Bill C-68
probably means nothing but a power play
By D.A. Geekie Bill C-68, an act to amend the Medical Care Act, is on its way to becoming law. The stated purpose of this bill is to limit the rate of increase of fed¬ eral spending on medicare and allow federal-provincial cost sharing for "new, alternative, less-expensive health care delivery programs" by extending the types of programs and services for which the federal government can share the costs. The alternative purpose of this legislation (never mentioned in public) is to "persuade" the provinces
to negotiate a new cost-sharing agree¬ ment for all health services. This latter
may prove far more important and make the details of the law insignificant. Indeed, if this known objective of the federal government is realized, C-68 may prove to be the ultimate in
"nothing legislation". The government's intent
support for medicare
to limit its
first an¬ nounced in the June throne speech by the then minister of finance, John Turner. Health Minister Marc Lalonde gave substance to that intent July 8 with Bill C-68 legislation that would limit the increase of federal government support to 13% (plus a maximum pop¬ ulation adjustment of 1.5%) in 197677, 10.5% in 1977-78 and 8.5% forever after. was
Each and every province protested. The CMA, its provincial divisions and practically every segment of or¬ ganized medicine protested. A series of meetings was held across Canada between the minister of health and representatives of provincial gov¬ ernments and the profession. The government acknowledged the protests, particularly on the permanent 8.5% increase ceiling, and announced it would propose amendments to the legislation. The permanent 8.5% ceiling would be removed in favour of au¬ thority vested in the cabinet to set future annual limits "if required and following consultation with the prov¬ inces." It is to be further amended so as to allow federal cost-sharing for some new programs (home care such as renal dialysis, ambulatory care by non¬ medical personnel, optometric services and community health care services have been mentioned) on an individual
provincial basis.
was subjected to long, and bitter, debate in the House of Commons. The Opposition parties, and in particular Conservative and NDP
The bill
at times
critics, in essence launched a filibuster. Closure was invoked. The bill received second reading and was referred to the health, welfare and social affairs com-
If incr. shared equally
federal share
amount
sisi
&m
&symy%v
708 CMA
*###
If federal incr. only 5% 't^m
?m
IlitS JOURNAL/APRIL 17, 1976/VOL. 114
mittee of the House for in-depth re¬ view. What could be said about this bill that had not already been chewed over six times in the House was ques¬ tionable, but then, that is what the system calls for. The committee showed uncommon haste in getting its deliberations underway. The bill passed second reading Thursday, Mar. 18; the committee had its first meeting at 9:30 am Mar. 19. The bill has been given top priority by the committee. Indeed it has met six times during the last 10 business days to consider this one matter. The CMA received formal notice Mar. 22 that it was to appear before the committee Mar. 25. Obviously the government means business and intends that those concerned especially the provincial are aware of this fact. governments Incidentally, the dominion-provincial ministers of finance conference was held during the first few days of April. The ministers of health are scheduled to meet during the last week of the month. A delegation led by CMA President Dr. L.C. Grisdale argued that Bill C-68 would transfer the responsibility for establishing the level of medicare fund¬ ing from the provinces to the federal cabinet. By utilizing data provided by Statistic Canada and the Department of National Health and Welfare, the asso¬ ciation proved that the economics of the medicare program have been effec¬ tively controlled and managed at the provincial level. The data showed that Canada spent 7.3% of its gross national product for all health services during 1975 identical to the figure for 1972. While the association acknowl¬ edged that the percentage of GNP spent on hospital insurance had increased from 2.6 to 3.05 between 1972 and 1975, the amount spent on medical care per se (the only thing that Bill C-68 is concerned with) actually de¬ creased from 1.33% to 1.19%. In subsequent testimony before the
.Naprosyn®
pruritis, sweating and purpura. Angloneurotic edema has been seen rarely. Central Nervous System: Headache, dizziness, drowsiness, depression and fatigue Brief Prescribing Information have been seen occasionally. Only a few patients had to discontinue treatment beTherapeutic Classification cause of the severity of some of these Oral anti-inflammatory, analgesic and complaints (headache, dizziness). antipyretic agent. Hematologic Reactions: Although a def inite causal relationship has not been Indications The treatment of osteoarthritis, rheumatoid established, rare cases of thrombocytopenia or leucopenia have been reported. arthritis and ankylosing (rheumatoid) spondylitis. Cardiovascular Reactions: Dyspnea, mild peripheral edema, ecchymoses and palpitaContraindications tions have been