BUSINESS * LES AFFAIRES
GST~on cosnietic procedue wil drive
patients away,
surgeons say
Patrick Sullivan
Should face-lifts be taxable? What about hair transplants? Liposuction? A little-noticed section in the technical paper outlining the federal government's proposed goods and services tax (GST) says these procedures should be, and that is bad news for the country's plastic surgeons, one group of physicians that still collects a large amount of its income through elective procedures performed outside medicare. Dermatologists, who also perform a large number of these procedures, will also be affected. Plastic surgeons are worried about the effect the 7% tax - all physicians' services except for purely elective cosmetic surgery are to be exempted from it when it takes effect in 1991 - will have on their practices and patients. Dr. Peter Wyshynski, who operates a major plastic surgery clinic in Kitchener, Ont., thinks cosmetic surgery was too easy a target for the taxmen to ignore. "There's this idea out there that only wealthy widows and movie stars have the surgery, and of course that's not true. I see teachers and I see women who work on Patrick Sullivan is CMAJ news tures editor.
an assembly line. This tax will deter a lot of them." Dr. Lefter Mantse, an Ottawa plastic surgeon who is heavily involved in liposuction and hair transplantation, is worried too. "Of course this will drive patients away", he says. "We're not just operating on millionaires, although everyone seems to think we are." Mantse thinks the term cosmetic surgery is often used pejoratively. "They can say that it is cosmetic, that it is unnecessary, that only vain people have it done, but they do not mention that psychiatric problems very often accompany these 'cosmetic' problems, that young men will drop out of school because their premature baldness bothers them so much. I have operated on men and the operation literally
changed their whole life." Wyshynski says plastic surgeons will be hit with a double whammy. First, they will have to absorb the 7% tax that will be applied to elective cosmetic surgery procedures such as face-lifts, or pass it on to their patients. "Most will add it, and that will probably mean that many people and fea- would have to think twice before proceeding with a procedure. That
will mean lost patients. And then we'll have 7% added to our overhead costs, on everything from needles to syringes to gauze." This means procedures that are now being taxed for the first time will also cost more to perform. Since overhead costs already eat up about 55% of a plastic surgeon's revenue - Wyshynski says many of the procedures are performed in private clinics, not hospitals - he expects the GST will increase overhead costs to about 60% of total revenue. "When overhead goes up, that cost has to be passed along to patients", he says. Wyshynski also thinks some rules concerning provincial funding of cosmetic surgery are ludicrous. "For instance, OHIP (Ontario Health Insurance Plan) will pay for a breast reduction, so with that there is no GST. If the breasts are enlarged it will not pay, so there will be GST. OHIP will pay for an operation to correct varicose veins, so there will be no GST, but most of these operations are done for cosmetic, not medical, reasons. If you come to me as a child who has protruding ears, the operation will be covered by OHIP. There will be no tax. Come to me the day after CAN MED ASSOC J 1990; 142 (1)
55
lect $2.10 per plug, an amount that would soon add up. Mantse says 100 plugs or more can be transplanted during a single session. Wyshynski, secretary of the Canadian Society of Aesthetic Plastic Surgeons, says two-thirds
you turn 18 and you will not be covered. You will pay the GST. It makes you wonder." Mantse wonders who will de-
fine "purely elective" cosmetic surgery, the term used in the GST technical paper. "Would you tell me what purely elective means? Say you are on TV, a place where looks are very important, and you have a face-lift because you want to keep your job. Is that purely elective?" Dr. Leith Douglas, the Toronto-based president of the 300member Canadian Society of Plastic Surgeons, is concerned about another aspect of the tax. "To deal with a car dealer where they say the price is this and then add the tax is one thing, but I do not think physicians should be placed in that position", he says. "We should not have to become tax collectors for the federal government." How much tax would the surgeons have to collect? For faceTHERAPEUTIC CLASSIFICATION Antianginal agent
ACTI: ADALAT is a calcium entry blocker which, by selectively inhibiting the influx of extracellular calcium into the cells of cardiac and vascular smooth muscle through specific ion (slow) channels, inhibits the contractile processes of these tissues. While the detailed mechanisms by which ADALAT relieves angina have not been fully determined, they are believed to be related to the drug's vasodilatory action. ADALAT dilates coronary arteries and arterioles in norn ischemic regions and inhibits coronary artery spasm. erties increase myocardial oxygen delivery and Anfialycf AT5AAt in v_suspasic lg.r.efficacy of ADALAT in chronic stable a MOIAIOS: ADALAT is indicated f * Angina resulting from coronain a without eviden * Chronic stable (effort vasospasm in patients who remain symptomatic despite adequate doses of beta blockers and/or organic nitrates or who cannot tolerate those agents. ADALAT may be used in combination with beta blockers in patients with chronic stable angina However, blood pressure should be monitored closely, since hypotension can occur from the combined effects of the drugs. CONTRAINICTIONS: ADALAT is contraindicated in patients who: * are pregnant or of childbearing potential. * have severe hypotension.
