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Research Atlas Research Atlas Supply of Physicians’ Services KEY MESSAGES in Ontario ✓ The supply of active physicians increased steadily from 1991/92 to 1997/98 concurrent with the population rate growth. 1,2,3,4 Ben Chan ✓ The geographic maldistribution of doctors in Ontario has increased. Doctors continue to practise in 1Scientist, Institute for Clinical Evaluative Sciences, Toronto, Ontario 2Assistant Professor, Department of Health Administration, University of Toronto urban centres, while underserviced 3Assistant Professor, Department of Family and Community Medicine, University of Toronto areas continue to lose doctors. 4Lecturer, Department of Public Health Sciences, University of Toronto ✓ The comprehensiveness of primary care services has declined. Fewer general practitioners and family physicians are working in hospitals, nursing homes and obstetrics, opting instead to work more exclusively in their offices. ✓ Women physicians have made a Key Terms & Concepts significant entry into many fields of medicine, but have low participation • Physician Supply in some specialty areas. This may • Alternative Funding Plan (AFP) represent either lifestyle choices or • Full-time Equivalent (FTE) continued barriers. The opinions, results and conclusions are those of the author and no endorsement by the Ministry of Health or the Institute for Clinical Evaluative Sciences is intended or should be inferred. Supply of Physicians' Services in Ontario There is no "right" formula for determining the number of doctors needed. As Background the authors of the influential 1991 Barer-Stoddart report on physician human The Canada Health Act aims to provide Canadians with access to a resources put it: comprehensive range of essential medical services. A critical component to An "optimal" number of physicians cannot be defined for policy maintaining this ideal has been to ensure that there are enough physicians to purposes by technical means; this is ultimately a social rather than a provide these services, and that these physicians are located in areas where technical judgement.1 they are needed. Policymakers and leaders in the medical community have a responsibility to ensure that the proper financial incentives and regulatory Hence, it is beyond the scope of this report to proclaim a judgement as to mechanisms are in place to meet these demands. whether or not Ontario needs more or fewer doctors. Such decisions should follow public debate on the effectiveness of adding more doctors and the Predicting the demand for physician services, however, has been a difficult public’s willingness to pay for them. However, this study does aim to provide challenge. From 1964 to the early 1990s, the supply of doctors has increased stakeholders with baseline information on the state of physician supply over steadily, after health planners in the 1960s expanded the number of medical the past six years. These data, in turn, can serve as a starting point for school places in anticipation of a rapid growth in the population. The expected meaningful debate. rate of population growth never occurred, but the expansion of the physician workforce continued nonetheless.1 In light of this finding, the Deputy Ministers A second set of issues concerns the distribution of physicians and the mix of of Health across the country signed the Banff Accord in 1992, in which they services provided. Where are doctors practising, and what are they doing? agreed to a 10 per cent reduction in medical school enrolment. Such questions raise a number of important concerns regarding patient care and access. The Ministry of Health and the OMA have long recognized that In Ontario, additional measures were implemented to limit the supply of there is a geographic physician maldistribution problem in the province, and doctors. Temporary restrictions on new billing numbers for out-of-province have initiated a number of programs to address the issue. This study aims to 2 graduates were put in place between 1993 and 1996. From 1997 to 1999, shed light on what the impact of such policies may have been over time. financial penalties were instituted for recent graduates who wanted to establish a practice in selected urban areas designated as "overserviced."3 These The specific research questions addressed in this study, therefore, are the measures were part of a series of agreements negotiated between the Ministry following: of Health and the Ontario Medical Association (OMA) aimed at controlling • How many doctors are practising in Ontario? Has the number of doctors health care costs. gone up or down over time? The policies governing physician supply are controversial. Traditionally, • Where are these doctors located? What is the extent of geographic physician organizations have argued that Canada does not have enough maldistribution? Has this maldistribution increased over time? doctors. Recent policy papers by the Ontario College of Family Physicians4 and editorials5-8 by physician leaders reinforce this position. Physician organizations • How old are Ontario’s physicians? Is the physician population