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Toward improved access to medical services for relatively underserved populations : Canadian approaches,… Barer, Morris Lionel, 1951-; Wood, Laura Christine, 1955-; Schneider, David G. May 31, 1999

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Toward Improved Access to Medical Servicesfor Relatively Underserved Populations:Canadian Approaches, Foreign LessonsMorris L. BarerLaura WoodDavid G. SchneiderHHRU 99¡3 May,1999Toward Improved Accessto Medical Services forRelatively UnderservedPopulations:Canadian Approach€srForeign LessonsMorris L. BarerLaura WoodDavid G. SchneiderCentre for Health Services and Policy ResearchThe University of British ColumbiaMay 1999Canadian Cataloguing in Publication DataBarer, Morris Lionel, 1951-Toward improved access to medical services for relativelyunderserved populations(Research reports / Health Human Resources Unit ; HHRU 99:3)ISBN 1-894066-96-01. Rural health services--Canada. 2. Rural health services. 3.Medical policy-Canada. 4. Medical care, Cost of-Canada. I.Wood, Laura Ch¡istine, 1955- II. Schneider, David G. IU.University of British Columbia. Health Human Resources Unit. IV.Title. V. Series: Research reports (University of British Columbia.Health Human Resources Unit) ; HHRU 99:3.RA77t.7.C3837 1999 362.1',04257'0971 C99-911065-9I{EALTH HUMAN RESOURCES UNITThe Health Human Resources Unit (HI{RU) was established as a demonstration project by theBritish Columbia Ministry of Health in 1973. Since that time, the Unit has continued to be funded'on an ongoing basis (subject to annual review) as part of the Centre for Health Services and PolicyResearch. The Unit undertakes a series of research studies that are relevant to health humanresources management and to public policy decisions.The HHRU's research agenda is determined through extensive discussions of key current issuesand available resources with the senior staff of the Ministry of Health. Various health careprovider groups participate indirectly, through on-going formal and informal communications withMinistry of Health officials and with HHRU researchers. Research is undertaken by sevenprofessional staff, including secretarial and analyst support; Arminée Kazanjian is the AssociateDirector and Principal Investigator for the Unit.Three types of research are included in the Unit's research agenda. In conjunction withprofessional licensing bodies or associations, the HHRU maintains the Cooperative Health HumanResources Database. The Unit uses these data to produce regular status reports that provide abasis for in-depth studies and for health human resources planning. The Unit undertakes moredetailed analyses bearing on particular health human resources policy issues and assesses theimpact of specific policy measures, using secondary analyses of data from the CooperativeDatabase, data from the administrative databases maintained under the HIDU, or primary datacollected through surveys. The HHRU also conducts specific projects pertaining to themanagement of health human resources at local, regional and provincial levels.Copies of studies and reports produced by the HHRU are available at no charge.Health Human Resources UnitCentre for Health Services and Policy Research#429-2194 Health Sciences MallVancouver, BCv6T tz3Ph: (604) 822-4810Fax: (604) 822-5690email: hhru@chspr.ubc.ca[IRL: www.chspr.ubc.caAcknowledgements'We are grateful to the many provincial/territorial and international correspondentswho so kindly provided us with updates of policy initiatives in their respectivejurisdictions: Elizabeth Gillies, Vicki Foerster, Steven Gray, Carl Whiteside, CharlesNormand, Laurence Malcolm, Ross Barnett, Paul Gavel, Alan Maynard, Kevin Grumbach,David Kay, Thorsten Duebel, Dianne Anderson, Barbara Hague, José Velasco, DanielPoirier Bill Leonard, Donna Mulholland, Johanne Irwin, Brian Taylor, Keith Dyer, JanHorton, Jane Seltzer, Anne Finlay, David Salter, Susan Paetkau, Janet Mann, Elizabeth-Ann MacDonald, Fran Curran, Brenda Snider, Gail McNutt, Regina Cody, Sheila Rennieand Lynn Elkin. Without their cooperation, this report would have been either very short,or very out of date (or both). This report builds on earlier background work undertakenin late 1996 and early 1997; we remain indebted to those with whom we coffesponded atthat time, who were not involved in the current round: Sandra Woodhead-Lyons, BarbMillar, Eileen Mahood, Margaret Dunn, Bonny Hoyt-Hallett, Rick Cameron, Jeff Young,Rick Callaghan, David Kindig, Fitzhugh Mullan, Jeff Richardson and Donald Taylor; andto Jonathan Lomas, for extensive comments on that earlier work. Diane Helmer headedup the literature search process, assisted by Allyson McDonald; Doug Jameson and DianeHelmer translated a number of French-only documents, and Doug Jameson and JustinBarer assisted with manuscript preparation.This research was funded by Health Canada, through the Knowledge Development andAnalysis Unit of the Health Promotion and Programs Branch. The project team was madepossible through the B.C. Ministry of Health's sustaining grant to the Centre for HealthServices and Policy Research in support of its Health Human Resources Unit. The earlier(1996197) work was funded through the New Brunswick Department of Health andCommunity Services. The views expressed in this report are solely those of the authorsand do not necessarily represent the views or official policy of Health Canada.Copyright : FIER MAJESTY TIIE QUEEN IN RIGHT OF CANADA (1999)as represented by the Minister of HealthTable of ContentsIiiiiiI36A.1012L7182t293235B.c.4353606570819098r03r05111ll51234567891011t2AcknowledgementsTable of ContentsList of TablesAppendices:British ColumbiaAlbertaSaskatchewanManitobaOntarioQuebecNew BrunswickNova ScotiaPrince Edward IslandNewfoundlandllabradorNorthwest TerritoriesYukon Territory37D.Scope of Project and IntroductionWhat's the Problem Anyway?Canada is Not UniqueGeographic Location of Physicians -Understanding the DeterminantsGeographic Location of Physicians -Influencing the DecisionsAn Overview of Provincial InitiativesSelected International ApproachesUnited KingdomUnited StatesAustraliaNew ZealandSelected Other ExperiencesSummary and Discussion118ReferencesList of TablesTable 1 Contemporary Provincial/Territorial Policy Approaches 15Table A1.l Hourly rates of remuneration for on-call physicians in BritishColumbia communities eligible for Northern and IsolationAllowance Premia, 1999 47ulA. Scope of Project and IntroductionThis document is intended to provide a status report on initiatives in place across Canada,the primary objective of which is to improve access to medical care in areas that areconsidered underserved. The number of such policies and practices one finds as onecanvasses the provinces and territories is astonishing, the fact that one finds variants onthe same few themes virtually everywhere one looks is revealing, and the relativelyineffective record of this panoply of policies in reducing the geographic disparity ofprimary and secondary medical services, is sobering.'Because it is so obvious that Canada continues to suffer from relative policy impotence inthis arena (despite copious good will and much creativity and innovation), we alsoexamined a small set of other countries in the hopes of gleaning some lessons from abroadabout what might be importable, and effective. To this end, we offer relatively detaileddescriptions of initiatives in the United Kingdom, the United States, Australia and NewZealand.More specifically, the objectives of this report are to:provide in one document a detailed account of the historical and current initiatives ineach province and territory, intended to redress geographic imbalance in the provisionof medical services (Appendices l-12);report on the approaches taken in other countries to which Canada often looks forpolicy inspiration (bad examples can also inspire important avoidance strategies)(Section C);summarize the provincial/territorial experiences, in order to draw out common themesand experiences (Section B);a offer some reflections and lessons on the basis of the information and materialsgathered in support of the first three objectives (Section D).t Indeed, there are indications that, at least in some locations, the geographic disparity may be gettingworse, although the reasons for this erosion al'e not clear. For example, Hutten-Czapski (1998) arguesthat "[r]educed enrolments in medical schools, which began in the early 1990s, have reduced the flow offamily medicine residents to rural Canada", without providing any supporting evidence. One might beforgiven for wondering, if dramatically increased enrolment did not substantially alleviate the rural areaprimary care problem in previous decades, how a much smaller reduction in that enrolment might beimplicated so quickly now. In fact, in most medical schools, completing a family practice residency takesfour years of undergraduate training plus two years for the residency itself. The "early 1990s" reductionsbegan in 1993. From here it appears that Hutten-Czapski's claim is mathematically impossible. It seemsmore likely, if anything, that the change in posrMD faining requircment, to a minimum tvyo-year familypractice residency, may have reduced the flow of such rcsidents. Decisions about how to allocate post-MDtraining slots rest with the academic health centres of this countl'y. If the most pressing needs are forrural family practice training, those health centres have the levers to make it happen.We employed two main research'engines'in pursuing these objectives. The first was aninformal (and admittedly not exhaustive) written (paper and electronic) survey of keycontacts in each of the provinces and tenitories. We provided each with a description ofpolicies in their jurisdiction as we understood them to have been as of late 1996,accompanied by three requests:i) that they correct, expand, and update the information provided, to reflectthe current situation;ii) that they provide us with any internal (public but not published) documentsthat would offer details of historical or current policies;iii) that they provide us with any internal (but public) documents describingevaluations of any of the policies addressing these geographic inequities.We followed a similar strategy for the four international perspectives. Supplementingwork completed in 1996 with a review of more recent literature, we developed a profile ofpolicy experience in each country, which was then sent to key informants in each countrywith similar requests.The second'engine'was a literature search, through which we canvassed published as wellas so-called "fugitive" or "grey" materials (e.g. technical reports, conference proceedings,theses, and government papersþolicy documents) addressed to this topic. We searchedMedline, HealthStar, and Embase in order to obtain as many relevant articles as possible.The MoSH terms used for Medline and HealthStar included "Professional PracticeLocation", "Physicians", "Medically Underserviced Area", "Education Medical", "RuralHealth Services", "Rural Health", and "Internship and Residency". Subheadings such as "--Manpower", "--Supply and Distribution" and "--Trends" were applied to the MeSH termswhere appropriate. The terms used in Embase included "General Practice", "PrimaryHealth Care", "Health Service", "Clinical Practice", "Community Medicine", "FamilyMedicine", "Rural Health Care", "Rural Area", "Geographic Distribution", "Health CarePolicy", in combination with the following terms; "General Practitioner", "MedicalSpecialist", "Physician", "Medical Education", "Physician Attitude", "Decision Making",and "Manpower Planning". Additional key words (e.g. underserv: adj2 area) were usedin order to refine the search further.lVe also searched the Canadian Business and Cunent Affairs (CBCA) database and OCLCFirstSearch database in order to access articles not indexed in Medline, HealthStar, orEmbase. Library catalogues such as the Canadian Institute for Scientific and TechnicalInformation (CISTI), BC Ministry of Health Web Catalogue, and Health Canada Library,as well as many Canadian University Health Library Catalogues were all checked forbooks, reports and other documents relating to this project. The Joumal of Rural Healthand The Canadian Journal of Rural Health were hand-searched to identify relevant articles.The detail that emerged on the provinces and territories can be found in the set of 12appendices to this report. It will not escape the observant reader that these are ofvariable comprehensiveness and coverage, in three respects - temporal, policy range, andevaluative. Some provinces provided more historical detail than others. Rather thanforcing consistency (to the lowest common denominator) by eliminating all but the mostrecenlcurrent policy information, we have attempted to include summaries of allinformation provided to us. Similarly, while all provinces provided information on the'core'regulatory/administrative and financial policies, we suspect that we have a lesscomplete record of (current and past) core and continuing medical education, andtelehealth initiatives, for example. And finally, we have reported on evaluations aboutwhich we are aware; there may be others. Within the time and funding constraints of thisproject, we were not able to bring complete closure to what had become seeminglyendless iterations of information gathering, processing, and updating. Nevertheless, webelieve that the overall Canadian picture that emerges is sufficiently 'in focus'that it wouldnot be significantly enhanced through 'higher resolution'.One of the unavoidable hazards of this sort of policy analytic work is that it will be out-of-date not only before it reaches its intended audiences, but indeed before the writing iscompleted. While we have attempted to ensure that our information is up-to-date, the"date" tends to be a moving target. We first canvassed provincial/territorial contacts, andundertook our initial literature reviews, in the late spring of 1998. Some respondedalmost immediately; from others we received this first round of information well into thefall. Immediately we had the problem of inconsistent'reporting' dates. As we completedprovincial/territorial summaries, these were sent back to those contacts, for confirmation,but also by then, for further updates. Again, jurisdictions responded over a two monthperiod. New information, and new literature, continued to come in even as we wereattempting to close the files. The descriptive sections of the report should be taken torepresent the policy landscapes as of late fall 1998/early winter 1999, except where weexplicitly indicate other dates of record (as, for example, through more recent personalcommunications). While it is sometimes tempting to get lost in the ever-changing details,which do reflect the tenacity of these policy issues and the huge effort expended toaddress them, both here and internationally, one should not lose sight of the fact that thisis a classic policy soap opera - tune out for a few years, and there is a reasonable chancethat not much will have changed when one returns.What's the Problem Anyway?Underlying Health Canada's interest in this work was a) a sense that this 'problem'was, ifanything, getting worse; and b) a feeling that there must be some co¡nmon truths, orlessons, that might emerge from a comprehensive appraisal of what was being doneacross the country to address the'problem', and with what measurable effects (personalcommunication, Judith Dowler, March 1998).But what exactly is the problem? It is variously charactenzed as "geographicmaldistribution of physicians", "inequitable access to primary care services", "underservedareas", "overworked physicians in rural, remote and isolated communities", and so on.What is often not clear is whether the problems are primarily those of patients andpotential patients having difficulty accessing necessary and appropriate services, those ofphysicians (and occasionally other, although much less vocal, health care personnel) facingsituations and workloads that are quality-threatening and impossible to sustain, or unmetincome aspirations. In practice, each situation is unique. In some, the argument is thatphysicians are over-worked, have to deal with unreasonable call, and do not have adequatesupport in many smaller communities across the country. They get burned out, and headfor more hospitable work environments. In others, the problem is simply that acommunity cannot hold onto a source of primary care services, and so it is the potentialrisks (and considerable inconvenience) to future patients that come to the fore. In many, itappears to be a combination of too few (and therefore overtaxed) care resources leavingpopulations vulnerable; and in a few, one is drawn to the inescapable conclusion thatincomes, rather than workload or quality of care or access to care, are the pre-eminentissues for physicians.There is no consensus as to what constitutes appropriate distribution of physicians (or forthat matter of any other of the myriad health professions). It may be reasonable to thinkabout a distribution of general/family practitioners that is roughly equal across regions ofsome particular size as being appropriate. But such a criterion for evaluating thedistribution of thoracic surgeons, for example, would be clearly inappropriate for regionswithin a province such as Saskatchewan, simply because of the much larger populationrequired to sustain a single practice in thoracic surgery -- for most regions, a reasonablenumber of resident surgeons in this specialty might be zero or, looked at another way, therelevant size of "region" when considering the requirements for some types of specialists,may be the whole province, or even a cluster of provinces. The corollary is that unequaltravel "convenience", for example in getting to a thoracic surgeon, is an unavoidable fact.But even for general practitioners, an objective of equøl distribution may not beappropriate. For example, arguing that each region of British Columbia should have thesame general practitionerþopulation ratio as one of that province's major urban centres,seems transparently inappropriate if there is general agreement that there is an oversupplyof general practitioners in that urban centre. On the other hand, it could be (and has been)argued that a community with ready access to a full range of specialists and tertiaryservices, should, in fact, require fewer general/family practitioners (setting aside thequestion of whether all the specialists are required). Furthermore, because of the need foron-call coverage and relief, it is often argued that a higher ratio may be necessary insmaller communities (see, e.g. Professional Association of Internes and Residents ofOntario, 1997). So the arguments about "equality" cut many ways. Even were we tochoose a baseline community which all agreed had a reasonable ratio, there may still becommunities with insufficient population to support a resident general practitioner -- ergo,equal is not an appropriate criterion. At the end of the day, there is no objective sciencethat can help us out of this fundamentally social/political dilemma. An appropriate supplyof physicians of any particular type is that supply that a society feels it needs and isprepared to support (Barer and Stoddart,l99la). The corollary is that an "appropriatedistribution", of any type of health care personnel must also be, in the end, a socialjudgement. These will vary across countries, provinces, and