
                       TOO MANY, TOO FAST, TOO MUCH?

                             By SHARON KIRKEY
                              Ottawa Citizen

     OTTAWA - MD, the initials that command power, prestige and respect,
     have become the signature of one of the greatest threats to
     Canada's health care system.

     Collectively and individually, doctors are playing a significant
     role in driving up health costs.

     Physicians deny it, but observers contend Canada's mushrooming
     health spending can be traced to an oversupply of doctors, and a
     fee-for-service system that rewards them for cramming as many
     patients and services as they can into a day.
     Canada has been pumping doctors into the system at four times the
     rate of population growth. From 1979 to 1989, the number of doctors
     practising in Canada shot up 41 per cent, while the population rose
     a modest 10 per cent.

     In any normal market, a dramatic increase in suppliers would
     produce fierce competition for customers, and costs would fall.

     But in what health economist Richard Plain calls the ``lunatic
     economics of Canadian medicare,'' there's considerable evidence
     doctors are creating their own demand.

     Health and Welfare Canada figures show that, over the past decade,
     the number of medical services being billed to medicare is rising
     in direct proportion to the increase in doctors - not to the
     increase in population.

        See also <01health -per 571> for statisitics on doctors

     Doctors say it's a coincidence, but critics like Plain are
     convinced many physicians are seeing patients more often than they
     should, and performing tests and procedures that aren't needed, in
     order to maintain their incomes.

     They say that unless doctors put a stop to rocketing health costs,
     governments must do it for them.

     That means reducing the number of doctors practising in Canada by
     capping medical school enrolments, putting limits on how much
     doctors earn, restructuring the way they are paid and expanding the
     role of other health care professionals - people like nurses and
     midwives who can provide cheaper care where doctors' skills aren't
     really needed.

     Doctors say they're under siege by politicians and critics looking
     for a scapegoat for the country's health care woes, and that
     politicians have no business meddling in medicine.

     ``This thing about physicians eating out of the public trough and
     wanting to overservice patients is unfair and untrue,'' said Dr.
     Hedy Fry, a Vancouver family doctor and president of the British
     Columbia Medical Association.

     Fry said doctors are willing to look at ways to help reign in
     galloping health spending. But she warns governments will court
     disaster in the long run if arbitrary limits are imposed on their
     professional freedom.

                                   * * *

     There's a sleek, modern clinic in downtown Toronto that promises
     prompt medical attention for patients in a hurry.

     At Health First Inc. on Church Street, you can walk in off the
     street without an appointment and usually see a doctor within 20
     minutes. No fuss, no hassle, few questions asked.

     Storefront walk-in clinics like Health First have become an
     exploding phenomenon in major Canadian cities. But their detractors
     refer to them as ``docs in a box,'' and say they're the single
     greatest proof of Canada's glut in physician supply.

     Most doctors working in these clinics don't have hospital
     privileges. That's because there aren't enough hospital beds to go
     around for the 1,500 new doctors being churned out of Canadian
     medical schools each year.

     Meanwhile, doctors in private practice are marketing themselves
     more aggressively. Some have begun taking out display ads in yellow
     pages. Medical publications like the Canadian Medical Association
     Journal have begun running articles on marketing tips to improve
     ``profitability'' and productivity.

     Health economists have been warning for years that Canada has too
     many doctors.

        See <19health> for a discussion of nurses' role in health care

     The World Health Organization recommends one doctor for every 600
     residents. In 1964, Canada had one doctor for every 800 people. By
     1989, the ratio had plunged to one for every 515.

     One federal-provincial study warns Canada is facing an oversupply
     of 6,000 doctors by the end of the century, costing taxpayers $3
     billion a year.

     Dr. Adam Linton, vice-president of the Ontario Medical Association,
     said the WHO figure was ``just plucked out of the air,'' and that
     there's no conclusive evidence that Canada has too many doctors.

     Still, figures show that almost everywhere the supply of doctors is
     outstripping the supply of patients. Yet doctors have managed to
     maintain their position as the highest paid workforce in Canada.

     In 1988, the latest statistics available, the average self-employed
     doctor in Canada earned a gross income of $113,810, although out of
     that they pay overhead expenses.

     In Ontario, the average gross payment to doctors was $174,000 in
     1988, and $159,000 in Alberta. Doctors in specialties such as
     dermatology and ophthalmology gross, on average, more than $250,000
     each year.

