MEDICAL REFORM Newsletter of the Medical Reform Group Issue 127 Volume 23, Number 2 Fall, 2003 CAN AN ONTARIO ELECTION BE GOOD FOR OUR HEALTH? Rosana Pellizzari
ntario’s Tobacco Control Act, western Ontario, have struck down by- second-hand smoke and serious health proclaimed in 1994 to make laws. Clearly, it’s time for a change and effects among non-smokers,” Osales to minors illegal, eliminate perhaps an election, and a change in and ends with four recommendations the sale of tobacco in pharmacies and government, is what it will take. aimed at government. vending machines, and restrict smoking An OMA position paper In addition, the paper includes in certain public places, is long overdue published in February 2003’s Ontario proposed amendments to Ontario’s for an overhaul. Medical Review has called for a 100% Tobacco Control Act: amendments According to an expert panel ban on environmental tobacco smoke in which would repeal the weak Smoking report submitted to then-Minister of all Ontario workplaces and public places. in the Workplace Act, expand the ban to Health Elizabeth Witmer in 1999, The superb paper begins with the all workplaces and well-defined “public” necessary amendments to both the statement places, and incorporate whistle-blowing Tobacco Control Act and the Smoking “The overwhelming body of medical protection into the act. in the Workplace Act have not been evidence contained in hundreds of That is exactly the right made, allowing considerable exposure to scientific studies and six internationally prescription for legislative change in environmental tobacco smoke in recognized comprehensive reviews Ontario to protect all our workers and workplaces and public places to continue. undertaken during the last decade, citizens from the single largest cause of During their time in clearly demonstrates the direct causes preventable premature mortality in government, the Tories have slashed and linkages between exposure to Canada. Tobacco continues to kill about budget allocation for tobacco control to 12,000 Ontarians each year, a number that $1.70 per capita, an amount representing accounts for one in six deaths. only one tenth of the level recommended In the meantime, Ontario’s for comprehensive and effective tobacco INSIDE Tobacco Control Act has allowed the control programmes by the U.S Centres tobacco industry to influence local politics Public Health...... 4 for Disease Control. Ontario’s low price and intimidate Boards of Health into CHA on Trial...... 4-6 for tobacco products makes it easy for passing weak by-laws which either allow all smokers, especially price-sensitive National Health Council...... 7-9 unenclosed smoking in certain workplaces youth, to purchase cigarettes. Guyatt Columns...... 10-11, 14, 17 and public places, mandate designated Left to wander in the Boutique Medicine...... 12-13 smoking rooms, or DSRs which do not wilderness, Boards of Health had had protect workers and have never been P3s...... 13-15 both successes and failures in acquiring proven to completely eliminate the municipal or regional government Medical Necessity...... 16-17 exposure risk to the over 4,000 chemicals support for smoke free bylaws. Some, PNHP releases...... 18-19 in tobacco smoke, or contain sunset like Athens Township in Leeds and MRG Principles...... 20-21 clauses extending as far into the future as Grenville County, have passed by-laws never, or as in the Region of Peel’s new Steering Committee...... 21-23 allowing proprietors to choose whether bylaw, not until 2010. to maintain a smoke-free environment. Please visit ourweb-site: Others, like communities in north- http://www.hwcn.org/link/mrg (continued on page 2)
Medical Reform Group, Box 40074, RPO Marlee Toronto, Ontario M6B 4K4 CAN AN ONTARIO ELECTION BE MedicalReform GOOD? (continued) Medical Reform is the newsletter of the Medical Reform Group of Ontario. Subscriptions are included with member- ship, or may be purchased separately at In a study examining 25 instances that the DSRs are not guaranteed in $50 per year. Arrangements to purchase in which the tobacco industry opposed perpetuity. multiple copies of individual newsletters health board regulation in the U.S.A., What really irks Niagara bar and or of annual subscriptions at reduced researchers identified three main restaurant owners is that the Niagara rates can be made. Articles and letters on health-re- strategies: “accommodation” (tobacco Casino, the second largest employer in lated issues are welcomed. Submissions industry public relations campaign to the region, has been exempted. Casino should be typed, or sent by e-mail to accommodate smokers in public places), owners, who grossed almost $600
This is in spite of the fact that to a comprehensive tobacco control targeted to youth. The announcement the economic impact of smoke free by- program for the province, suing tobacco caught some media interest in July. laws on the entertainment and companies to recover health care costs The New Democrats have also hospitality industry is relatively neutral, attributable to tobacco-related disease, made a public commitment to strengthen although the myth being perpetuated by and a ban on tobacco advertising in retail the Tobacco Control Act and make all the bar industry, and fuelled by the stores. public and work places smoke free. In a tobacco industry, is that smoke free The funding of a provincial letter to Heather Crowe, the Ottawa-area bylaws are bad for business. On the program could include support for waitress who has developed lung cancer contrary, both American and Canadian interventions proven to be effective in from her workplace exposure, Howard research consistently has shown that reducing tobacco use: reducing out-of- Hampton promised to make a restrictive legislation has no significant pocket costs for effective smoking comprehensive tobacco control strategy, effect on sales. cessation treatments, patient telephone which includes a 24 hour help line and The battle being waged in support (Quit lines), mass media increased smoking cessation clinics, Northwestern Ontario by Medical campaigns, and provider education and available to Ontarians. The NDP have Officer of Health Dr Peter Sarsfield support for reminder systems. Useful also identified the banning of retail will determine whether Ontario’s Health sites to bookmark include OCAT displays as a component of the party’s Protection and Promotion Act (HPPA) (www.ocat.org) and Guide to anti-smoking strategy. gives public health officials authority to Community Preventive Services Clearly, Ontario has fallen behind close down smoky workplaces and (www.thecommunityguide.org). in its efforts to protect citizens from public places on the grounds that second With an election call imminent, the tobacco-related illness. Solutions have hand smoke poses a health hazard to Liberal Party has announced its promise been proposed by researchers, health care those exposed. Frustrated with inaction, to strengthen legislation, increase cigarette professionals, advocates and advisors. Dr Sarsfield used Section 13 of the prices, harness additional taxation What has been lacking is the political will HPPA to order owners of public places revenues to support smoking cessation to deal with the issue. Hopefully a to prohibit smoking in their estab- and alternative agricultural crops, and provincial election will make a lishments. embark on a anti-smoking campaign difference.♦ The orders are being appealed, with hearings scheduled in late September. The outcome of the hearings will set a precedent determining whether Ontario’s Medical Officers of Health have authority to overrule their local board of health or municipality if it fails to introduce effective bylaws to protect the public. Last October, the Ontario Campaign for Action on Tobacco (OCAT) gave the government a failing grade on its 2nd annual tobacco control report card, in addition to recom- mendations on what needed to be done. The five point plan to reduce tobacco use in the province includes increasing tobacco taxes by at least $10 per carton, instituting a 100 per cent ban on smoke in all public places and workplaces, dedicating at least $90 million annually
Volume 23, Number 2 - Fall, 2003 Medical Reform 3 MCLELLAN PUBLIC HEALTH CANADA ANNOUNCEMENT HEALTH ACT Rosana Pellizzari ON TRIAL Steven Shrybman n follow-up to the Calgary think tank lion to the front lines now and a dou- on public health organized by MRG bling of current spending over the Imember Dr John Frank, a coalition next 5 years. arlier this year the Canadian Union of public health advocates has organized 2. National leadership in public of Public Employees, the to campaign for a stronger public health health to provide a focal point, facili- ECommunications Energy and system. As one of its first actions, the tation, coordination and a pan-Cana- Paper Workers Union of Canada, the Coalition issued a media release on Au- dian approach to Public Health. This Canadian Federation of Nurses Unions, gust 19th to congratulate Canada’s Health includes a National Institution for the Canadian Health Coalition, and the Minister for her announcement to estab- Public Health, with national, regional Council of Canadians decided to take lish a new Canadian Public Health Care and virtual participation under the the Federal Minister of Health to court Centre and increase public health capac- leadership of a National Public Health for failing to live up to her obligations ity. Officer. under the Canada Health Act. While the “The Minister has given early rec- 3. A national information and delivery of health care services is ognition of some of the steps that must communications systems for public predominantly a provincial matter under be taken to ensure that Canada has an health which allows timely and ad- our constitution, federal leadership was adequately resourced system for public equate surveillance, information shar- needed to establish Canada’s medicare health services that protects and pro- ing, analysis and decision-making system and is now needed to defend it. motes the health of Canadians for to- across jurisdictions. The groups are particularly day, and for tomorrow’s emergencies”, 4. Strengthened public health hu- concerned about a proliferation of said Dr David Butler-Jones, Co-Chair man resources to increase capacity, privatization initiatives that challenge the of the Coalition. “Canada also requires including surge capacity, which in- fundamental principles of universality, leadership from a national public health cludes ongoing continuing education, accessibility, portability, public officer to lead the proposed Centre”, 5. Legislative reform including a administration, and comprehensive upon Butler-Jones added. new federal Public Health Act which which the medicare model is based. The Canadian Coalition on the would, like the Canada Health Act, Ontario, Alberta and British Columbia Future of Public Health in the 21st Cen- include criteria and establish manda- have been very keen to promote various tury is optimistic that the soon-to-be-re- tory standards which provinces must privatization schemes that would leased recommendations of the Naylor meet in order to qualify for funding. introduce private investment, private Advisory Committee will address the 6. New financing mechanisms at all funding, or for-profit delivery to whole need for legislative reform to clearly de- levels of government to ensure capac- new areas of the health care system. The lineate government responsibilities and ity and accountability for public health groups decided to go to court when public health’s role in issues such as drink- delivery. there efforts to engage with the Minister ing water quality, chronic disease preven- At the August 18th meeting of the around these issues, were ignored. tion, environmental health issues, SARS CMA in Winnipeg, Health Minister Their application to the federal and emerging communicable diseases. McLellan promised “the Government court focuses on the responsibilities of MRG members have been active of Canada will respond, not simply with the Minister to monitor provincial in pursuing issues raised by John Frank words, but with concrete, timely action.” compliance with, and enforce the at the recent members meeting by par- The MRG has recently written to Minis- requirements of the Canada Health Act. ticipating in the coalition. The coalition is ter McLellan to thank her for her stand The Minister is also obliged to report calling on government leaders to address on the formation of a national Health annually to Parliament concerning the 6 key steps to build a public health infra- Council, as recommended by Commis- administration and operation of the Act. structure to meet Canada’s needs in the sioner Romanow. This week’s announce- The Minister’s enforcement and reporting 21st century: ments are further indications that the obligations represent essential 1. Immediate and continued finan- Minister is on the right track. accountability mechanisms of the Act. cial investment in public health. This These are supposed to ensure that investment in capacity includes $1 bil- Parliamentarians and all Canadians are (continued on page 5)