regions, and hold trueirrespective of the method of health care financing.There is also a danger in focusing too closely on any one category of personnel in thispursuit of the distributional holy grail, because doing so runs one the risk of overlookingpolicy solutions that lie outside the subset of interest. The Yukon Territory, for example,relies on a model of primary care centred around a combination of primary care physiciansand extended role nurses, and has policies in place to discourage the immigration of newphysicians. Unlike most provinces, the Yukon philosophy is that adequate quality primarycare can be provided to many segments of its population using a different model. This isnot to argue that the populations in large urban centres of this country would (or evenshould) accept a similar care model. But it does suggest that expanded horizons mighthelp alleviate some of the allegedly critical shortages of physicians in some of thecommunities south of the 6¡th parallel.Leaving aside the matter of what constitutes a "shortage" (another debate that "science"will not help us resolve; see recent exchange between Ryten (1998) and Evans (1998)), wecan observe the very real variations in per capita supply of physicians, we can measureregional variations in use of services, we can relate these variations to estimates of need(based on, for example, the age, sex and socioeconomic mix of populations, theprevalence of particular health care problems, health status indicators, etc.), and we candevelop reasoned and reasonable judgments, with the help of quantitative research, aboutthe appropriateness of physician availability, given the availability of other health careresources, the ease of inter-regional transport and proximate health care facilities, andother considerations that should bear upon the need for particular types of services, andtherefore particular types of health care personnel, in particular locations (Roos et al.,1996; Roos,1997).Making matters even more complicated is the fact that specialty and geographicdistribution often get bluned in policy discussions. The likelihood that a student willeventually enterrural practice is closely related to the specialty chosen. In general, themore specialized the discipline, the less likely the physician will ever (or should ever)practice in rural areas. One can clearly have different degrees of geographicmaldistribution for different specialties. But "specialty maldistribution" is generally takento mean that there is an inappropriate overall distribution of physicians across specialtycategories (general practice, internal medicine, etc.). Such a maldistribution may result ingeographic maldistribution of certain specialties, although one could certainly have whatwas considered a serious geographic distribution problem, without there being anyaccompanying overall specialty distribution problems.Why is this relevant to the topic of this report? The interconnectedness of the twovariables (choice of specialty, choice of practice location) means that policies intended toaddress one will inevitably affect the other. Individuals choosing general/family practice,or a generalist specialty, are more likely to end up serving a rural/remote community. Itwould make no sense to increase the number of sub-specialty residency positions, at theexpense of general practice or generalist specialty positions, if a predominant policypreoccupation is primary care in rural and remote communities. Having said that,however, it would make just as little sense for medical schools to address the rural areaprimary care problem by reducing the number of specialty residencies in order to boost thecomplement of family practice residencies, if at the same time other policies were not putin place to ensure that a significant proportion of the new family practice graduates wereactually going to end up practicing in those rural areas where the needs were. In theabsence of such complementary policies, one is likely to end up with a shortage of manyspecialties, an exacerbated urban surplus of general/family practitioners, and ruralcommunities in much the same situation as they have been in for decades.All of this is meant to emphasize that the problems are rarely as clear cut or one-sided asmany accounts in the popular media (or even scientific journals) would suggest, and thesolutions, if there are any, are likely to be complex, multi-factorial, interdependent, anddynamic. There is a reason these problems have been with us for so long.Canada is Not UniqueWide variations in the geographic supply of physicians is a part of the landscape invirtually every country in the developed (and developing) world. It is thus a commonfeature across a rich and varied mix of health care system organizational and financingarrangements (Organization for Economic Cooperation and Development (OECD), 1994),and has survived an equally rich and creative mix of attempts at remediation. We findlarge differences in per capita physician supply across the countries of the OECD. Forexample, 1994 data from the OECD reveal a range from 920 people per physician inTurkey, to 250 people per physician in Greece (OECD, 1996). In all of these countries,considerable regional supply variation persists despite, in many cases, decades of waitingfor the markets to solve the problem, or regulatory or financial initiatives intended toimprove these situations.As a leading example of this intra-country variation, the population per physician in theUnited States varied in 1991 from about 660-725 in states such as Alaska and Idaho, to265-280 in Maryland, Massachusetts, and New York) (personal communication, BradleyGray, January 1997). This wide variation in physician supply has been seen as a significantpolicy problem in many OECD countries for many years (see, e.g., Ritsatakis, 1988;Kalandidi and Ritsatakis, 1988; Malcolm, 1991). Those countries where geographicdistribution is not seen as an issue tend also to be countries which are geographicallymuch smaller than Canada, with much higher population densities, and in which the overallsupply of physicians per capita is much higher (e.g. Belgium, Switzerland, Israel). In thesecountries, over-supply is a much more urgent problem than any distributional problems.Closer to home, we find 1996 populations per physician ranging from 468 in Quebec to791in PEI and 1055 in the Northwest Territories (these are based on so-called'headcounts'rather than full-time-equivalents (Pitblado and Pong, 1999). And, within eachprovince and territory, one can find similar variations (Kazanjian, Wong Fung and Wood(1993) report fte variations for British Columbia; Pitblado and Pong report head counts byregion). For example, Pitblado and Pong (1999) report that, in 1996,9I.6Vo of Ontario'sphysicians (by head count) practiced out of urban core (Statistics Canada definition)locations. About 767o of the province's population lived in those urban'cores'. Thecomparable figures for Nova Scotia were70.8%o and39.Ivo.Geographic Location of Physicians - Understanding the DeterminantsCentral to any reasoned attempt to affect the distribution of physicians must be a clearunderstanding of how that distribution comes to pass. Physicians do not set outdeliberately to distribute themselves in ways that create inequitable access to theirservices. Rather, the distributions that we observe are the aggregation of a myriad ofindividual career decisions which, in turn, are influenced by many inter-related, oftensubtle and complex, factors. Matters of importance to a physician in determining whereto locate a practice (and which are therefore of interest to those attempting to developrecruitment strategies) may only partially overlap those that influence a decision aboutwhether to move on (which would be of importance in thinking about retentionstrategies). And even where the same factors are important in both decisions, they maycome into play with different "weights" (or relative importance).Policy approaches to geographic disparities have historically been dominated byeconomic/financial incentives. Yet the literature on the determinants of practice locationsuggests that a complex and subtle set of interactions, involving far more than financialconsiderations, underlie these decisions.2 The variables of importance can be usefullyclustered into the following categories:t personal background.) professional education factorsI professional practice factors<) personal/family factorst community factors0 economic factors.The most important factors from within the personal background category appear to bewhere the physician, and/or the physician's spouse, spent their childhood/adolescence.Among professional education factors are the extent of exposure to rural and non-tertiary practice situations during medical and intern/resident training, curricular emphasison the special problems of providing care in non-urban, non-terti afy care settings, and thelocation of the medical school itself. The professional practice factors that have beenreported as significant to location and retention decisions include the availability of2 There is a voluminous and still growing literature on the topic of location decision-making byphysicians. Because our primary objective here is to report on policy approaches, we provide here only abrief summary of the research on this topic, supported by a small sample of references. A more completelist is, however, available from the authors.professional support and back-up (including access to specialists and on-call relief), theavailability of facilities such as a community hospital or medical centre, and continuingeducation opportunities.PersonaVfamily factors include the preferences of the spouse, the size of aprofessionaUsocial peer group (in turn often a function of the socioeconomiccharacteristics of the community), educational and extra-curricular opportunities forchildren, and the proximity of family and friends. Commonly noted community factorsinclude climate, recreational and cultural opportunities, the socioeconomic status of thecommunity, and more generally the extent of match between what the community andsurrounding environment has to offer, on the one hand, and a practitioner's preferred"lifestyle" on the other. The economic factors of most importance are relative grossincome opportunities, practice costs, financial risk (i.e. predictability/reliability ofprofessional income), and employment opportunities for the spouse.But it seems unlikely that these factors would ever all be equally weighted by anyphysician making either an initial location or a re-location decision. The scientificliterature that has explored the nature of these decisions suggests rather convincingly thatthey are dominated by family, and particularly spousal, considerations (see, e.9., Costa eta1.,1996). Indeed, the willingness of a spouse to locate in a non-urban area, which inturn will be a function of the spouse's personal background, as well as cultural,recreational, and employment opportunities and educational and other prospects forchildren, seems to dominate. For example, a significant number of physicians are marriedto spouses with their own professions and career aspirations. This makes it particularlydifficult, in many cases, to find suitable professional opportunities for the spouse in morerural and remote areas (Ferrier et al., 1996). This literature also indicates thatpractitioners who have grown up in less highly populated areas, or who maffy individualswith non-urban backgrounds, are more likely to be prepared to set up practices in suchlocations (see, e.g., Canadian Medical Association,1992; Costa et al., 1996; Fryer et al.,1997;Kazanjian and Pagliccia, 1996). PersonaVfamily and community considerations alsoweigh heavily in the stay/leave decision. As Kazanjian et al. (1991) note, "...while much ismade in the literature of the professional isolation that can discourage physicians fromrural practice, respondents seemed more likely to cite personal/family reasons for thedecision to leave rural areas" (p. 53).Professional considerations, such as the availability of partners or other (e.g. locum) reliefarrangements and proximity to consultants, are also important (Pope et al. ,1998),particularly in the "retention" dimension - decisions regarding whether or how long tostay once in a rural/remote location. It is often difficult to disentangle the importance ofthese from the effects of the training process, particularly with respect to the "recruitment"dimension - decisions about initial practice location. Many primary care practitioners,for example, may feel uncomfortable practicing in situations without the proximity oftertiary specialist support because their training has insufficiently prepared them for thebreadth of situations and expectations faced in more rural areas, rather than because suchsupport is essential to a good quality rural medical practice. For example, in a 1989survey of B.C. residents and intems about to make decisions about where to establishpractices, it was found that "[flew of the responding residents and intems had spent any oftheir post-graduate experience in rural areas. A sizable proportion of each group had noundergraduate medical experience in rural practice" (Kazanjian et al., 1991, p. 89). Whilethis situation is likely to have improved as most provinces have made some rural practiceexposure a key component of undergraduate and/or residency training during the pastdecade (see section B below), insufficient perceived familiarity with the expectations ofrural/remote practice may, nevertheless, continue to be a factor in these decisions.3Limited opportunities to become involved with their professional association, and to"secure uninterrupted free time from work", have also been noted as importantconsiderations (Kazanjian et al., 1991).Perhaps the most counter-intuitive result to emerge from this literature is that mostfinancial considerations are well down the list in terms of relative importance. Theopportunity to receive financial assistance, a guaranteed minimum income level, or anincome bonus in return for practice in rural areas, for example, were found not to beparticularly important considerations among students about to make career locationdecisions in British Columbia (Wright, 1985), or among rural physicians in Alberta(MacDonald and Associates, 1996), and a Canadian Medical Association report (CanadianMedical Association,1992) noted that "[flactors that might have influenced physicians tostay in rural practice were, in order, additional colleagues, locum tenens, an opportunityfor group practice, specialist services, alternative compensation, continuing medicaleducation, improved facilities and emergency transportation" (Rourke, 1993);"[p]hysicians in rural areas were ..[un]likely to report that financial incentives had been akey factor in their location decision, with just I in 10 reporting that they were veryimportant" (Canadian Medical Association, 1992, p. 17). One could always argue that thefinancial incentives have simply not been large enough. But one doesn't need to travel toofar down this path before other approaches would quickly become more cost-effective.The ameliorability of impediments to recruitment and retention of physicians to/in less-highly-populated centres is highly variable. "Modifiable factors" (Rourke, 1993) includeeducation and recruitment practices, practice opportunities and support facilities, workingconditions, and financial factors. But it is considerably more difficult to devise publicpolicies that will address the spousal and family concerns that seem to dominate so manyof the original location, and subsequent retention, decisions. And some modifiable factors,particularly medical school and residency training, may have less effect than is oftenpresumed, or hoped (Rabinowitz and Rattner,1997; Xu et a1.,1997).3 Familiarity with the peculiarities and challenges of rural/remote practice is also important in the locationdecisions of specialists. A recent Norwegian study found that "location of postgraduate traininginfluences later locational choices" among specialists (Kristiansen and Førde (L992).Geographic Location of Physicians - Influencing the DecisionsTurning to the literature describing the array of approaches to improving the geographicdistribution of physicians, these can be grouped in ways that will assist in describing andevaluating this policy landscape. We suggest six generic clusters, although these areoften, in practice, interdependent and even overlapping, rather than mutually exclusive:regul atory/administrati vefunding/paymenteducation-related fundingeducation/trainingmarket-basedother (including communication technology).For example, many (most) financial incentives are rooted in enabling legislation - theyfall within both regulatory/administrative and funding/payment clusters. Similarly, as wenote below, many of the education/training-related initiatives have involved providingfinancial incentives to medical students and residents - these fall within both thefunding/payment and the education/training clusters. Furthermore, a billing numberspolicy which restricts the issuance of 'rights' to bill a provincial medical plan for servicesrendered could be viewed as a financial disincentive program in which the disincentive wasa07o fee proration. And finally, communications technology is being viewed as havingpotential both in the process of care delivery, and as a continuing education tool.Nevertheless, we found this to be a useful way to cluster policies, and many seem to fitrelatively comfortably within one of the above categories.Regulatory/administrative approaches are public policies with a primary intent ofinfluencing location decisions, which are'codified'in provincial or federal acts orregulations, or which are the result of policies enacted by bodies who have been given self-regulatory powers through acts or regulations, or which are implemented on the strengthof administrative rules or guidelines. These would include not only "billing numbers"-typepolicies which impose conditions on where individual physicians may practice, but also theissuing by medical Colleges of conditional licenses, or immigration laws which resffict theentry conditions of foreign-trained physicians.,Funding/payment approaches would encompass different methods of paying providers,as well as financial incentÍves within a payment system. They are perhaps the mostfamiliar and long-standing in Canada, and include northern/isolation allowances or incomeguarantees, loan forgiveness, assistance with practice expenses, funding continuingmedical education through subsidies and support of locum programs, differential fees, andthe like. They will often, as with the U.S. National Health Service Corps program, berooted in legislation that dictates to whom funds can be made available.Education-related funding approaches involve providing a variety of financial incentivesto physicians-in-training, in order to encourage them to select particular trainingexperiences, particular specialties, or particular practice locations post-graduation. Theyl0range from support for rural placements, to bursaries and loan packages, the latter oftentied to retum-in-service commitments.Within an educationaUtraining cluster are a wide range of policies spanning the earlystages of the "physician life cycle" (Barer and Stoddart,l99la). These might begin withhigh school science enrichment and student counseling programs for rural areas, throughmedical