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Toward integrated medical resource policies for Canada : background document Barer, Morris Lionel, 1951-; Stoddart, Gregory Lloyd, 1948- Jun 30, 1991

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TOWARD INTEGRATED MEDICAL RESOURCEPOLICIES FOR CANADA:BACKGROUND DOCUMENTMorris L BarerGreg L StoddartHPRU 91:6D JUNE 1991. HEALTH POLICY RESEARCH UNITCentre for Health Services and Policy Research429 - 2194 Health Sciences MallUniversity of British ColumbiaVancouver, B.C. CANADAV6T 1Z3The Centre for Health Services and Policy Research was established by theBoard of Governors of the University of British Columbia in December 1990.It was officially opened in July 1991. The Centre's primary objective isto co-ordinate, facilitate, and undertake multidisciplinary research inthe areas of health policy, health services research, population health,and health human resources. It brings together researchers in a varietyof disciplines who are committed to a multidisciplinary approach toresearch, and to promoting wide dissemination and discussion of researchresults, in these areas. The Centre aims to contribute to the improvementof population health by being responsive to the research needs of thoseresponsible for health policy. To this end, it provides a researchresource for graduate students; develops and facilitates access to healthand health care databases; sponsors seminars, workshops, conferences andpolicy consultations; and distributes Discussion Papers, Research Reportsand publication reprints resulting from the research programs of Centrefaculty.The Centre's Health Policy Research Unit Discussion Paper series providesa vehicle for the circulation of preliminary (pre-publication) work ofCentre faculty and associates. It is intended to promote discussion andto elicit comments and suggestions that might be incorporated within thework prior to publication. While the Centre prints and distributes thesepapers for this purpose, the views in the papers are those of theauthor(s).A complete list of available Health Policy Research Unit Discussion Papersand Reprints, along with an address to which requests for copies should besent, appears at the back of each paper.The appendices to this Discussion Paper are available as HPRU DiscussionPaper 91-7D. This Discussion Paper is being simultaneously released as aWorking Paper of the Centre for Health Economics and Policy Analysis,McMaster University.TOWARD INTEGRATED MEDICAL RESOURCE POLICIES FOR CANADA:BACKGROUND DOCUMENTMorris L. BarerDirector, Centre for Health Services and Policy Research,and Professor, Department of Health Care and Epidemiology,University of British Columbia; Associate, Population HealthProgram, Canadian Institute for Advanced ResearchGreg L. StoddartProfessor, Centre for Health Economics and Policy Analysis, andDepartment of Clinical Epidemiology and Biostatistics, McMasterUniversity; Fellow, Population Health Program, CanadianInstitute for Advanced ResearchReport prepared for the Federal/Provincial/Territorial Conference ofDeputy Ministers of Health. Final report submitted June 1991.•This report is dedicated to the memoryof Roberta Labelle. Her strong beliefthat knowledge and understanding canmake a difference will sustain ourcommitment to this work.ACKNOWLEDGEMENTSOur greatest debt is to the many individuals and organizations, listed inAppendix A, who gave freely, not only of their time, but of their candidviews, concerns and hopes. Their insights provided a depth of informationand understanding well beyond what one could ever hope to cull frompublished literature, commissioned reports, or research based on secondarydata sets. We are particularly indebted to Eva Ryten, Michel Berard,Stuart MacLeod, Roberta Labelle and William Tholl.The project team included: Neil Stuart who assisted us with interviewing;Marc-Andre Fournier and Andre-Pierre Contandriopoulos, who provided uswith a more detailed and enlightened picture of the Quebec policy scenethan we could possibly have developed ourselves within the tight projecttime frame; Jonathan Lomas who provided thoughtful policy advice, acritical eye, and assistance with the drafting of selected sections of thereport; Kathy Friesen, who was the project manager, assisted with asignificant proportion of the interviews, prepared one of the appendices,and helped us organize and wade through the voluminous literature in thiscontentious area; Charlene Crumback at UBC, who bore the brunt of the'manuscript production' and logistical responsibility for the project;Nancy Bishop, Diane Rogers and Lynda Marsh at McMaster, who provided avariety of types of assistance during the project; Christel Woodward, whoserved as a consultant and critical reviewer on selected aspects of theproject; and our seven international consultant teams who prepared thereports that appear as Appendices D through J. An undertaking of thismagnitude could not possibly have been completed in such a short timewithout the energetic assistance of these individuals. We suspect,nevertheless, that none of them would wish any part of the report to beattributed to them; convention suggests we should accommodate those wishes-- the analyses, opinions, recommendations, and