medical Reform Group has repeatedly called on provincial governments to reform the delivery of primary health care. We have strongly supported alternative methods of physician remuneration and have called for the recognition of other health care workers in the system. We advocate that the fee schedule apply only to specialists, laboratories, and diagnostic imaging services and that primary care be based on a salary or capitation system which includes monitoring and accountability. We ask the NDP government to abandon this misguided and hazardous project to `delist' services, and renew its commitment to the principles of the Canada Health Act - that it be universal, accessible, and comprehensive.

Dr. Rosana Pellizzari and Dr. Mimi Divinsky for the Steering Committee of the Medical Reform Group of Ontario.

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