school recruiting strategies, through curricular and clinical exposures providedduring medical and post-graduate training, to continuing education/skills upgradinginitiatives Included would be initiatives based on where training programs are physicallylocated, as well as where students are sent for training.Market-based approaches involve letting 'the market' take care of it. This approach iscommonly based on the view that, as urban centres become more crowded, there will be aspill-over or'trickle-down'effect which will result in more physicians setting up practice inrural areas. For example, with increasing HMO penetration in some areas in the UnitedStates is coming some redistribution of primary care physicians (and physician incomes)(Simon, Dranove and White, 1997). But it would also include efforts by communities,regions, or even Ministries/Departments of Health, to 'advertise' opportunities in, and theattractions of, particular locations attempting to attract physicians. Initiatives such as"recruitment fairs" or "recruitment tours", intended to heighten a\ryareness amongpracticing and soon-to-be-practicing physicians ofopportunities in underserved areas, canbe considered key components of a "market-based" policy cluster.Finally, an emerging set of initiatives (which at this juncture could not, in mostjurisdictions, be considered policies) that are viewed in some quarters as offeringenoÍnous potential for ameliorating problems of rural/remote service access are the rapidadvances in communications technology. These would include efforts to establishremote connections between remote communities and regional or urban 'hubs', with thelatter becoming 'virtual' members of the professional community available to the remoteresidence. These more centralizedphysicians could be involved in reading andinterpreting diagnostic tests, remotely assisting with surgeries, and the like.llB. An Overview of Provincial/Territorial InitiativesEvery province in Canada currently has a set of (often uncoordinated) policies designedwith the specific objective of changing the current geographic distribution of physicians.In 1990 this was viewed as one of the most serious health care system problems facingCanadian provinces and territories (Barer and Stoddart, 1991a); what we have seen in ourinformation-gathering for this report suggests convincingly that it remains a first tier policypre-occupation. Many regions have had a variety of initiatives in place for decades,because this has been seen as a problem for decades.Detailed descriptions of the policy history and current approaches for each province andterritory can be found in the Appendices. Here we focus on the'current'a policy landscape,and attempt to provide a summary and to draw out some highlights and common themes.In Table I we have attempted to develop a simple check-list (without providing the detailsof individual policies) which provides, at a glance, a picture of which policies are in placein each jurisdiction.5Perhaps the most striking thing about this table is the sheer number of rows with at leastone / ,each such row representing a different lever being used/tried somewhere in thecountry.6 The second notable feature is the relative number of funding/payment rows,and the number of / in many of those funding/payment rows - these continue to be thepredominant type of policy instrument in place in Canada. Indeed, many of these rowssuggest that virtually "everyone's doing it". Particularly noteworthy here are the numberof jurisdictions offering: a) either subsidized incomes or guaranteed minimum incomecontracts for physicians practicing in rural/remote/isolated areas; b) "return-of-service"bonuses and grants; c) funded rural area locum programs; d) specific funding for rural areaon-call coverage; e) student loans, grants and bursaries tied to "return-of-service"commitments; and f) funding to allow rural/remote physicians to take advantage ofcontinuing education/skills upgrading opportunities.Despite their widespread deployment, there is little evidence that these financially-basedinitiatives are particularly effective. For example, the general experience of provincesproviding return-of-service-tied grants, loans and bursaries to students and residents isthat the recipients often buy their way out of the service commitment (see, for example,appendices 3 and 6, on Saskatchewan and Quebec), although some provinces (seeappendix 4 on Manitoba) appear to have been more successful than others. Even whenrecipients complete their terms, these initiatives have limited effect on longer-terma Bearing in mind our earlier caution about the constantly changing state of play in this arena.5 Similar tabular summaries have been developed for Canada (Barer and Wood, 1997; Hutten-Czapski,1998) and Australia (Australian Medical Workforce Advisory Committee, 1996).6 A few of the rows in the table contain no / . They are included in the table because we found mentionof such policies in our canvassing of international literature, and because we could conceive of no reasonwhy such policies could not be tried in Canada (indeed, it is possible that there are examples of suchpolicies currently in place here, of which we are simply unaware at this point).12retention. American experience with the National Health Services Corps (see below) issimilar.In contrast to the plethora of funding/payment-based incentives, there is comparativelyless being done in the education/skills areas. Aside from most provinces now offeringdedicated rural area training/exposures during the years of undergraduate medicaleducation, and a fair number of opportunities for rural residency experiences, particularlyfor family practice, other initiatives are less common.TA promising development has been the recent re-emergence of interest in, andestablishment of, training programs for what have traditionally come to be known as"nurse practitioners". There are training programs in at least three provinces, with anumber of other jurisdictions either having such programs in the planning stages, or underdiscussion. But there appears still to be considerable confusion in this country over whattypes of individuals ought to be trained, and for what purposes.s There are multiple'standards' which have an effect on where or whether graduates of certain programs can bedeployed in certain locations (e.g. it is our understanding that Health Canada's MedicalServices Branch has a peer review committee that evaluates training programs; onlygraduates of programs that meet that committee's standard can be employed by MSB orjurisdictions that adopt the MSB standard). Provinces appear to have differentconceptions of how independently, and in what situations, they would like such extendedscope personnel to practice.To date, three provinces have made amendments to existing Acts (subsets of Actsgoverning the practices of nursing, prescribing pharmaceuticals, and laboratory andradiology diagnosis) so that practitioners other than licensed physicians are legally able toperform a limited range of primary care functions. Other provinces, such as Manitoba andSaskatchewan, are currently planning, or in the process of enacting, similar regulatorychanges.The apparent lack of activity at the local level in raising funds to support recruitment orretention is misleading. Our impression from speaking with our provinciaUterritorialcontacts is that some of this occurs virtually everywhere, but little of it is as a result ofofficial provincial/tenitorial Ministerial/Departmental policy (see, e.g., Arnold, 1999);indeed, most Departments/IVlinistries would prefer this sort of uncoordinated initiative didnot exist, because it creates a'whipsaw'effect in many situations and, in turn, putsadditional pressure for resources on the central Departments/lVfinistries.7 This is not to say that progress is not being made. A recent survey of family medicine programs acrossthe country found a significant increase in re-entry opportunities, a significant share of which are madeavailable for physicians intending to (return to) practice in rural areas (Chaytors et al., 1999).8 In part, the debate appears to be over whether one should be training "advanced clinical nurses" who areable to provide highly specialized nursing skills, but whose focus continues to be the "nursing function",or practitioners who are skilled nurses but who also have the capability of providing some of the servicesusually provided by physicians (e.g. some primary care diagnostic, test ordering, and prescribing activity)(see Hill and Pickup, 1998).t3Also noteworthy is the fact that two of the rows containing no y' repres.nt initiativesrelated to spousal support or education support for children. This is not surprising on theone hand, and ironic on the other. As noted above, these tend to be among the least'policy-ameliorable' of the factors affecting physicians' decisions to locate or stay inrural/remote areas. Yet at the same time, they are among the most importantconsiderations in those decisions.An examination of the table by column makes clear that most provinces/territoriescurrently employ policies from more than one of the generic clusters. Nevertheless,financially-based approaches continue to dominate the geographic policy landscape. Thereis an increasing number of policies based on alternative methods of payment (e.g. salariedor contract positions, non-fee-payments for on-call), although many of the more-widespread funding/payment initiatives intended to improve access to care in rural orremote areas are still tied to fee-for-service reimbursement.It is interesting that the continued heavy reliance on financial instruments in Canada comesdespite the facts that: "(a) the research on determinants of locational decision-makingseems to suggest that other factors outweigh financial considerations; and (b) theevaluative evidence suggests that the financial approaches to date have not beenparticularly effective" (Barer and Wood, 1997). Indeed, the fact that Canadian provinceshave relied so heavily on these instruments, and that the problems remain so evident, andso high-profile, would seem to provide primafacie evidence that different approaches aregoing to be needed if progress is to be made in the future. This leads rather naturally toquestions about whether approaches in other health care systems have been different, orany more successful. We turn to some of those experiences in the next section.t4Table I : Contemporary ProvinciaUTerritorial Policy ApproachesRegulatory/AdministrativeDirect Funding -Practice-relatedDirect Funding -Education RelatedBilling numbersProvincial medicallicense tied to retum ofservice in mral areaForeign medicalCraduates withresfrictions on practicelocationEnabling legislation forexpanded role physicianextenders/nursesSubsidized income orguaranteed minimumincome contractDifferential fees - bonusfor practice in under-serviced resionDifferential fees - pro-ration for practice inover-serviced resionSala¡ied and other'alternate payment'mcitinncGrants/Bonus tied toreturn ofserviceSpecial ravel allowancesfor rural practiceSpecial program/fundingfor locrrm sunmrlAssistance with practiceestâblishme¡t côstsFinancial support forvanalinn lnri¿l rinp nff\ ,/Special on-call paymentsfnr cne¡iqlicfcSpecial on-call paymentsfor emergencv coveraseUndergraduate/post-graduate studentloans/grants/bursarywith retum ofserviceSpecial funding or loansfor residency andspecialty skillsdcvelnnmenfSpecial travel allowancefor students to get tosummer placements orresidenciesFinancial support forcontinuing medicaleducation15Table 1: Contemporary Provincial/Territorial PolicyApproaches cont'dEducation/IrainingRural training/exposure forrrnderomdualp-c,/ ,/ ,/ ,/Rural placementlteaching units inassociation with a ruralpractice residency orsDeciâltv,/Special (re-enty) access toræidency and/or newspecialty skillsdewelonmenl,/ ,/Special recruitmentpolicieVcriteria for newundergraduate medicalstudents, e.g. aboriginals,ruralSpecial recruitmentpolicieVcriteria forgraduate level ræidencytr¡inin sDevelopment of continuingeducation capacity usingnew communicationtechnolosias,/ ,/Promotion of ru¡al practicein medical schoolsNurse practitioner orsimilar DrosramMarket-basedInitiativesRecruitment fairytours ,/ r/Allow locally raised fundsto directly supportprovision ofphysicianservices (e.9. housingcrrhcidv cf¡ \,/ ,/ ,/Other InitiativesFunding for new remotediagnostic technologiese o Tple-radinlnov ef¡ ,/ ,/ ,/Spousal Support InitiativesEducation Support forChild¡en (e.9. boardingschool for older childrenetc.)Physician Resources Co-ordinatnrT6C. Selected International ApproacheseIn this section we review recent and current policy approaches found in the UnitedKingdom, the United States, Australia and New Zealand. These choices were responsesto a combination of constraint and practicality. On the former, the time and financialconstraints on this project dictated the choice of a circumscribed set of internationalexperiences. On the latter, one quickly runs into diminishing returns in internationalquests of this nature. While the details in each country and, indeed, at the level of sub-country units, vary, we have found (in earlier, wider canvassing) that the generalapproaches tend to repeat, as they do in the provinces and territories in this country.Since Canada tends to look to the U.S. and the U.K. for policy lessons (positive andnegative) and experiences, and to Australia because its health care system is seen asbearing some considerable resemblance to our own, these seemed like logical choices for ashort list. We added New Zealand because recent developments in primary care reformappear to offer some important insights for Canadian policy-makers.Before turning our attention to these specific country experiences, it is perhaps worthnoting that, to our knowledge, there is virtually no cross-country collaboration in thedevelopment or implementation of policies intended to improve the geographicdistribution of physicians. Indeed, if anything, there is open competition - Canadarecruits physicians from South Africa; the United States recruits primary care practitionersfrom Canada; Australia recruits practitioners from Canada; Canada recruits practitionersfrom the United Kingdom; the United States allows individuals from other countries toenter on J-l visas (meaning they are expected to return to country of origin once theycomplete training), in part presumably as a form of foreign aid (to allow them access tothe training expertise in the country), then makes it relatively easy to get waivers allowingthose residents to stay in the U.S.; and so on. Of particular interest in this respect will bethe countries in Europe, since barriers to inter-country mobility are being dramaticallyreduced. Whether pan-European policies intended to address geographic distribution ofphysicians emerge over the next few years remains to be seen. What we do know,however, is that some countries (e.g. Italy) have significant surpluses, while others (e.g.the United Kingdom) have plans afoot to ramp up their domestic medical school training.One of the few exceptions to this general story may be the World Organization of FamilyDoctors (WONCA), which has established a Working Party on Training for RuralPractice. This Working Party produced a document in 1995 (WONCA, 1995) whichoutlined a series of recommendations intended to improve access to adequate medical carein rural and remote areas around the world. While the recommendations containede Much of this section bonows heavily from Barer and Wood (1997), although for each of the fourcountries we have attempted to ascertain and report on the nature and extent ofpolicy changes since 1996.We have focused on the regulatory/administrative and funding/payment clusters, in the interest of timeand space. A comprehensive review of individual state, region, or school-specific education initiatives inany one of these countries could be the subject for an entire separate report. However, other than learningabout how many there are, we feel it is unlikely that we would find initiatives not already mentionedsomewhere in the present report.t7therein focus (not surprisingly) largely on education-related initiatives, there are alsorecommendations focusing on personal and professional support in rural settings and theneed for local community involvement. In general, these recommendations largely mirrorthose of earlier, and later, documents (see, e.g., Barer and Stoddart, l99la; PAIRO, 1998,1997).United KingdomFrom the time the National Health Service was established in 1948, the UK has had inplace a "negative direction" or negative control regulatory policy affecting the distributionof general practitioners. A central "Medical Practices Committee" (MPC¡ must approveall gp applications for practice. This Committee has the power to refuse an application ifit considers that the number already practicing in the requested area is adequate.Adequacy is determined by the length of patient rosters (referred to as 'lists'). Designatedareas are those with average gp lists of 2500 patients and above, open areas have averagelists of 2I0l - 2499, intermediate areas have average lists of 170l-2100 patients, andrestricted areas are those with average lists of 1700 or fewer patients per gp.Applications to practice in designated and open areas are usually granted withoutquestion, while those for intermediate and restricted areas are considered on the basis ofdetailed advice from the appropriate local family practice committee (FPC) and may berefused (Haynes, 1987) (FPCs, later re-named Family Health Services Authorities, havenow all been merged with Health Authorities, but have the same role). Importantly, theMPC "must approve the location decision of ø// GPs seeking to locate in an area andprovide care in the NHS" (Taylor, 1998,714).The negative direction policy was evaluated in the mid-1970's, and has proved to havesome perverse effects. One of the most important is that the areas with the fewestphysicians were less likely to be "designated" because of their sparse populations. Morerecently, its effects have been dampened by the rather liberal list size'cut points'. Forexample, there are few "designated" areas remaining in the UK, and in practice manyapplications to "intermediate" areas are granted. Nevertheless, overall the policy is widelyseen as having provided a reasonably equitable distribution of gp services (Maynard andWalker, 1997), so that the current UK preoccupation appears to be more with"inequalities of access" (IVatt, Franks and Sheldon, t993,1994) than with absoluteunderservicing or unmet primary care needs, even in the least well supplied areas.The U.K. has also utilized financial policies. An initial practice allowance is payable forthose setting up practices in designated areas. Those who remain in practice indesignated areas for a period of time also receive additional remuneration in the form of adesignated area allowance. The latter was found to be the more effective, although mostpractitioners regarded it as far too low to affect practice decisions. In addition, theallowances might be counter-productive in that they give established physicians indesignated areas an incentive to discourage or refuse newcomers, since the allowance isl8lost once list sizes drop below the margin, and the MPC membership is dominated by gp's(Haynes, 1987).The other key "mainstream" component of the UK approach was introduced with the1990 NHS gp contract. An index called the "UPA 8" (which is a weighted average offactors such as percent of elderly living alone, one parent families, unemployed, socialclass V) is used to designate the status of geographical small areas. The weights on thesefactors were derived from a survey of a lÙVo national sample of gps, who were asked howimportant they felt each factor was in influencing their workloads (Jarman, 1983). Areasthat have high "underprivileged area index" values are deemed "deprived" (althoughquestions about the relationship between "deprivation" and gp workloads, or aboutwhether the index is in fact better correlated with those workloads than other possibleindexes, have not been adequately answered: see Can-Hill and Sheldon, 1991; Davey-Smith, 1991). A "deprivation payment" is then 'attached'to all area residents, and the gpswho have such patients on their lists receive a capitation supplement, as an incentive toserve patients from areas with these characteristics.The annual capitation supplements ranged in 1995196 from approximately $15 to $25 perdesignated patient (Taylor, 1998). Since these areas tend to be those generally lesscoveted by physicians looking to locate practices, this has the effect of being an incentiveto set up practice in relatively less well-served areas. However, one of the effects of useof the UPA 8 appears to have been to channel deprivation payments more to inner cityLondon locations than to rural areas in the North and elsewhere, which may actually bemore under-serviced (Taylor, 1998; Townsend et al., 1988).In addition, the UK employs a wide variety of other more ad hoc programs, such as an"Inducement Scheme" that provides physicians with "a family-sized house and a surgeryfor rent..