IIMGS: ADALAT should be used with care in patients who: * are prone to develop hypotension. * experience an unexplained increase in angina symptoms on starting ADALAT or when the dose is increased. * may develop a syndrome on withdrawal from beta blockers. Initiation of ADALAT will not prevent this syndrome; thus, beta blockers should be tapered while initiating ADALAT. * have severe heart failure or severe aortic stenosis. PRECAUTIONS: As ADALATs vasodilatory action may lower blood pressure, it should be monitored closely, especially in patients
already taking antihypertensives. ADALAT's vasodilatory action may cause mild to moderate peripheral edema. Where angina is complicated by congestive heart failure, peripheral edema should be distinguished from the effects of increasing left ventricular dysfunction. Peripheral edema usually responds to diuretics. ADALAT should be administered cautiously to elderly patients, espedally those with hypotension or cerebral vascular insufficiency. The use of ADALAT in diabetic patients may require adjustment of their control.
of his income is "non-OHIP", with the bills paid directly by patients and thus subject to the GST. "Across the country I'd guess the ratio is 50:50 - half of the money comes from patients, half from health care plans", he says. Mantse: Who defines purely elective?
lifts, which can cost up to $10 000 in the Toronto area, they could find themselves collecting $700 for the federal treasury. For hairtransplant procedures, in which plugs of hair are transplanted to bald areas, a typical charge per transplanted plug is $30. With the GST the government would col-
Douglas says the Canadian Society of Plastic Surgeons has not made an official presentation to the government on the issue. Wyshynski has contacted his local member of Parliament, while Mantse, who had not been aware the tax would affect him until CMAJ called, said he was writing a letter to Finance Minister Michael Wilson "as soon as I hang up the phone".m
DRUG MTERACTIONS: ADALAT may be co-administered with nitrates, digitalis glycosides, furosemide and anticoagulants. ADALAT may potentiate the effects of antihypertensives. ADVERSE REACTIONS: Adverse reactions were reported in 27.9% of the heterogeneous group of 7146 patients treated with ADALAT and required discontinuation of treatment in 5.5%. The most common adverse reactions. which aenerallv result from ADALAT's
In all cases dosage should be adjusted to individual patient requirements. The starting dose is one 10 mg capsule, swallowed whole, 3 times/day. The usual effective dose range is 10-20 mg three times daily. Some patients, especially those with evidence of coronary artery spasm, respond only to higher doses, more frequent administration, or both. In such patients, doses of 20-30 mg three or four times daily may be effective. A maximum daily dose of 120 mg may be used. In general there shouldr interval of at least three days between increases in d order to adequately assess the In hospitalized patients under it 'myprcdror rapIdy. autiously to elderly patients and id gradually adjusted depending Dsage ; itient to a. (See Precautions.) e for greater flexibility of dose
snortness Ot breatn, dyspnea (1 .3%); sleep oisturbances 11.1 '/0); blurred vision (0.9%); diarrhea (0.9%); depression (0.6%); constipation (0.6%); nasal congestion (0.5%); syncope (0.4%).