encountered infrequently. Naprosyn should not be given to patients One case of jaundice which rewith active peptic ulcer or active inflamma- Hepatic: appeared on challenge with Naprosyn has tory disease of the gastrointestinal tract. been reported, but definite relationship to It is also contraindicated for those who the drug has not been established. have shown a sensitivity to it and for Special Senses: A few eye abnormalities, patients in whom aspirin or other nonincluding corneal changes, lens opacities, steroidal anti-inflammatory drugs induce macular degeneration and blurred vision the syndrome of asthma, rhinitis or have been reported, but the relationship to u rticaria. Naprosyn has not been established. Occasional instances of mild to moderately Warnings severe tinnitus have been seen. The safety of Naprosyn in pregnant, lactating or pediatric patients has not been Mouth and Throat Reactions: A few cases established and, therefore, its use is not of severe sore throat have been observed, recommended under these conditions. but the relationship to the drug has not been established. Precautions Laboratory Tests: It should be kept in mind Naprosyn should be given under close when bleeding times are determined that supervision to patients prone to gastroNaprosyn decreases platelet aggregation intestinal tract irritation and to those with and prolongs bleeding time. Other laboradiverticulosis or a history of peptic ulcer. tory tests during Naprosyn therapy have Naprosyn may displace other albuminshown sporadic abnormalities, but no bound drugs from their binding sites and trend was seen that would indicate may lead to drug interactions. For example, definite potential toxicity. patients receiving bishyd roxycoumarin, warfarin, hydantoin, sulfonamide or sulDosage and Administration fonylurea should be watched closely for The usual daily dosage of Naprosyn for signs of overdosage or toxicity when osteoarthritis, rheumatoid arthritis and Naprosyn is added to the regimen. Mild ankylosing spondylitis is 500 mg in divided peripheral edema has been observed in a doses. This may be increased to 750 mg or few cases. Consequently, patients with decreased, depending on the response of compromised cardiac function should be the patient. Administration more frequently kept under observation when taking than twice daily is not necessary. Naprosyn. The prescriber should be alert to the fact that anti-inflammatory, analgesic Dosage Forms and antipyretic effects of Naprosyn may Naprosyn.. is available as oval, biconvex mask the usual signs of infection. Naprosyn tablets, engraved N on one side and is excreted primarily in the urine and SYNTEX on the other. Each pale green should be administered with adequate tablet contains 125mg naproxen. Bottles precaution to patients with diminished of 100 and 500 tablets. Each yellow tablet renal function. Naprosyn may produce 250mg naproxen. Bottles of 50 contains increased urinary values in the assay for and 250 tablets. 17-ketogenic steroids due to interaction between naproxen or its metabolites and Product Monograph available on request. m-dinitrobenzene used in this assay. It is, therefore, suggested that Naprosyn therapy be temporarily discontinued 48 1. Kogstad, 0.: Scand. J. Rheum. (Suppl.), hours before adrenal function tests are 2:159,1973. performed. 2. Diamond, H. etal.: VI Pan Amer. Cong. Rheum. Diseases, Toronto, June 15, Adverse Reactions 1974, in J. Clin. Pharmacol., 15:4, 1975. Gastrointestinal Tract: Infrequent bleeding 3. Hill, H. F. H. etal.: Proceedings of a with or without ulceration. In some cases, Symposium, London, 1973. the relationship to Naprosyn was difficult to assess. Other adverse effects, in decreasing order of prevalence, were: heartburn, constipation, abdominal pain, nausea, diarrhea, dyspepsia and diverticulitis. Only a few complaints were severe enough to warrant discontinuation of therapy. Skin: Rashes have been relatively uncommon and generally cleared on withdrawal Syntex Ltd. of the drug. Other reactions encountered, Montreal, Quebec H4P 2B5 in decreasing order of frequency, were:
SYNTEX
712 CMA JOURNAL/APRIL 17, 1976/VOL. 114
committee, Mr. Lalonde acknowledged that the cost of medical care insurance has been controlled in an acceptable manner. He acknowledged that the average 10.5% increase for medical care insurance since 1971 had not been excessive. Indeed, the minister appeared to be going out of his way during his appearances before the committee to speak well of the program and the economic responsibility that had been exhibited by provincial governments and the medical profession. However, he indicated that he was concerned that the rise in costs for medicare was expected to reach 16.6% during the current fiscal year - and that he was particularly concerned with recent physician demands for 30 to 50% increases in fee schedules. Mr. Lalonde acknowledged that the CMA's concern for the effect of this legislation on the so-called "have-not provinces" was a matter for debate. The CMA quoted hypothetical examples (see Table I) which indicated that, should the federal government restrict its contribution increase to 5% when the actual increase in cost was 10% for a "have-not province" such