4 Medical Reform Volume 22, Number 2 - Fall, 2003 CANADA HEALTH ACT ON TRIAL (continued)
properly informed about whether form of affidavits from three experts systems will be shared. The result has Canada’s health care systems are on Canada’s health care system. A been a patchwork quilt of information providing universal access to synopsis of their evidence provides a which often defies comparison or comprehensive and insured health care good summary of what the case is all meaningful assessment. services, on uniform terms and about. As for the consequences of these conditions to all those covered by the Pat Armstrong is a professor in failures, Professor Armstrong concludes Act. the Department of Sociology and in the that these include: But as pointed out repeatedly by School of Women’s Studies at York o Parliamentarians and Canadians are Auditors General of Canada, successive University in Toronto. She currently holds deprived of vital information Ministers of Health have failed to live a CHSRF/CHIR Chair in Health Services needed for rational policy making, up to these monitoring, reporting and and Nursing Research, and is also the chair the efficient allocation of health care enforcement obligations. While the audits of the National Coordinating Group on funding, and effective program make the headlines for a day or two, they Health Care Reform and Women. She is design or reform; have had little impact of the Ministers’ also the author or co-author of a large o Widespread misconceptions about willingness to take their obligations more number of articles and books on health the performance of the health care seriously. policy and politics. system abound, often creating a The need for greater Professor Armstrong confirms sense of crisis where none is justified accountability for the performance of the conclusions of the Auditors General and undermining public confidence Canada’s health care system was also a and makes the following observation in and support for Canada’s major focus for the Romanow concerning the Minister’s efforts to medicare system. Commission. It recommended the enforcement the Act: At the same time, problems that establishment of a new “Health Council” The Minister has also consistently may undermine the effectiveness of to fill the accountability gap. But the failed to conduct investigations and Canada public health care insurance plans Health Council has now become bogged implement enforcement measures remain obscure and are allowed to down in federal and provincial wrangling concerning extra billing and user charges persist. as several provinces resist efforts that in a timely and effective manner. Canadians are unnecessarily denied would make them more accountable for Moreover, with respect to the failure of access to comprehensive health care their health care systems. Moreover, health care insurance plans to satisfy the services on uniform terms and conditions given the limited mandate and authority criteria of the Act, the Health Minister because non-compliant practices are of the Council as it was described by has chosen to systematically ignore often not identified in a timely manner, the First Minister’s Accord, it seems like violations of the Act rather than invoke addressed through the enforcement a poor substitute for the much stronger the consultation and other procedures procedures of the Act, or properly accountability mechanisms already built established to resolve such issues of non- reported to Parliament. into the Canada Health Act. compliance. The failure of the Minister Joan M. Gilmour is a professor For instance, under the Canada of Health to even once invoke these of law on the faculty of Osgoode Hall Health Act the federal government may procedures in the face of substantial and Law School. She has developed and is require provinces to report on the persistent evidence of non-compliance the Director of Osgoode’s new Master’s performance of their health insurance suggests that the Minister has adopted a program specializing in Health Law. She systems, and is empowered to withhold policy of non-enforcement concerning is also the past Acting Director of the funding where the provinces fail to meet the five criteria that represent the core York University Centre for Health the requirements of the Act. But in the elements of Canada’s health care system. Studies. Professor Gilmour has carried face of chronic non-compliance by On the subject of monitoring and out research and analysis concerning the several provinces, the Minister has simply enforcement she places much of the impacts of privatization on the health been unwilling to enforce the Act. blame for the inadequacy of the care system, and more particularly on Now, CUPE et al. will seek an Minister’s reports on a voluntary reporting access to publicly funded health care order from Federal Court requiring her regime which allows the provinces services by those covered by the Act. to do so. In support of their application, themselves to determine how much The purpose of her evidence was the groups have filed evidence in the information about their health care twofold. First, to describe how the (continued on page 6) Volume 23, Number 2 - Fall, 2003 Medical Reform 5 CANADA HEALTH ACT ON TRIAL (continued)
proliferation of initiatives to privatize system, but its strengths and successes as effort to track the extent to which insured health care services can undermine the well. The failure of the Minister’s reports hospital services are being provided by objectives and purpose of the Act. to properly report on either creates an investor owned for-profit health care Second, to relate this evidence to the information vacuum within which facilities, these efforts have failed because federal Health Minister’s obligation to perceptions of the system can be most provinces fail to either gather or report annually to Parliament concerning manipulated to serve a particular agenda. provide this information. He further the administration and operation of the In many instances, this agenda will be one notes that with respect to the health Act. that promotes the privatization of outcomes associated with for-profit Professor Gilmour describes how Canada’s health care system. delivery of hospital services, the Minister’s the twin themes of unaffordability and Philip Devereaux MD, is currently report offers no indication that any effort individual responsibility are being relied a clinical scholar and cardiologist in the is being made to gather this information. upon by these critics of the medicare Department of Medicine at McMaster Finally Dr. Devereaux concludes model to justify a transfer of health care University and a candidate for a PhD in that without reliable and accessible responsibilities from the public to the Clinical Health Sciences (Health Research information about the extent to which private sphere, that is, to justify a shifting Methodology) also at McMaster hospital services in Canada are being of costs from the single payer – University. He is the recipient of several delivered by investor owned for-profit government – to private individuals and national awards, and has lead a team of providers, or the health outcomes insurers. However, because of the researchers who have published associated with such services, the public intensity of public support for publicly important studies comparing health policy debate about the use of public funded health care, the move towards outcomes in investor-owned private for- funding to support investor owned for- privatization — by increasing reliance on profit and private not-for-profit health profit delivery of hospital services is for-profit delivery and private payment care delivery systems. Those studies offer seriously hampered. It is also impossible for those services – is being pursued compelling evidence that investor-owned to know whether investor owned for- obliquely, either without acknowledging for-profit delivery of health care services profit delivery of such services is the end result or by focussing attention significantly increases the risk of death compatible with the goals of ensuring on the purported benefits of to patients, when compared to the not- that all Canadians have universal access privatization. for-profit delivery of the same health to comprehensive high quality health care Relating these concerns to the care services. services.♦ Minister’s Annual Report to Parliament, Dr. Devereaux’s evidence The case should be heard by the Professor Gilmour concludes that it: introduces the key concept of quality, as Federal Court of Canada, later this year, (i) fails to properly document the an indicia of whether the goals of the or early in 2004. characteristics of, and changes being Canada Health Act are being met. As his Steven Shrybman is a partner in the law firm made to, provincial health care affidavit states: Sack Goldblatt Mitchell. insurance plans and provincial law and From a clinical point of view the policy, that facilitate the privatization goals of providing accessible and of insured health services; and, comprehensive health services to (ii) fails to consider the consequential Canadians must be understood and impacts of such privatization initiatives assessed with regard to the quality of on the objectives and purposes of the services being delivered. Therefore, Canada Health Act including ensuring evaluating the performance of that all insured persons have access to Canada’s health care system requires publicly funded, comprehensive health an understanding of both the care services on uniform terms and availability and quality of the services conditions. being provided to Canadian residents. According to the Professor, Relating his research work to the appropriate reporting to Parliament Minister’s reporting obligations under the would not only reveal weaknesses and Canada Health Act, Dr. Devereaux notes shortcomings in the publicly funded that while Health Canada is making some
6 Medical Reform Volume 22, Number 2 - Fall, 2003 DO NOT BE DETERRED BY THE RESISTANCE OF THE PROVINCES On June 27, 2003, Steering Committee Member Gordon Guyatt sent a letter with the following text to the Minister of Health:
e are writing to encourage you to insist on the establishment of a Canada Ethel Meade has been a community Health Council whose membership is dominated by public representatives activist focusing on health care issues Wand academic experts in issues of health care delivery. Roy Romanow since her retirement as professor of correctly identified that to be credible and effective, a Canada Health Council cannot English Literature at Ryerson University be dominated by individuals representing either the federal or provincial governments. in Toronto. In addition to her involve- A council of public representatives and experts will be objective, use the available ment in the Older Women’s Network, evidence to guide their recommendations, and hold both federal and provincial she has served as co-chair of the Ontario politicians to account. A council dominated by government representatives will simply Coalition of Senior Citizens’ Organi- be another forum for the airing of federal and provincial disagreements and will zations (an organization concerned with therefore be altogether ineffectual. all issues affecting the quality of life of We would like to recommend individuals whom we think would do a good Ontario’s seniors), as vice-chair of Care job representing expert analysis and individuals who would do a good job representing Watch Toronto (focused on home care, the public interest. We have asked each of the individuals we are recommending particularly supportive care for those whether they would be willing to serve on the Canada Health Council. All have suffering from age-related disabilities), agreed to do so. and as community co-chair of the As public representatives we recommend the following individuals: Wendy Ontario Health Coalition. Ethel Meade Armstrong, Colleen Fuller, Ethel Meade, and Kathleen O’Grady. As experts on the may be reached by phone at (416) 363- delivery of health care in Canada, we recommend the following individuals: Joan 1289, by email at [email protected], Bickford, Alba DiCenso, Robert Evans, John Frank, Brian Hutchison, Nuala Kenny, or at 115 The Esplanade, #1206, John Lavis, Steven Lewis, Noralou Roos, Greg Stoddart, and Armine Yalnizyan. Toronto, Ontario M5E 1Y7. The attachment to this letter presents the contact information for each of these individuals, and a brief summary of their relevant credentials. Kathleen O’Grady is the Director of Please do not be deterred by the resistance of the provinces. A strong, Communications for the Canadian independent, and effective Canada Health Council is critical to the future of public Women’s Health Network and a health care in our country.♦ Research Associate at the Simone de Beauvoir Institute, Concordia University. Wendy Armstrong is a policy analyst Colleen Fuller works in public health She is the editor of several books on and consumer advocate with a long- policy. She is a member of the board of women’s issues, and numerous reviews standing interest in health policy issues directors of a community health centre and articles, as well as being the editor from a public perspective. Author of in Vancouver serving some 15,000 east of A Friend Indeed, the health newsletter three investigative reports on the side residents. She is the director of for women in menopause and midlife. changing environment for healthcare in PharmaWatch, a consumer advocacy She is a Cambridge Commonwealth Canada and the impact of health system group on drug safety issues (and also a Scholar and a former Bank of Montreal restructuring on Alberta families and partner with DES Action), is active in Visiting Scholar at the University of communities, she is familiar with issues the BC Health Coalition, and is on the Ottawa. Kathleen O’Grady may be related to insurance, private and public national board of the Council of reached by phone at (514) 271-7498, by markets, genetic technologies, medical Canadians. In addition, she is the president email at [email protected], or technologies, information technologies, of the Society for Diabetic Rights, a at 5244, rue St-Denis, Montreal, Québec consumer and patient rights issues in consumer group. Colleen Fuller may be H2J 2M2. Canada and other countries, and CAM reached by phone at (604) 255 6601 (h); (complementary and alternative medi- or (604) 687 1633 (o), by email at Joan Bickford has extensive experience cine). Wendy Armstrong can be reached [email protected], or at 2576 at all levels in the health system, beginning by phone at (780) 454-9450, by email at Pandora Street, Vancouver, BC V5K with her first position as a public health [email protected], or at 11029 - 1V8. nurse in rural communities just prior to 123 Street, Edmonton, Alberrta T5M the advent of Medicare. She was OE4. subsequently employed at senior
Volume 23, Number 2 - Fall, 2003 Medical Reform 7 DO NOT BE DETERRED BY THE RESISTANCE OF THE PROVINCES (continued) provincial government levels in the internationally recognized expert in health (CHEPA), Co-director of the formulation of health policy, programs, economics and a consultant to provincial Community Care Research Centre (a health organization and management, and and federal governments in Canada and research and training partnership of implementation in all areas. She has been abroad. He was a member of the McMaster University researchers and a senior policy adviser in the Deputy National Forum on Health from 1994 over 30 Hamilton community care Minister’s office and more recently has to 1997 and in 1998 was the first recipient agencies), and McMaster Site Director for worked in the federal-provincial unit of of the British Columbia Health the Ontario Training Centre in Health the Deputy Minister’s office. Joan Association Legacy Award for his Services and Policy Research. A family Bickford may be reached by phone at contribution to health policy in the physician for 30 years, his areas of by email at [email protected], by phone province. Robert Evans is a Fellow of research include organization, funding at (204)475–6697, or at 900 - 155 the Royal Society of Canada and is on and delivery of primary and community Wellington Crescent, Winnipeg, Manitoba the editorial board of a number of care, needs-based health care resource R3M 0A3. scholarly publications. Robert Evans may allocation and funding methods, and be reached by phone at (604) 822-4692, preventive care. Brian Hutchison may be Alba DiCenso is the CHSRF/CIHR at email at [email protected], or at reached by phone at (905) 525-9140, Nursing Chair in Advanced Practice the Centre for Health Services and Policy extension 22123, by email at Nursing and a professor in the School Research, Room 429, 2194 Health [email protected], or at McMaster of Nursing & Department of Clinical Sciences Mall, UBC Campus, Vancouver, University, Health Sciences Centre Room Epidemiology and Biostatistics at British Columbia V6T 1Z1. 3H1D, 1200 Main Street West, Hamilton, McMaster University. Her mandate as a Ontario L8N 3Z5. CHSRF/CIHR Nursing Chair is to John Frank is the Scientific Director, increase Canada’s capacity of nurse CIHR - Institute of Population and Nuala Kenny is nationally recognized researchers who will conduct applied Public Health, a professor of Public educator and physician ethicist. She has research related to advanced practice Health Sciences at the University of taught pediatrics in Nova Scotia and nursing (APNs) that serves the needs of Toronto, and a Senior Scientist at the Ontario, and has travelled extensively as managers and policy makers in the health Institute for Work and Health in Toronto, a distinguished lecturer. In addition, she sector. She is the Director of the Ontario of which he was the founding Director has served on or chaired a number of Training Centre for Health Services and of Research. He is a Fellow with the committees in the areas of pediatrics and Policy Research and a co-investigator in Canadian Institute for Advanced ethics, including chairing the Values a CIHR-funded training centre to Research Population Health Program. As Committee of the Prime Minister’s increase capacity in interdisciplinary a physician-epidemiologist with special National Forum on Health. Dr. Kenny is primary health care research and a expertise in prevention, his main area of past President of both the Canadian MOHLTC- funded project to develop interest is the biopsychosocial Pediatric Society and the Canadian interdisciplinary education and service determinants of health status at the Bioethics Society, and was a founding delivery models in long-term care. Alba population level. John Frank may be member of the Governing Council of DiCenso may be reached by phone at reached by telephone at (416) 946-7878 the Canadian Institutes of Health (905) 628-4317 (home) or (905) 525- (c/o Gail Bryant), by email at Research (CIHR) and chaired their 9140, extension 22408, by email at [email protected], or at CIHR Working Group on Ethics. In 1999 she [email protected], or at 78 Institute of Population and Public Health, was appointed an Officer of the Order Davidson Blvd, Dundas, Ontario L9H Suite 207-L, Banting Building /University of Canada for her contributions to child 7M2. of Toronto, 100 College St., Toronto, health and medical education. Nuala Ontario M5G 1L5. Kenny may be reached by phone at Robert Evans is a professor in the (902) 494-3801, by email at Department of Economics and a faculty Brian Hutchison is a professor in the [email protected], or at the member since 1991 of the Centre for Departments of Family Medicine and Department of Bioethics, Dalhousie Health Services and Policy Research at Clinical Epidemiology and Biostatistics University, 5849 University Avenue, the University of British Columbia. He at McMaster University, Director of the Halifax, Nova Scotia B3H 4H7. Tel: 902- is a distinguished academic, an McMaster University Centre for Health 494-3801 Fax: 902-494-3865. Economics and Policy Analysis (continued on page 9) 8 Medical Reform Volume 22, Number 2 - Fall, 2003 DO NOT BE DETERRED BY THE RESISTANCE OF THE PROVINCES (continued)
John Lavis is the Canada Research Chair Noralou Roos is a Professor in the Armine Yalnizyan is an economist and in Knowledge Transfer and Uptake, an Department of Community Health activist who has worked with and for Associate Professor in the Department Sciences at the University of Manitoba, community groups since 1985. She has of Clinical Epidemiology and and Director of the Manitoba Centre for worked with public and private sector Biostatistics, a Member of the Centre for Health Policy. Dr. Roos has recently been partners to develop tools for needs Health Economics and Policy Analysis, awarded the Canada Research Chair in assessment and broker practical solutions, and an Associate Member of the Population Health. She was a member and has written extensively about trends Department of Political Science at of the Prime Minister’s National Forum in the labour market and in government McMaster University. His principal on Health, was a member of the Medical social and budgetary policies. She has research interests include knowledge Research Council and its executive, and served on provincial and federal transfer and uptake in public served on the Executive of the Interim government advisory groups, and has policymaking environments and policy- Governing Council of the Canadian been invited to advise local governments making about health-care systems. He is Institutes of Health Research. From 1988 and international organizations on also interested in how provincial - 2002 she was an Associate of the strategic policy development. In 1998 governments make decisions about Canadian Institute for Advanced Armine Yalnizyan authored The Growing introducing changes to the health-care Research. You can contact Dr. Roos at Gap, a ground-breaking report on income systems they govern. John Lavis sits on [email protected] inequality in Canada. Since 2001 her work the Board of Directors of both the has focused on issues of access to health AIDS Committee of Toronto (Canada’s Greg Stoddart is a health economist and care. In 2002 she was the first recipient largest AIDS-service organization) and health services researcher and one of of the Atkinson Foundation Award for the Rekai Centre (a 126-bed, not-for- Canada’s leading health policy analysts. He Economic Justice; she is using that profit nursing home in downtown is a Professor in the Centre for Health opportunity to work with the Canadian Toronto). John Lavis may be reached at Economics and Policy Analysis Centre for Policy Alternatives on the [email protected] or [email protected]. (CHEPA), the Department of future of Canada’s public health care Economics, and the Department of system. Armine Yalnizyan may be Steven Lewis is a Saskatchewan-based Clinical Epidemiology and Biostatistics reached by phone at (416) 425-1527, by educator and consultant. A member of at McMaster University. He has email at [email protected], or at 204 the National Forum on Health from 1994 researched and published extensively on Bayview Heights Drive, Toronto, to 1997, he was CEO of Saskatchewan’s health care financing and organization, in Ontario M4G 2Z5.♦ Health Services Utilization and Research addition to serving on numerous Commission from 1992 to 1999, with commissions and task forces provincially, major focus on communicating health nationally, and internationally, and acted care analysis, evaluation and performance as a consultant to the World Health measurement to the media, public, Organization, the World Bank, and providers, and managers. He is currently several Canadian ministries of health. a member of the boards of the CIHR, Greg Stoddart is also well known for the Quality Council (Saskatchewan), and his work on the determinants of health, the Canadian Centre for the Analysis of and was a co-founder of the Population Regionalization and Health, the Prairie Health Program of the Canadian Institute Regional Officer of the CHSRF, for Advanced Research (CIAR), where President of Access Consulting Ltd., and he has been a Fellow for the past fifteen an Adjunct Professor of Health Policy years. Greg Stoddart may be reached by at the University of Calgary. Steven phone at (905) 525-9140, ex. 22143, by Lewis may be reached by phone at (306) email at [email protected], or at the 343-1007, by email at Department of Economics, Health [email protected], or at Access Sciences Centre, Room 2D1, McMaster Consulting Ltd., 211-4th Avenue South, University, 1200 Main St. West, Hamilton, Saskatoon, Saskatchewan S7K 1N1. Ontario L8N 3Z5.