auvl-rar
in 10 mg gelatin capsules in the
Rarely, ADALAT has been reported to precipitate an angina attack and to cause mild to moderate transient elevations of enzymes, such as alkaline phosphatase, CPK, LDH, SGOT, SGPT. Two cases of hypersensitivity, resulting in an allergic hepatitis, have been reported. SYMPTOMS AND TREATMENT OF OVERDOSAGE: There is no well documented experience with ADALAT overdosage. Gross overdosage could result in excessive peripheral vasodilation and clinically significant hypotension. Active cardiovascular support would be required, possibly including a vasoconstrictor to restore vascular tone. As ADALAT is 90% protein bound, dialysis is not likely to be of benefit As ADALAT is almost completely metabolized in the body, clearance would be expected to be prolonged with impaired liver function.
willuIl wuiltaliz; a
oncor hnypc nf iI gn LUI {119 WA;; Ul uIOspll;wl
ADALAT (nifedipine) 5 mg gelatin capsule: bottles of 100. PRODUCT MONOGRAPH AVAILABLE ON REQUEST.
REFERENCES
1. Deedwania P, Medical World News, March 13, 1989:p. 16. 2. Cohn PF et al. The Nifedipine-Total Ischemia Awareness Program, Am J Cardiol 1989; 63:534-39. C A
MILES CANADA INC., 1989 TM The Trademark of the Adalat I capsule, Registered Trademark consisting of its colour, shape MILES CANADA INC. is the Registered and size, is a trademark of User of the trademark ADALAT , MILES CANADA INC. the original brand of nifedipine TREATS THE TOTAL ISCHEMIC
DOSAGE AND ADMMTTION
BURDEN
DOSAGE GUIDE 10 mg t. i. d. STARTING DOSE 10 or 20mg t.i. d. USUAL MAINTENANCE DOSE MAXIMUM DAILY DOSAGE 120mg When complete beta blocker withdrawal is required, titration of the beta blocker is mandatory. See beta blocker prescribing information.
hlictpr lOtel
paks of 10 capsules) plus an empty dispenser box for loose blister storage. Bottles of 500 are available for institutional purposes only. Store below 30°C and avoid freezing.
~~K7UKi7UEE7~~~~~~~~UE ~~ISLENT nifedipine .
MILES 77 BE'tHED D Elm8C(SO"m19W"If
ML
D
1
PlAA7BI CP
AD-171-04- 89/E
GST~on cosnietic procedue wil drive
patients away,
surgeons say
Patrick Sullivan
Should face-lifts be taxable? What about hair transplants? Liposuction? A little-noticed section in the technical paper outlining the federal government's proposed goods and services tax (GST) says these procedures should be, and that is bad news for the country's plastic surgeons, one group of physicians that still collects a large amount of its income through elective procedures performed outside medicare. Dermatologists, who also perform a large number of these procedures, will also be affected. Plastic surgeons are worried about the effect the 7% tax - all physicians' services except for purely elective cosmetic surgery are to be exempted from it when it takes effect in 1991 - will have on their practices and patients. Dr. Peter Wyshynski, who operates a major plastic surgery clinic in Kitchener, Ont., thinks cosmetic surgery was too easy a target for the taxmen to ignore. "There's this idea out there that only wealthy widows and movie stars have the surgery, and of course that's not true. I see teachers and I see women who work on Patrick Sullivan is CMAJ news tures editor.
