It should be a time of joyful anticipation. But for hundreds of Ontario women this summer the sweet news that they are pregnant is being quickly soured by an unforeseen complication—finding someone to deliver their babies. The expectant mothers are caught in the middle of a bitter dispute between the Ontario government and the province’s 19,000 doctors over health-care funding. Leading the charge are a growing number of obstetricians who are responding to recent clawbacks and cutbacks to physicians’ fees by declining to take on new patients. And that has left people like Helen Haggith, a 30-year-old secretary from LaSalle, Ont., near Windsor, in a quandary. Haggith is expecting her second child in February, a delivery that will have to be done by caesarean section. But all 12 obstetricians in the Windsor area, including the one who delivered Haggith’s first child, have joined the protest. “I don’t know what I’m going to do when my due date rolls around,” Haggith told Maclean’s last week. “Do I simply sit in emergency and scream until someone delivers my baby?”
Haggith’s dilemma may soon be faced by thousands of other Ontarians—men and women alike. On Aug. 6, the executives representing nearly 9,000 physicians in 32 specialist fields—from allergists to urologists—agreed in principle on a plan to stop taking on new patients as of Oct. 1. If the
broad membership endorses that campaign in votes to be held next month, it could lay the groundwork for the worst health-care crisis in the province since 1986, when Ontario’s doctors waged a 25-day general strike—the longest work stoppage by physicians in Canadian history—over the issue of extra billing. In fact, the physicians’ demand for more healthcare funding puts them at cross purposes with Premier Mike Harris’s Conservative government, which remains determined to eliminate the province’s $8.2-billion deficit by the year 2001.
The Ontario dispute is strongly reminiscent of recent controversies in Alberta, where Conservative Premier Ralph Klein’s own successful deficit-fighting campaign saw total annual health-care funding reduced by $520 million. As part of that effort, the government cut its physician expenditures to $737 million in the 1996-1997 fiscal year, down 19 per cent from four years ago. The government had planned further health-care cuts but agreed instead late last year to start “reinvesting” money in the health-care system following widespread public unease about the adverse effect the cuts were having on the quality of medical services.
Despite the turnabout, such concerns
persist. Last week, as Alberta MLAs reconvened for a rare summer session, demonstrators marched outside the legislature to protest, among other things, the closure of a downtown Calgary hospital. Inside, the opposition Liberals pounced on some recent highly publicized deaths among hospital and emergency patients, which some critics have blamed on the cutbacks. Noting that the government is now projecting a healthy budget surplus, Liberal Leader Grant Mitchell ^ said: “The premier calls these « people ‘victims of the week.’ § They used to be called our fellow I Albertans, our neighbors, and § we used to care what happened | to them. We’ve got the money. 8 What is the government saving that money for if it isn’t to save lives in this health-care system?”
Passions are also running high in Ontario. “We are trying to sound a warning to the public that the health-care system is unstable because of underfunding,” says David Mendelssohn, a Toronto-based kidney specialist and chairman of the Ontario Medical Association’s specialist coalition. He points out that the government has set a limit of $3.8 billion on total physician billings in the province, a level that is slightly lower than that of 1992. But the population of Ontario has grown by 700,000 since then, he adds, and even the government’s own estimates say that the demand for physician services will top out at about $4.3 billion this year.
That $500-million shortfall has profound implications for patient care in the province, says Mendelssohn, since at some point, doctors will not do work for which they are not paid. Already, Ontario physicians complain that they have seen their incomes seriously eroded. A clawback scheme first introduced by the former NDP government now lops 10 per cent off every doctor’s gross salary. As well, the Tories introduced new billing caps for physicians in July. For example, a family doctor who bills more than $251,000 a year will now receive 67 cents on every dollar billed over that amount; 33 cents on every dollar billed above $276,000 and 25 cents on every dollar billed above $301,000.
But the final straw for many physicians was a decision by the Ontario government earlier this year to stop paying the lion’s share of doctors’ increasingly expensive malpractice insurance. Without that subsidy—which was granted to all physicians in 1986 in lieu of a fee increase—specialists working in the high-risk fields of neuro-
surgery, orthopedie surgery and obstetrics were suddenly on the hook for the full $24,000 a year in insurance premiums. And although the government agreed in June to temporarily reinstate most of the subsidy pending a review of the insurance system, many doctors say that, in the long run, they do not expect the Tories to maintain that level of support.
Richard Johnston, an obstetrician and gynecologist based in Orillia, Ont., readily concedes that, because of their high gross incomes, doctors often find it difficult to elicit much public sympathy about fee cutbacks. But Johnston, who is also chairman of the Ontario Society of Obstetricians and Gynecologists, insists that the income figures are misleading. He notes that between 40 and 50 per cent of an obstetrician’s average $275,000 annual salary goes to pay office staff and overhead. More to the point, he says, delivering babies has become something of a loss leader. With the base fee for delivery set at a mere $300, it makes greater economic sense to concentrate on the gynecological side of his practice where there is a steady stream of patients—and no emergency calls in the middle of the night. “There’s no doubt that staying in your office is far more renumerative than looking after sick people, which is an incredible statement,” says Johnston. “Our fee schedule doesn’t account for sick people.”
Johnston, who stopped taking on new obstetric patients in June, says that, unless
things change, delivering babies is simply not worth the personal stress and the strains on a physician’s family life. And what about the prospective mothers? “Look, most of us like working with our patients, that’s what we went into it for,” replies Johnston. “But we’re also very worried about our own personal health. Fatigue is no defence to leaving a sponge in after you’ve been four days on call. The judge has no sympathy.”
With the prospect of a major work slow-
down by thousands of specialists across the province this fall, the health ministry and the Ontario Hospital Association were immersed in talks last week over possible contingency plans. Among the ideas floated so far: moving the most serious patients to where care is available, even if that means taking them to the United States. At the same time, Ontario Health Minister Jim Wilson insisted that there was no more money available to address the physicians’ concerns. And while he tried to downplay the doctors’ threats as little more than routine contract negotiations, Wilson also al-
The doctors and the province wage The battle of the spin'
lowed that, “If the aim is to make sure that I don’t sleep at night, it’s working.” According to Sid Noel, a political scientist at the University of Western Ontario in London, the government and the doctors are now engaged in “the battle of the spin.” Both sides, he adds, are trying to win over public opinion by painting themselves as the true defenders of medicare. ‘The government will portray it as unreasonable doctors denying care,” says Noel, "while the doctors will say it is an uncaring government refusing to pay for an essential service.” In this contest the doctors may have an inherent advantage. “In rankings of public trust in various professions, doctors always rank very highly,” observes Noel. “Politicians rank right near the bottom.”
That may well explain why Helen Haggith, despite being refused obstetrical care, has only kind words for the medical profession—and nothing but scorn for the Ontario government. Noting that the Tories promised during the last provincial election not to touch health-care funding in their drive to eliminate the deficit, Haggith says that “they have lied and lied and lied, and gone back on everything they said.” As it tries to win the battle of the spin, the government will have to first overcome the cynicism bred of broken promises.
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