Volume 23, Number 2 - Fall, 2003 Medical Reform 9 POLITICIANS BENEFIT PERSONALLY FROM SUPPORTING INVESTOR-OWNED FOR-PROFIT CARE
ast year, I flew to Singapore to per board, supplemented by payments to The Tories set up rules to favor for- participate in a medical conference. attend meetings. profit companies that have received two LThe man sitting beside me proved Not so for the Senate. Many thirds of the new beds. At the end of the to be a fascinating companion. Senators sit on Boards of Directors while two decades, the for-profit owners can Jack (not his real name) is an elite still serving their country. Michael Kirby convert the new facilities, paid for by executive who rescues corporations in offers an example. Ontario taxpayers, to residential financial trouble. Jack takes over as CEO Kirby, the Chair of the Senate apartments. of the troubled company, diagnoses the Committee on Social Affairs, Science and The province awarded the largest problem, plans the corrective strategy Technology, produced an influential health allotment of new nursing home beds to (often employee lay-offs), and implements care report in 2002 that also included Central Care Corporation, a company the solution. recommendations for expanding investor- controlled by the Toronto-based Job done, he moves on to his next owned for-profit health care delivery. Reichmann family. The nursing home assignment. Senator Kirby is a Director of Extendicare, allocations to Central Care Corporation Jack was curious about my own a giant for-profit nursing home company, will generate $1.36 billion in provincial work as an academic physician. Chatting and sits on three of the board’s committees. operating subsidies over the next two in the Tokyo airport while changing flights, In this column two weeks ago, I decades. he had a suggestion for me. pointed out that research studies have Bill Davis, former Ontario premier, I should consider joining the Board demonstrated that investor-owned, for- is a founding trustee and the current of Directors of some health care profit health care leads to higher hospital chairman of Central Care Corporation’s companies. Providing a little advice in a and out-patient kidney dialysis death rates parent corporate parent, Retirement few meetings each year, I could make a than does not-for profit health care Residences Real Estate Income Trust lot of easy money. delivery. For-profit health care companies (REIT). A current trustee is former Davis How do you get on these Boards have a high incidence of fraud. Fraud cabinet member, Darcy McKeough. Mr. of Directors, I wondered. You have to be represents as much as 10% of total health Davis retains an option to purchase 50,000 friends with the right people, Jack care costs in the U.S., according to the trust units for $10 each. He is paid $30,000 informed me. American Justice Department. Health care annually as company chairman. Mr. Politicians with particular policies Commissioner Roy Romanow found no McKeough has a trustee’s option to get to be friends with the right people. evidence that for-profit companies deliver purchase 45,000 units, and owned 6,000 Take Don Mazankowski. The former care more efficiently, or save money. as of last December. Conservative deputy-Prime Minister I wondered, in the face of the When now-Premier Ernie Eves’ left received at least $204,000 in 2000 for evidence, why Ontario’s provincial politics for a year in 2001, he became a sitting on Boards, and providing advice, government is actively expanding investor- REIT trustee. Eves was granted a three- for the parent company that owns Great- owned delivery of health care in hospitals, year option to purchase 35,000 trust units West Lifeco, one of Canada’s largest outpatient MRI facilities, and nursing for $10 each, paid a $15,000 annual providers of supplementary health care homes. I suggested that the large donations retainer, and up to $1,000 per board insurance. the Conservative party regularly receives meeting. Mr. Eves is now back leading the In 2001, Mazankowski produced from powerful for-profit companies that province, implementing policies to extend a report that Alberta has used as a blueprint ultimately receive government contracts investor-owned for-profit health care. for changes in health care. Among is part of the explanation. Having a big business-friendly Mazankowski’s recommendations was an The anticipation of post-politics orientation is good for politicians’ income expansion of investor-owned, for-profit income offers another explanation. Recent when they leave elected office. When the health care delivery, a development that Ontario government decisions in the prospect of long-term personal gain could ultimately expand business for nursing home sector shows how the system tempts politicians into decisions that harm private health insurance companies. works. the citizens of the province, like support Members of the House of In 1998, the provincial Tory for investor-owned for-profit health care, Commons and the provincial parliament government promised to build 20,000 new it becomes a serious problem.♦ typically wait until leaving politics before nursing home beds before 2006. First published July 25, 2003 as one of Dr. Guyatt's starting to pick up fees of $10 - $25,000 biweekly columns in the Hamilton Spectator
10 Medical Reform Volume 22, Number 2 - Fall, 2003 EVIDENCE-BASED MEDICINE IS CHANGING MEDICAL PRACTICE
fter a decade of encouraging This problem plagues all McMaster has been a world leader women who have gone through “observational” studies. If people taking in helping understand such issues. In fact, Amenopause to take hormone a treatment are healthier than people who McMaster may be the single institution that replacement therapy, it’s unpleasant telling don’t, we may falsely attribute life-saving contributed most to EBM. them that they’ve been taking a dangerous properties to that treatment. Dr. Haynes, for instance, has done drug.” How do researchers solve this more than any other researcher in the The speaker, a family doctor I met problem? They decide who gets treatment world to get the evidence to doctors in a at a medical conference, was uncom- by, in effect, flipping a coin. This “random clear, usable way. fortable. She had followed expert advice, allocation” makes sure that people who “EBM still faces big challenges,” Dr. and told her patients that they could reduce get treatment are, at the start of a study, Haynes says. “We need to do a better of their risk of heart attacks by using the no healthier or sicker than those who job of helping doctors understand EBM hormone replacement therapy (HRT). A don’t. principles, and making sure they have the new study had shown that HRT does not This explains the HRT results. In best evidence at their fingertips. Expert reduce risks of heart attack, and may even earlier, observational studies, women recommendations must reflect the best increase the risk. Furthermore, the study taking HRT were at lower risk of evidence, and consider patients’ values and found that HRT increases breast cancer cardiovascular disease than women who preferences.” risk. didn’t take HRT. They may have exercised Other health workers can also “If the experts making the more, had less stress, or been wealthier, benefit from understanding and applying recommendations had understood the all factors associated with better health evidence-based principles. Nursing, for principles of evidence-based medicine,” outcomes. instance, has its own share of myths. For says Dr. Brian Haynes, Professor of So, it looked as if HRT reduced instance, randomized trials have shown Medicine at McMaster University, “the heart attacks when, in reality, women that the widespread practice of shaving family doctor would not have got herself, taking HRT were destined to have fewer patients before surgery increases, rather and her patients, in so much trouble.” cardiovascular events whether or not they than decreases, wound infections. Traditionally, doctors have not took HRT. The randomized trials revealed McMaster Professor of Nursing been taught how to understand original the real situation. Alba DiCenso has played a key role in research articles. That means they could There are other examples of establishing evidence-based nursing. Her not independently decide whether evidence doctors going wrong because they didn’t soon to be released text book will provide was strong or weak. They were at the respect the principles of evidence-based the ideal guide for nurses interested in mercy of experts, or pharmaceutical medicine (EBM). Othopaedic surgeons using evidence to guide their practice. representatives. Perhaps even worse, were sure that they could help patients with McMaster has also been a key doctors had limited training in helping painful osteoarthritis of the knee by, in participant in an international effort, the patients weigh up the benefits, and risks, effect, washing the knee out. They inserted Cochrane Collaboration. The of alternative therapies. a surgical instrument, an arthroscope, into Collaboration’s goal is to bring high-quality Many research studies had the knee and “washed out” chemicals they evidence summaries to doctors and patients. suggested that HRT could lower believed caused the pain. You can join the Cochrane Consumer cardiovascular risk. But the research had In 2002, researchers reported the Network through their website, http:// used weak study designs. results of a randomized trial in which www.cochraneconsumer.com/ So what is a “weak study design”? patients received the real surgery or As they better understand EBM, Consider a study of whether hospitals “mock” surgery in which surgeons made experts and doctors will create fewer keep people alive, or kill them. The study a cut in the skin, but never used the problem stories like HRT and arthroscopic shows that people are more likely to die arthroscope. The result? No difference in arthritis surgery. And, as a patient, you will in hospital than in the community. So, pain at any time during two years of receive more accurate information about hospitals are hazardous, right? follow-up. the benefits and risks of the treatments We would laugh at that conclusion. How could doctors have gone so that medicine has to offer.♦ More people die in hospitals not because wrong? They underestimated “placebo” Firat published June 27, 2003 as one of Dr. they are risky places, but because people effects. We often feel better when we Guyatt's biweekly columns in the Hamilton in hospital are sicker than people in the receive a treatment we believe is helpful, Spectator community. even if there is no real effect.
Volume 23, Number 2 - Fall, 2003 Medical Reform 11 BAD NEWS FOR ONTARIANS: BOUTIQUE MEDICINE ARRIVES IN TORONTO Steering Committee member Irfan Dhalla here shares his July 2 letter to the College of Physicians of Ontario and their July 25 response to him on what he has called boutique medicine. Stay tuned for his report on participating in the review of block fees.