getting have also developed models of physician supply that predict a massive older or younger? physician shortage in the next 10 to 20 years.9-11 This diagnosis, however, is • What is the rate of entry of women into practice? What proportion are disputed by some analysts who believe that a significant proportion of women, and how does that proportion vary by region or specialty? physician services could be delegated to nurse practitioners, and that issues of fragmentation of services are more important than supply.12 Competing models • What is the practice mix of Ontario’s general practitioners/family of physician growth developed by non-physician academics predict that practitioners (GP/FPs)? How comprehensive are the services they physician supply will keep pace with the rate of population growth and aging,13 provide, and how has this changed over time? and that even with the 10 per cent reduction in medical school enrolment, there will still be an accumulating surplus of physicians by the year 2010.14 Methods How to Count Doctors This study uses three methods for counting the number of doctors. The first is a Where the Data Come From simple head count of doctors billing OHIP in a given year. However, previous Most of Ontario’s physicians work on a fee-for-service basis. They submit a bill research has shown that 15 per cent of doctors have very low annual billings (less than $35,000), and these physicians account for only 1.5 per cent of total to the Ontario Health Insurance Plan (OHIP) for each insured service they 15 provide, using the standard fee schedule developed through negotiations billings. Such physicians may be spending the large majority of their time between the Ontario Medical Association and the Ministry of Health. OHIP engaged in other activities (e.g. research or administration) and maintaining a maintains a database which records, for each service, a fee code describing the modest clinical practice. This large group of relatively inactive doctors may service performed, the date of service and number of services performed. distort the actual number of physicians in practice. The OHIP database also has some limited data on the characteristics of each A second method is to count active physicians, who bill above some minimum physician, such as gender, age and location of practice. Extra information on threshold. In this analysis, annual billings of $35,000 were arbitrarily selected each doctor’s subspecialty was added from the Southam Medical Database as the cut-off point. The $35,000 threshold has been adjusted for changes in (SMDB). The complex methods for linking the SMDB and OHIP databases are prices from year to year. described in detail in the Technical Appendix. The third method, the full-time equivalent (FTE) method, assigns a weighting to The OHIP billings database contains information only on fee-for-service physicians depending on their billings. Thus, a part-time physician is counted physicians. The Ministry of Health and the Canadian Institute for Health as a fraction of a physician, depending on how his/her activity compares to Information provided additional information on estimates of the number of those physicians near the mid-range of physicians in the same specialty. non-fee-for-service physicians. Physicians with very high billings are considered as having the workload of more than one physician (see the Technical Appendix for more details). Data from the Ontario Physician Human Resource Data Centre (OPHRDC) was used to validate estimates of physician counts. The Centre telephones physicians periodically to verify information on physician specialty and Fee-for-service vs. Alternative Funding Plans location. However, OPHRDC data was not used in this study because it does not contain information about varying workloads among physicians. Approximately 94 per cent of practising physicians derive the bulk of their earnings by billing OHIP on a fee-for-service basis (Canadian Institute for The total number of physicians in OPHRDC correlates well with estimates in Health Information, unpublished data). The remainder participate in alternative this study, and counts of family physicians and surgical subspecialties agree to funding plans (AFPs), such as the following: within five per cent. However, the number of subspecialty internists reported • here is lower than OPHRDC estimates by approximately 20 per cent. This Health service organizations (HSOs). Physicians in HSOs are paid by discrepancy occurred because a more stringent criteria for defining capitation, where they receive a set amount per year for each patient subspecialty was applied in this study; if a physician was coded as internal enrolled in their practice. medicine in both the NPDB and SMDB but had a functional subspecialty, that • Community health centres (CHCs). CHCs are multidisciplinary clinics physician was coded as internal medicine. In OPHRDC, an internist practising which offer a comprehensive range of health services. CHC physicians mostly cardiology would be classified as a cardiologist, even if he or she did typically receive a salary.
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