Canadian health care system source of


debate in journals

Judith David


ith this issue, CMAJ introduces a new column, Reading Room, which will feature synopses of articles In Maloney's view, payroll taxes guarantee dealing with health policy, health economics, medical education and universality, and they have enough flexibility to other topics. It will appear irregumake them the fairest option. larly. Author Judith David will be searching the literature for topics, and her main sources will be journals that most physicians do not have ready access to, but contain ble system into place. She opposes go. They note that among articles of broad general interest. user-pay systems because the reve- countries paying physicians on a Maloney M: Feeding the health nues they generate are too small fee-for-service basis, Canada's syscare leviathan. Policy Options to have any effect on shortfalls in tem has enjoyed notable success if 1991; 12 (4): 27-31 - Maloney funding. Premiums are also reject- governments' criterion for evalustates clearly that maintaining ed because they place a dispropor- ating the system is a low aggregate universality is her first consider- tionate financial burden on lower- amount of national income devotation when evaluating methods income groups, thereby compro- ed to physicians' services. Canada for funding health care. She ex- mising universality. They also spent 0.87% of its gross domestic plores a number of funding op- force the system to rely on the product (GDP) on ambulatory tions, including personal and cor- generosity of health care profes- physician services in 1987. In the porate income taxes, user fees, sionals, including physicians, to same year Belgium, Germany, premiums and employers' payroll carry the burden of providing ser- Switzerland, the US, Austria and taxes. General revenues - those vices without compensation. In France spent at least 1.3%. Howgenerated by personal and corpo- Maloney's view, payroll taxes ever, if analysts consider the rate rate taxes - are rejected because guarantee universality, and they of growth in national income detheir fairness is contingent on the have enough flexibility to make voted to physicians' services, the fairness of the income-tax system. them the fairest option. picture is less rosy; Canada is markedly less successful at conMiddle- and lower-income earners tend to bear the brunt of the tax Rublee D, Moser J: Recent trends trolling the rate of growth in the burden and governments lack the in expenditures on physicians' ser- percentage of GDP given over to political will to put a nmore equita- vices in Canada. Health Policy those services. The authors look at 1991; 18: 119-129 - Rublee and national patterns and at patterns Moser are analysts at the Center in Ontario, Quebec, Nova Scotia Judith David is a writer-editor with the for Health Policy Research, Amer- and British Columbia, examining ican Medical Association, Chica- three elements in the growth of CMA's Department ofPublications. FEBRUARY 15, 1992

CAN MED ASSOC J 1992; 146 (4)


payments to physicians: the number of services billed, the prices for services and the mix of services. They believe the results reflect regional restraint

pothesize that changes in the professional, social and legal environment are determinants of malpractice trends. Use of health care services and the quality of health policies. care professionals are markers in the professional environment. SoBoudreau F: Partnership as a new cial factors include the propensity strategy in mental health policy: to litigate and demographic The case of Quebec; and Rochefort changes. In the legal field, the D: Partnerships: A more en- costs of suing and rules concernthusiastic view. J Health Polit Pol- ing liability and compensation inicy Law 1991; 16: 307-333 - fluence trends. The authors found Boudreau has observed the extent that major surgery accounts for to which "partnership" and "part- more than 90% of the variation in ners" have become political by- the frequency of malpractice litiwords. She voices suspicion about gation, through time and particupolicies of partnership, suggesting larly across specialties. They that policymakers and politicians found no evidence that age, place are attracted to them because they of training or degree of specializaare desirable, rational and market- tion had a significant impact. The able. Boudreau is more interested study did suggest that there has in the manifestation of partner- been an increased tendency for ship than she is in the specifics of aggrieved persons to sue profesthe policies being hung on its sionals who offer services directly framework, but she uses le par- to people - professionals such as tenariat (partnership) of Quebec's dentists, lawyers and physicians. mental health policy to examine Specific demographic and ecopartnership. She is sceptical, con- nomic factors also appear to influtending that governments have ence trends. The authors conclude borrowed the partnership strategy that increases in the frequency of from the corporate world to han- claims are determined to some dle problems confronting the extent by legal changes broadenstate: shortages of resources, loss ing the scope of liability, but that of faith in government and profes- the frequency of claims is affected sionals, and the elusiveness of more by the fact that damages consensus. Boudreau says the have increased where fault has Quebec government has willingly, been found. Coyte and colleagues but selectively, surrendered some suggest that other factors, includcontrol over the system and ing the public's reduced willingadopted a role as a mere partner. ness to bear the consequences of The concept of le partenariat is risk taking, play a large role. The attractive, but the process leaves authors do not try to forecast in place the structure of interests trends. and groups (including physicians) that previously dominated policy. Deber R, Hastings J, Thompson She advises caution. In an accom- G. Health care in Canada: Current panying commentary, Rochefort trends and issues. J Public Health expresses a less cynical evaluation Policy 1991; 12: 72-82 - Despite of government forays into part- the success of Canadian medicare nership. there are perceptions that it is threatened. These authors suggest Coyte P, Dewees D, Trebilcock M: that the system, perceived by obCanadian medical malpractice lia- servers inside and outside Canada bility: An empirical analysis of re- as a model for health care, is a cent trends. J Health Econ 1991; victim of its own success. The 10: 143-168 - The authors hy- problems that face the system now 590

CAN MED ASSOC J 1992; 146 (4)

are more intractable and it will be difficult to improve health status significantly by relying solely on medical means. Universal health insurance has helped, but there are wider determinants of health status, such as poverty and education. The authors say "transition is difficult, ideologically charged" and that change "has only limited public support," making it "politically dangerous." They examine public policy options in light of these tensions.

Krasny J, Ferrier I, Waldo D, Sonnefeld S: A closer look at health care in Canada. Health Aff (Millwood) 1991; 12: 152-165Krasny and Ferrier compare Canadian and American data on health care expenditures and reach three conclusions: the differences in spending are exaggerated by accounting methods, restrictions on access to care account for the slower rate of growth in spending and cultural differences mitigate against the acceptance of a Canadian model in the US. In a commentary following that paper, Waldo and Sonnefeld take strong issue with those first two hypotheses. Hughes J: How well has Canada contained the costs of doctoring? JAMA4 1991; 265: 2347-2351 Hughes examined spending on physicians' services in Ontario, Quebec and British Columbia from 1975 to 1987. The author found that use of the health care system, fuelled by an increased supply of physicians, had the largest influence on spending. The effect was particularly apparent in Quebec - it registered the greatest change in physician-to-population ratio, but the number of services rendered per physician has remained fairly stable. Hughes suggests that cost containment may not only depend on controlling fees and use, but also on limiting the number of new physicians entering the system.a LE 1 5 FEVRIER 1992

Canadian health care system source of lively debate in journals.

READING ROOM * SALLE DE LECTURE Canadian health care system source of lively debate in journals Judith David W ith this issue, CMAJ introduces a...
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