ccording to a column in the June “There are about 10 000 family argued in the New England Journal of 17 Globe and Mail, two Toronto doctors in Ontario. If each of them Medicine that “luxury primary care overall Adoctors have established a restricted their practice to 150 patients, will remain a threat to access.” Some practice where they charge patients as the doctors in the Globe and Mail lawmakers are so opposed to the practice $2,500 per year for “a detailed medical article aim to do, only about 1 out of that legislation has been introduced into workup,” “a customized health care every 7 Ontarians would have a family Congress to bar boutique doctors from plan,” and “24/7” access. doctor.” said MRG spokesperson, Dr. having access to Medicare and Medicaid This type of practice, which has Irfan Dhalla. “Boutique doctors provide payments. been growing in popularity in the United extra services for wealthy individuals who “Provincial insurance plans already States since the mid 1990s, and has now can afford to spend thousands of dollars pay for necessary medical care. Boutique crossed the border, is bad news for a year to have a physician at their beck doctors prey on patient anxiety by Ontarians. Today, the Medical Reform and call, but they reduce access for charging for services which have no Group asked the College of Physicians everyone else.” proven medical benefit,” said another and Surgeons of Ontario to investigate Even in the United States, MRG spokesperson, Dr. Gary Bloch.♦ this issue – commonly known as boutique medicine has come under Released July 2, 2003 “boutique medicine.” criticism. A respected commentator
LETTER OF INQUIRY TO THE COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO
Re: Possible violation of CPSO policy Namely, points 4, 5, and 7 below common in the United States and have on block fees (reproduced from the CPSO website): raised considerable concern (see Brennan We are writing in response to a 4. The patient must be given the TA. Luxury Primary Care—Market Globe and Mail column written by option of paying individual charges Innovation or Threat to Access. New Margaret Wente on June 17, 2003. Wente for the uninsured services as they are England Journal of Medicine 346:1165- describes two family physicians, Dr. rendered. 1168). Although these practices have been Sharla Lichtman and Dr. Rochelle 5. The decision as to whether or not endorsed by the American Medical Schwartz, as charging their patients a to elect this form of payment must Association, legislation has been $2,500 annual fee for “a detailed medical be the patient’s, and must not be a introduced into Congress to bar workup,” “a customized health care condition of the patient being physicians who charge retainers from plan,” and “24/7” access. Drs. Lichtman accepted by the doctor. having access to Medicaid and Medicare and Schwartz are aiming for practices 7. Fees for the service of “being funding. We feel strongly that “boutique with 150 patients each, rather than the available to render a service” cannot medicine” is not in the best interest of customary 2000 or so. be charged in advance and are not to Ontarians. Drs. Schwartz and Lichtman claim be included in block fees. We would very much appreciate in the article that they are “playing entirely We understand that the CPSO’s a response from the CPSO regarding by the rules.” Nevertheless, if the details policy on block fees is to be reviewed both the specific practices described in Ms. Wente’s column are correct, it by September 2003. We urge the CPSO above as well as the more general issue would appear to us that they are violating to consider the issue of “boutique of boutique medicine. Thank you very at least the spirit, and possibly the letter, medicine” during this review. These much for your attention to this matter. of the CPSO policy on block fees. practices have become increasingly We look forward to hearing from you.♦
12 Medical Reform Volume 22, Number 2 - Fall, 2003 ONTARIO’S PRIVATE FOR-PROFIT MRI AND CT SCANNERS: SAVIOUR OR SCOURGE? Bradley MacIntosh and Ted Haines
equests for Proposals (RFP) for according to a news release by the parent independently assess whether the RFP private for-profit MRI and CT company, Canadian Medical Laboratories process was in fact fair and consistent. Rservices were issued officially by Ltd., their imaging business will receive a Pre-licensing inspection of all private the Ontario Government on November 15, tax-cut on payment of facility fees, effective MRI/CT clinics will be conducted by the 2002 and closed on January 6, 2003. There August 1, boasting of additional revenue of College of Physicians and Surgeons of were over 700 individuals that asked for an approximately $2.5 million annually. Ontario (CPSO). The CPSO has RFP package over all 8 regions (e.g. service In the RFP documentation, there is acknowledged that “queue jumping”, providers, media, etc.) and 104 RFP formal mention of an “independent fairness whereby patrons can pay out-of-pocket for applications. The accompanying table commissioner” whose job was “to oversee medically non-necessary scan, will not be shows the list of the 4 companies who won the release and evaluation of the RFPs” and supported. The CPSO also states that all the RFP. Private CT services will not be ensure the process was carried out “in a fair radiological consultations require a provided in the City of Brantford because and consistent manner”. requisition from a physician indicating that the bid price was too high. Instead, Norfolk Attempts by MRG, in addition to the procedure is medically necessary. General Hospital will receive a CT scanner. other interest groups, to learn the name of It remains to be seen how the Tory The other 7 private centres are said to be this individual and receive a copy of their Government will respond to this constraint, open by Dec 7, 2003. formal report have failed up until the time of since it was generally assumed by private Rules stipulated that no more than 3 publication. Currently, there is a pending service providers that such “yuppie scans” regions would be awarded to any one freedom of information document submitted would be a means of generating additional respondent. DC DiagnosticCare Inc., owned to the Ministry of Health by the Ontario profits.♦ by Tory TOP 5 donor Dr. John Mull, was Association of Radiology to ascertain this awarded this maximum. In addition, critical information. It will be used to CPSO REPLIES Winners of the Private For-Profit MRI/CT Scanners
Re: Possible Violation of CPSO policy Company Diagnostic City Financial Connection to Tories on block fees. Imaging Your letter dated July 2, 2003 has been reviewed. It is unclear from 1. Kingston MRI MRI Kingston None Found your letter whether you would like this Inc. matter investigated as a formal Vaughan Contributed $11,000 to Health complaint At this time. 2. KMH Cardiology MRI Kitchener Minister Clement's leadership The College of Physicians and & Diagnostic Centre MRI campaigna Surgeons is in the process of reviewing the “block billing” policy. It is possible 3. DC MRI/CT Ajax Dr. John Mull is president and CEO DiagnosticCare Inc. CT Huntsville of parent company Canadian that you may wish to participate in the CT Mississauga Medical Laboratories Lts. Total review. donations to Tories since 1999 at If you would like to CT $105,000b participate, may I suggest that you contact Ms. Maureen Boon in our 4. Superior Imaging Thunder Bay None Found Policy Department. Inc Yours truly, (original signed by) G. Patrick McNamara MD CCFP a The Toronto Star, Feb. 22, 2003: “Four Firms Gain Licenses to Open Diagnostic Clinics” Associate Registrar b The Toronto Star, May 24, 2003: “The Fine Art of Giving” Medical Director, Investigations and Resolutions Cc Ms. Maureen Boon.♦
Volume 23, Number 2 - Fall, 2003 Medical Reform 13 EXPLAINING MYSTERIOUS GOVERNMENT POLICY nvestor-owned, private, for-profit the cost of policing. The FBI has 500 $336,545 to the Conservatives, $72,918 health care delivery is a bad deal for agents investigating heath care fraud. to the Liberals and $2,000 to the NDP. IOntario citizens. Yet the government With such compelling evidence One long-term care company, is pursuing a policy of handing over health against investor-owned, for-profit health Retirement Residences REIT, and care delivery to profit-making companies. care, why have the Tories replaced not- associated companies have given more If for-profit delivery threatens public for-profit provision of home care services than $17,000 to the Tories since 2002. The health, and the public pocket book, why is in Ontario with investor-owned delivery? companies also gave Eves’ leadership the government persisting? Why have they chosen for-profit firms to campaign $10,500, Jim Flaherty’s Is investor-owned health care run new MRI facilities? Why are they so campaign $10,000, and Tony Clement’s delivery really such a bad idea? A team of enthusiastic about public-private campaign a whopping $43,568. researchers from McMaster University partnerships (so-called P3 arrangements) REIT later received contracts to has examined all the research studies that mandate private sector management build 2,653 beds, with a potential of over comparing investor-owned private for- of Ontario’s new hospitals? Why do they $1.3 billion in government subsidies. profit health care to private not-for profit support investor-owned medical Nursing home giant Extendicare donated delivery. laboratories and nursing homes? $36,727 to the Tories and got contracts These systematic reviews Perhaps ideology is the explanation. for 1,613 beds. Leisureworld gave summarize all relevant, high quality If your philosophy is that the private sector Clement’s campaign $18,000 and received research. The results, published in the always does it better, evidence becomes 1,895 beds. Same story with laboratories. leading Canadian and American medical an annoyance to be ignored and dismissed. The Dynacare Health Group, the largest journals, showed higher death rates in both Maybe. But a look at whom the private laboratory company in Ontario, the for-profit hospitals and for-profit Conservatives chose to receive the recently gave Eves $25,000. kidney dialysis clinics. awarded contracts to deliver MRI services The provincial Conservatives point When investor-owned firms reward in the community suggests another out that bureaucrats at arm’s length from shareholders with money that should be explanation. the government make the individual award going to patient care, they must cut Five of the seven facilities will be decisions. Focusing on the impact of corners. And cutting corners results in owned and operated by companies that political donations on individual funding higher death rates. The results mean that have made major donations to the decisions, however, misses the crucial if we converted all Canadian hospitals to Conservative party in the last four years. point. for-profit status, the price would be 2,200 Canadian Medical Laboratories got three If new MRI units, like the existing additional deaths each year. clinics - the maximum allowed under machines, were housed in our hospitals, Perhaps if for-profit care saved bidding rules. The company donated investor-owned firms would have no enough, we could endure the extra deaths $25,000 to the Tories in 1999, more than opportunity to benefit from expanding in hospitals and use the savings to improve $4,000 in 2000, and gave $10,000 to diagnostic facilities. If the government care elsewhere. Health care commissioner Premier Ernie Eves’ leadership used traditional funding mechanisms, no Roy Romanow looked hard for evidence campaign.KMH Cardiology and large consortiums could profit from of cost savings with for-profit delivery, Diagnostic Centre, which will own and managing publicly-funded hospitals. and found none. operate two clinics, donated $11,000 to What health-care companies expect In fact, Canadian experience Health Minister Tony Clement’s failed when they make donations is expanded suggests higher costs to for-profit delivery. leadership bid. for-profit delivery. Once in the running For instance, the recently terminated for- Looking at the bidders for the for public money, they anticipate their profit cancer clinic at Sunnybrook Hospital contracts to build and manage P3 hospitals share of success. cost the government $500 more per patient shows the same story. Tony Clement So, we have the explanation for that the not-for-profit provincial cancer received donations last year from partners provincial government policy. Investor- clinics. Furthermore, the figures omit a in all three private consortiums short-listed owned for-profit health care delivery is a hidden cost of investor-owned health care: to build and operate a re-developed Royal bad deal for Ontario citizens, but a great the risk of fraud. In the U.S., where for- Ottawa Hospital. Three consortium deal for Ontario’s Conservative party.♦ profit health care is a much bigger player companies made donations to Ernie Eves’ First appeared July 11, 2003 as one of Dr. Guyatt's than in Canada, the Justice Department leadership campaign. Same story in twice monthly columns in the Hamilton Spectator estimates that fraud costs the health system nursing homes. Between 1995 and 1999, $100 billion each year. That doesn’t count long-term care companies donated