errors of commission oromission are, in the end, ours.i• I• ITABLE OF CONTENTSAcknowledgementsTable of ContentsPrefaceChapter 1: Summary, Recommendations and Guide to ReportExecutive SummarySummary of Recommendations and OptionsReader's Guide to the ReportChapter 2: History, Objectives, Constraints and ProcessObjectivesConstraintsProcessInformation GatheringAnalysisReport WritingChapter 3: Promoting Change: General ThemesLiivii1-11-41-142-12-22-42-52-62-102-11Summary 3-1Themes 3-4Figure 3.1: Analytic Framework for the Report 3-17Chapter 4: Problems in Physician Resource ManagementA. From the Perspectives of Those InterviewedSummaryOverall Physician SupplyMedical School EnrolmentUndergraduate Medical School CurriculaGraduates of Foreign Medical Schools (GOFMS)Proliferation of Sub-Specialties and Numberof Residency ProgramsNumber and Mix of Residency PositionsSpecialty ShortagesRole and Funding of Academic Medical CentresGeographic Distribution of PhysiciansLicensure of Physicians and Regulation ofMedical PracticeRemuneration for Medical ServicesResearch, Planning and InformationMiscellaneous Other ProblemsB. From an International PerspectiveOverall Physician SupplyMedical School Enrolmentii4A-l4A-l4A-64A-74A-84A-94A-IO4A-124A-154A-164A-194A-224A-244A-264A-274B-l4B-l4B-3C.Undergraduate Medical School CurriculaGraduates of Foreign Medical SchoolsSpecialty Training and SpecialtyShortages/SurplusesGeographic Distribution of PhysiciansLicensure of Physicians and Regulation ofMedical PracticeRemuneration for Medical ServicesResearch, Planning and InformationFrom Our Perspective, All Things ConsideredSummaryOverall Physician Supplya. Undergraduate Enrolment in MDTraining Programs in Canadab. Graduates of Foreign Medical Schools(GOFMS)Residency Training and Specialty Certification(Numbers and Mix)Specialty MaldistributionRole and Funding of Academic Medical Centresa. Multiplicity of Sources of Fundingb. Instability of Sources of Fundingc. Lack of Correspondence of Sources withFunctionsd. Fragmented Control over Levels andAllocations of Centre Revenuee. The Use of Fee-for-Service as a Methodof Remunerating Clinical Practice inAcademic SettingsGeographic MaldistributionPatterns of Medical Service UtilizationLicensure and RegulationPhysician Remunerationa. Fair and Equitable Remuneration forthe Provision of Medical careb. Political, Human and Financial Costs ofFee or Income Negotiationc. Lack of Incentives to Deploy PhysicianResources Efficientlyd. Linkages Between Dominant Method ofRemuneration and Increases in Utilizationof Medical Servicese. Effects of Dominant Method of Remunerationon Relationships Between Institutions andthe Physicians Who Use ThemGlobal Expenditure PolicyInformation Creation and Provisioniii4B-34B-44B-44B-54B-64B-64B-64C-l4C-l4C-64C-94C-l64C-234C-324C-344C-364C-374C-394C-404C-404C-424C-474C-5l4C-564C-564C-584C-584C-604C-6l4C-664C-69Chapter 5: Approaches to Physician Resource ManagementA. From the Perspectives of Those InterviewedSummaryOverall Physician SupplyMedical School EnrolmentUndergraduate Medical School CurriculaGraduates of Foreign Medical SchoolsNumber and Mix of Residency PositionsSpecialty MaldistributionRole and Funding of Academic Medical CentresGeographic Distribution of Physiciansa. General Thoughts and Constraintsb. Admission Criteriac. Training Programmes, Sites and CurricularExposuresd. Financial Approachese. Public Servicef. Geographic Restrictions on PracticeOpportunitiesg. Organizational Approachesh. Regulatory Approachesi. Alternative Health Care Personnelj. Other MiscellaneousLicensure of Physicians and Regulation ofMedical PracticeRemuneration for Medical Servicesa. Restructuring within a Fee-for-ServiceSystem of Remunerationb. Restructuring of Methods of Remunerationc. Dispute Resolutiond. Other Cautions, Suggestions and SolutionsGlobal Expenditure ConsiderationsResearch, Planning and InformationOther More General Policy ConsiderationsMiscellaneous Other Solutions and SuggestionsB. The Quebec ExperienceC. Lessons from International Experience?Overall Physician SupplyUndergraduate and Post-MD TrainingGeographic Distribution of PhysiciansLicensure of Physicians and Regulationof Medical PracticeRemuneration for Medical ServicesGlobal Expenditure InitiativesResearch, Planning and InformationOther Potentially interesting PolicyInitiativesivSA-ISA-ISA-2SA-3SA-SSA-6SA-7SA-llSA-12SA-14SA-14SA-ISSA-ISSA-17SA-18SA-18SA-18SA-19SA-19SA-20SA-20SA-21SA-21SA-23SA-23SA-24SA-24SA-26SA-28SA-29'SB-ISC-ISC-2SC-3SC-4SC-SSC-SSC-6SC-7SC-7Chapter 6: Policy Analysis, Options and RecommendationsA. Policy FrameworkFigure 6.1: A Framework for PhysicianResource PolicyB. What Could or Should be Done?SummaryUndergraduate MD Educationa. Enrolmentb. Admissions Processc. Curriculad. Provision of Information to MedicalStudentsGraduates of Foreign Medical Schools (GOFMS)Post-MD Pre-Licensure Traininga. Numbers and Clinical Exposuresb. Return-In-Service PoliciesResidency Training and SpecialtyCertificationa. Overall Number of Residency Training Slotsb. Specialty Mix, and Location, of ResidencyTraining Positionsc. Funding of Post-MD Residency Trainingd. Residency Training 'Curricula'Specialty MaldistributionRole and Funding of Academic Medical CentresGeographic MaldistributionPatterns