Give family docs more freedom

Posted on October 13, 2010 in Health Debates

Source: — Authors: – Opinion/Editorial
Tuesday, Oct. 12, 2010

Yesterday marked the start of “Family Doctor Week” in Canada. It provides an occasion to celebrate the contributions and hard work of Canada’s general practitioners, but also to take stock of the serious challenges facing these doctors and their patients across the country.

According to a report released by the Canadian Medical Association (CMA) and the College of Family Physicians of Canada (CFPC), in Dec. 2009, 4.1 million Canadians — 14% of the population –did not have a family physician. A series of focus groups conducted for the CMA by Ipsos-Reid in 2007 further revealed that some people had been unsuccessfully searching for a family physician for as long as several years.

And those Canadians with family doctors enjoy less timely access to them than citizens of other industrialized nations. According to a Commonwealth Fund survey conducted in 2007, and cited by the CMA, Canada had the lowest rate of same-day physician appointments: Only 22% of respondents, versus 30% in the United States and 41% or better in the other five countries surveyed, reported being able to see their doctor within the day. Canada also had the highest rate of respondents who waited six or more days to see their doctor, at 30%, as opposed to 20% for Germany and the United States, and lower for the other four nations surveyed.

What causes our shortage of family doctors? The perception that family medicine is not as “prestigious” as highly specialized disciplines is one problem, as is the difficulty in attracting family physicians to remote or outlying communities. But according to a 2005 report from the CFPC, the main reason is money: “[A] lack of remuneration is the leading cause of a decline in medical students choosing to take up family practice. It is also the prevailing reason why family doctors are forced to close their practices.” A 2008 report by the same organization found that family doctors earn an average of 33% less than physicians in other specialties.

Yet when searching for a solution to the shortage, discussion more often centres on increasing the supply of doctors, instead of their remuneration. Some observers claim Canada should attract and accredit more foreign doctors. But two recent studies found that between 2001 and 2008, only half of international medical graduates (IMG) passed their accreditation in Canada, versus over 93% of Canadians..

Other critics would like to increase the number of medical students in Canada. But if these students continue to prefer specialization over general medicine, this will not improve the situation.

If the paycheque is the problem, the answer is not to increase the supply of family physicians, but to increase the reward they receive. In a state-run, monopoly-payer system, this would mean having government pay higher fees for service. But public health budgets are stretched to the limit — and they already fail to deliver enough bang for the taxpayer’s buck.

According to Nadeem Esmail, former director of health policy at the Fraser Institute, Canadians currently underwrite the developed world’s second most expensive universal public health system. In an article published in 2009, he notes, “Only Iceland spent more on universal access health insurance system than Canada as a share of GDP, while Switzerland spent as much as Canada… Twenty-five developed nations who maintain universal health insurance programs spent less than we did; as much as 38% less as a percentage of GDP in the case of Japan.”

Instead of fighting market forces, through a rationed, monopoly-payer system, Canada should allow family doctors to practise both public and private medicine. This would allow them to diversify the sources of their revenues, and exert better control over their working hours and the quality of care they deliver.

A trend to private family medicine is happening already in parts of the country. Leading the charge is Quebec, where between 2007 and 2009, the number of private family doctors nearly doubled, from 61 to 113. An estimated 20-25 physicians leave the public system each year. According to the Quebec Family Doctors Federation, as of 2009, Quebec had a shortage of 800 general practitioners (there were 8,000 in practice that year). Doctors cite the desire for higher pay and lower stress as their chief motivations for going private.

Some provinces, such as Ontario, expressly forbid physicians from setting up general practices which bill patients instead of the medicare system. The fear is that “going private” will further diminish the number of doctors available to treat patients “for free.” But the reality is that such edicts only encourage physicians to vote with their feet, and move to jurisdictions which allow them choice in how they earn their living, and their patients choice in how to pay for medical services.

The answer is not more public money, but a more efficient allocation of resources from both the public and private sector that will increase compensation for family doctors, allow them to achieve greater work-life balance and thereby make the practise of family medicine more attractive. Now that would be something for “Family Doctor Week” to celebrate.

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