[plus]..807o of the cunent agreed average general practitionerearnings..[and]..locums for annual and study leave...paid for by the health authority"; an"Associate Scheme" that provides "salary and expenses, at approximately senior registrarlevel, for a doctor to work on a shared basis between two or three isolated practices ...atleast ten miles apart" (Macleod, 1995); and compensation to primary care physicians for"increased time spent traveling when caring for patients in sparsely populated areas"(United States, 1994). Rural practices in areas of sparse population are often supportedby some of these schemes, which in practice have effects similar to salaried posts. Thesephysicians often have extra training, for example in obstetrics or cardiology.There are even ad hoc programs for less well-served parts of urban centres. The "PrimaryCare Initiative Program" provides selected assistance to Live¡pool practices that require it,and the "London Initiative Zone" provides a variety of allowances intended to encouragenew practice arangements within the"LlZ" (Review Body on Doctors' and Dentists'Remuneration, 1996). But these appear to be secondary 'fiddling' alongside the major UKprograms.t9These schemes are all overlaid on a system in which gps are paid on a capitation basis tostart with. This might lead one to question the need for these other approaches, since"[u]nder a strict capitation system competition for patients (or their associated capitationfees) would produce strong financial incentives to locate in areas of under supply".However, ".. a large proportion of an average gp's income comes from non-capitationsources" (Birch and Maynard, 1991). Indeed, while the largely capitation-based methodof funding primary care is viewed as having been quite an effective approach to ensuringreasonable access to primary care services (Maynard and Walker,1997), nevertheless itseffects on geographic distribution have undoubtedly been somewhat vitiated by the richmix of 'envelopes'through which general practitioners can receive income (Review Bodyon Doctors'and Dentists'Remuneration, 1996, Appendix A, pp. 65-69; Bloor andMaynard (1995)).10 Indeed, there has been a tendency for the proportion of capitation inoverall gp incomes to exhibit a cyclical pattern, falling over time until a new capitationlevel (usually amounting to about 807o of total income) is agreed to, before beginning tofall again as special payments and arrangements are layered in, and so on.On balance, however, the combination of central decision-making through the MedicalPractices Committee and funding based to a considerable extent on the number of patientson a gp's practice list has left the UK in a situation where geographic maldistribution ofprimary care physicians is not seen as a cuffent problem (although clearly pockets ofunderservicing remain).With respect to specialist services, most specialists are (at least in part) salaried employeesof Hospital Trusts. Funds for specialist services are allocated to regions according to a'weighted capitation' formula (a modification of the original Resource Allocation WorkingPaty (RAWP) formula), and the regional health authorities contract with hospital trustsfor provision of an agreed set of services for an agreed population. Trusts have someindependent latitude in setting "terms and conditions of employment" for specialists, whichmay make it easier for some of the more problematic specialty shortage areas to recruit(Maynard and Walker,1997). 'Life under RAWP' has, apparently, improved thedistribution of specialist services, because it has been able to steer specialists to thepopulations in need of those services (who would have the funding available to employ thehospital specialists). Like the capitation-based funding for gp services, the approach ofhaving funding follow populations seems to have reduced problems of geographicmaldistribution.Can the UK improve on this situation? Taylor (1998) has recently suggested that furtherprogress could be made by developing "more refined weighted capitation means offunding [regional purchasing authorities], leaving "local discretion to reallocate resourcesl0 Over and above the capitation fees, general practitioners are entitled to an overhead allowance,allowance for employing an assistant, and allowances for treating patients in "deprived areas". But inaddition, they are eligible for "target payments" and "fees for items of service" for a wide variety ofspecific activities such as administering childhood immunizations and pre-school boosters, doing cervicalcytology, running a practice health promotion program, chronic (e.g. diabetes) disease management, andthe like.20between primary and secondary care" to local governing bodies (p.722). This might, forexample, counteract some of the apparently anomalous and concentrated distribution ofthe deprivation funding. In the meantime, there are plans afoot to increase the intake ofthe UK's medical schools, although this decision, and the underlying concerns thatmotivated it, seem largely unrelated to matters of geographic distribution (Goldacre,1998). And with the new reforms in much of the UK are to come "primary care groups"and "local health groups", with wide commissioning and budgetary responsibilities(Chisholm, 1998). How, or whether, these will affect the distribution of gp servicesacross the UK seems at this point in time unclear.In terms of lessons for Canada, there would appear to be a number. The keys to theU.K.'s relative success in distributing physician resources have been a combination ofadministrative (the negative direction policy) and financial incentives (funds followpatients). A number of jurisdictions in Canada have tried, or are currently using, policiessimilar to the U.K.'s negative direction policy, although this class of policy continues to bein flux in this country because of the legal uncertainties surrounding its application. Whatdoes seem clear is that any province that attempts a policy of this nature should beprepared to weather the legal stom. At the very least, such policies should notdiscriminate according to where physicians have been trained or previously resided. Butto go beyond that, and to address the widespread sentiment among internes, residents andnew physicians that they should not be restricted from competing for practiceopportunities in the more desirable locations of the country, one would need to look to theother sorts of initiatives adopted in the U.K. Both through RAWP funding to hospitals,from which consultant (specialist) incomes derive in large part, and through the largelycapitated arrangements for family practitioners, the U.K. policy has been to have fundingmade available on the basis of the number and characteristics of the patient population,rather than on the basis of the services that physicians in a particular locale end upproviding. It seems fair to say that Canada has barely scratched the surface of this sort ofapproach, and that this has the potential of yielding significant gains in terms of improvingrural/remote access problems (although the practical logistics are not trivial; as but oneexample, special circumstances of small communities would require special adjustments toany population-based funding approach).United StatesThere is substantial agreement among all observers of the U.S. scene that there are seriousproblems with the geographic distribution of physicians, including primary care physicians,despite continuing increases in supply over the last 25 years. For example, about "20percent of the U.S. population lives in rural areas while only 9 percent of the nation'sphysicians practice in rural communities" (Konrad,1996). While the ratio of practicingphysicians to population decreased form 1:593 to I:379 between 197 5 and 1995, thenumber of government-designated medically underserved areas was unchanged (Iglehart,2t1998)," and actually increased over the decade 1984 - 1994 (Rivo and Kindig,1996).Indeed, the number of Americans without access to primary care increased during thatdecade (ibid.). For a time, the difficulty was exacerbated by the increasing preference ofrecently-trained physicians to choose non-primary-care specialties and sub-specialties.This appears to have been changing recently (Simon, Dranove and White, 1997), althoughthe effects of such a shift on overall physician distribution will take some time to play out.Between 1989 and 1994,the geographic distribution of all primary care physicians in theUnited States did not become more even (Politzer, Cultice and Meltzer, 1998).Policy-makers in the US, at the state and federal levels, have put their faith and hopeslargely on market forces, supplemented by a number of small-scale, ad /roc programswhich use educational and financial levers, to address distributional issues. Indeed, theU.S. approach has been recently described (by an American observer) as "...a piecemealeffort to respond to geographical problem areas....and not a coherent strategy designed torationalize the allocation of health resources to improve access" (Taylor, 1998,p.7I4).Much of the activity has occurred, and continues to occur, at the state or individualinstitution level (see, for example, Summitt, Herrick and Martins, 1998), and there is alarge and constantly expanding literature on that experience. A canvassing of thatliterature was determined to be well beyond the scope of this project.'2If there is a "general approach" in the U.S., it would appear to be to provide federal orstate funding to "medically underserved" or "health professional shortage" areas, or toindividual health care professionals prepared to set up practices in those areas. Thedetermination of whether an area is "underserved" or has a "shortage" is based on thecomparison across geographic areas of index values created from combining factorsviewed as being indicative of these phenomena. There has been considerable controversyover the methods used to designate areas, and over the uses of those funds. We focushere on the two most widely known initiatives, the National Health Services Corps(NHSC), and the Medically Underserviced Area (NflJA) programs.The NHSC is a financial incentive program rooted in federal legislation. It is designed torecruit (and retain) primary care physicians to (and in) rural and underserved (includingmetropolitan) areas. Developed in 1972, and offering a combination of incentives andcoercion (scholarships and loans, with an obligation of "return-in-service"), it has trainedrr While Iglehart (1993) claims that this presents a "paradox" for federal policy, in fact it is really nomystery. For increasing supply to have changed the number ofunderserved areas would require that a'trickle-down' policy actually works. There is sufficient evidence now out there, even for federal policy-makers in the US, that this is expensive and ineffective policy. As Noren (1997) noted recently, "marketforces operating during the past several decades have not solved the underservice problem for these 45million people [in FIPSAs], and the numbers make it quite clear that simply continuing to increase thesupply of physicians will not solve the access problem" (p.220). On this point, see also Sparer (1997),who concludes that market forces in the U.S. appear to have had some influence on reshaping specialtydistribution, but not geographic distribution.12 A recent example is Rabinowitz et al. (1999) who examined the effects of one medical college's"physician shortage area program" and found that graduates of that program were considerably morelikely to be practising in rural or remote areas than their non-program counterparts.22over 20,000 health professionals, the majority of whom have been physicians.'3 Theplacement of those professionals is based on the identification of Health ProfessionalShortage Areas (IIPSA);Ia only FIPSAs are eligible for NHSC funds. The HPSA "index"combines information on the population:primary care physician ratio with "locallyprovided information on health need[s] and health facilities" (Taylor, 1998,p.7I7).However, the population:physician ratio appears to be the most important factor, and the'cut-off ratio appears to have been set not on the basis of any evidence that areas havinghigher ratios were truly "in need" and those having lower were not, but rather so as toensure that about one-quarter of all U.S. counties were eligible for NHSC funds at thetime of inception. Since the inception of the NHSC, however, a variety of other financialassistance programs have also adopted the HPSA as the basis on which they allocate funds(United States, 1995). As in the United Kingdom, indices developed for a specific policypurpose have tended to take on a life of their own, and the underpinnings and originalintents tend to become forgotten (Taylor, 1998).The other major financial incentive program has its roots in the Health MaintenanceOrganization (HMO) Act of 1973. This Act uses a different index, the "Index of MedicalUnderservice", which is a weighted combination of the population: primary care physicianratio, the proportion of the population 65+ years of age, the proportion of the populationbelow the poverty line, and the infant mortality rate, to identify "Medically UnderservicedAreas" (lv[uA) (Taylor, 1998). The original intent of this initiative (and therefore theoriginal purpose of the index) was to make funds available to underserviced areas in orderto encourage the development of HMOs in those areas.Small areas (usually counties) must apply to the federal govemment for designation eitheras an MUA or an FIPSA, in order to be eligible for funds that can be used for programsintended to improve recruitment or retention of health care professionals. Under theIIPSA program, counties must re-apply every three years, or they are dropped from thelist, and new shortage areas are only added if they actually apply for designation. As aresult, the list of HPSAs could change without any changes in the actual relative supply ofhealth care professionals. Historically, there has been considerable variation in theprobability that a shortage area would bother applying, depending largely on whether itperceived that funds would be forthcoming, and on whether the host state was aggressivein assisting small areas (Konrad, 1996).The NHSC programs have undergone extensive, albeit rather narrowly focused,evaluation. Evaluations have focused primarily on whether physicians who go throughthis program end up staying in HPSAs beyond their term of "service repayment".rs13 In 1994 the NHSC awarded 429 scholarships (189 for physicians) and 536 loan-repayment contracts(217 to physicians).ra For a more detailed discussion of the designation of HPSAs, see Council on Graduate MedicalEducation (1998).l5 This leaves the rather more interesting questions about effects of the programs on the health of thetargeted populations, or even on their access to care, largely unexamined (personal communication, KevinGrumbach, April 1999).23Pathman and colleagues (1992) reported that, between 1984 and 1990, fewer NHSCphysicians than non-NHSC physicians remained in the practices in which they worked in1981, or in practice in a rural county. Long-term (8 year) retention percentages forNHSC and non-NHSC physicians were I2Vo versus39%o; 29Vo of NHSC physicians, ascompared with52Vo of non-NHSC physicians, who began in non-metropolitan practices,remained in practice in a rural county eight years later. Problems with retention andsatisfaction have since been studied extensively. Key factors associated withdissatisfaction, that resonate with the earlier-reviewed literature on the determinants ofretention, were failure to match NHSC physicians to states where they had previouslylived or trained, and inadequate consideration of the needs of spouses and children andpersonal life issues (Pathman et al., 1994). In addition, within FlPSA-designated areas,there are more and less desirable places to practice. The task of the NHSC is to placepractitioners into areas on the basis of relative need, whereas those settling in HPSA areason their own, can choose their locations. As a result, it seems likely that the NHSC-placedindividuals are, on average, in the less desirable of the HPSA-designated areas, relative tothe non-NHSC physicians (personal communication, Fitzhugh Mullan, November 1996).A more recent evaluation of rural IIPSA retention was carried out between 1990 and1992. About20Vo of primary care physicians who had located to underserviced areasduring the study period had gone through the NHSC program. About 60Vo of NHSCphysicians and 40Vo of non-NHSC physicians had left their rural practice setting withinfour years of arrival. Seventy percent of NHSC physicians intended to leave their assignedpractice within 6 years. About 40Vo of NHSC physicians in rural practice intended to stayfor six years in rural practice at the time they began their NHSC service, in contrast toabout two-thirds of the non-NHSC physicians in the same IIPSAs. About 40Vo of theNHSC participants in tIPSAs intended to move to urban areas within the first six years, inmarked contrast to less than l07o of the other rural (non-NHSC) physicians surveyed. Atleast one-third of the NHSC physicians indicated only a short-term interest in underservedarea practice (Konrad et al., 1993).Rosenblatt et al. (1996) surveyed all recipients of NHSC scholarships who had graduatedbetween 1980 and 1983 from family practice residencies and who had gone to practice inrural areas. They found that in 1994 one-quarter of these graduates were still practicing inthe counties to which they had been assigned by the NHSC six years after graduation, anda further quarter were still practicing in some rural area.Konrad (1996) notes that "..about one of every four new primary care physicians enteringHPSAs in the late 1980s was placed there under the NHSC