ELEMENTS FOR A PROPOSED POLICY STATEMENT ON THE REMUNERATION OF HEALTHPROFESSIONALSSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 64, No.1 (January/February 1973), pp. 105-106Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41987117 .

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ELEMENTS FOR A PROPOSED POLICY STATEMENT ON THE REMUNERATION OF HEALTH PROFESSIONALS

Health services in Canada are entering a period of basic and necessary changes. Thé public involvement in health care has grown dramatically over the past two decades through the introduction of universal public prepayment mechanisms for hospital and medical care. These prepayment mechanisms now established all across Canada, imply a contractual relationship between the public, on the one part, who accepts to pay for serv- ices, and the health care institutions and pro- fessions, on the other part, who agree to pro- vide an agreed upon package of services.

Even though the public has lived up so far to its share of the contractual obligations, the health system has not succeeded in producing and delivering the prepaid services. Although resources allocated to the health sector have increased at a considerably higher rate than the resources of this nation, the health care system has not succeeded so far in eliminat- ing inequities irt distribution of services and significant unmet needs. This failure is attrib- uted to inadequate organization of the health sector which manifests itself by a distortion of priorities so that institutional care is em- phasized over preventive and non-institu- tional forms of health care.

Reorganization and Remuneration Plagued with a major productivity prob-

lem, the health care system of this country needs a major reorganization, and fundamen- tally tied to this reorganization is the issue of remuneration of key health professionals such as dentists and physicians, among oth- ers. It is important to distinguish at the out- set between level and mode of remuneration. Level or amount of remuneration for profes- sional services depends very much on social values, as well as on market factors. In both cases, dentists and physicians in our society stand very well; theiř social image remains

high, as their market value, because of real or apparent shortages in supply and distribu- tion.

Mode of remuneration, on the other hand, has important ramifications in how the health care system works. Most health professionals work on a salary basis; most dentists and physicians, although probably not more than two thirds, work on a fee-for-service system of payment. The predominant fee-for-service system for medical services is a real deterrent to change in the health care system; it en- courages separation and isolation of doctors' services from those of the rest of the health care team; it prevents transfer of many as- pects of health care which can as well, if not better, be provided by other health profes- sionals; it encourages over-utilization by fos- tering surgery and hospitalization where these are often unnecessary; it encourages specialization over and beyond the needs of the populaton, to the disadvantage of family physicians; it promotes professional intransi- gency and consequently, the adoption of po- sitions by professional organizations which confuse economics with professional stand- ards and ethics. Most importantly, the fee- for-service payment system serves as a very large barrier to rational changes in our health care delivery system.

Methods of payment for services are inextricably interwoven with methods of or- ganization of services. Neither can sig- nificantly change without concomitant change in the other. Reducing emphasis on hospital or other institutional care cannot de- velop simply by limiting the supply of these resources; they must be reduced in emphasis by developing alternatives such as vastly im- proved ambulatory team care and home care services. Yet, the isolation of the dentist and the medical practitioner behind a wall which is very largely based on the insularity of the

January/ February 1973 Policy Statements 105

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fee-for-service system makes significant im- provement in these alternative forms of care extremely difficult and probably impossible to achieve.

Other Methods of Remuneration Alternatives to fee-for-service exist, and

are widely in use in Canada, even today. Many physicians for instance, work for straight salaries based on training, experience and responsibility, in many agencies such as universities, industries, public health units, private agencies, governments, and what is so often forgotten, for other physicians. Many dentists and physicians work in association in medical clinics and share their incomes on a prearranged basis which, in effect, becomes a salary plus bonus based on profits. As many as one third of Canadian physicians earn their incomes primarily from salaries. Thus prearranged incomes based upon such factors as training, experience, responsibility, work- ing time and the degree to which goals of health care are achieved do exist. All these factors can indeed be taken into account in determining a given level of remuneration through a contract based on an annual, monthly or even sessional payment scale.

Capitation as a payment system has re- ceived much unfavourable discussion in Can- ada, perhaps because of the biased opinions of many among the British trained contin- gent of physicians, who left the United King- dom because they had opted out of its Na- tional Health Service. It must be made quite clear however, that a system which provides for health services to a defined population group can be paid for on an average per cap- ita grant basis without detriment to either the quantity or the quality of health services. Under such arrangement, a community board which undertakes responsibility to op- erate a broad health care program could pay dentists, physicians and all other health pro- fessionals fair and adequate incomes based on many professional and goal achievement factors as well as on the many social and

market factors linked to professional services in our society. i

What must be emphasized then, is that the method of payment, not the level of pay- ment for professional services, is a critical is- sue in the future evolution of our health care system. The development of a real, co-oper- ative and functional health care team will not be possible with the fee-for-service payment for physicians. The medical profession is in- creasingly aware of this dilemma, and many practitioners now recognize the fundamental importance of this issue. Over the years ahead, many in the medical profession will take part in the comprehensive health care programs on payment systems other than fee-for-service.

Recommendations 1 . The Canadian Public Health Association

calls upon governments, the medical pro- fession, all health professionals and related organizations to recognize that the fee-for- service method of payment is outmoded, and forms a serious barrier to future evo- lution of Canada's health service system. The Canadian Public Health Association calls upon all involved in health care plan- ning, the delivery of health services and the use of health services to begin immedi- ate multilateral discussions of appropriate alternatives to the fee-for-service payment system for early implementation, so that the present inequities within the system will not serve to prevent evolution and ra- tionalization of our health care system. The membership of this Association feels that the issue is important and must be faced up to in a mature, informed and ra- tional way, without the polemical and emo- tional aura which has surrounded it for so long.

2. The Canadian Public Health Association will bring these considerations to the atten- tion of governments, the health professions and the public, with a view to encour- agement of appropriate action by all.

106 Canadian Journal of Public Health Vol. 64

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