Answering my own questions since 2001

Canada, Doctors and User Fees

I recently found this interesting post about obtaining rural (well, more rural than Vancouver) medical care in BC:

i drove across town to the strip mall that starts with petcetera and ends with save-on foods and has a medical clinic somewhere in the middle. as i drove by looking for parking, i notice a line of about 30-35 people along the sidewalk and immediately thought:

“that better not be the walk-in clinic.”

of course, it was. destined to open its’ doors in another minute or two and already with 3 dozen people patiently waiting in line for what looked like movie tickets as much as medical aid.

Apparently there is only one medical clinic serving Prince George’s 75,000 citizens, and it only opens after 4:00pm.

On a related topic, the last time I visited my doctor, he explained to me that he thought the traditional GP or family doctor would soon disappear. He said nearly all new doctors were specializing. I have no idea if he’s correct about this, or totally off his rocker.

One strategy for reducing line-ups at clinics and doctor’s offices is user fees. When I lived in Ireland, they had a user fee system in place. I thought it was a bit exorbitant, but you basically paid 30 Euros to see a doctor.

The level of service I received from my GP was far superior than his Canadian equivalent. The appointments were longer and the doctor was more attentive. After all, I was paying for a service, and receiving suitable advice in return.

One side effect of this user fee system was that the role of the pharmacist changed significantly. In Canada (or at least here in Vancouver), pharmacists are mostly prescription-filling machines. In Ireland, they were ad hoc nurses. I overheard many conversations at the pharmacy or ‘druggist’ which you’d normally hear in a Canadian doctor’s office. You couldn’t so much as buy cold medication without having a brief consultation with the local pharmacist.

The problem with user fees is that doctors don’t like them. After all, fees would reduce their customer volume. So, we could charge a modest user fee ($5 or $10) and you turn around and pay most of that money to doctors.

Let’s be honest, whether you’re a bricklayer or a doctor, money talks. If we want to keep more doctors in Canada, and encourage them to become GPs, we need to pay them more money. Otherwise, we’re going to keep seeing long line-ups and waitlists (which, in truth, aren’t that bad when compared to other nations) at all those babyboomers get older and sicker.

The same goes for nurses, though unfortunately they’re unionized, so that complicates matters.

16 Responses to “Canada, Doctors and User Fees”

  1. Ryan

    I don’t think that doctors object to user fees due to volume, since most GP’s already have too many patients and are turning new patients away. The issue is the overhead of collectng the fee.

    The current billing system is insanely complex, and adding collection of a basic fee on top of that makes it worse.

    User-fees for GP’s won’t work unless something was simplified somewhere else – and current alternative billing pilot projects haven’t shown a lot of promise.

    Just throwing more money at the system won’t fix the structural issues, but may be needed as most new doctors specializing. Last year the UBC Medical Residency program had unfilled spaces for family practice.

  2. Marc-André Bélair

    I have to agree with what Ryan is suggesting regarding the overhead on collecting user fees, etc. The current health care system, as it is, is increasingly complex and makes it inordinately difficult for doctors and health practitioners to collect their standard insurance fees.

    Add to that having to collect $20 from each patient, especially when they want to pay by Interac or credit card, and you get yourself an additional administrative nightmore.

    Again, I echo Ryan’s sentiment that there are structural issues that need to be addressed.

    That being said, however, I know Germany and Sweden have both been successful in relieving the burden of front-line health care workers by introducing user fees (while exempting low-income families/individuals) in order to reduce the amount of “frivolous” health visits.

    The question remains, “How much money would we need to charge to dissuade the vast number of frivolous visits while not discouraging the legitimate visits?”

    MAB

  3. Ryan

    Very insightful post Darren.

    With a user fee in place, it would certainly reduce the number of folks visiting their doctor for a minor cough or cold. Additionally, one could certainly expect more quality consultation time with one’s doctor — rather than to be in an out of there as quickly as possible.

    Luckily downtown Vancouver has a plethora of walk-in clinics from which to choose. Although I have a GP, I often elect to visit a Carepoint medical clinic instead, as visiting my GP usually involves an hour wait or more!

  4. double-plus-ungood

    Charging a fee would probaly end up costing the system a lot more as well. People with low incomes would be less likely to visit the doctor to check stuff out, and treatable conditions will turn into expensive-to-fix condtions (or potentially terminal conditions, like colon cancer that require palliative care, also expensive).

    Preventative medicine is far cheaper than fixing the consequences of less accessible preventative medicine.

    If there are not enough GPs, why not simply pay them more to be GPs? A fee isn’t required.

  5. Ryan

    While definitely convenient, walk-in clinics can be a part of the solution, but shouldn’t be used as a replacement to your GP.

    Ideally, we would encourage “minor cough and colds” to go to walk-in clinics, while anything above and beyond should be run through your GP.

    This will reduce the load on GPs yet still allow them to keep a complete history of your health (or lack thereof). This can result in your GP being able to more quickly diagnose problems and should result in improved ability for them to offer preventative advice.

  6. Andrea Coutu

    User fees mean that poor people will be less likely to seek medical attention. The Rand study — the largest study on copayments ever — found that, although shared costs or user fees has no detrimental effect on health for the general public, it does affect health outcomes for the poor.

