Different views on privatization

CMAJ 1997;156:770
The article "It's time for CMA to put the lid on privatization" (CMAJ 1996;155:1156-7 [in brief / en bref]), by Dr. Cynthia Carver, paints physicians as self-serving as they attempt to ensure the viability of their profession. The 2 issues she raises are billing-number restrictions and the use of private funding to pay for physician-based care. There are other dynamics to examine.

There is nothing wrong with physicians defending their professional security. The erosion of physicians' worth over the past 20 years now causes many graduates to consider it unreasonable to enter full-time practice in Canada. By 1992 the Ontario Health Insurance Plan fee schedule had been devalued to 60% of the Ontario Medical Association (OMA) fee schedule. Today, dentists make more for a teeth cleaning than a general practitioner makes for a complete general assessment. Similar comparisons can be made with services provided by chiropractors, optometrists and lawyers. This is not unbearable, but unless we take a stand as a profession to curb the downward slide, it soon will be.

As Carver may have noted, the public purse is tapped out. With the progressive decrease in federal transfer payments, an increasing and aging population and increasingly complex diagnostic and therapeutic modalities, there is simply not enough public money available to supply the level of care that Canadians expect and physicians expect to supply. Unless private funds enter the system, the inevitable conclusion is that the government will continue to look at cutting payments to physicians as the way to achieve a balanced budget.

One fact that is usually ignored was outlined in a report presented to the OMA council in 1995.1 It stated that in the 15 European countries studied, the average patient copayment for physician services was 19%. Copayments based upon income and an annual ceiling would not be restrictive or create undue hardship, and would not necessarily create a two-tier system. Carver is hopeful that savings can be found through more efficient health care delivery, which will let Canada avoid the introduction of private money into the system. This does not seem realistic in an open-ended market in which patients bear no responsibility for the resources they demand.

Her article implies an unrealistic expectation of new graduates. Would Carver mind if her billing number were moved to a far-northern community tomorrow? Billing-number restrictions violate almost every physician's professional rights. In Ontario the government has not acted on viable proposals to rectify relative underservicing, the most recent being an extensive report from the Professional Association of Internes and Residents of Ontario. No other profession has had restrictions on practice location applied to them.

Everyone in society may indeed be facing uncertainty, as Carver points out, but this should not stop efforts to maintain our professional viability and freedom.

Paul Leger, MD
Lakefield, Ont.


  1. Scully H (chair), Subcommittee on Health Care Funding. Health care system reform [discussion paper]. Toronto: Ontario Medical Association; 1995:21.

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| CMAJ March 15, 1997 (vol 156, no 6) / JAMC le 15 mars 1997 (vol 156, no 6) |