scholarship or loan repaymentprograms". Whether "..this fact alone boldly illustrates the impact of the program inquantitative terms", is questionable, however, since we have no way of knowing whetherthose same, or other, primary care physicians might have settled in HPSAs in the absenceof the NHSC. Certainly the evidence from the Pathman and Konrad evaluations suggeststhat those who choose to settle in HPSAs tend to be more committed to rural areapractice and more likely to stick with it, than those physicians attracted to such practicesthrough a financial incentive program. However, whether this reflects problems with the24program administration, lack of comparability because of failure to adjust for the relativedesirability of sub-regions within HPSAs, or simply the fact that what attracts physiciansto rural areas is not fundamentally financial considerations, is impossible to ascertain fromthis evidence.A recent review of strategies for improving physician distribution to underserviced areas inCalifornia recommends that the state should provide its own funds to match the NHSCloan repayment programs, as a means of supporting an additional25-30 physicianplacements each year. The authors conclude that overall, "both the federal and stateNHSC programs in California have little difficulty attracting physicians to participate andappear to be reasonably successful in retaining graduates in underserved communities",quoting the results of a recent survey to the effect that 4l%o of the State Loan RepaymentProgram recipients who had completed service obligations prior to June 30, 1998 werestill in practice at their original placement site (Grumbach et al., 1998). Of course theeffectiveness of the NHSC in encouraging underserved area retention should be evaluatedin comparison with other measures with the same objectives. A recent study noted thatrural counties in sparsely settled states typically lost 3 or more physicians for every fournew ones they acquired, this despite the fact that many of these states have medicalschools that encourage matriculation of students from rural backgrounds, place specialemphasis on primary care and rural practice, and have well-developed rural-orientedgraduate medical education programs (Konrad and Li, 1995).In the only recent study of which we are aware that underlook an international comparisonof leading national policies, Taylor (1998) notes that "...the National Health Service Corpsis one of the most highly visible and probably most-evaluated of the responses togeographical problem areas in the U.S. Yet it is debatable whether the program is asuccess, or not.....It is a difficult program to evaluate because its purpose isunclear.....NHSC physicians have provided care to those in some of the most deprivedparts of the U.S., but few have remained beyond their commitment and many report beingdissatisfied from their experience, and potentially less likely to provide care in deprivedareas in the future." In contrast, Taylor notes that the MPC "has produced a fairly evendistribution of GPs across the UK...the policy has worked reasonably well, but additionalefforts to respond to geographical problem areas became necessary since the MPC doesnot have the policy scope to compel GPs to particular areas, only to approve or denyrequests of GPs to locate in particular areas".Moving beyond the NHSC to other less extensive funding programs, Medicare bonuseshave been paid to physicians practicing in underserved areas since 1989. At that time, a57o bonus payment was made available to rural HPSAs with the most severe physicianshortages. This was increased to l07o in 1991 and was extended to all rural and urbanHPSAs . This policy was enacted despite the fact that "relevant literature has indicatedthat physician location and retention decisions are [only] somewhat influenced by financialfactors..", largely, it seems, on the grounds that "payment incentives appear to havegreater potential for retaining physicians currently located in underserved areas than forattracting new physicians.." (emphasis added) (Physician Payment Review Commission,251994,429), and bonuses are applied only on services provided to the Medicare (largelyseniors) population.Another funding initiative has been the development of certified rural health clinics(RHCs) to serve Medicare and Medicaid populations., Established by Congress in 1977,the RHC was designed as a primary care site in rural areas without adequate physicianservices. These clinics are staffed by mid-level practitioners (physician assistants, nursepractitioners, or nurse midwives), working under the general direction of a physician whois, however, not required to be on-site full-time.'6 As of 1994, about 2000 RHCs wereexpected to be in operation. About 407o of them are provider-based (i.e.,linked to ahospital outpatient department, skilled nursing facility, or other health care agency), whilethe remaining60To are independent, owned by physicians or other practitioners. In orderto be certified, a RHC must be established in a designated area as determined/defined byone of tIPSAs, MUAs, Medically Underserved Population Areas (MUPAs), or in a"shortage area as defined by criteria recommended by the state's governor and approvedby the US Public Health Service" (Sullivan and Peoples, 1998, p.228).In the last few years, questions about physician supply and geographic and specialtydistribution appear to have become of increasing policy interest in the U.S., not leastbecause the perception is growing that there is a general glut of physicians, with specialistphysician oversupply being most acute (largely due to the inroads being made by managedcare), while at the same time, despite (or perhaps because oÐ those inroads, seriousdistributional problems remain (Simon et al, 1997, Escarce, 1998; Berlin, 1996). Whilethe perception that market forces are not sufficient to solve problems of distribution maybe gaining ground (certainly more observers seem to be calling for govemmentintervention; see American College of Physicians, 1998, and references therein), and evenadvocates of market forces concede that such forces alone are not going to increasephysician availability in rural and remote areas (Foreman, 1996)17, at the federal level thereseem to be limited policy levers at the moment, and these are focused largely on thefunding of graduate medical education.Federal funding for medical schools appears to have been designed rather perversely, againexposing the ad hoc nature of U.S. physician resource policies. It is well known thatfamily physicians/general practitioners are much more likely to settle in small isolatedcounties than their specialist counterparts. Yet the amount of federal (particularly NIH)funding a school receives is inversely related to its propensity to graduate physicians whowould be likely to locate in rural areas. Indeed, Rosenblatt et al. (1992) noted fourcharacteristics that are strongly associated with the tendency to produce rural graduates:ró Not only does the physician not need to be on-site full-time, but once every two weeks satisfies therequirements, so long as the physician is "in communication" and provides "periodic review" of servicesprovided by staff (Sullivan and Peoples, 1998).t7 Foreman (1996) argues that "[y]oung doctors tend to go where the opportunities are, and increasinglythe opportunities are in locations that were formerly undesirable." However, he also notes that theseimprovements at that time had come largely in less desirable urban areas, and that the problems inunderserved rural/remote areas were not likely to be solved by the market forces then at play.26location of school in a rural state, public ownership, emphasis on family physicians, andless NIH funding" (emphasis added). The generous funding made available federally fortraining residents has also created strong incentives for teaching institutions to createpositions, irrespective of the local care needs or the country's workforce needs. Inparticular, it has meant that many institutions have simply created and filled residencypositions with international medical graduates (IMGs) in order to attract the federalfunding (Iglehart, 1996).Perhaps because of this, in 1997, the federal government moved to reduce the Medicare-based component of the subsidy for graduate medical education. Medicare is the singlelargest source of such funding (Iglehart, 1998). Not only did Congress move to reducedirect paymentsr8 for GME to teaching hospitals with residency programs, but indirectpaymentsre, based on the number of fte residents in training in each facility, are also to bereduced. For the first time, a cap has been placed on the total number of residencypositions that will be supported through Medicare. This was intended to counteract the26.4Vo increase in the number of residents in training between 1989 and 1996, an increasemade up almost entirely from IMGs entering US training programs (Iglehart, 1998; Dunnet al., 1998). In addition, in order to encourage teaching facilities to reduce the numberof residency positions, while providing a bit of a 'soft landing', hospitals which pledge toreduce their residency programs by 20 or 25Vo over 5 years will be funded not on the basisof actual residents, but on the basis of a three year moving average (Iglehart, 1998;Goldstein, 1997). This latter proposal is patterned after an initiative developed earlier inNew York State (Korcok, 1997). Whether most teaching institutions will 'buy in'to thisproposal, and whether it will even survive the onslaught of criticism ("The idea that we aretaking the taxpayers'money and paying people not to train doctors is almost unbelievable"Senator Phil Gramm, quoted in Iglehart (1998)), is yet to be determined. And how thiswill affect the distribution of physicians is, of course, not yet clear. While it is true thatspecialists are less likely to end up practicing in underserved areas, the evidence on therole of IMGs in improving access to services in relatively underserved areas seems moremixed.As in Canada, there is a heated and ongoing debate about the role and desirability of IMGs(FMGs in Canada). In Canada they are more likely to practice in rural/remote areasbecause of the conditional licenses or other restrictions they face on entry. However, it iswell-known that their rural/remote retention rates are not high, so that over time, theyexacerbate over-supply situations in larger urban centres. Those entering the country intoresidency programs tend to be recruited into programs which cannot be filled withCanadians; in so doing, they serve institutional care provision and program critical massneeds rather than helping meet broader physician resource policy objectives (Barer andStoddart, 1991a).l8 Direct payments include "a share of residents' stipends, faculty salaries, administrative expenses, andinstitutional overhead allocated to residency programs" (Iglehart, 1998).re Indirect payments are to reflect the higher patient care costs in teaching environments (Iglehart, 1998).27A recent study looking at geographical distribution of US physicians and the contributionof IMGs concluded not only that recent "physician growth has not produced dividends ingeographic distribution" but also that "in most cases, IMGs are not only not gap filling,but they are exacerbating the deterioration" of distribution; in other words, "theavailability of gplþs [in rural areas] has been sustained by the contribution of USMGs farmore so than the IMGs" (Politzer et al., 1998). This seems consistent with the findings ofBaer et al. (1998), who examined post-resident IMGs as a proportion of the primary carephysician workforce in non-metropolitan Health Professions Shortage Areas (HPSA) andnon-HPSAs. Although their work emphasizes the slightly greater presence of IMGs innon-metropolitan (relative to metropolitan) areas, they also report that only I8.77o of allprimary care physicians in non-metropolitan IIPSAs were IMGs in 1996, while in non-tIPSAs the corresponding figure was 14.37o. They do not provide data that wouldindicate whether the proportion of primary care physicians in IIPSA areas who are IMGshas changed in recent years. In any case, US policy-makers have begun to argue for areduction in the number of resident places given to IMGs (Jacott, 1997; Noren,l997).20While IMGs must pass both parts of the US Medical Licensing Exam (US graduates areonly required to pass Step One at this time) and are subject to visa restrictions, fully halfof the IMGs remain in the US after their GME is complete because they are able to obtainwaivers that are "granted to federal agencies for physicians from abroad whose continuedparticipation in certain programs is deemed to be in the US public interest" (AmericanCollege of Physicians, 1998). Each state is entitled to up to 20 of these waivers each year,and the total number of physicians covered by the waivers has increased from 70 in 1990to 1374 in 1995. These waivers now represent more positions than are funded throughthe NHSC (American College of Physicians, 1998). But, since some 44Vo of IMGs areeither permanent US residents, naturalized US citizens or native US citizens, it is unclearhow effective any restrictions on IMGs would be. While the American College ofPhysicians acknowledges that "[r]esidency training opportunities must also be maintainedfor limited numbers of IMGs who satisfy the examination and certification requirements ofthe Educational Commission for Foreign Medical Graduates and are naturalized U.S.citizens, permanent U.S. residents, refugees, and U.S. citizens who obtained theirundergraduate medical education abroad", they do not specify what limits could beapplied, other than the restriction of graduates from unaccredited foreign medical schools(American College of Physicians, 1998). Problems in enforcing the waiver program aresuggested by the move by the Department of Housing and Urban Development to suspendits J-l visa waiver program in early 1997 because of complaints from the Texas MedicalAssociation and a report from the General Accounting Office suggesting that someresidents and fellows on J-l visa waivers who had received these waivers on the basis ofproviding service in underserved areas were not, in fact, practicing in shortage areas(Association of American Medical Colleges, 1997;United States 1996).20 The 1998 report of the Council on Graduate Medical Education noted that "[a]lthough some MGsprovide valuable services to underserved rural and urban populations, most end up practicing in well-supplied urban areas, and their addition to the U.S. workforce deprives their home countries of neededphysicians while contributing to U.S. oversupply" (COGME, 1998, p. xiv).28As in Canada, some US observers are concerned lest a diminution in the number of IMGsend up further skewing the distribution of physicians and exacerbating the problems inunderserved areas (Mick and Sutnick, 1996). The General Accounting Office's 1996Report to Congressional Committees on "Foreign Physicians: Exchange Visitor ProgramBecoming Major Route to Practicing in U.S. Underserved Areas" examined the J-l visawaiver program and concluded that IMGs were being recruited to shortage andunderserved areas, though in typical uncoordinated US fashion, these efforts were dividedamong several federal and49 state agencies and were "somewhat weak for ensuring thatphysicians continue to meet the terms of their agreements" (United States, 1996). Also asin Canada, IMGs are an important component of staffing in some teaching hospitals,which "often are heavily dependent on IMGs to staff residency positions considered lessdesirable by U.S. medical school graduates - these residents provide vital patient servicesto indigent clientele" (Berlin, 1996). Even proponents of restrictions on IMG access haveacknowledged that hospitals which serve poor and underinsured populations will need tobe adequately funded in the event of any decrease in the number of residency positions(American College of Physicians, 1998; Iglehart, 1998).Can Canada take away any useful lessons from this policy patchwork? It would seem thatmost would be negative rather than positive lessons - things not to do, rather than thingsto emulate. At the top of such a list we would suggest that the American experience is thesingle best illustration of two important facts: 1) simply increasing physician supply doesnot, and will not, resolve rural/remote access problems; and2) relying on financialincentives to encourage physicians to locate in such areas will leave one far short ofsolving those problems. Two other lessons come immediately to mind: 3) there isconsiderable scope for deploying nurse practitioners to improve access to primary care inareas that have difficulty attracting physicians; and 4) some of the funding made availableto academic health centres may need to come with more explicit strings attached if we areto expect those centres to meet the training needs of the public. Whether a NationalHealth Service Corps analogue for Canada would be helpful is difficult to ascertain, giventhe rather mixed evidence on retention from the U.S. evaluations.AustraliaIn 1989 rural physicians across Australia formed the Rural Doctors'Association ofAustralia (RDAA). The formation of the RDAA was motivated by general dissatisfactionwith medical policy and programs at the state and national level. This national associationwas instrumental in the development of the first National Rural Health Conference, held in1991 (Gregory & Humphreys, 1997). Interestingly, the Conference co-organizers werethe Council of Remote Area Nurses and the Country Womens' Association of Australia.This inaugural conference became a 'watershed' in the evolution of rural/remote physicianresources policy in Australia (Hays et al., 1997)In L992 the Commonwealth Government unveiled the first national strategy to addressthe undersupply of medical care in rural Australia. The National Rural Health Strategy29(NRHS) followed directly from the policy paper emerging from the 1991 conference(Brooks, 1994; Humphreys,l99T; Hays et aL,1997). Major policies included funding agp Rural Incentives Program (GPRIP) and the creation of the Australian Rural HealthResearch Institute, a consortium of five universities with rural campuses. Also funded wasa new academic journal, the Austalian Journal of Rural Health.The GPRIP was a comprehensive program intended to address both recruitment andretention issues. On the recruitment side, it included relocation grants (up to $20,000AUS) for urban-based physicians prepared to move to rural/remote communities, skillsupgrading grants for urban physicians prepared to relocate (up to $50,000), and remotearea grants. On the retention side it provided continuing medical education grants andfunding for locums grants (Holub and lVilliams, 1996; Humphreys and Rolley, 1998).In general, policy discussions leading to the NRHS identified two types of program thatmight successfully address the long term policy objective of providing a stable andacceptable level of physician services for residents of rural and remote areas. These longterm programs included initiatives that would: 1) bring more students with ruralbackgrounds into medical schools; and2) provide more training in a rural setting toundergraduate and graduate medical students (Kamien & Buttfield, 1990a,b & c; Jackson& Jackson, 1991; Rolfe, Pearson et al. 1995; Kamien, 1995; Bollen,1996; Norington,1997). The former initiative was facilitated through the commitment in 1992 of $2.5million to medical