     Doctors point out that physician incomes make up only about 16 per
     cent of the nation's total medicare bill.

     But doctors also influence spending on hospitals and drugs - you
     can't get a hospital admission, or a prescription drug, without a
     doctor's approval - and those costs have more than doubled in the
     past decade.

     In Alberta, the number of doctors has increased 50 per cent over
     the past decade, while the population rose just 18 per cent.
     Physician billings to Alberta Health Care rose 213 per cent, while
     the cost of lab tests shot up 300 per cent.

     In Ontario, payments to physicians soared 55 per cent from 1986 to
     1990 while government spending on prescription drugs shot up 300
     per cent.

     Dr. Ray Hulyk, head of the Alberta Medical Association, said
     doctors are only responding to increasing demand from consumers who
     believe they have a fundamental right to all the cradle-to-grave
     health care they want.

     But Pam FitzGerald, executive co-ordinator of the Canadian Health
     Coalition, insists a portion of the spending can only be linked to
     what she calls the crude phenomenon of ``revolving door medicine.''

     Last year, a Toronto physician was accused of professional
     misconduct for failing to provide lawyers with a medical report of
     a patient who was trying to get compensation for injuries she
     suffered in a car accident.

     During a disciplinary hearing, the doctor testified he was ``too
     busy'' to send the report because he was seeing 400 to 500 patients
     each week.

     ``Five hundred patients a week! How can you possibly provide
     quality medical care if you're seeing 100 patients a day?'' said
     Dr. Michael Rachlis, a Toronto physician and founding member of the
     Medical Reform Group of Ontario.

     Committees of doctors appointed by provincial governments use
     computer analysis to spot doctors whose patterns of practice and
     medicare billings are significantly different from the average for
     their type of practice.

     Some provinces have recovered more than $1 million in one year from
     physicians who charged for unnecessary services, or for services
     that were never performed.

     But critics says the system doesn't scrutinize the average doctor,
     just those whose billing patterns are alarmingly abnormal. And only
     10 per cent of doctors who are suspected of abusing the system are
     ever referred to the College of Physicians and Surgeons for review.

     College registrar Dr. Michael Dixon blamed the low percentage of
     referrals on the college's lack of success in proving cases.

     Even when a committee unanimously agrees that a doctor sees a
     patient too often, or charges for procedures that aren't needed,
     the decision is often overturned on appeal because it boils down to
     one doctor's opinion against another's.

                                   * * *

     Critics say the way to improve the system is to revamp the way
     doctors are paid and stem the tide of new doctors.

     The vast majority of Canada's doctors - an estimated 80 per cent -
     work under the fee-for-service system, as opposed to salaries.

     Under this system, doctors are paid a pre-determined fee for
     virtually everything they do. For example, in Ontario, a
     consultation by a general practitioner costs $48.30. To increase
     income, a doctor only has to pump up volume.

     Dr. Bill Canham, head of the Nova Scotia Society of Medicine, said
     doctors are much more ambivalent on fee-for-service today than they
     were 10 years ago, when it was viewed as ``the greatest thing since
     sliced bread.

     Physicians like Rachlis recommend that governments set aside a lump
     sum each year to pay doctors, instead of simply negotiating fee
     increases, as is done now in most provinces. He also recommends
     that more doctors be encouraged to work on salary, and that some be
     paid per patient, rather than per procedure.

     Ontario has been perhaps the most progressive province in terms of
     alternative payments schemes for doctors through its network of
     community health clinics - where doctors are paid a salary.

     Since 1987, the number of CHC's in Ontario has risen from 13 to 33,
     and the government expects another 20 to be approved in the next 18
     months.

     Another approach has been adopted by Quebec, which limits the
     amount general practitioners can bill during each quarter of the
     year. Doctors get only 25 per cent of the normal rate once they
     exceed the ceiling.

     To address the imbalance of doctors between cities and rural areas,
     the limit is higher in remote regions but new doctors in
     overserviced areas - Montreal, Sherbrooke and Quebec City - get
     only 70 per cent of the rate during their first three years.

        See also <17health> for a discussion of rual doctors

     But Rachlis said no reforms will be successful unless steps are
     taken to curb the number of new doctors entering the system. He's
     calling for a 30-per-cent reduction in medical school enrollments,
     beginning in September.