14 Medical Reform Volume 22, Number 2 - Fall, 2003 BRAMPTON’S P3 HOSPITAL: WHAT THE CANDIDATES HAVE TO SAY Bradley MacIntosh
he Ontario Progressive contact William Osler Health Centre the Brampton Health Coalition, and Conservative Provincial management. commented that Jeffrey “has shown the TGovernment is experimenting The main virtue seen by Joe [Brampton Health Coalition] no support, with a new financial model for a hospital Spina justifying the P3 hospital was a she has done nothing to oppose the P3 in Brampton, known as a public-private savings of time and money at the [Hospital] and now she claims that a partnership (P3). The construction deal construction level. After all, the city of Liberal government would work quickly between the William Osler Health Brampton has witnessed a significant to make these new facilities publicly Centre, the 6th largest hospital population boost. owned”. corporation in Ontario with hospitals in Given that the NDP has been Despite the many Brampton, Georgetown and Etobicoke, opposed to public-private partnership in uncertainties, such as contract-breaking and the Healthcare Infrastructure multiple sectors, we asked NDP penalties, it seems clear that converting a Company of Canada is estimated to cost candidate Kathryn Pounder to provide P3 hospital back to a publicly financed $350 - $380 million. some insight. Quoting from an example hospital would be quite costly. Under the With the provincial election of P3 hospitals in Britain, Pounder stated reign of the PC Ontario Government, looming on the horizon, the MRG that “private consortiums make between an era characterized by cutting and off- attempted to contact the three 15 – 25% profits”. She disagreed with loading public services, P3 hospitals candidates: Joe Spina MPP, Progressive the argument that the Government seem to be a natural next step. The Conservative (PC), Kathryn Pounder, would avoid the capital costs. Paying ominous question remains, however, New Democrat Party (NDP) and Linda “inflated lease costs for 25 years”, is not whether this next step will take Ontario Jeffrey, Liberals in the Brampton Centre cost-effective since “the Government can further away from our universally riding on this issue. Despite several borrow more cheaply than can the accessible public health care system.♦ reminders Liberal Linda Jeffrey did not private consortium”. Pounder also respond during the two week period. explained that the promise of speedy All three candidates were construction has been delayed by another asked what future they envisioned for year (2006 instead of 2005) due to the Brampton P3 hospital. Incumbent public-private negotiations in an 8,000 Joe Spina explained the Brampton P3 page contract document. Pounder hospital will be built “faster than the more foresees “problems of design, traditional method of accumulating the construction, and maintenance problems necessary capital dollars to build with these hospitals” due to the incentives hospitals”, although, he assured “The of building as “cheaply as possible”. Eves Team is fully committed to the According Jeffrey’s website, principles of the Canada Health Act”. the Liberals are opposed to the P3 In a secondary question on Brampton hospital, since she states “an increased efficiency he suggested that the Ontario Liberal government would Brampton P3 hospital would: “attract work quickly to make these facilities new medical technologies to work with publicly owned”. Spina affirmed this the [new hospital]”, “recruit new medical statement saying that Jeffrey has staff (Resumes are already coming in promised “to cancel the new [Brampton] from around the world!),” and “use the hospital”. “However, [Liberal leader] savings from construction costs and put McGuinty supports the same P3 it towards medical services”. financing idea for the new hospital in Unfortunately, Spina did not provide any Ottawa because that’s where he lives!” justification for his anticipated increases Pounder is a member of an in operation efficiency and that we organization opposed to the P3 Hospital,
Volume 23, Number 2 - Fall, 2003 Medical Reform 15 MEDICAL NECESSITY AND YUPPIE SCANS The Steering Committee is monitoring closely the pressures for expansion of MRI and CT scanning and its implciations for access to publicly funded health care in Canda. We reproduce below the test of two recent letters, the first, dated July 16, 2003 from the Registrar of the College of Physicians and Surgeons of Ontario, and the second, dated Augsut 7, 2003, to Health and Long Term Care Minister Tony Clement, seeks clarification on the minister's position on queue jumping .
hank you for your letter of June I would like to refer you to In the RFP document sent to all 13, 2003.The College of Physicians Chapter 4: Requesting and Reporting bidders there is a section entitled “Queue Tand Surgeons of Ontario (CPSO) Mechanisms. Several sections in this Jumping.” It clearly allows for the CPSO, was asked by the Ministry of Health and chapter clearly indicate that it is the through the IHF program assessor, to Long Term Care to undertake the intention of the Task Force to ensure assess non-insured services being development of Clinical Practice than only “medically necessary” tests are provided in MRI and CT facilities. Paramaters and Facility Standards to carried out. Therefore, this allows the assessor inform the RFP process and to carry out More specifically, all radiological to check that only appropriately ordered subsequent assessments of services being consultations require a requisition by a tests are completed and to ensure that provided by private MRI and CT clinics physician and must be approved by the there is no broadbased screening taking in Ontario. quality Adviser of the facility who is also place. As with the development of all a physician essentially ensuring “medical Based on the above it is clearly the guidelines, the CPSO Independent necessity.” position of the CPSO and the intention Health Facilities program formed a task Also on page 21 of the guidelines of the Task Force who developed these force of experts to complete this task. it states “No screening radiological guidelines that queue jumping and broad The guidelines that resulted from examination should be performed unless based screening are not supported.♦ this Task Force are available on line at evidence-based or part of an organized www.cpso.on.ca population-based screening program.”
e are writing with a concern We have written to the College of about the newly established Physicians and Surgeons concerning such Winvestor-owned, private for- medically unnecessary screening scans. profit community-based MRI and CT The College’s reply indicates that the facilities. College does not support such screening. In early announcements about the The College’s reply did not, however, facilities, you indicated that they would indicate what action it could or would be allowed to carry out scans intended take if the clinics violated their guidelines to screen for disease that had not yet and conducted private-pay screening manifested symptoms. Because such outside of OHIP. screening is not medically necessary, the We would appreciate clarification facilities would be able to charge patients of your position regarding these scans. directly for such services. Charges for the Will clinics be allowed to conduct private- services could presumably be set at pay screening MRI and CT scans? If the whatever level the market could bear. answer is no, how does your Ministry Furthermore, your remarks intend to monitor to ensure the clinics suggested that, again because they were do not violate the prohibition? not medically necessary, persons Again, if your answer is that clinics presenting for such scans needn’t be are not allowed to conduct these scans, subject to the waiting list rules that would what penalties do you intend to levy apply to patients needing MRI because should they nevertheless do so?♦ of medical necessity.
16 Medical Reform Volume 22, Number 2 - Fall, 2003 POACHING BY PRIVATE, FOR-PROFIT MRI CLINICS THREATENS HOSPITAL CARE
he Ontario Association of the hospitals’. Unfortunately, the called “yuppie scans”. They will screen Radiologists are a smart group of government won’t say how much it’s healthy individuals with MRI, looking for Tdoctors. Early in 2002, the provincial giving each clinic, and the contracts illnesses like cancer and heart disease, government first floated the idea of private are privileged information, not open charging what the market will bear. for-profit outpatient facilities offering high to public scrutiny. Tony Clement has vowed that he tech MRI scans. The radiologists predicted The government’s refusal to will not allow the for-profit clinics to charge that the investor-owned clinics would poach provide the needed information patients who would like to bypass MRI scarce technologists from hospital-based MRI prevents us from assessing its claim waiting times by paying to jump the queue. facilities. that the for-profit clinics will cost less Let’s call this Tony’s No Queue-jumping In response, Health Minister Tony than not-for-profit hospital facilities. Policy. It is unclear whether Clement has Clement promised a No Poaching Policy for But, just as a matter of logic, how any better enforcement mechanism in the new clinics. could the for-profit clinics costs be less mind than he did for the No Poaching Guess what happened. So far, two if they are paying their technologists Policy. investor-owned for-profit MRI facilities have more? Whatever the enforcement plan, the opened. Seven hospitals, including Toronto’s I asked Dr. Harald Stolberg, a rule against direct patient charges only University Health Network (UHN) and the Hamilton radiologist with more than applies to medically necessary services. Kingston General Hospital, have lost 40 years involvement in the specialty Yuppie scans are unproven. In fact, they technologists to the private clinics. at local, national, and international may show abnormalities that require What about the government’s No levels, that question. further dangerous and expensive testing, Poaching Policy? “Hospitals deal with sicker but turn out to be harmless. They may “You can’t control the mobility of the patients,” Stolberg explained, therefore do more harm than good. labour market,” Premier Ernie Eves has “conducting the scans, and interpreting Because their benefit is unproven, yuppie responded. them, will be more time-consuming and scans are not considered medically Right, Ernie, but why then did your expensive than in the community.” necessary, and so not subject to the government offer its No Poaching Policy? But if that’s true, the prohibition against direct patient charges. Not that the government isn’t government won’t really be saving The College of Physicians and concerned about the function of the hospitals’ money at all? Surgeons, the body responsible for MRI units. Eves has also said that the Ministry “Right,” said Stolberg. The protecting the public against possible of Health should “ensure that any existing practice of treating less sick, and physician misbehavior, has said that as far MRI in any public hospital is not prevented therefore less expensive patients, is as it is concerned, the clinics should not from operating through lack of expert sometimes called “cream-skimming”. be doing yuppie scans.The College is personnel.” American private for-profit health care making that recommendation because Unfortunately though, hospital MRI providers often use cream-skimming yuppie scans are potentially dangerous. services are affected. Both the Kingston to maximize their profits. They would also, however, rob MRI slots Hospital and the UHN have had to cut back Stolberg offered other from patients who really need the test. services, and other hospitals may be forced explanations. “The facilities may cut Clement has been repeatedly asked to as well. A senior radiologist from the UHN corners, and reduce standards of whether his Ministry will allow the clinics imaging department has said that “this exodus service where it is least visible.” to charge patients for yuppie scans. So of techs is causing significant problems in That made me think of two far, he has not provided a direct answer. terms of capacity and quality of imaging for reviews from McMaster that By poaching technologists, the us.” summarized all the high quality studies investor-owned MRI facilities are How did the clinics persuade the comparing death rates in private for- threatening the care of hospital patients. technologists to leave the hospitals? The profit, versus private not-for-profit, Dr. Stolberg’s observations make it clear answer: money. The clinics offer the MRI hospitals and dialysis centers. Both that technologist poaching is only one technologists signing bonuses and higher reviews found higher death rates in the reason why investor-owned for-profit salaries. private for-profit facilities, likely a MRI scanning is a bad idea.♦ Which brings us to the government’s result of the sort of corner-cutting that First published Augsut 22, 2003 as one of Dr. stated reason for turning to investor-owned Stolberg fears. Guyatt's biweekly columns for the Hamilton MRI in the first place. The Tories claim that Finally, Stolberg thinks the Spectator the clinic’s operating costs are cheaper that facilities are planning to conduct so- Volume 23, Number 2 - Fall, 2003 Medical Reform 17 NEW RESEARCH AND CAMPAIGN NEWS FROM PHYSICIANS FOR A NATIONAL HEALTH PROGRAM