as Newfoundland (where the federal government pays close to 80% of the medicare bill), it would result in a 30% budget increase for the province. His only response: "There is some degree of truth to this hypothetical case, but the discussions I have had to date with the provinces indicate that the threat of runaway inflation on medical costs - where have not provinces are required to meet the payment levels of the have provinces - is even more serious. The CMA asked, "Do the members of this committee believe that such major increases in provincial funding are possible in our have-not provinces? We believe that the effect of this legislation will result in a rationing of services, a deterioration in the quality of medical care or both. Such a result would be in direct contradiction to the spirit of the four basic principles of federal government involvement in medical care insurance as enunciated by former Prime Minister Lester Pearson when the program was introduced." The minister's response to the CMA suggestion of such dire results: "I find it difficult to take such statements seriously. The medical profession has been issuing this kind of dire consequence statement for close to 20 years, but we still have what everyone acknowledges is the best medical care insurance program and system in the world." Well, where are we? It's highly uncontinued at foot of opposite page
CMA Council on Medical Services concerned with problems of pharmacare In a time of economic crisis an expensive pharmacare program is probably the last thing on the minds of the federal Treasury Board. Nevertheless, members of the CMA Council on Medical Services are worrying themselves about the imminence of the introduction of such a program and the implications for the medical profession. The subject arose at their meeting in Ottawa Mar. 8 and 9 during a report from Dr. Ian Henderson, chairman of the council's subcommittee on pharmacotherapy. Dr. Henderson pointed out that provincial governments are already introducing programs to provide prescription drugs as part of tax-paid health care, and he suggested there is a need for the medical profession to be more active in the planning of these programs. There is a possibility, he suggested, that unless guidelines for quantities of drugs and information about interactions between drugs and between drugs and food are supplied, there could be overprescribing, overuse, inappropriate use and adverse drug reactions. This also could lead to "fantastically high" costs for pharmacare. Dr. Henderson suggested the CMA should join with the Canadian Pharmaceutical Association to draw up guidelines on drug prescribing. He said the Canadian government has already set up panels of its own experts to set guidelines on antibiotics,
anxiolytic drugs and antihypertensive drugs. Dr. Henderson's report was primarily a verbal description of a recent workshop on government drug programs in Winnipeg. He said a subject aired at that workshop is the problem caused by physicians who evade the limit that exists in some provinces on maximum quantities of drugs that may be dispensed (this limit is for a 30-day supply); the physician will, for instance, triple the desired dosage on the prescription form and give the patient verbal instructions to take only onethird the dosage as written down. This practice obviously could lead to serious consequences. One council member suggested that each patient be encouraged to register with one pharmacist who would maintain an accurate profile of drugs used by the patient. The council also considered further the dangers that could arise from a physician's using injections prepackaged in a hospital pharmacy. An opinion had been sought from the Canadian Medical Protective Association, and Dr. N.P. Da Sylva, council coordinator, presented the resultant correspondence. The question had arisen about the legal liability in the event of an error in the packaging, with the result that the patient receives the wrong drug or the wrong strength or amount of the
right drug. The CMPA opinion was that, if the error is in the labelling before the physician receives the injectible material, providing there is nothing about the appearance of it which should alert the doctor to an error in labelling, "the responsibility should be assigned elsewhere." However the physician should insist on detailed labelling of the content, amount and concentration and "might want to know by whom the material had been prepared." The CMPA also forsaw concerns including the possibility of contamination in transit and mislaying and outdating of certain materials. These matters would be the responsibility of the hospital or those administering the program. The council discussed a number of documents, including the third and final part by the requirements committee of the National Committee on Physician Manpower, a paper on primary care by Dr. W.L. Davis, a paper on care of the elderly by Dr. J.B. Wonnacott and a paper on indirect services by Dr. F.P. Ceresney. Drs. Davis, Wonnacott and Ceresney are members of the council. The papers will form the basis of a number of recommendations to the CMA General Council meeting in June and, if accepted, will become CMA official policy.