  7. Richard

    A wise man (a former nurse) once told me that of the ideal qualities to have in a health care system (good, fast, and cheap) you can only have 2 out of 3.

    (This, mind you, was before I read about the Pick Two rule.)

  8. Jessica Doyle

    This is an interesting topic. Having grown up in New Brunswick (Saint John and Fredericton) I held witness to the shortfallings and upsides of the Canadian healthcare system in the Maritimes. Both cities have two walk-in clinics respectively, that are first come first serve. SJ didn’t have one until 4 years ago and even then you had to call ahead of time to make an appointment. You were turned away and told to go to the emergency room if you showed up in person with no appointment.

    After moving to Vancouver (3.5 years ago) I am in awe of the services available here especially those geared towards mental health issues and the actual availability of treatment.

    I agree with those above that a user fee would discourage many. Something my doctor actively does is return phonecalls and accept messages from her patients. By doing so she eliminates the need to see the patient for something minor. The key in any relationship has always been open dialogue between the two parties involved.

    On the other hand when I moved to BC I was unaware that I had to pay for MSP. One does not pay for medicare in the Maritimes. On second thought it may be a decent idea to implement MSP payments to increase the services available backeast

  9. Nico

    I don’t have a problem with a user fee, and as someone who typically needs to check in with my doc for my asthma, I’d rather get into her office fast to treat an issue rather than need to opt for the ER because her office is full of “I have a sniffle” folks.

    I see way too many “sniffle” patients while sitting waiting for my appointment, be it a walk in clinic, ER or GP visit. People could stand to take a moment and think “is this really a serious medical concern or not?”

    Granted, some things are, that weird symptom that hangs around and such.

    I have a friend who is a med student and she’s hoping to be able to remain in BC. From what I’ve seen and my own doc’s service, I think she’s awesome and not paid enough.

    So if slapping down a ten, or 20 is what it takes, I’m ok with that. ( I’m assuming there’d be provision for low income/fixed income)

  10. Joe Drumgoole

    Fees in ireland are now €45 and you can bet they won’t stay there forever. If you have kids this can be become pretty expensive each time you have to drop in.

    It is tax deductible, but I suspect many Irish people don’t do the tax deductions at the end of the year.

  11. Rayne

    Darren you bring up an interesting point about Pharmacists.

    I know several of them here in BC, and the consensus is that they wish it were like Ireland… after all they go through 5 years (1 general and 4 pharmacy) of training.. for what? to decipher a physicians scrawl, fill a bottle, and catch the physicians’ prescribing errors.

    My mother is a former pharmacist, and in her home country things function as it seems they do in Ireland with respect to prescribing.

  12. Heather

    I think we have user fees already…Alberta Health Care fees. Heh.

    I’m not thrilled at the idea of user fees, but I would gladly pay them if I had to. I had the good fortune of finding a family physician who works with the medical education program at the local university…and the practice has about six or seven doctors working there – they take after hours calls, and they supervise medical students. With the whole MS thing going on, I’d be afraid to move to another city and not find a family doctor…or worse yet, not be able to find one who’d take me on – the symptoms I have are treated by my family doc and his nursing staff, with the occasional referral out to a neurologist or for things like MRI bookings.

  13. bree

    I think your GP’s right on the money. I have had a lot of trouble finding a GP who is accepting patients. As a result, I’ve used only walk-in clinics for the last six or seven years. At one point I sort of foudn a GP. She was about to go on maternity leave but saw me once or twice before she took off to have her baby.

    It’s really hard to find a doc who’s accepting patients if you don’t have a referral.

  14. Kerry Hinzman

    I’ve been reading many sites gathering statistics for a letter to the federal government regarding health care reform in Canada.
    Users fees sound like a very good idea on the surface but the people who need doctors the most are usually the people who can’t afford to pay a user fee because they come from low income families who can’t afford to eat healthy foods and have to rely solely on processed foods that contain mostly carbs. So the idea though ideal for some would likely result in preventing low income families from seeking medical attention when it might desperately be needed.
    The trouble with our health care problem in Canada is actually a lack of funding as far as medical training and provincial funding for health care services on behalf of our federal government. Most doctors in the country are over 55 yrs of age, it takes roughly 10 yrs to train a doctor and with tuition fees being what they who can blame doctors for wanting to pay off their $140 Grand student loans? And if that means leaving Canada for greener pastures I guess they will. Eventually the medical profession will either be filled with doctors of wealthy families or doctors from India seeking a better life for themselves and taking full advantage of our shortage.
    I wouldn’t mind paying a user fee if I thought it would help, but I seriously doubt my $5 is going to keep my doctor in the country. This government needs to offer some kind of financial incentives to people coming out of medical school to keep them in Canada.
    Maybe wipe out some student loans for doctors who are willing to become plain old family GP’s instead of surgeons and who are willing to stay in the country. Just a thought:-)

  15. Ryan Cassidy

    How about reducing specialist payments so GPs can have a bigger piece of the pie? This could involve wiping off student loans, or just increasing GP fees at the expense of specialist fees. A surgeon-in-training friend of mine has said that, informally, the general rule is that, when all the doctors in a province bargain collectively for new fees, no one’s fees, specialist or otherwise, decrease. However, certain specialist procedures have become much easier to do in the wake of new technology, yet the specialist fees are just as high.

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