Friday, December 16, 2016

Not So Green Pastures In The Land Of Green Gables

Canada's doctors would do well to take a close look at PEI for reasons having nothing to do with a golf getaway.

Canada's Maritimes are a hell of a place to train in medicine. You see more, do more, and learn more than you ever would moping around the wards of the tertiary- and quarternary-care megahospitals of Ontario. Once non-Maritime MDs finish training, though, they tend to forget about Atlantic Canada. Too much medical-political oxygen gets sucked up in the legislative vortexes of Toronto and Victoria for a place like Prince Edward Island to register even a blip on a doctor's radar.

In some ways it's easy to ignore PEI. It's tiny, taking up roughly the same square footage as the Greater Toronto Area, but home to less than 3% of the GTA's population. And it's all too often seen as contributing little to modern Canada apart from potatoes, golf, and Anne of Green Gables-themed tourism.

It's high time doctors paid very close attention to health policy in PEI, because under new legislation that has passed second reading, the Minister of Health will acquire extraordinary authority over where and how doctors can practice. To make matters worse, this is happening right in the middle of negotiations between the province and its medical association, negotiations that have dragged on longer than a year. While the Ministry is seeking input on the specifics from the medical association, there's nothing to prevent them from doing as they please once the law's in place.

Though a good number of docs in PEI are paid by contract/salary, fee-for-service (FFS) is a common method of remuneration for others. Unlike Ontario, though, FFS billing numbers on the island aren't valid province-wide, but are routinely limited to geographic regions - in a province the size of Toronto! The number of permitted billing numbers for a given county/region isn't determined by rigid process, but rather a blend of history and (perceived) need, much like the way school boundaries are worked out.

Under the new legislation, family doctors looking to change either their location or their scope of practice will need to apply to the Minister's office to retain their billing privileges. Read that again. Giving the Minister authority to restricting locations is perhaps understandable. If your spouse needs to be in one of the "urban" areas (Charlottetown, the capital, has less than 50,000 residents), it could be construed as unfair to close your rural practice to set up shop in the city.

But the Minister gets to approve your scope of practice? Think of the ramifications.

Say you've been a devoted, comprehensive family doctor in a small town for 15-20 years. For whatever reason, you decide you'd like a change - not to an area of focus with a stink on it, like pain management or methadone prescription, but say, palliative care or psychotherapy. You devote the time and money to complete the necessary and accredited training. In order to make the new practice economically viable, however, it will need to be located in the city. You'll have a pain of a commute each day, but so does everyone that lives west of New Brunswick. So you get the proper forms, send them into the Ministry...

Did I mention that your family practice is in the Health Minister's home riding? And that some of your patients bombard the Minister with angry phone calls? And that the Minister doesn't need to interview you in person before making a decision? And though College endorses your new qualifications, it has no say in whether or how you get paid?

We aren't just talking about billing restrictions placed on new doctors, or financial incentives for moving to underserviced areas (or disincentives for moving to adequately-serviced regions). This is a direct intrusion on a doctor's professional autonomy. Furthermore, as this is about billing numbers, and not a contract, it gives a single politician final say on how and where a doctor can eke out a living - the doctor becomes a de facto employee of the state without a guaranteed income to go with it.

If the law stays in place and survives a court challenge, it could easily become the template for similar laws across the country. Forget the provincial Colleges and their obsessive processes around change of scope. This is the profession being outright hijacked by the government of the day.

Don't think your province's policies around doctors can get any worse? Keep a finger on the pulse of PEI.

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