an assembly line. This tax will deter a lot of them." Dr. Lefter Mantse, an Ottawa plastic surgeon who is heavily involved in liposuction and hair transplantation, is worried too. "Of course this will drive patients away", he says. "We're not just operating on millionaires, although everyone seems to think we are." Mantse thinks the term cosmetic surgery is often used pejoratively. "They can say that it is cosmetic, that it is unnecessary, that only vain people have it done, but they do not mention that psychiatric problems very often accompany these 'cosmetic' problems, that young men will drop out of school because their premature baldness bothers them so much. I have operated on men and the operation literally
changed their whole life." Wyshynski says plastic surgeons will be hit with a double whammy. First, they will have to absorb the 7% tax that will be applied to elective cosmetic surgery procedures such as face-lifts, or pass it on to their patients. "Most will add it, and that will probably mean that many people and fea- would have to think twice before proceeding with a procedure. That
will mean lost patients. And then we'll have 7% added to our overhead costs, on everything from needles to syringes to gauze." This means procedures that are now being taxed for the first time will also cost more to perform. Since overhead costs already eat up about 55% of a plastic surgeon's revenue - Wyshynski says many of the procedures are performed in private clinics, not hospitals - he expects the GST will increase overhead costs to about 60% of total revenue. "When overhead goes up, that cost has to be passed along to patients", he says. Wyshynski also thinks some rules concerning provincial funding of cosmetic surgery are ludicrous. "For instance, OHIP (Ontario Health Insurance Plan) will pay for a breast reduction, so with that there is no GST. If the breasts are enlarged it will not pay, so there will be GST. OHIP will pay for an operation to correct varicose veins, so there will be no GST, but most of these operations are done for cosmetic, not medical, reasons. If you come to me as a child who has protruding ears, the operation will be covered by OHIP. There will be no tax. Come to me the day after CAN MED ASSOC J 1990; 142 (1)
55
lect $2.10 per plug, an amount that would soon add up. Mantse says 100 plugs or more can be transplanted during a single session. Wyshynski, secretary of the Canadian Society of Aesthetic Plastic Surgeons, says two-thirds
you turn 18 and you will not be covered. You will pay the GST. It makes you wonder." Mantse wonders who will de-
fine "purely elective" cosmetic surgery, the term used in the GST technical paper. "Would you tell me what purely elective means? Say you are on TV, a place where looks are very important, and you have a face-lift because you want to keep your job. Is that purely elective?" Dr. Leith Douglas, the Toronto-based president of the 300member Canadian Society of Plastic Surgeons, is concerned about another aspect of the tax. "To deal with a car dealer where they say the price is this and then add the tax is one thing, but I do not think physicians should be placed in that position", he says. "We should not have to become tax collectors for the federal government." How much tax would the surgeons have to collect? For faceTHERAPEUTIC CLASSIFICATION Antianginal agent
ACTI: ADALAT is a calcium entry blocker which, by selectively inhibiting the influx of extracellular calcium into the cells of cardiac and vascular smooth muscle through specific ion (slow) channels, inhibits the contractile processes of these tissues. While the detailed mechanisms by which ADALAT relieves angina have not been fully determined, they are believed to be related to the drug's vasodilatory action. ADALAT dilates coronary arteries and arterioles in norn ischemic regions and inhibits coronary artery spasm. erties increase myocardial oxygen delivery and Anfialycf AT5AAt in v_suspasic lg.r.efficacy of ADALAT in chronic stable a MOIAIOS: ADALAT is indicated f * Angina resulting from coronain a without eviden * Chronic stable (effort vasospasm in patients who remain symptomatic despite adequate doses of beta blockers and/or organic nitrates or who cannot tolerate those agents. ADALAT may be used in combination with beta blockers in patients with chronic stable angina However, blood pressure should be monitored closely, since hypotension can occur from the combined effects of the drugs. CONTRAINICTIONS: ADALAT is contraindicated in patients who: * are pregnant or of childbearing potential. * have severe hypotension.
IIMGS: ADALAT should be used with care in patients who: * are prone to develop hypotension. * experience an unexplained increase in angina symptoms on starting ADALAT or when the dose is increased. * may develop a syndrome on withdrawal from beta blockers. Initiation of ADALAT will not prevent this syndrome; thus, beta blockers should be tapered while initiating ADALAT. * have severe heart failure or severe aortic stenosis. PRECAUTIONS: As ADALATs vasodilatory action may lower blood pressure, it should be monitored closely, especially in patients
already taking antihypertensives. ADALAT's vasodilatory action may cause mild to moderate peripheral edema. Where angina is complicated by congestive heart failure, peripheral edema should be distinguished from the effects of increasing left ventricular dysfunction. Peripheral edema usually responds to diuretics. ADALAT should be administered cautiously to elderly patients, espedally those with hypotension or cerebral vascular insufficiency. The use of ADALAT in diabetic patients may require adjustment of their control.
of his income is "non-OHIP", with the bills paid directly by patients and thus subject to the GST. "Across the country I'd guess the ratio is 50:50 - half of the money comes from patients, half from health care plans", he says. Mantse: Who defines purely elective?
