“Where Have All the Doctors Gone?”*

Presentation to the National Meeting on Physician Compensation, “Sustainability of Physician Services”

Victoria, B.C.

R.G. Evans, R. McKendry, K. McGrail and M.L. Barer

Centre for Health Services and Policy Research, UBC

October 17, 2008

“Everyone knows” that Canada needs more doctors…

• Patients report difficulty finding a family doctor, and excessive waits for appointments (particularly specialists)

• The news media have taken up the cause, as yet another “crisis”,

• And the CMA trumpets the issue from the housetops (well, the sides of busses).

Less well known …help, plenty of it, is on the way..

• Policies ten years ago have already determined our future for the next two decades, at least

• Further increases in training places now will only add to the surplus twenty years from now.

Canadian medical school enrolment and graduates, 1968-2007

Well, How Many Doctors Are There?

• The number of doctors per capita has hardly changed in twenty years

• In 1990, this ratio was called a surplus.

• True, the population have aged, but in itself this makes little difference (0.3% -0.5% per year)

Figure 5: Canada, Physicians per 10,000 Population, 1968-2006

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All physicians Specialists Family physicians

Figure 6: Canada, Physicians per 10,000 Population, 1968-2006

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All physicians Specialists Family physicians BC total BC Specs. BC GP/FPs

"The system will become one holy mess" unless there is more co-operation among government, doctors and medical schools to control the supply of doctors.”

Dr. Gerald Caron, executive secretary, Quebec Medical Association

Montreal Gazette, Aug 12, 1986

“A majority of physicians surveyed this month say fewer foreign doctors should be allowed to practice in Canada and almost half said enrolment in medical schools should be cut.”

... conducted for the CMA by Angus Reid, June 10-12, 1993

Winnipeg Free Press, June 22, 1993

“Canada will resemble a 3rd world country if the doctor shortage is not addressed.”

Rowland Nichol, President of the Alberta Medical Association

Edmonton Journal, Aug 25, 1999

But whatever the history or the head count, Isn’t there a severe shortage today?

What might constitute reliable evidence of a shortage?

• Long and growing wait lists? • Declining age-adjusted per capita

supply?• Declining use of physician services, or

even stable use in face of aging pop?• Survey-based indications of difficulties

finding a physician?• Other?

No evidence of shortage in utilization data

Average payments per physician in B.C. (adjusting for fee increases) have, like expenditures per capita, been rising rapidly for the last decade.

BC MSC Expend’s per Physician, $1991/92, NPDB Fee Index, Total and Components, 1969/70 to 2007/08

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MSC Total Exp Medical Care Exp Medical FFS Exp APP Exp FFS+3S

BC MSC Expenditure, Total and Components, constant $1991/92 p.c., NPDB Fee Index, 1969/70 to 2007/08

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MSC Total Exp Medical Care Exp Medical FFS Exp APP Exp FFS+3S

Annual % Growth in B.C. MSP Expenditures per

Physician, Fee-Adjusted, NPDB Index

69-07 69-90 90-98 98-01 01-07

Total 1.55 1.76 0.53 2.25 1.87 Medical 1.63 1.88 0.52 3.12 1.48FFS 0.99 1.80 -0.53 0.46 0.48APP* 7.02 3.85 14.35 16.02 4.53S&S&S** 4.97 3.85 7.92 15.46 0.16FFS+3S 1.27 1.88 0.03 2.04 0.44FFS+1/2 3S 1.14 1.84 -0.24 1.29 0.46* Alternative Payment Programs** Salaried, sessional, and service agreements

Is Physician Productivity Really Rising This Fast?

• If yes, why do we need more doctors?

• If no, what are they being paid for?

Doctors Are Working Less

Decline in Self-Reported Weekly Hours of Clinical Work, Canadian GP/FPs

• Watson et al. (1993-2003) - 8.5%

• Crossley et al. (1982-2003) - 15.6%

And in Working Days per Year (B.C. MSP billing data)

Distribution of GPs who billed at least once in each month, by # of days billing minimum $50, 1994/95 and 2004/05

Distribution of surgical specialist who billed at least once in each month, by # of

days billing minimum $50, 1994/95 and 2004/05

Distribution of medical specialists who billed at least once in each month, by # of days billing minimum $50, 1994/95 and 2004/05

Distribution of total payments to GPs, 2005/06 dollars

So what do we know so far….?

• Doc/pop ratio stable• Hours and days of work per doc

declining• Fee-adjusted payments per capita and

per doc per year increasing• Large (and unchanged) variation in

output/billed activity per doctor, or at least per GP/FP

But Other Countries Have More Doctors

• But there is no relation between doctor numbers and contributions to population health

• For that matter, there is no relation between health spending and health status either, at least not in high income countries.

American studies of regional variations:

More physicians (principally specialists) and more hospital capacity are associated with:

Higher utilization and costs, but

• Poorer quality,• Higher mortality• No greater patient satisfaction

More Doctors for Canada?

• Better Health?

• Greater Effectiveness and Efficiency?

• Or Just More Activity and Higher Cost?

Well….

Expenditure Equals Income

Bu Why Does the CMA Want More Doctors?

“At CMA, defending and promoting the interests of Canada’s doctors is central to our mission. Advancing the medical community’s financial interests is an important element of that commitment.” -- Victor Dirnfeld, former president, CMA

“To every complex question there is a simple answer: Neat, Plausible, and Wrong.” H.L. Mencken