schools, specifically to help with recruiting undergraduates from ruralareas. Several medical schools also changed entrance requirements so that rural applicantscould be accepted with lower grades. More recently, three of the country's medicalschools have gone to a graduate entry program, whereas previously all medical schoolsaccepted applicants straight from high school (Horvath et al., 1993).Also in 1992 aFaculty of Rural Medicine (FRM) was established by the Royal AustralianCollege of General Practitioners (RACGP). The FRM was created to develop andadminister a new four year graduate diploma in rural general practice (a graduate diplomain general practice being three years). The additional year of formal education providesadvanced training in obstetrics, pediatrics, emergency medicine and other specialization(Rourke & Strasser, 1996; Brooks, 1994).In March, 1996 a Conservative Coalition federal government was formed after 13 years ofLabour rule. In the 1996197 Commonwealth budget, the GPRIP and its $15 million annualbudget were enhanced. Relocation grants of up to $20,000 dollars and training grants ofup to $78,000 were maintained. Continuing education grants, locum grants and ruralundergraduate grants were also kept. Remote area grants of up to $50,000 per year forpractice in particularly remote locations were also retained. New components added tothe GPRIP included: l) $ZO million to allow rural hospitals to serve as training facilitiesfor undergraduate and graduate medical students; 2) $Zl million over four years for sixuniversity-linked departments of rural health to be established in rural areas; 3) 600scholarships by the year 2000, providing up to $10,000 over four years to undergraduateand graduate medical students to work and study in rural regions; and 4) funds to establish30an Advanced Specialist Training Posts Program to create specialist training posts in majorrural centres.In addition to these measures, in 1997 the Commonwealth Government provided funds totrain 100 permanent resident physicians (physicians trained overseas but without access toAustralian certification) as long they committed to working in rural areas upon completionof training (Australian Medical Workforce Advisory Committee and Australian Institute ofHealth and Welfare, 1999, forthcoming). It is also giving consideration to the use of nursepractitioners in communities without a general practitioner (Humphreys and Rolley, 1998).Most State/Territory governments have also created programs, including Rural HealthTraining Units (e.g., Jackson and Jackson, 1991; Mudge, 1993) and programs for locumrelief. At all levels of government, but particularly at the state level, programs are almostentirely focused on gps, although the Commonwealth introduced a number of pilotprojects in 1995 aimed at "improving the delivery of specialist services to rural and remoteareas", and "allocated additional funding for rural/regional specialist training positions"(Australian Medical Workforce Advisory Committee,l996,p.25). At this point in time,physician under-supply in rural areas in Australian continues to present a problem; inaddition, none of the programs noted here have yet been comprehensively evaluated and,indeed, it is probably premature to attempt such evaluation, particularly for thoseprograms with an explicitly longer-term focus.In late 1996 Australia introduced a nøtínnal provider number policy, whereby the numberof practitioners eligible to claim payments through the national Medicare program wouldbe linked to the achievement of particular post-MD training. Existing physicians were'grandfathered', but then-current and all future cohorts of interns and residents will berequired to apply for a number. Numbers are only provided to gps who have completed arecognized vocational training program (equivalent to a residency training program inCanada, and including family practice'residency') (Australia, 1996). The usual route is tocomplete undergraduate medical school, then proceed to a year of what would previouslyin Canada have been a rotating internship. This is then followed by either"undifferentiated . . . work within the public hospital system" (Australia, 1997), orentrance into a vocational training program.Without a provider number, neither the physician, nor the physician's patients, is/are ableto seek reimbursement from Medicare. The Commonwealth restricts the number offunded first year places in vocational training programs in each year to about 400; theimplication is that as many as 950 newly graduating general practitioners must seekpositions in public hospitals (Australia, 1997;1998). Most physicians emerging from thefirst postgraduate year will queue for a vocational training spot for a number of years,gaining experience in the public hospital system. The expectation is that physicians willtake up posts in rural areas due to the limited number of available hospital posts in largercentres (Horvath et al., 1998). To date, there has been no evaluation of the distributionaleffects of this new legislation. At present the plan does not involve geographicrestrictions, per se, although the Commonwealth Minister also introduced a companion3rprogram whereby new medical graduates can be granted temporary provider numbers ifthey are prepared to undertake locum work in rural areas (personal communication, J.Richardson, October 1996; Australia, 1996). However, as of the end of 1998, notemporary numbers had yet been issued (personal communication, P. Gavel, Februaryt999).Interestingly, while individual states in Australia have the power to register physicians andso could, in principle, restrict access to urban areas or otherwise direct location decisionsthrough legislation, the Australian system embodies inter-state portability. This meansthat any physician currently practicing in any state has the right to practice anywhere inany other state. If Queensland, for example, were to invoke a policy of excluding its newregistrants from setting up practice in Brisbane, this would not stop already registeredNew South Wales physicians from moving north to, and setting up practices in, Brisbane.Not surprisingly, states have not implemented such policies.What lessons might there be in the Australian record for Canadian policy-makers?Australia appearc to continue to struggle with a situation similar to that in Canada, havingemployed a mix of policies quite similar to those in Canada. There, as here, the messageseems to be that something different will be necessary to make greater inroads. The recentAustralian development of a national'billing numbers'policy is a potentially interestingapproach made easier by Commonwealth funding of medical care than it would be in theCanadian situation of each province/territory having its own agreement with its physicians.Furthermore, it is too early to tell what effects this is going to have on geographicdistribution of physicians. It would seem to warrant "watchful waiting". Australia hasbeen extremely active in the education/training arena, and there may be initiatives therethat would be worthy of additional Canadian attention. But we would caution that despitethis extensive effort, there are clearly still serious problems of reasonable access to primarycare in many parts of Australia. The Australian experience raises, in our minds, a questionabout how much one can expect to achieve from education-related approaches, even givenample resources and policy scope.New ZealandNew Zealand is another country which offers potentially useful lessons for Canada. LikeCanada, the majority of health care (777o) in New Zealandis publicly funded. Over 90Voof the public funding derives from general taxation (Ashton L996). New Zealand hasexperienced a physician shortage in many regions of the countr!, and especially in ruraland remote regions, for many decades (Barnett, l99la; Brown and Crampton, 1997).Initiatives intended to address the issue date back at least to 1941, when 34 "SpecialMedical Areas" (SMAs) were designated. Within these SMAs, gps held salaried postsfunded by the national government (Brown and Crampton, 1997). The SMAs werereduced to 23 in 1967,largely as a response to physicians feeling that the salariedpositions were an attempt to implement unpopular "free GP services", and further reducedto 12 in 1993 (Crampton and Brown, 1998).32In 1966 New Zealand began to offer guaranteed incomes for physicians practicing incertain rural areas. By 1993 there were five such areas, offering public sector incomefloors of about $N260,000. In 1969 a lÙVo bonus for rural fee-for-service wasintroduced. In 1970 a subsidy was implemented to encourage rural physicians to hire apractice nurse. The amount of this subsidy was initially 50Vo of the cost of the hiring; thiswas increased to l00%o coverage in 1974, but reduced to757o in 1986 (Brown andCrampton, 1997). The amount of the subsidy has been 707o since 1991 (personalcommunication, L. Malcolm, February 1999).As part of the response to the physician supply crisis in the early 1970s, a second medicalschool was built and foreign medical graduates (FMGs) were encouraged to emigrate toNew Zealand (Barnett l99la). By the late 1970s, the national physician shortage hadturned into a national physician surplus. In response, medical school enrolment wasreduced by 25Vo, and between 1980 and 1990, FMGs were restricted to practice in"shortage areas", most being rural and remote (ibid.). Since then, there has been little inthe way of new policy intended to adjust physician supply. As of the early part of thisdecade, considerable regional differences in supply still existed, although "politicallyembarrassing'doctor shortages' [were] no longer in evidence" (Barnett, 1991b).New Zealand provides ample evidence of the ineffectiveness, and costliness, of a laissez-faire approach to geographic maldistribution. Between 1981 and 1987, despite largeincreases in physician supply and medical care utilization in the country, urban-ruraldisparities actually got worse. To the extent that underserved areas attracted primary carepractitioners during this period, they were largely foreign medical graduates (Barnett,1993).In response to the major reforms announced in 1991, general practitioners began toorganize themselves into independent practitioner associations (IPAs), of which therewere over 40 in the country by 1995 (Malcolm, 1999; Barnett, Barnett and Kearns, 1998).Some of these IPAs have now had five years of experience with fund-holding forpharmaceutical and laboratory services. There is now active discussion and debate aboutproviding integrated capitation for the core provision of primary care services by IPAs,and possible secondary care fund-holding (Malcolm, 1998,1999). How this might beextended to the provision of primary care in areas without the physical proximity ofgroups of primary care physicians, or whether it has had any impact on the distribution ofprimary care practitioners around the country, is not yet clear.New Zealand has also had some recent experience with B.C. style billing numbers policy.In 1997, the then-Northern Regional Health Authority began dictating where new foreigngraduates could establish practices. This policy was challenged and deemed illegal by theNew Zealand courts, and was replaced by a policy applied to ALL new graduatesattempting to set up practice in this region (personal communication, Ross Barnett,February 1999). Our understanding is that the current policy is a hybrid billing numbersand "points" approach, through which new graduates may be granted so-called "Section3351"2r unrestricted rights to bill only after establishing practices in designated rural areas;such practices attract sufficient points that, after three years, the physician's subsequentlocation of practice becomes unrestricted. This policy is to be implemented country-widelater this year (personal communication, Laurence Malcolm, April 1999).Some of the regional authorities have also sought to use capitation-based contracts as ameans of restricting general practitioner access to areas of the regions deemed relativelyover-supplied (Barnett, Barnett and Kearns, 1998). How successful this has been inencouraging the establishment of practices in less-well-supplied areas is unclear; in theabsence of a comprehensive within-region approach, let alone a uniform cross-regionalpolicy in this respect, it seems unlikely that great strides would have been seen inimproving distribution of primary care providers.General practitioners in New Zealand are also encouraged to practice in designated areasthrough a policy amounting to differential fees. The govemment provides public subsidiesfor the provision of care to low income families (e.g. about one-half the cost of an officevisit would be subsidized). However, new general practitioners who choose to practice in"restricted" (read oversupplied) areas are ineligible for the subsidies, even if they aretreating low income patients (personal communication, Ross Barnett, February 1999,April 1999). This policy has apparently not been particularly effective in improvingaccess for low income families because the remaining out-of-pocket cost can still besubstantial, and because of the stigma associated with registering in order to be eligible(personal communi cati on, Ross B arnett, Apnl 1999).'z2Another related and potentially important recent development in New 7-ealand has beenthe emergence of community-owned and -managed services. The most importantexample has been the Hokianga Health Enterprise Trust, serving a population of some9,000 people, a large proportion of whom are Maori, in the rural north of the country.The Trust owns the small rural hospital, receives integrated funding for the provision ofcomprehensive primary health care and employs its four general practitioners on a salariedbasis. Similar developments are being implemented elsewhere. For example, acommunity-owned trust has been established by a Maori tribal organization on the eastcoast of the north island. There has also been recent growth in the numbers of Maoritribal providers, and in the number of contracts for primary care between Maori groupsand health funding authorities These developments illustrate the extent to whichcommunity participation is emerging as an increasingly important factor in ensuring theprovision of adequate health services to rural communities (personal communication, L.Malcolm; R. Barnett, February 1999, April 1999).2t This refers to Section 51 of the 1993 Heatth and Disabilities Services Aø which gave then-practicingprimary care physicians continued rights to "unfettered fee-for-service payments" (Barnett, Barnett andKearns, 1998).22 Eligible individuals and families who apply are provided with a "Community Services Card" whichtriggers the public subsidy to eligible physicians. However, although the subsidy may help with access toprimary care practitioners, often the patients will not be able to afford prescription medicines.34Current policies being used to attempt to influence distribution and ensure adequatephysician supply in rural areas include the placing of restrictions on initial licensing andlocation of practice for all newly graduated gps (including FMGs; see above), and theprovision of some fee bonuses for rural physicians (107o on consultations;2í%o forsituations where travel to patient is required). The restrictions on location of practice fornew gps appear sufficiently effective to keep the current government from introducing anyother new policies, save some extra funding for rural hospital care and for the provision of24hour on-call services @nglish, 1998).The New Zealandexperience is revealing in that the country appears over the past six oreight years to be slowly moving in directions reminiscent of the approaches which haveevolved in the United Kingdom. Their recent billing numbers initiatives are similar to theU.K.'s negative direction policy, and they appear to be moving toward a greater relianceon capitated funding for primary care. The recent development of community trusts, inwhich local areas have responsibility for providing integrated care, bears some similaritiesto Canadian regionalization initiatives. A major difference is that the community trustsreceive funding with which to provide a full range of integrated services. To date, theCanadian approach of segregating pharmaceutical and physician funding from allocationsavailable to regions would seem to stand in the way of this more rational approach to trulyintegrated care.Selected Other ExperiencesWe do not pretend that this exhausts the experiences from abroad that might usefullyinform Canadian discussion and debate about improving access to medical services. Buteven with this review of four countries, we may have reached the point of rapidlydiminishing returns in our quest for other innovations. Nevertheless it seems useful to adda few other observations. In the Netherlands, while physicians are theoretically able to setup practices wherever they choose, in practice their choices are limited by the willingnessof regional sickness funds23 to contract with them, and by the willingness of the generalpractitioners already in place to make satisfactory affangements for collaboration(weekend and evening schedules, for example). Indeed, increasingly the sickness fundsthemselves are making contracting contingent on the establishment of such arrangements(personal communication, K. Okma, September 1996). In addition, gp contracts with thesickness funds are for payment by capitation, which imparts a clear incentive to'locatewhere the patients are'. However, some gps are able to secure sufficient private patientsthat they are not dependent on sickness fund capitation, muting that incentive effect insuch situations. Perhaps most important, the Netherlands is amply supplied withphysicians, and covers a small geographic area, so that one has far fewer situations ofisolated and clearly underserved communities than are found in Canada or the U.S.23 Sickness funds operate as regional insurers and purchasers of care on behalf of their enrolled/insuredpopulations. For more details, see Okma, 1997 and Saltman et al., 1998.35Norway and Sweden both have long-standing, and apparently successful, experiences withestablishing medical schools in rural areas, Sweden in the 1960s, Norway in the early1970s. In Norway the northern medical school must recruit a quota of students fromnorthern Norway (507o since 1979). As of 1990, over one-half of the graduates (56Vo)were practicing in rural/remote areas. An astounding 827o of those who both grew up inthe north and were educated at the University of Tromso were still in the North 5 to 10years after graduating (Magnus and Tollan, 1993). Also in Sweden, in 1993, a "FamilyDoctor System" was established, among the features of which were the requirement thatall citizens join a primary care practice roster, and the shifting of primary care practitionersfrom salaried employees of the County Councils to capitation-based contractors withthose Councils.In short, when looking abroad we find policies both similar to and different from thosebeing tried in Canada. We should not pretend that Canadian policy-makers haveexhausted the possibility set.36D. Summary and DiscussionThis survey of policy initiatives designed to improve access to necessary medical servicesin rural, remote and isolated regions offers up a number of general observations:ô all provinces and territories are experiencing wide inter-regional variations in thesupply of physicians, including