DOUG'S DIGEST
him verify the statement on direct question), "I think there is a very good chance - I am very optimistic that we will be able to realize a new dominion-provincial cost sharing formula for all health services this year." If a new cost-sharing formula is realized for all health services - hospital insurance, medical care insurance, etc. - the profession may never have to worry about the federal cabinet arbitrarily setting medicare budget limits in 1978-79. Bill C-68 could become a nothing piece of legislation - it would cease to exist.
If that does occur, physicians will be competing at the provincial level for adequate funding for their services with budget demands for hospitalization, optometric services, ambulatory and home care programs - indeed, they will be competing for budget allocations with highway construction, law enforcement - all provincial-government-funded programs. Such prospects will not bring joy to the hearts of physicians - especially officers of provincial medical associations. But at least the picture would be put in a clear, honest perspective.E
continued from page 712 likely that anyone can answer that question with any degree of certainty. The answer will depend on the results of discussions between the federal and provincial ministers of finance - and when the ministers of health meet later this month. However, Mr. Lalonde may have given us a distinct clue as to where we are going, during his most recent appearance before the House of Commons committee. He stated (I had
JIM GARNER
CMA JOURNAL/APRIL 17, 1976/VOL. 114 713
probably means nothing but a power play
By D.A. Geekie Bill C-68, an act to amend the Medical Care Act, is on its way to becoming law. The stated purpose of this bill is to limit the rate of increase of fed¬ eral spending on medicare and allow federal-provincial cost sharing for "new, alternative, less-expensive health care delivery programs" by extending the types of programs and services for which the federal government can share the costs. The alternative purpose of this legislation (never mentioned in public) is to "persuade" the provinces
to negotiate a new cost-sharing agree¬ ment for all health services. This latter
may prove far more important and make the details of the law insignificant. Indeed, if this known objective of the federal government is realized, C-68 may prove to be the ultimate in
"nothing legislation". The government's intent
support for medicare
to limit its
first an¬ nounced in the June throne speech by the then minister of finance, John Turner. Health Minister Marc Lalonde gave substance to that intent July 8 with Bill C-68 legislation that would limit the increase of federal government support to 13% (plus a maximum pop¬ ulation adjustment of 1.5%) in 197677, 10.5% in 1977-78 and 8.5% forever after. was
Each and every province protested. The CMA, its provincial divisions and practically every segment of or¬ ganized medicine protested. A series of meetings was held across Canada between the minister of health and representatives of provincial gov¬ ernments and the profession. The government acknowledged the protests, particularly on the permanent 8.5% increase ceiling, and announced it would propose amendments to the legislation. The permanent 8.5% ceiling would be removed in favour of au¬ thority vested in the cabinet to set future annual limits "if required and following consultation with the prov¬ inces." It is to be further amended so as to allow federal cost-sharing for some new programs (home care such as renal dialysis, ambulatory care by non¬ medical personnel, optometric services and community health care services have been mentioned) on an individual
provincial basis.
