PMHx: The extra-billing crisis

By 1971, each province had a healthcare insurance plan, with doctors’ fees negotiated between the government and provincial medical associations. Every province also permitted physicians to extra-bill. But in 1984, in an effort to ensure accessibility to medical services, the Canada Health Act was adopted and stated that provinces would lose $1 for every $1 a doctor extra-billed. Provinces that permitted extra billing past 1987 would lose their right to recover funds withheld by the federal government. Some provinces quickly banned extra billing, but in others, like Ontario and Alberta, physicians strongly rejected what they saw as the government dictating how medicine should be practised. Eventually, Ontario passed a law on June 20, 1986, prohibiting the province’s doctors from billing patients more than the amounts set out in the provincial fee schedule. “The government had created a legal 10% differential between the Ontario Medical Association fee and the government fee and then made it illegal, but blamed doctors,” retired Ontario cardiologist Dr. Lorne Finkelstein said. Read: PMHx: the Northern B.C. docs dispute Leading up to the new law, some doctors attended rallies and closed their offices. On June 12, they started what would become a 25-day strike. One rally garnered national news coverage. “Some doctors wore their white coats and stethoscopes around their necks and jumped the barricades at Queen’s Park,” said Dr. Finkelstein. “This just left a very negative impression that these doctors were only interested in their income.” That’s when Dr. Finkelstein got involved. “I felt no one cares about our income and it’s the wrong focus.” Dr. Finkelstein, who became chair of the Hamilton Academy of Medicine public relations committee in 1986, held public forums in Hamilton and wrote letters to the local newspaper. “Our whole thing was: Stay away from the money issue. Stay away from the banning of extra billing. Let’s focus on clinical problems for patients. We are the advocates of patient’s health. Don’t let the government take over that role,” he said. “There was this insinuation by some in the government that we were money grubbers. We were only out to get our income. We don’t care about patient health and the government will take care of your health. The problem was, in the mid-1980s, the Ontario government was underfunding the health system and waiting lists crept in.” Read: PMHx: Telemedicine’s great leap forward in N.L. Dr. Finkelstein said waiting lists for a coronary angiogram grew from one week to six months, waits for hip replacements and cataract surgery increased to months-long. “This had to do with the government not sustaining the appropriate amount of payments to hospitals to fund these procedures. But we were blamed because of extra billing,” he said. Through years of public outreach, Dr. Finkelstein said, the message slowly got through. “We never talked money. We said we are the people who look out for your health,” he said. “It worked. Public opinion was on our side. The net result wasn’t any better, but at least we weren’t hopping fences."

PMHx: The extra-billing crisis

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