general/family practitioners;t virtually all developed countries face similar problems of inequitable access to basicmedical services;0 these problems are long-standing;t despite the fact that most OECD countries experienced rapid growth in physiciansupply over the three decades 1965-1995, this increased availability has failed to solvethe access problems in the relatively "underserved" areas of these countries (includingCanada);ô even in the United States, which comes closest to embracing almost religious faith inthe power of the market to solve these sorts of problems (along with most others),there is a grudging but growing recognition that this particular problem will not besolved by the invisible hand alone;a the country which appears to have been most successful in improving geographicdistribution of physicians, the United Kingdom, has employed a combination ofadministrative fiat and alternative (to fee-for-service) methods of payment;t in countries as diverse as the United States, the United Kingdom, the Netherlands,New Zealand and Sweden, one finds capitation-based contracting methodsincreasingly being used, particularly to finance primary care; Canada's continuedresistance to these approaches is increasingly leaving it the'odd man out';0 Canadian provinces and territories employ a rich and creative mix of regulatory,administrative, funding, and educational policies and programs in an attempt toimprove access to medical care for the residents of the less highly populated areas ofthe country;0 the majority of these Canadian policies involve the use of financial incentives -differential fees, income guarantees, settlement and'good behaviour' (retention)bonuses, student loans and bursaries;ö a growing number of financially-based Canadian policies are not linked to fees-for-services. These include direct locum employment pool arrangements, salaried andcontract positions in designated communities; and non-fee-based payments for beingon-call in areas where call requirements are more than would be considered'normal'or'reasonable';t nevertheless, there continues to be limited general innovation evident in the use ofalternative (to fees-for-service) funding models for physician services in ruraVremoteregions; while there have been calls from some physician groups for such innovation,these tend to fly in the face of the more widespread love affair with fee-for-serviceremuneration of provincial/territorial medical associations. Most agreements betweenprovincial Ministries of Health and medical associations lock the available medical carereimbursement funds in fee-for-service silos. As a result, any alternatives emerge from37add-on funding, or from already existing alternative payments pools. Since neither isgrowing particularly rapidly in the cunent fiscal climate, one ends up with limitedinnovation;I alternative methods of paying physicians (particularly for primary care) should not,however, be viewed as a panacea. Implementation of such alternative models wouldnot come without many significant implementation and administrative complexities;0 there are growing numbers of education-related initiatives, particularly directed togeneral/family practice training for rural areas, in Canada. These include exposure torural area practice during undergraduate medical training; compulsory and optionalrural area rotations in residency training; opportunities for skills upgrading andincreased availability of continuing education opportunities for rural area physicians;t a few programs are beginning to reflect in their entry policies the evidence on therelationship between childhood/adolescent residence, and probability of being preparedto practice in rural/remote areas;t the 'new horizon' of communications technology shows promise, but must beconsidered at this stage unproven as an effective policy for improving access to care inrural/remote areas;24ô although progress is being made, there continues to be far Iess use of, and innovationrelated to, non-physician personnel to meet primary care needs in "underserved" areasof the country, than would seem desirable. The evidence has been around for decades(indeed, some of the seminal work in this area has been Canadian; see Spitzer, 1984,and Lomas and Stoddart, 1985), and in the United States, use of such personnel is farmore widespread than in Canada. There is still relatively limited training capacity inthe country for nurse practitioners who are able to practice relatively independently inrural/remote primary care settings, and many jurisdictions still lack the necessaryenabling regulatory environment to make such practice possible;0 the judgement in the Waldman case in British Columbia appears to have established astringent set of conditions to be satisfied by any future regulatory initiatives of a"billing numbers" or "differential fees" nature. Of particular importance (assuming thejudgement is upheld at appeal) would seem to be the necessity not to discriminatebetween physicians in place in the jurisdiction, and physicians from outside thejurisdiction. In this respect the judiciary seems to be more in tune with the spirit of theMinisters of Health 1992 agreement than some subsequent Ministers have been (seebelow);I despite the fact that some provinces (e.g. Alberta, Ontario) have developed relativelycomprehensive packages of initiatives intended to address this issue, it would appearthat no policy package currently extant in Canada can claim success.While all regions of the country have some policies in place intended to improve access tomedical services in rural and remote areas, there appears to be virtually nothing of a "pan-2a The recent PAIRO/SRPC (Ontario) document captures the dilemma as follows: "The development ofTelemedicine is plagued with three basic problems: a. Unclear remuneration/liability for consultantsrendering opinions; b. Unsatisfactory infrastructure for reliable transmission of suitable imagery; c. A "topdown planning" error of attempting to compensate for inadequate training of rural physicians byproviding "hand holding" Telemedicine links" (PAIRO, 1998, p.26),38Canadian" nature in place. This is undoubtedly in large measure due to the fact that"health" is, constitutionally, a provincial/territorial matter. As a result, there are relativelyfew policy levers held at the federal level (immigration policy being the one significantexception). Less immediately explicable is the vacuum in "national" (as distinguished from"federal") policy. There are some processes in place (and some have been in place fordecades). All jurisdictions share approaches and policy ideas through fora such as theFederalÆrovincialÆerritorial Advisory Committee on Health Human Resources, and theNational Coordinating Committee on Post-graduate Medical Training; sadly any cross-national ideas emerging from the deliberations of these committees must return home toface the realities of limited policy levers (e.g. over decisions taken within the black boxesof academic health centres), the local political music, or both; more often than not they getdrowned out.25All provinces and territories face the same issues, and find themselves, instead, tryingmany of the same general policy approaches, with local colour added (see appendices).This can become circular, and insular. The failure to develop any pan-Canadian initiativeshas meant a history of destructive competition rather than co-operation. One has only torecall the temporary Ontario billing numbers policy of a few years back, wherebygraduates of Ontario medical schools or those in training in that province, were givenpreferential access to'billing rights'through OHIP, or B.C.'s more recent differential feespolicy, which exempted those then in training in 8.C., to find examples of anti-cooperation. Viewed from a naffow single provincial perspective, these two policies, andothers like them, probably made perfect sense when set against some narow criteria. Butthey were hardly enacted in the spirit of co-operation and collaboration so evident in theall(but Quebec)-Ministerial pronouncements of 1992 (Provincial/Territorial Conference ofMinisters of Health, 1992).There is more to collaboration in this area than simply "being friends". The solutions toissues of access in rural and remote areas would seem largely beyond the reach of anysingle jurisdiction. For example, there is clearly scope for expanded deployment of'physician extenders' (nurse practitioners, physician assistants, and the like) in many ofthese areas. Yet there is limited training capacity and considerable confusion aroundscope, standards, and regulations for such personnel in Canada. To our knowledge, therehas been no discussion about "Canadian" training resources of this nature. As with mostother issues in this complex field, so far provinces/territories seem to be "doing their ownthing". It may not be necessary for every province to develop training capacity; it wouldseem worth investigating a small number of truly Canadian schools, funded by allprovinces and territories, graduating practitioners who would satisfy standards agreed toby all jurisdictions; but then this would require co-operation. In some25 While there was general pan-Canadian agreement with most of the recommendations emerging fromthe Barer-Stoddart report (Barer and Stoddart, l99la), and these were reflected in subsequent Ministerialaction plans, very few of those recommendations have actually been acted on. There appeared to be pan-Canadian support for the "Victoria reporf'(Federal/?rovincialÆenitorial Advisory Committee on HealthServices (1995), on the creation of new primary care organizations, but again the ideas were not picked upat the level where the policy rubber must hit the road. These are but two of many such examples.39provinces/territories, deployment of the graduates of such programs in ways that tookadvantage of their full scope of practice potential, would still require new regulatoryinitiatives.We were taken aback by the lack of readily available information in this area. There wasno consolidated source of information on types of expanded scope nurse training,availability of training programs, numbers of entrants and graduates, where graduateswere (and could be) practicing, what each jurisdiction had done to date with respect toregulatory amendments, and so on.26 This would seem a logical, and badly needed,follow-up piece of work.z7In a similar vein, there has been discussion for years of the need to move away fromfunding primary care solely by fees-for-services. Yet we are in the unhappy situationacross this country of having the policy flexibility in this area locked away in individualprovincial-medical association agreements (Barer, Lomas and Sanmartin, 1996).28 Notonly are provinces/tenitories generally hamstrung with respect to changing the mix offunding approaches, but in provinces which have adopted regional structures, theagreements with the medical associations also continue to lock in place the province-profession level of negotiation, precluding the development of new models at the regionallevel. And even if these constraints did not exist, were only one province to move in thisdirection, it could face an out-migration, of physicians resistant to'anything other than fee-for-service', to provinces and territories where the "status quo" prevailed, perhapsdefeating its own objectives of moving its supply around within its borders, and at thesame time exacerbating the physician supply situations in those other jurisdictions.As is the case internationally, an exception to this spirit of non-cooperation appears to beemerging in the education arena. The Society of Rural Physicians of Canada, along withthe College of Family Practitioners of Canada, is in the process of developing nationalcurricula and guidelines for the training of rural physicians (personal communication, CarlWhiteside, January 1999). While this is certainly a step in the right direction, and no oneis likely to argue that more extensive and consistent initiatives in the physiciantraining/experiential arca ate necessary to an improved situation, we found no evidence(from Canada or elsewhere) to suggest that they will ever be sufficient. Indeed, one of thegaps in our understanding of the relative effectiveness of policy initiatives in this area isthe fact that one comes away from the literature, and from speaking with individualsinvolved in the educational enterprise, without any clear sense of the full potential ofeducatior/training-based initiatives.26 The recent report by Hill and Pickup (1998) goes some way toward this objective, but is far fromcomprehensive.27 Indeed, a number of the contacts from whom we attempted to gather some limited information on thisissue expressed frustration that such information was not readily available, and hoped that we would beable to fill that void. A comprehensive examination of this matter was clearly beyond the scope of thecurrent work; nevertheless, since all jurisdictions are actively examining this matter, such information isclearly needed.28 This despite a recognition within the profession that fee-for-service payment methods stand in the wayof improving the situation in rural areas (Hutten-Czapski, 1998)40In conclusion, the challenge of providing adequate access to necessary medical servicesfor all residents of this huge country is one that continues to defy the best minds, and theenormous amounts of good will, of large numbers of dedicated health care practitioners,bureaucrats, and researchers. Are there answers out there? We believe that there are, thatsome of the experiences in Canada, and some from abroad reviewed here, could bedeployed more extensively to improve the situation in this country.Our review and analysis suggests that there is potential to do more in many of the broadpolicy avenues described earlier. Within the regulatory/administrative realm, we havenot come close to exhausting the potential of deploying non-physician personnel, givenappropriately accommodating regulatory environments. Within education/training, thekey lesson emerging from the foregoing analysis is that we have barely scratched thesurface of our understanding, or of the policy potential, of this set of influences.Academic health centres have access to our future physicians at the key influence anddecision points in their professional lives - from decisions about who gets into medicalschool, through the exposures and training they receive, to the more subtle messagesabout the relative importance and prestige of different types of public service. And thosesame centres have the potential to develop additional programs for training non-physicianpersonnel who can ably meet many of the challenges of providing some primary careaccess in rural and remote regions of this country. The challenge for the policycommunity (and this clearly reaches beyond Ministries of Health) is to find mechanisms toensure that the academic enterprise becomes more accountable for its performance inmeeting these very important public objectives. As for communication technology, weare reminded at every turn about its virtually endless potential, but it is less clear what willbe practical, and cost effective, in terms of extending the capabilities of providers on theground in rural/remote area.Finally, we should not too-quickly dismiss the potential of "financial incentives". Whatis necessary is an expanded view of what this means, and a keener eye on the extensiveliterature which has created a relatively comprehensive picture of the limited potential ofmore nanow, traditional applications. Experience with the use of these latter approaches(e.g., differential fees; isolation allowances; on-call supplements) has largely been builtupon a base of fee-for-service remuneration. As such, these approaches have done little, ifanything, to address the most fundamental problems with that method of payment (Barerand Stoddart,lggla). Physicians are still largely responsible in this country for "providingservices", rather than being responsible for "caring for patients". The financial magnetcontinues to be services, not patients. There are alternative models out there, derived fromthe ideas contained in the "Victoria report" (Federal/ProvincialÆerritorial AdvisoryCommittee on Health Services, 1995), extending through some of the innovativecontracting anangements being put in place across the country to the various primary caredemonstration projects now being developed and evaluated. To date, however, this has allseemed like little more than nipping at the heels of the rural/remote access problem.4tAchieving a more comprehensive, enduring and effective set of innovations will requiremore than this type of fiddling around the edges, another financial caffot here, anotherpilot project there. It will require bold strokes, local political risk, and nationalcollaboration. It will require creating new opportunities for some, and disturbing old andcomfortable situations and relationships for others. It will require transparency and goodwill. Above all, it will require a more thoughtful consideration of evidence that is there forthe taking -- the lessons from the research on the matters that matter in the multitude ofindividual decisions by individual physicians and physicians-to-be, about where to practicemedicine. And in the end, even this may not be enough, which is why looking beyondphysicians may end up being an important piece of the solution calculus.42Appendix LBritish Columbia43British ColumbiaBeginning in 1978, British Columbia instituted a "Northern and Isolation Allowance" forphysicians paid fees-for-service and who were prepared to live in remote communities.This allowance 'topped-out' at a bonus of l57o over then-existing fee levels, and the actualallowance in individual cases was a function of the degree of 'remoteness' (based ondistance from nearest hospital, availability of specialists, physician/population ratio, andthe like). In the early 1980s there were about 250 physicians receiving an average ofabout $10,000 in allowances.At the present time (January 1999), the Northern and Isolation Allowance programcontinues in force with some recent modifications. As of fall 1996, approximately 85communities in the province were assigned "points" ranging from 6.6 to 20. Each pointrepresents a l7o fee bonus, so that a physician practicing in a location such as Bella Coola,a "20 points" area, would be eligible for a207o bonus or allowance on all fee items billed.As of April l, 1999, the range of points will be from 4.2 to 30.In 1997 the NIA program budget was about $6.8 million, and about 280 physiciansreceived an allowance or bonus through the program (for an average of about $25,000).By October 1998, almost 400 physicians working in 91 rural and isolated communitieswere involved. (8.C. Ministry of Health, 1998b).We are unaware of any formal evaluation of the effectiveness of this program. It is ofcourse impossible to determine how many of the physicians receiving these bonuseswould, in their absence, not be practicing in NlA-designated areas. What can be said isthat the number of communities in the NIA program has been growing, as have thenumber of eligible physicians. Like the programs in the U.S., this program is based oncommunities actually applying to the Ministry of Health for designation. Questions havebeen raised about the logic of tying the amount of the allowance to fees received forservices rendered. Indeed, it could be argued that the most isolated regions, where it ismost difficult