was subjected to long, and bitter, debate in the House of Commons. The Opposition parties, and in particular Conservative and NDP
The bill
at times
critics, in essence launched a filibuster. Closure was invoked. The bill received second reading and was referred to the health, welfare and social affairs com-
If incr. shared equally
federal share
amount
sisi
&m
&symy%v
708 CMA
*###
If federal incr. only 5% 't^m
?m
IlitS JOURNAL/APRIL 17, 1976/VOL. 114
mittee of the House for in-depth re¬ view. What could be said about this bill that had not already been chewed over six times in the House was ques¬ tionable, but then, that is what the system calls for. The committee showed uncommon haste in getting its deliberations underway. The bill passed second reading Thursday, Mar. 18; the committee had its first meeting at 9:30 am Mar. 19. The bill has been given top priority by the committee. Indeed it has met six times during the last 10 business days to consider this one matter. The CMA received formal notice Mar. 22 that it was to appear before the committee Mar. 25. Obviously the government means business and intends that those concerned especially the provincial are aware of this fact. governments Incidentally, the dominion-provincial ministers of finance conference was held during the first few days of April. The ministers of health are scheduled to meet during the last week of the month. A delegation led by CMA President Dr. L.C. Grisdale argued that Bill C-68 would transfer the responsibility for establishing the level of medicare fund¬ ing from the provinces to the federal cabinet. By utilizing data provided by Statistic Canada and the Department of National Health and Welfare, the asso¬ ciation proved that the economics of the medicare program have been effec¬ tively controlled and managed at the provincial level. The data showed that Canada spent 7.3% of its gross national product for all health services during 1975 identical to the figure for 1972. While the association acknowl¬ edged that the percentage of GNP spent on hospital insurance had increased from 2.6 to 3.05 between 1972 and 1975, the amount spent on medical care per se (the only thing that Bill C-68 is concerned with) actually de¬ creased from 1.33% to 1.19%. In subsequent testimony before the
.Naprosyn®
pruritis, sweating and purpura. Angloneurotic edema has been seen rarely. Central Nervous System: Headache, dizziness, drowsiness, depression and fatigue Brief Prescribing Information have been seen occasionally. Only a few patients had to discontinue treatment beTherapeutic Classification cause of the severity of some of these Oral anti-inflammatory, analgesic and complaints (headache, dizziness). antipyretic agent. Hematologic Reactions: Although a def inite causal relationship has not been Indications The treatment of osteoarthritis, rheumatoid established, rare cases of thrombocytopenia or leucopenia have been reported. arthritis and ankylosing (rheumatoid) spondylitis. Cardiovascular Reactions: Dyspnea, mild peripheral edema, ecchymoses and palpitaContraindications tions have been encountered infrequently. Naprosyn should not be given to patients One case of jaundice which rewith active peptic ulcer or active inflamma- Hepatic: appeared on challenge with Naprosyn has tory disease of the gastrointestinal tract. been reported, but definite relationship to It is also contraindicated for those who the drug has not been established. have shown a sensitivity to it and for Special Senses: A few eye abnormalities, patients in whom aspirin or other nonincluding corneal changes, lens opacities, steroidal anti-inflammatory drugs induce macular degeneration and blurred vision the syndrome of asthma, rhinitis or have been reported, but the relationship to u rticaria. Naprosyn has not been established. Occasional instances of mild to moderately Warnings severe tinnitus have been seen. The safety of Naprosyn in pregnant, lactating or pediatric patients has not been Mouth and Throat Reactions: A few cases established and, therefore, its use is not of severe sore throat have been observed, recommended under these conditions. but the relationship to the drug has not been established. Precautions Laboratory Tests: It should be kept in mind Naprosyn should be given under close when bleeding times are determined that supervision to patients prone to gastroNaprosyn decreases platelet aggregation intestinal tract irritation and to those with and prolongs bleeding time. Other laboradiverticulosis or a history of peptic ulcer. tory tests during Naprosyn therapy have Naprosyn may displace other albuminshown sporadic abnormalities, but no bound drugs from their binding sites and trend was seen that would indicate may lead to drug interactions. For example, definite potential toxicity. patients receiving bishyd roxycoumarin, warfarin, hydantoin, sulfonamide or sulDosage and Administration fonylurea should be watched closely for The usual daily dosage of Naprosyn for signs of overdosage or toxicity when osteoarthritis, rheumatoid