The issue of extra billing by doctors— charging patients above the level already paid for by provincial government health plans—represents a major challenge to Canada’s health care system. Under the Canada Health Act, the federal government can withhold transfer payments from provinces where doctors extra-bill patients. So far, six provinces have outlawed extra billing. In Alberta and Ontario the issue has sparked heated controversy. Last December, Ontario Premier David Peterson’s government proposed legislation which it claims would guarantee universal accessibility to medical care by banning extra billing. The bill, now before public hearings, has inflamed an already sensitive debate. Maclean’s assistant editor Janet Enright recently interviewed two of the key opponents in the battle, in Toronto.
Dr. Hugh Scully is chairman of the 1,700-member Ontario Medical Association (OMA), a professional organization fighting for extra billing. The doctors’ main concern is that the Ontario legislation will lead to total state control over medicine.
Maclean’s: Do you agree with the principle of medicare?
Scully: Absolutely. The profession has always agreed that it is very important that all citizens have access to goodquality care and that there should not be any important or significant barriers to that access. [But] that isn’t to say that a government can afford to cover all the costs.
Maclean’s: But would not extra billing represent a barrier for some patients seeking health care?
Scully: And we’re quite happy to look at it in the context of the accessibility of the whole system. Physicians would be prepared to discuss and negotiate the principle of extra billing in the context of a review of accessibility problems generally.
Maclean’s: Why are doctors so concerned over the issue of extra billing? Scully: The profession sees its freedom of choice being taken away. It would allow the government to say why, where, when, how much and whom physicians could treat. That has happened in some other provinces. In Quebec, there has been [a ceiling placed on] incomes and a staggered fee schedule in an effort to redistribute medical manpower, which has not worked.
Maclean’s: But Ontario’s legislation is only concerned with extra billing.
Scully: The only issue that it addresses is extra billing. We don’t agree that extra billing is the major impediment to accessibility. There are many other areas of difficulty which are more important. And not one of those is addressed in that legislation. [They include] current funding mechanisms, [the avail-
ability of] cancer treatment, emergency care facilities, mental health facilities, the psychiatric hospital situation, construction, manpower. There is a need for more or better convalescent and chronic care outside the acute care institution. If we don’t do something different, every bed in the province will be filled in 20 years’ time. That means that you and I won’t be able to get treatment. Maclean’s: But is it not the job of government, rather than doctors, to ensure that medical services are evenly distributed to everyone?
Scully: People don’t get what they require. All governments are under financial constraints. The costs have gone up at a rate greater than inflation because of labor contract settlements within the
hospital and community health arenas, [and] because of negotiations between the medical profession and government with regard to the government insurance scheme.
Maclean’s: It appears that negotiations between doctors and government have broken down.
Scully: There were many discussions during the fall, both privately and in small groups, between the OMA and the secretary of cabinet, the premier, the health minister and other cabinet ministers. The premier indicated privately that the government was in a difficult position to provide first dollar coverage [total financial support] for everybody. Maclean’s: The legislation offers doctors a choice to opt out of or stay in, the public insurance scheme. But it does not allow them to bill above the government insurance rate. Is the issue the freedom to choose how much they charge their patients?
Scully: From my perspective it is not a money issue. The issue is what the legislation empowers the government to do. Where a degree of control has been exercised elsewhere in this country, within 10 to 15 years the quality of care has deteriorated.
Maclean’s: Has medical care deteriorated in Quebec?
Scully: Yes, relative to where it was 15 years ago.
Maclean’s: Your fees have increased 10 per cent since 1982—considerably more than the rate of inflation.
Scully: That reflects what didn’t happen in the 1970s. The present five-year contract has been greater than inflation partly because in the 1970s the medical profession was way behind. The contract was intentionally structured as a catch-up. If you look at the actual adjustment for inflation, it has not been out of line at all.
Maclean’s: For at least the past 25 years doctors have been ranked by Revenue Canada as having the highest income in the country. Would your concerns about extra billing be easier to get across to the public if doctors were not so wealthy? Scully: Not at all, and I don’t think the question is pertinent. You keep bringing this back to money. I’m not going to get into a discussion about a physician’s income in this context of extra billing. That is a completely separate issue. Maclean’s: What is the middle ground? Scully: Something between the government position and our position—which is one of constructive co-operation rather than taking shots from the sides,
The Ontario government's health care accessibility act (Bill 9k) banning extra billing by doctors could be passed as early as May. Should the bill become law, it would levy fines of as much as $10,000 for extra billing. Leading the Ontario government's attempts to sell the bill, both to doctors and the public, is provincial Health Minister Murray Elston.