lifts, which can cost up to $10 000 in the Toronto area, they could find themselves collecting $700 for the federal treasury. For hairtransplant procedures, in which plugs of hair are transplanted to bald areas, a typical charge per transplanted plug is $30. With the GST the government would col-
Douglas says the Canadian Society of Plastic Surgeons has not made an official presentation to the government on the issue. Wyshynski has contacted his local member of Parliament, while Mantse, who had not been aware the tax would affect him until CMAJ called, said he was writing a letter to Finance Minister Michael Wilson "as soon as I hang up the phone".m
DRUG MTERACTIONS: ADALAT may be co-administered with nitrates, digitalis glycosides, furosemide and anticoagulants. ADALAT may potentiate the effects of antihypertensives. ADVERSE REACTIONS: Adverse reactions were reported in 27.9% of the heterogeneous group of 7146 patients treated with ADALAT and required discontinuation of treatment in 5.5%. The most common adverse reactions. which aenerallv result from ADALAT's
In all cases dosage should be adjusted to individual patient requirements. The starting dose is one 10 mg capsule, swallowed whole, 3 times/day. The usual effective dose range is 10-20 mg three times daily. Some patients, especially those with evidence of coronary artery spasm, respond only to higher doses, more frequent administration, or both. In such patients, doses of 20-30 mg three or four times daily may be effective. A maximum daily dose of 120 mg may be used. In general there shouldr interval of at least three days between increases in d order to adequately assess the In hospitalized patients under it 'myprcdror rapIdy. autiously to elderly patients and id gradually adjusted depending Dsage ; itient to a. (See Precautions.) e for greater flexibility of dose
snortness Ot breatn, dyspnea (1 .3%); sleep oisturbances 11.1 '/0); blurred vision (0.9%); diarrhea (0.9%); depression (0.6%); constipation (0.6%); nasal congestion (0.5%); syncope (0.4%).
auvl-rar
in 10 mg gelatin capsules in the
Rarely, ADALAT has been reported to precipitate an angina attack and to cause mild to moderate transient elevations of enzymes, such as alkaline phosphatase, CPK, LDH, SGOT, SGPT. Two cases of hypersensitivity, resulting in an allergic hepatitis, have been reported. SYMPTOMS AND TREATMENT OF OVERDOSAGE: There is no well documented experience with ADALAT overdosage. Gross overdosage could result in excessive peripheral vasodilation and clinically significant hypotension. Active cardiovascular support would be required, possibly including a vasoconstrictor to restore vascular tone. As ADALAT is 90% protein bound, dialysis is not likely to be of benefit As ADALAT is almost completely metabolized in the body, clearance would be expected to be prolonged with impaired liver function.
willuIl wuiltaliz; a
oncor hnypc nf iI gn LUI {119 WA;; Ul uIOspll;wl
ADALAT (nifedipine) 5 mg gelatin capsule: bottles of 100. PRODUCT MONOGRAPH AVAILABLE ON REQUEST.
REFERENCES
1. Deedwania P, Medical World News, March 13, 1989:p. 16. 2. Cohn PF et al. The Nifedipine-Total Ischemia Awareness Program, Am J Cardiol 1989; 63:534-39. C A
MILES CANADA INC., 1989 TM The Trademark of the Adalat I capsule, Registered Trademark consisting of its colour, shape MILES CANADA INC. is the Registered and size, is a trademark of User of the trademark ADALAT , MILES CANADA INC. the original brand of nifedipine TREATS THE TOTAL ISCHEMIC
DOSAGE AND ADMMTTION
BURDEN
DOSAGE GUIDE 10 mg t. i. d. STARTING DOSE 10 or 20mg t.i. d. USUAL MAINTENANCE DOSE MAXIMUM DAILY DOSAGE 120mg When complete beta blocker withdrawal is required, titration of the beta blocker is mandatory. See beta blocker prescribing information.
hlictpr lOtel
paks of 10 capsules) plus an empty dispenser box for loose blister storage. Bottles of 500 are available for institutional purposes only. Store below 30°C and avoid freezing.
~~K7UKi7UEE7~~~~~~~~UE ~~ISLENT nifedipine .
MILES 77 BE'tHED D Elm8C(SO"m19W"If
ML
D
1
PlAA7BI CP
AD-171-04- 89/E