arthritis and Naprosyn is added to the regimen. Mild ankylosing spondylitis is 500 mg in divided peripheral edema has been observed in a doses. This may be increased to 750 mg or few cases. Consequently, patients with decreased, depending on the response of compromised cardiac function should be the patient. Administration more frequently kept under observation when taking than twice daily is not necessary. Naprosyn. The prescriber should be alert to the fact that anti-inflammatory, analgesic Dosage Forms and antipyretic effects of Naprosyn may Naprosyn.. is available as oval, biconvex mask the usual signs of infection. Naprosyn tablets, engraved N on one side and is excreted primarily in the urine and SYNTEX on the other. Each pale green should be administered with adequate tablet contains 125mg naproxen. Bottles precaution to patients with diminished of 100 and 500 tablets. Each yellow tablet renal function. Naprosyn may produce 250mg naproxen. Bottles of 50 contains increased urinary values in the assay for and 250 tablets. 17-ketogenic steroids due to interaction between naproxen or its metabolites and Product Monograph available on request. m-dinitrobenzene used in this assay. It is, therefore, suggested that Naprosyn therapy be temporarily discontinued 48 1. Kogstad, 0.: Scand. J. Rheum. (Suppl.), hours before adrenal function tests are 2:159,1973. performed. 2. Diamond, H. etal.: VI Pan Amer. Cong. Rheum. Diseases, Toronto, June 15, Adverse Reactions 1974, in J. Clin. Pharmacol., 15:4, 1975. Gastrointestinal Tract: Infrequent bleeding 3. Hill, H. F. H. etal.: Proceedings of a with or without ulceration. In some cases, Symposium, London, 1973. the relationship to Naprosyn was difficult to assess. Other adverse effects, in decreasing order of prevalence, were: heartburn, constipation, abdominal pain, nausea, diarrhea, dyspepsia and diverticulitis. Only a few complaints were severe enough to warrant discontinuation of therapy. Skin: Rashes have been relatively uncommon and generally cleared on withdrawal Syntex Ltd. of the drug. Other reactions encountered, Montreal, Quebec H4P 2B5 in decreasing order of frequency, were:
SYNTEX
712 CMA JOURNAL/APRIL 17, 1976/VOL. 114
committee, Mr. Lalonde acknowledged that the cost of medical care insurance has been controlled in an acceptable manner. He acknowledged that the average 10.5% increase for medical care insurance since 1971 had not been excessive. Indeed, the minister appeared to be going out of his way during his appearances before the committee to speak well of the program and the economic responsibility that had been exhibited by provincial governments and the medical profession. However, he indicated that he was concerned that the rise in costs for medicare was expected to reach 16.6% during the current fiscal year - and that he was particularly concerned with recent physician demands for 30 to 50% increases in fee schedules. Mr. Lalonde acknowledged that the CMA's concern for the effect of this legislation on the so-called "have-not provinces" was a matter for debate. The CMA quoted hypothetical examples (see Table I) which indicated that, should the federal government restrict its contribution increase to 5% when the actual increase in cost was 10% for a "have-not province" such as Newfoundland (where the federal government pays close to 80% of the medicare bill), it would result in a 30% budget increase for the province. His only response: "There is some degree of truth to this hypothetical case, but the discussions I have had to date with the provinces indicate that the threat of runaway inflation on medical costs - where have not provinces are required to meet the payment levels of the have provinces - is even more serious. The CMA asked, "Do the members of this committee believe that such major increases in provincial funding are possible in our have-not provinces? We believe that the effect of this legislation will result in a rationing of services, a deterioration in the quality of medical care or both. Such a result would be in direct contradiction to the spirit of the four basic principles of federal government involvement in medical care insurance as enunciated by former Prime Minister Lester Pearson when the program was introduced." The minister's response to the CMA suggestion of such dire results: "I find it difficult to take such statements seriously. The medical profession has been issuing this kind of dire consequence statement for close to 20 years, but we still have what everyone acknowledges is the best medical care insurance program and system in the world." Well, where are we? It's highly uncontinued at foot of opposite page