ADMINISTRATIVE COSTS IN MARKET-DRIVEN U.S. HEALTH CARE SYSTEM FAR HIGHER THAN IN CANADA’S SINGLE-PAYER SYSTEM: New Research Shows With National Health Insurance, United States Could Cover the Uninsured
ASHINGTON, D.C. – New England Journal of Medicine Study Shows percent of total U.S. health spending in Bureaucracy in the health care U.S. Health Care Paperwork Cost $294.3 1999 compared to 16.7 percent in Wsystem accounts for about a Billion in 1999, Far More Than in Canada. Canada. They also found that third of total U.S. health care spending – administration has grown far faster in the a sum so great that if the United states The first study, which is to be published United States than in Canada. Between were to have a national health insurance Thursday in The New England Journal 1969 and 1999, administrative and clerical program, the administrative savings alone of Medicine, finds that health care personnel in the United States grew from would be enough to provide health care bureaucracy cost U.S. residents $294.3 18.2 percent to 27.3 percent of the health coverage for all the uninsured in this billion in 1999. The $1,059 per capita work force. In Canada, those personnel country, according to two new studies. spent on health care administration was grew from 16 percent in 1971 to 19.1 The studies illustrate the failure of more than three times the $307 per capita percent in 1996. the private, fragmented and business- in paperwork costs under Canada’s oriented U.S. health care system to control national health insurance system. Cutting Harvard/Public Citizen Report Finds administrative costs, as compared to U.S. health bureaucracy costs to the National Health Insurance Would Save $286 Canada’s single-payer system. One of the Canadian level would have saved $209 Billion on Administration in 2003 - Enough studies, in seeking to answer whether the billion in 1999, researchers found. [The to Cover All Uninsured and Seniors’ Drug ascendancy of computerization, study was conducted with grant support Costs managed care and more businesslike from the Robert Wood Johnson approaches to health care have decreased Foundation. The Foundation does not The researchers also released a second administrative costs, answers the question endorse the analyses or findings of this report co-authored with Dr. Sidney with a resounding “no.” report or those of any other independent Wolfe, director of Public Citizen’s Health The second study provides a state- research projects for which it provides Research Group. This report, based on by-state breakdown of savings each state financial support.] data adjusted to reflect estimates of 2003 could achieve if the United States The study, the most compre- spending, found that health bureaucracy adopted a national health insurance hensive analysis to date of health now consumes at least $399.4 billion program. administration spending, was conducted annually and that national health insurance “Hundreds of billions are by researchers at Harvard Medical could save about $286 billion in squandered each year on health care School and the Canadian Institute for administrative costs. This is equivalent to bureaucracy, more than enough to cover Health Information, Canada’s quasi- $6,940 for each of the 41.2 million all of the uninsured, pay for full drug official health statistics agency. The authors people uninsured in 2001 (the most coverage for seniors, and upgrade analyzed the administrative costs of recent figure available for the uninsured). coverage for the tens of millions who health insurers, employers’ health benefit In addition to providing health coverage are under-insured,” said Dr. Steffie programs, hospitals, nursing homes, for the uninsured, these savings could Woolhandler, co-founder of Physicians home care agencies, physicians and other provide drug coverage for the nation’s for a National Health Program and lead practitioners in the United States and seniors. author of the studies. “Americans spend Canada. They used data from regulatory The researchers found wide almost twice as much per capita on health agencies and surveys of doctors, and variation among states in the potential care as Canadians, who have universal analyzed Census data and detailed cost administrative savings available per coverage and live two years longer. The reports filed by tens of thousands of uninsured resident. Texas, with 4.96 administrative savings of national health health institutions in both nations. million uninsured (nearly one in four insurance make universal coverage The authors found that Texans), could make available $3,925 per affordable.” bureaucracy accounted for at least 31
18 Medical Reform Volume 22, Number 2 - Fall, 2003 NEW RESEARCH AND CAMPAIGN NEWS FROM PHYSICIANS FOR A NATIONAL HEALTH PROGRAM (continued) uninsured resident if a national health plan “Only national health insurance wasted on administrative expenses. In were implemented. Massachusetts, can squeeze the bureaucratic waste out the current economic climate, with which has very high per capita health of health care and use the money to give unemployment rising, we can ill administrative spending and a relatively patients the care they need,” said Dr. afford massive waste in health care. low rate of uninsured, could make David Himmelstein, co-founder of Radical surgery to cure our available $16,453 per uninsured person. Physicians for a National Health Program failing health insurance system is sorely The high U.S. administrative costs and lead author of the studies. needed.”♦ can be attributed to three factors. First, “Republicans are pushing to Drs. Woolhandler and Himmelstein are private insurers have high overhead in move seniors into HMOs, whose co-founders of Physicians for a National Health both nations but play a much bigger role overhead is three times higher than Program, a 10,000-member organization that in the United States than in Canada. Medicare’s. National health insurance advocates for Canadian-style national health Second, doctors and hospitals in the could cover everyone without any insurance in the United States. Public Citizen United States must deal with hundreds increase in costs.” is a non-profit, member-supported, consumer of different insurance plans (at least 755 Added Wolfe, “These data should advocacy organization. in Seattle alone), each with different awaken governors and legislators to a coverage and payment rules and referral fiscally sound and humane way to deal networks that must be tracked. In with ballooning budget deficits. Instead Canada, doctors bill a single insurance of cutting Medicaid and other vital plan, using a single simple form, and services, officials could expand services hospitals receive a lump sum budget. by freeing up the $286 billion a year
DOCTORS CALL FOR NATIONAL HEALTH INSURANCE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION PUBLISHES PHYSICIANS’ PROPOSAL FOR NATIONAL HEALTH INSURANCE SIGNED BY 7,782 PHYSICIANS
ASHINGTON, D.C., be presented in D.C. at The National private insurers - such as calls for tax- AUGUST 11, 2003 — In an Press Club on August 12 at 10am in the credits, Medicaid/CHIP expansions, and Wunprecedented show of Murrow room. pushing more seniors into private physician support for National Health “This is an historic moment. HMO’s - are prescriptions for failure. By Insurance (NHI), 7,782 U.S. physicians Today, thousands of physicians are taking perpetuating administrative waste, such propose single payer NHI in an article a stand on the side of patients and proposals make universal coverage in the August 13 issue of the Journal of repudiating the powerful insurance and unaffordable,” said Dr. Young. the American Medical Association drug lobbies that block wholesome The physicians call for national (JAMA). reform,” said Dr. Quentin Young, a health insurance that would cover every The “Physicians’ Proposal for leading Chicago physician who chaired American for all necessary medical care National Health Insurance” was drafted the Department of Medicine at Chicago’s - in essence an expanded and improved by a blue ribbon panel of leading Cook County Hospital and convened the version of traditional Medicare. physicians. The signers include 2 former group of prominent physicians that * Patients could choose to go to any U.S. Surgeons General, the former drafted the proposal. doctor and hospital. Most hospitals Editor-in-Chief of the New England The doctors’ article also critiques and clinics would remain privately Journal of medicine,hundreds of the health reform plans that have been owned and operated, receiving a medical school professors and deans, offered by President Bush and the major budget from the NHI to cover all and thousands of practicing doctors Democratic presidential contenders. operating costs. Physicians could throughout the nation. The Proposal will “Proposals that would retain the role of (continued on page 20)
Volume 23, Number 2 - Fall, 2003 Medical Reform 19 NEW RESEARCH AND CAMPAIGN NEWS FROM PHYSICIANS FOR A NATIONAL HEALTH PROGRAM (continued)
continue to practice on a fee-for- vast resources we do on the capita on health care as any other nation. service basis, or receive salaries from administrative costs, executive salaries, 41 million people are uninsured, and group practices, hospitals or clinics. and profiteering of the private insurance millions more are under-insured and can’t * The program would be paid for by system”, states Dr. Marcia Angell, Senior afford vital medicines. How bad does it combining current sources of Lecturer in the Department of Social have to get before our politicians admit government health spending into a Medicine at Harvard Medical School, we need national health insurance?” asked single fund with modest new taxes that and former Editor-in-Chief of the New Dr. Steffie Woolhandler, lead author of would be fully offset by reductions in England Journal of Medicine. “We get the proposal and Associate Professor of premiums and out-of-pocket too little for our money. It’s time to put Medicine at Harvard. spending. those resources into real health care— The full list of signers is available * The proposed single payer NHI for everyone.” on the internet, but will be password would save at least $200 billion The physicians’ call for NHI comes protected until the JAMA’s embargo is annually by eliminating the high as rising health costs and premiums, and lifted. To obtain a password, members overhead and profits of the private, the increasing number of uninsured have of the press may call (312) 782-6006. investor-owned insurance industry and stimulated a new round of health reform Physicians for a National Health Program reducing spending for marketing and initiatives. Yet most politicians have was founded in 1987 and includes other satellite services. steered clear of NHI, offering proposals physicians in every state and medical * Administrative savings would fully for incremental reforms of the current specialty. For local contacts or other offset the costs of covering the system. information, contact PNHP’s uninsured as well as giving full “How bad does it have to get headquarters in Chicago at (312) 782- prescription drug coverage to all before politicians are willing to prescribe 6006 or visit: www.pnhp.org.♦ Americans. the major surgery our health system “In the current economic climate, needs? Premiums are skyrocketing and we can no longer afford to waste the we already spend twice as much per
EQUITY VS. EQUALITY: MRG PRINCIPLES GO UNDER THE KNIFE Gary Bloch
ver the past few months, the centres on the definition of “equity” in define the ideological direction of the Medical Reform Group the MRG’s statement of principles. budding Group. Those principles, Osteering committee has been Participating in this discussion highlighted centered on a dedication to accessible, grappling with a number of issues that the excitement – and some of the affordable health care for all, have stood strike at the heart of the MRG’s self- challenges – of belonging to an as the foundation for the MRG for over definition. Readers may have noticed the organization that questions and pushes two decades. lively debate around the MRG’s ideological boundaries. As the health care system changes, involvement in international issues that Those ideological boundaries and as society and progressive thought emerged in the last few issues of the were first laid out with the formation change, so must our principles. A few Newsletter. It is this type of debate that of the MRG twenty four years ago. At months ago, spurred on by the urgings reaffirms the MRG as an organization that time, a group of physicians who of a new MRG member, members of dedicated to analysis and progressive considered themselves likeminded in the steering committee began to re- change. their progressive values developed an examine the “principles” document. We Another vigorous discussion that alliance for strength and support, and reaffirmed the core belief in universal, has been evolving over the past 6 months created a set of “principles” that would (continued on page 21)