Maclean’s: What is wrong with extra billing?
Elston: Philosophically, the question has to be addressed: is Ontario going to allow itself to fall behind the rest of Canada? The other question is: are we going to take ourselves back 20 years and take steps which probably would undermine our medical care program?
We have decided that people who come to live here, people who are born here, whether rich or poor, man or woman, are entitled to receive medical care. It is one of the most prized parts of our social system.
Maclean’s: Is it possible that part of the problem right now is that doctors see themselves differently from the way society perceives them?
Elston: I think that, in terms of philosophical standpoints, they are still servants of the patient. But stories indicate quite clearly that our system is not working to the extent it should. Doctors in Alberta were extra-billing welfare patients. Those indicators tell me and the public that our medical insurance program is being undermined, and we can’t have that.
Maclean’s: Many Ontario physicians point to British Columbia, where the government tells doctors where, geographically, they can practise, or Quebec, where doctors are told how much money they can earn, as proof that there is a drift toward greater government control over their profession.
Elston: That’s not what this [legislation] is about. It is very short; it’s not complicated. The only other thing [apart from banning extra billing] that is in that legislation is a mechanism which requires any minister of health to negotiate an acceptable and independent way of setting up the fee structure. Maclean’s: Many doctors say they believe that they should be able to function as businessmen. Should they?
Elston: A doctor sets up his clinic on the basis of a system which provides certain payments. We provide a fair percentage of backup for that business decision. There is not any retailer that can make a decision in the same way that a physician can. We have a health insurance program that guarantees at least a minimum [payment].
Maclean’s: Why is the issue so volatile in Ontario?
Elston: I think this is a major change for some practitioners here. We have a large medical population as well—a very advanced, trained group of physicians. I really do not know why it is more
volatile here—it may be that the profession wants to take one last kick at what its members perceive was a bad decision by the people of Canada in passing the  Canada Health Act unanimously in the House of Commons and in the Senate. I understand that the Canadian Medical Association, with the OMA, is a major driving force with respect to resistance of the Canada Health Act. Maclean’s: Does that mean that what happens in Ontario is pivotal?
Elston: That is probably correct. We clearly have a majority of the people in Canada in a system which prevents extra billing. Ontario must catch up to the rest of Canada, and, if you consider it pivotal, then we have to be very sure that we are going to stand behind our national insurance program, behind the principle of accessibility for everybody. Maclean’s: Since July, 198k, Ottawa has
withheld $50 million a year in transfer payments from Ontario because doctors still practise extra billing. Will those lost revenues be collected retroactively if a ban is implemented and funnelled into the health care system?
Elston: Yes. Anything that has been withheld until the time this bill is passed will come to us providing that we have got everything worked out by April 1, 1987. The premier, the treasurer and the minister of health are counting on it. Look at what we could do with the $50 million per year: $50 million would let us design a 300-bed acute care facility or 500 chronic care beds. It would help deal with the major portion of the cost of redevelopment of Princess Margaret Hospital [for cancer treatment in Toronto], which needs some work. The benefits are going to devolve to the people of Ontario when we have this legislation in place. We are running somewhere around $90 to $94 million held back. Maclean’s: There have been doubts raised in public about your government's ability to withstand a powerful lobby that represents an essential profession.
Elston: I do not see a problem with standing behind our promise to end extra billing. We are expanding to a more universal health care system. And to fall back from an insurance program as it was envisaged 20 years ago would put us under even more pressure than to remove the bill. There is no question that we are getting pressure from a very powerful lobby. But we have nine million people in Ontario and in terms of what they envisage for health care, it is that they won’t have to take their wallets out before they get their medical treatment. We would have more pressure if we fell off our promises. Maclean’s: If this bill passes, is it conceivable that patient care could suffer as a result?
Elston: Look at the radical statements that were issued in 1961 in Saskatchewan about what was going to happen [when medicare was introduced]: ‘You’re tearing apart our entire system.’ Saskatchewan has not fallen apart. What happened? [Saskatchewan] built a better system with a medical profession dedicated to serving patients. And Ontario will build a better system.
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