CMA Council on Medical Services concerned with problems of pharmacare In a time of economic crisis an expensive pharmacare program is probably the last thing on the minds of the federal Treasury Board. Nevertheless, members of the CMA Council on Medical Services are worrying themselves about the imminence of the introduction of such a program and the implications for the medical profession. The subject arose at their meeting in Ottawa Mar. 8 and 9 during a report from Dr. Ian Henderson, chairman of the council's subcommittee on pharmacotherapy. Dr. Henderson pointed out that provincial governments are already introducing programs to provide prescription drugs as part of tax-paid health care, and he suggested there is a need for the medical profession to be more active in the planning of these programs. There is a possibility, he suggested, that unless guidelines for quantities of drugs and information about interactions between drugs and between drugs and food are supplied, there could be overprescribing, overuse, inappropriate use and adverse drug reactions. This also could lead to "fantastically high" costs for pharmacare. Dr. Henderson suggested the CMA should join with the Canadian Pharmaceutical Association to draw up guidelines on drug prescribing. He said the Canadian government has already set up panels of its own experts to set guidelines on antibiotics,
anxiolytic drugs and antihypertensive drugs. Dr. Henderson's report was primarily a verbal description of a recent workshop on government drug programs in Winnipeg. He said a subject aired at that workshop is the problem caused by physicians who evade the limit that exists in some provinces on maximum quantities of drugs that may be dispensed (this limit is for a 30-day supply); the physician will, for instance, triple the desired dosage on the prescription form and give the patient verbal instructions to take only onethird the dosage as written down. This practice obviously could lead to serious consequences. One council member suggested that each patient be encouraged to register with one pharmacist who would maintain an accurate profile of drugs used by the patient. The council also considered further the dangers that could arise from a physician's using injections prepackaged in a hospital pharmacy. An opinion had been sought from the Canadian Medical Protective Association, and Dr. N.P. Da Sylva, council coordinator, presented the resultant correspondence. The question had arisen about the legal liability in the event of an error in the packaging, with the result that the patient receives the wrong drug or the wrong strength or amount of the
right drug. The CMPA opinion was that, if the error is in the labelling before the physician receives the injectible material, providing there is nothing about the appearance of it which should alert the doctor to an error in labelling, "the responsibility should be assigned elsewhere." However the physician should insist on detailed labelling of the content, amount and concentration and "might want to know by whom the material had been prepared." The CMPA also forsaw concerns including the possibility of contamination in transit and mislaying and outdating of certain materials. These matters would be the responsibility of the hospital or those administering the program. The council discussed a number of documents, including the third and final part by the requirements committee of the National Committee on Physician Manpower, a paper on primary care by Dr. W.L. Davis, a paper on care of the elderly by Dr. J.B. Wonnacott and a paper on indirect services by Dr. F.P. Ceresney. Drs. Davis, Wonnacott and Ceresney are members of the council. The papers will form the basis of a number of recommendations to the CMA General Council meeting in June and, if accepted, will become CMA official policy.
DOUG'S DIGEST
him verify the statement on direct question), "I think there is a very good chance - I am very optimistic that we will be able to realize a new dominion-provincial cost sharing formula for all health services this year." If a new cost-sharing formula is realized for all health services - hospital insurance, medical care insurance, etc. - the profession may never have to worry about the federal cabinet arbitrarily setting medicare budget limits in 1978-79. Bill C-68 could become a nothing piece of legislation - it would cease to exist.
If that does occur, physicians will be competing at the provincial level for adequate funding for their services with budget demands for hospitalization, optometric services, ambulatory and home care programs - indeed, they will be competing for budget allocations with highway construction, law enforcement - all provincial-government-funded programs. Such prospects will not bring joy to the hearts of physicians - especially officers of provincial medical associations. But at least the picture would be put in a clear, honest perspective.E
continued from page 712 likely that anyone can answer that question with any degree of certainty. The answer will depend on the results of discussions between the federal and provincial ministers of finance - and when the ministers of health meet later this month. However, Mr. Lalonde may have given us a distinct clue as to where we are going, during his most recent appearance before the House of Commons committee. He stated (I had
JIM GARNER
CMA JOURNAL/APRIL 17, 1976/VOL. 114 713