20 Medical Reform Volume 22, Number 2 - Fall, 2003 EQUITY VS. EQUALITY: MRG MRG PRINCIPLES (continued) STEERING accessible health care. Debate arose, access to care should be specifically COMMITTEE however, around the definition of equity targeted with health resources. To this in the context of health resource end, for instance, money may need to distribution. be diverted from specialized quaternary he Steering Committee is a small Prior to this discussion, the care services (such as heart transplant but dedicated group which principles document stated: surgery) to primary care or public health includes a range of disciplines, Equity – Everyone should have programs focused on disadvantaged T mainly living in the so-called Golden equal opportunities to make use of groups (such as harm reduction Horseshoe of southern Ontario. They are available health care resources, and programs for inner city drug users, or keen to engage other members, and can equal opportunity to live in an diabetes prevention programs on First be reached through the office. To give a environment conducive to good Nations reserves). sense of their interests, here are some health. In other words, equity should be short biographies. Critics of this statement dissected judged not only by access to care, but by the notion of “equal opportunity”. equity of health outcomes as well. And Ahmed Bayoumi is a general internist Members charged that it is insufficient these outcomes need to be determined and health services researcher in Toronto. to simply level the playing field for on a broad social as well as an individual His clinical and research interests focus Canadians in obtaining access to health level. on the health of people living with HIV care, i.e. to allow each person as much After much debate, the members and other disadvantaged populations. He opportunity as the next to access involved in this discussion agreed on a is committed to the concepts of social resources. new phrasing for the MRG’s equity and economic justice, which he views as In reality, Canadians have statement: incompatible with capitalism. fundamentally different starting points in Equity: Health resource allocation their health access needs, and therefore initiatives should be evaluated Gary Bloch is currently a final year an equitable system requires that some by their impact on the equity of resident in family medicine at St. Michael’s people have greater opportunity to health outcomes. These outcomes Hospital in Toronto. He has, since his access care than others. In its most should be measured based on a inception into the medical world a half obvious form, this opportunity would broad perspective on health that decade or so ago, set his sights firmly on be determined based on pure urgency takes into account physical, a career in inner city health. He’s spent of a patient’s medical condition. For psychological, and social wellbeing. far too much of his short life obsessed example, a patient with a brain tumour The goal of health resource with inequality, and he may be one of likely should have easier access to an MRI allocation should be to correct the first people to consider colonial machine than one with non-debilitating inequities between individuals and history an appropriate prerequisite area knee pain. groups in these three areas of study to medicine. The MRG, however, embraces a This statement better reflects the Consistently, however, he has far broader definition of health than one socially-determined vision of equity that found that the biggest impact he has in based on an individual’s physical we believe the MRG holds at its core. his work comes when he approaches wellbeing, one that includes physical, The debate is in no way over. It health through a lens of historical psychological and social status. Using this is presented as a starting point for disadvantage. While he knows that this broader definition, the discussion around discussion amongst the wider MRG disadvantage is even more pronounced equity becomes more socially based, and membership. It is this type of debate outside of a first world city than in it, he takes on greater transformative potential that keeps an organization such as the is way too addicted to the smog- in our society. MRG vibrant and truly progressive. We enhanced beauty of an urban sunset, and Under this conception of equity, welcome the input of all members on to instant access to top quality (fair trade health resource distribution requires this and every other element of our of course) coffee, to leave … so the proactive efforts to correct social “principles.” One of the greatest mistakes inner city it is! inequality. Therefore, to create equity, a progressive organization can make is groups with historically disadvantaged ♦ to fail to progress itself. (continued on page 22)
Volume 23, Number 2 - Fall, 2003 Medical Reform 21 STEERING COMMITTEE (continued)
PJ Devereaux is a cardiologist and Medicine Residency Program. His work After spending two years as a staff health care researcher who is currently in dissemination of evidence-based physician in Sioux Lookout, working advancing his education in clinical decision-making was recognized by a with First Nations people in remote and epidemiology at McMaster. Among the McMaster University President’s Award underserviced communities, he has issues about which he feels strongly is a for Excellent in Resource Design in 1996. continued working with marginalized physician’s interaction with the Dr. Guyatt was instrumental in founding and poorly served populations in pharmaceutical industry. Dr. Devereaux the Medical Reform Group in 1979 and Kingston. These include: the does not accept gifts or free food from has spent most of the subsequent two unemployed; those on social assistance; the pharmaceutical industry, and his decades as a spokesperson for the group. the disabled; intravenous drug users; principled stand was recently highlighted He has contributed to the development and street youth. He is also active in the in a major article in the Globe and Mail. of MRG policy, and in recent years has areas of Family Planning and taken a major role in packaging and contraception. In all of these areas, he Irfan Dhalla, a recent medical school dissemination of MRG approaches to maintains an interest in advocating for graduate, is an internal medicine resident health issues. patients whose health suffers due to at the University of Toronto. As a social and economic inequality, and who medical student, he helped lead a national Ted Haines helps people and are threatened by moves to limit medical student survey that showed workplaces solve occupational health universal access to high quality publicly increased tuition fees are having negative problems. While recognizing, imperfectly, supported health care. effects on the medical student the massive barriers posed particularly by population. He is currently interested in powerful political and corporate forces, Rosana Pellizzari is a Family Physician developing and using evidence-based he doesn’t see why Canadians shouldn’t at a downtown Toronto community health policy to defend the rights of the have a health care system that protects health centre serving a culturally diverse, more vulnerable populations in our and cares for them, irrespective of means. low-income neighbourhood. As an society. That would be part of the society we Assistant Professor in the Department want. He’s a co-chair of the Hamilton of Family and Community Medicine, Mimi Divinsky is a family physician in Health Coalition and on the she is actively involved in the training downtown Toronto, a Fellow of the administrative committee of the Ontario of medical students, Family Medicine College of the Family Physicians of Health Coalition. “Entre la jeunesse et la Residents and midwives. She writes Canada and a lecturer in the Dept. of sagesse”. regularly for the Toronto Star and has Family and Community Medicine at the hosted a national daily TV health U of Toronto. She was, until a recent Bradley MacIntosh holds a Master program in the recent past. She has illness, medical co-director of the Sexual degree in Medical Biophysics and is served as Chair of the local Board of Assault Care Centre at Women’s College currently working towards his doctorate Public Health and President of the Hospital. Dr. Divinsky has been active in Imaging Research at Sunnybrook and Association of Ontario Health Centres. in the Medical Reform Group since the Women’s CHSC. His research utilizes Dr. Pellizzari worked as a group’s inception, and has played an novel functional techniques with Magnetic community organizer and adult important role on the Steering Resonance Imaging with the application educator prior to entering medicine. Committee since 1985. to brain diseases such as stroke. He views She has experience working on health health as a basic human right, and issues in aboriginal, Latin American and Gordon Guyatt is a Professor in the recognizes that struggle for social justice Asian communities. She has completed Departments of Clinical Epidemiology fought and won in Canada are linked to additional post graduate training in and Biostatistics and Medicine at global well-being. epidemiology and community health. McMaster University. He has made She is involved in multicultural and important contributions to clinical and Adam Newman is a family physician in refugee health issues, women, violence health care research, recognized by over Kingston. He works at a Community and poverty issues. 350 publications in peer-reviewed Health Centre where he helped to journals. His educational work includes develop Kingston’s first integrated Yves Talbot is Associate Professor in seven years as Director of the Internal primary care nurse practitioner program. the Department of Family and (continued on page 23) 22 Medical Reform Volume 22, Number 2 - Fall, 2003 STEERING COMMITTEE (continued)
Community Medicine and Health 1995 in programs of Capacity Building in Care Reform and has a particular Administration at the University of Primary Care. The programs are aimed at interest in the role of primary care Toronto and Director of the International training teams of professionals working in and questions of Equity.♦ Programs in the department of Family different cities of Brazil, Chile and Argentina. and Community Medicine. He has been Dr Talbot has served on the Ontario involved in South America since August (PECCCAR) Committee for Primary Health
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Volume 23, Number 2 - Fall, 2003 Medical Reform 23 READERSHIP SURVEY Janet Maher
he Steering Committee Regardless of their own Several respondents expressed an commissionerd a survey on the preferences, nearly all members who interest in contributing to the newsletter, Tnewsletter in our spring issue, and responded thought we should provide but with one exception declined to here is a brief summary of the feedback unlimited free access to the newsletter on identify themselves. In general the received from about 15 per cent of the the web; and the great majority thought Steering Committee got high marks for membership. The Steering Committee there should be no differential fee for being topical and informative. will be reviewing the findings in the next paper copies of the newsletter. Among the issues recommended month, with a report to the fall meeting, In response to our questions on for newsletter coverage in future: and so we may be looking at some length and frequency, 54 per cent thought • More on international revisions to our format later this year. we could consider a shorter newsletter comparisons, global health issues With regard to the preference for with a more frequent publication schedule. (5 respondents) electronic or hard copy of the newsletter, Fourteen percent thought we should • More on mental health reform 58 per cent were content to receive by publish more but less often, and a third • What about unionizing family e-mail, whereas 29 per cent prefer to preferred the current quarterly schedule. physicians? continue receiving a hard copy. Thirteen In terms of length, 15 per cent thought • What about internet care of per cent would make use of both our current articles were too long, 5 per patients? electronic and hard copy. Of those cent thought they were too short, and 80 • Focus on MD position on issues· prepared to receive an electronic version per cent liked the current mix. • More on primary care reform, almost half would use PDF; just over Sixty per cent of respondents read capitation and alternative payment 20 per cent would prefer a document in several articles or all of each newsletter, ♦ MS Word; the remainder were not sure. and the remainder glanced through or schemes. read a few articles.
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24 Medical Reform Volume 22, Number 2 - Fall, 2003