of Medical Service UtilizationRegulation and LicensureRemuneration for Medical ServicesGlobal Expenditure PolicyInformation Creation and Provisiona. Information Creationb. Information DisseminationChapter 7: Next StepsHow, When, and By Whom?The Current EnvironmentFirst Steps Toward a National StrategyBibliographyA. Books, Articles and PresentationsB. Reports and Miscellaneous Other Documentsv6A-l6A-26B-l6B-l6B-46B-66B-76B-86B-176B-186B-206B-216B-216B-286B-346B-396B-426B-466B-536B-646B-696B-746B-876B-966B-976B-1017-17-37-5Physician resource policy in Canada is plagued by historical and political inertia, professional and geographic territoriality, incomplete and inconsistent information, frustration, and a great deal of nervous apprehension. It is also a field of remarkable complexity, encompassing issues of equity, distribution, supply, incomes, regulation, immigration, education and research, to name a few of the prominent ones. It would be pretentious of us to suggest that, in the short space of ten months, we developed a complete understanding of every nuance of every issue, and became sufficiently well informed and insightful that we can now do what others before us have avoided, or failed to do: provide a blueprint for a national physician resource policy that will 'work'. So we will not, because we did not. What struck us during the life of this project was not just the complexity of each issue area taken separately, but the fact that so many issues were so very interdependent. It is this 'inter-complexityr-- the fact that, to have any chance of meeting their objectives, initiatives in one area must be accompanied by concurrent policies in another - -  and the diversity of regional and provincial problems, which present the greatest challenges to a 'national approach' to policy co-ordination in this critically important area of health policy. It also points to the need to think of physician resource policy in a dynamic health and social policy context. We need to be able to do much better in monitoring and evaluating the effects of what we do on people's health and well-being, and then in adjusting or fine- tuning policies as may seem appropriate. Perhaps most importantly, we need to get over our collective Canadian-style fear of changing directions even when such re-direction is clearly called for. We must realize collectively that letting policy develop by default, disinterest, or insufficient will, is itself a policy strategy, but one that can only be expected to bring about satisfactory results by those who believe in winning lotteries. This is not to suggest that the task is impossible (although others may make that judgement after reading this document), or that there is no hope for a national strategy. On the contrary, we feel both that there are some areas in dire need of co-ordinated policy development, and that for some of these the most logical (indeed the only logical) approach must be a 'national' approach. But we cannot over-emphasize the fact that ten months of review and analysis, drawing on limited resources, cannot possibly do justice to the complexity of the task. This complexity is, in part, due to the shifting policy environment. Several significant events occurred during the period of this report, some but not all of which we were able to incorporate into our analysis (which was completed in late January 1991). For example, we have not been able to address in any detail the most recent proposed reforms in Quebec. The special report from our Quebec associates was completed in late November 1990, just prior to the public release of the proposals. Toward Integrated Medical Resource Policies for Canada: Background DocumentNevertheless, we hope we have been able to identify some priority areas for policy attention, to develop some new 'avenues of opportunity' for them, and to offer some initial directions for getting to those 'avenues'. We have tried also to identify both broad directions where stakeholders can be given the opportunity at the next stage to develop consensus on particular initiatives, and specific areas where more intensive and extensive investigation could pay dividends. We do not claim to have done more. MLB GLS May 1991 vii Toward Integrated Medical Resource Policies for Canada: Background DocumentToward Integrated Medical Resource Policies for Canada: Background DocumentToward Integrated Medical Resource Policies for Canada: Background DocumentToward Integrated Medical Resource Policies for Canada: Background DocumentToward Integrated Medical Resource Policies for Canada: Background DocumentToward Integrated Medical Resource Policies for Canada: Background DocumentToward Integrated Medical Resource Policies for Canada: Background DocumentToward Integrated Medical Resource Policies for Canada: Background DocumentToward Integrated Medical Resource Policies for Canada: Background DocumentToward Integrated Medical Resource Policies for Canada: Background DocumentToward Integrated Medical Resource Policies for Canada: Background DocumentToward Integrated Medical Resource Policies for Canada: Background DocumentToward Integrated Medical Resource Policies for Canada: Background 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