to recruit and retain adequate physician resources, might be precisely thoseregions where there is not quite a sufficient patient load (and therefore servicerequirements) to support a full+ime physician (or to support a second or third full-timephysician). This then raises questions about whether a fee-based NIA is the best processfor recognizing the importance of 'available capacity'. It is not unrelated to the issue ofreimbursement for'on call'services (see below), and again raises fundamental questionsabout the logic of remunerating practitioners in these sorts of situations through a fees-for-services basis (Barer and Stoddart, 1991a).Whether the increasing numbers reflect a growing awareness of the fact that the programcan assist with community recruitment efforts (leading to ever-more communitiesapplying), changed criteria for designation, or simply eroding rural area supply, is notclear. It seems obvious that the more conìmunities are designated as NlA-eligible, the lesseffective the program may be at attracting physicians to the most'needy'areas, in light of44the limited'bonus range' (6.2Vo-20Vo). Eventually rural/remote communities simply end upcompeting with each other for a small pool of willing (under current policy circumstances)physicians.In the early 1980s, B.C. had in place a number of other programs intended to encouragethe provision of medical services to residents of isolated communities. These included a"Subsidized Income Program" for specific communities, whereby physicians could receivesubsidies of up to $42,000 annually, were thereby guaranteed a minimum level of incomeof that amount, and were eligible for some subsidy even with incomes as high as $120,000annually; a "salaried physicians" program whereby funds were provided to certaincommunities in order to permit them to employ physicians; and a "northern and isolationtravel allowance" providing travel assistance for physicians willing to service selectedremote areas of the province.The "Subsidized Income Program" was terminated in l994,but the Northern and IsolationTravel Allowance (NITA) program continues, to cover the travel and ground expenses ofitinerant specialists. These specialists make periodic visits to about 30 rural and isolatedcommunities. A related initiative, the Physician Outreach Program (POP), covers thetravel time of specialists who agree to travel to patients near their own communities, andto encourage primary care physicians to provide outreach services to nearby communities.The Alternative Payments Branch (APB) of the Ministry has developed an extensiveprogram (with a budget of almost $125 million in !998/99) providing funding forphysicians paid other than by fees-for-service. Beginning in the early 1980's and lastinguntil 1995/95, the APB periodically entered into direct individual contractual arrangementswith physicians willing to practice in rural communities. The APB then paid a subsidy tosuch physicians who, however, continued to bill fees-for-services. By the end of theprogram, there were fewer than six communities making use of these arrangements. TheAPB funding is now made available to regional health authorities or community healthservice societies which contract with physicians to provide services. As of March 1999, ahealth authority or society may negotiate non-fee-based service agreements or contractswith physicians or groups of physicians, and then submit claims to APB for the set ofservices provided.More recently, the Ministry established a Northern and Rural Locum Program whichprovides subsidized locum services to NIA communities. These services make a locumavailable to allow the physicians in these communities some vacation reliel or to takeadvantage of continuing education opportunities. Initially eligible communities were thosewith three or fewer full time practicing physicians @lizabeth Gillies, personalcommunication, Sept. 1996). The program offers prospective locums a guaranteed dailyincome of $500, plus travel expenses and a monthly retainer. Between June 1996 andOctober 1998, respite locum services were provided about 100 times to physicianspracticing in small rural communities. The program was expanded to include NIAcommunities with 7 or fewer physicians for 1998-99. As of fall 1998, the program had45twenty-two physicians contracted to provide locum relief (8.C. Ministry of Health,1998b)Physicians providing emergency room coverage to hospitals and Diagnostic and TreatmentCentres in NIA communities in northern BC resorted to job action in early 1998 over theissue of on-call schedules (Borsellino , 1998a 1998b). This action spread to physicians inother areas of the province and to communities without hospitals before it was finallyresolved. The issue was characterized as being about insufficient back-up for physicians insmall communities who, as a result, were required to be on-call as much as every day orevery other day.However, the physicians in some of the affected communities seemed relativelyunreceptive to offers of additional support, suggesting that the real issue for many of themwas money - in other words, they could handle the on-call schedules if only there weresufficient funds to ease the pain (Fong, 1998; Jimenez,1998). After a mediator failed tobreak the impasse, a fact-finder (Dobbin) was engaged to file a report withrecommendations for resolving the issue. Dobbin filed her report in May 1998 (Dobbin,1998), and the Minister of Health/Seniors agreed to the recommendations in that report.The terms of the agreement arising from the Dobbin recommendations (8.C. Ministry ofHealth, 1998a) are complex and clearly inequitable (leaving aside the issue of whether on-call payments were appropriate in the first place). Funding for "emergency medicalcoverage" is available to any Health Authority containing one or more NIA communities.The Authorities in tum are required to arrange contracts with affected physicians.The agreement identifies three categories of physician: 1l gps in NIA communitiesproviding emergency coverage through the local hospital(s); 2l gp-surgeons and gp-anaesthetists in NIA communities who, in addition to providing anaesthesia services orundertaking surgery, also run general practices; and 3l gps in NIA communities withouthospitals and less than three (in practice three or fewer) physicians. Remuneration for on-call services for the communities with hospitals (category 1) is, in addition, a function ofhow many fte gps are in the community in question. Table 41.1 summarizes the paymentterms.Category I physicians were offered two options, one offering $30/hr (except for weekendsand statutory holidays in communities with <6 fte gps, where the rate is $40/hr) in lieu offees-for-service, the other offering $20lhr (except for weekends and statutory holidays incommunities with <6 fte gps, where the rate is $30/hr) over and above any fees-for-services actually provided. The latter option is, however, available only to gps incommunities with 9 or fewer fte gps.Category 2 gps (gp-anaesthetists and gp-surgeons) were offered only one option, apayment of $5 per hour in addition to fees-for-services, during periods in which they wereon-call (nights, weekends and statutory holidays) for the respective service (e.g.anaesthesia or surgery). These gps must decide whether they wish to be category I or46category 2 physicians during any particular on-call session, and cannot charge for bothcategories simultaneously. Category 3 gps, those practicing in communities withouthospitals, have been offered a $30,000 per year on-call bonus, to a maximum of $60,000per community, pending the development of a permanent formula.Table 41.1CategoryIweekdays 1800-0800weekendsstat holidays 0800-08002weekdays 1800-0800,weekends & stats324hour coverageHourly rates of remuneration for on-call physicians in BritishColumbia communities eligible for Northern and IsolationAllowance Premia, 1999(figures in parentheses are in addition to fees-for-services)No. of fte gplfps in community<6 6-9 >g$30 ($20)$40 153s;$40 ($30)($ s¡$30 ($20)$30 1926¡$30 152e¡($ s¡$30$30$30($ s¡($2,500/mth) nlaThere are a number of obvious problems with the terms of this agreement. First, andperhaps most fundamental, if one is going to be paid at 'work rates' to be on-call, thereseems no reason to be offering the option of also paying for services provided during thecall period (interestingly, the Ministry appears to have got this right for communities withmore than 9 physicians). This seems akin to paying those supervising medical students asalary for the supervision, while at the same time allowing them to bill a medical plan forservices provided under their supervision. Perhaps not surprisingly, the vast majority ofNlA-eligible communities (all but 4) have chosen the combined on-call plus fee-for-serviceoption. The four communities which have chosen the straight on-call option have veryfew (one or two) physicians at the present time.Second, the scheme appears to embody some rather perverse incentives for regions thatare constantly claiming that they have huge problems attracting physicians. For example,the category 3 physicians are eligible for $30,000 per year if there are up to two fte gps inthe community (in fact, the Ministry is prepared to provide a total of $60,000 for up tothree ftes). Were a community to need a fourth gp, the on-call bonuses would disappearunder the current scheme. On the other end, a community with two fte gps and nonla47hospital has $60,000 at its disposal for on-call coverage; a community with one fte gp andno hospital has $30,000 available. This might make sense if, for example, the lattercommunity had half the population of the former. But if instead the latter community isone which has severe difficulties recruiting physicians, the on-call requirements may be thesame, but the funding is not. These anomalies clearly expose the fact that the scheme hasnothing whatsoever to do with the underlyingcarclcoverage requirements of thecommunities involved. In this situation, money follows practitioners, not patients.Third, to these observers it would appear that in some cases 'equals'are treated unequally,and in others unequals are treated inequitably. For example, a gp-anaesthetist who doesnothing but anaesthesia (doesn't maintain a gp practice) is ineligible for the $5/hr on-callfee, even if (s)he is required to be on call. Even more problematic would seem to be thefact that a gp in a community without a hospital is currently restricted to the $30,000bonus plus fee-for-service earned while on call for being on-call continuously (or at leastVztime; or $20,000 if 1/3 time), whereas a gp in a community with a hospital and five orfewer fte gps who chose to be on-call just one weekend out of four, and one weeknightper week would receive $38,740 for the on-call time (plus fees-for-services providedduring these on-call periods)! !It gets worse. Consider a two-physician community with a hospital (yes, there are a few),assume that the two physicians share call equally, and that the physicians have chosen theoption of a lower on-call rate plus fees-for-services. Under the terms of the Dobbinagreement, each will collect approximately $80,000 in on-call payments alone, before anyfees-for-services are factored in! Were these physicians to be practicing in an adjacenttown with the same population but without a hospital or treatment centre, each would(under current terms) receive $30,000 plus fees-for-services during non-on-call hours.One might anticipate some adjustments to these affangements over the coming monthsand, indeed, the Ministry views all of these arangements as an interim solution pendingthe development of a longer-term on-call payment plan. Of course once an arrangement isin place, any changes will create winners and losers (since it seems highly unlikely that theMinistry would end up pouring even more money into on-call remuneration for this groupof communities); there may be more hot nights in the cold north before this is all resolved.But while the northern physician on-call dispute has received a considerable amount ofpolicy and media attention over the past year, perhaps British Columbia's most widelyknown geographic distribution initiative was Canada's first "billing numbers" policy, firstput in place in 1983, enacted in 1985, and put to rest when the province was not givenleave to appeal a B.C. Court of Appeal judgement to the Supreme Court of Canada, in1988. Under the terms of the policy, "billing numbers", entitlements to have fee-for-service claims paid by the Medical Services Plan of the province, were only available tonew physicians prepared to practice in certain designated areas. New physicians wererequired to apply for hospital privileges and, with privileges in hand, could then apply for ageographically restricted billing number. Already practicing physicians were"grandfathered" -- given geographically unrestricted numbers. The details of the stormylegal and "on-again, off-again" policy history can be found elsewhere (Barer, 1988).48No formal evaluation of the policy was ever undertaken (or at least published). TheCanadian Association of Internes and Residents (1992) suggested that it was ineffective,but in fairness, it was not given long to run before it met its demise at the hands of thecourts of the land. Even during its short life, it was 'on again, off again', and so there wasnever really an adequate opportunity to evaluate its effects or effectiveness. Certainlysome applications were denied during this period, and the assessment at the time was thatthe preliminary evidence suggested some reduction in the issuance of numbers as a resultof the policy. However, many of these denied applications showed up as unrestrictedIocum tenens (Barer, 1988).The most recent initiative in British Columbia was the'Permanent'Physician SupplyMeasures (henceforth PPSM) which came into effect on October 1,1996, and which builtupon the earlier-instituted so-called Interim Physician Supply Measures (IPSM) whichdated back to 1994. These were administrative measures applied in accordance with theterms of the Medicare Protection Act, according to details set out in various "Minutes" ofthe B.C. Medical Services Commission. Minute 96-0015 (April 4,1996) set out the detailsof the PPSM. The Commission is a tripartite body, which includes representation (l/3)from the provincial medical association.The PPSM was a financial incentive program, whereby differential fees were establishedaccording to the location where a physician established practice. The fee proration rangedas low as 50Vo. New physicians would eam20 "points" for each year in practice, unlesspracticing in an NlA-designated region. Once 100 points were accumulated (after fiveyears), the physician then changed "category" (there were thirteen different categories setout in Minute 96-0015), becoming eligible for l00Vo fees, irrespective of region orspecialty. A physician choosing to set up a practice in a NIA region was eligible for theNIA fee bonus, and annual bonus PPSM points equal to the NIA points for the region.Again using Bella Coola as an example, a physician setting up practice there would receivea207o fee bonus, the standard 20 PPSM points, plus an additional20 PPSM pointsannually. Under this arrangement, a physician settling in Bella Coola would amass thenecessary 100 points in2.5 years (Hanvelt, 1996).The proration for each region was provided in the Physician Supply Plan (PSP) developedby a Physician Supply Advisory Committee. That Committee was tasked withdetermining, on a semi-annual basis (MSC Commission Minute 96-0016) whether eachregion was "under, adequately, or oversupplied with physicians in each specialty" (MSCCommission Minute 96-0015. p. 10). Adequately supplied regions attracted a757oproration, oversupplied regions 507o.There were two significant exceptions to these general terms and conditions. The firstconcerned individuals who were in medical or post-graduate training in British Columbiaas of 1995. These individuals were eligible for 1007o billing numbers if they applied withinone year of completing their training. The second exception was for practitioners whoentered into agreements to serve as locums for "grandfathered" physicians, irrespective of49the region in which those physicians practice. These locums came to be a significantfactor as the policy 'played out', because they provided a route for securing net income inexcess of what would otherwise have been available if a practitioner were subject to 507oor 75%ò prorated fees (and had the usual practice expenses). At the same time thepractitioner could amass the same 20 points per year toward an unrestricted billing numberthrough such a locum affangement. For example, one would not be surprised to find thata physician faced with a choice of a L007o billing number in an undersupplied (but notNlA-eligible) region, a507o billing number in an urban centre, or, say, 50-607o fees withno expenses in an urban centre (as might reasonably be the case in alocum situation),might quite reasonably choose the revolvinglocum option for the five years necessary toaccrue the 100 points under the PPSM (Hanvelt, L996).A detailed examination of the micro-incentives embodied in the scheme (Hanvelt, 1996),which ended up playing a key role in the judgement in the case brought against the PPSM(see below), determined that the PPSM were unlikely to reduce supply, improvegeographic distribution, or help control health care costs. Indeed, the measures embodiedsome rather perverse incentives, such as the incentive for urban physicians contemplatingretirement to, instead, simply hire a locurn, since there were likely to be more locumsavailable in urban centres than in the absence of the policy, making it possible to negotiatefinancial affangements with locums that were advantageous to the established physician.lvith the September 1996 Minute 96-0054, the Medical Services Commission made anadjustment to the NIA program. In particular, any physician wishing to move to a MA-eligible community would from that point on receive "written confirmation of communitysupport" in order to gain a 1007o billing number and be eligible for the NIA bonus."Community support" was defined as either the existence of a hospital physicianworkforce plan or "[s]upport of senior local government official [sic] and local physicians"(British Columbia, 1996, Appendix A, p. 5).Recalling that the purpose of the NIA program is to attract physicians to relativelyunderserved areas, the only apparent explanation for this 'minor' adjustment is that itallowed physicians already in those areas to manage the delicate process of finding abalance between providing some necessary support and relief, on the one hand, and notremoving NlA-points-eligibility by increasing supply too much, on the other (Hanvelt andSchneider, 1996). This exposed an obvious conflict for physicians already in place in NIAcommunities, which seemed to stand in the way of the province's attempts to improvedistribution. Similar considerations may have come into play in the more recent debateand negotiations over on-call coverage.In August 1995, a petition was brought against the B.C. Medical Services Commissionand the Attorney General's Office of B.C. by a young female physician (DeborahWaldman) and two others who had been affected by the IPSM (this predated the PPSM).The action was based on alleged violations of B.C.'s Medicare Protection Act; certainconditions of the Canada HealthAø, specifically the requirement that any provincialmedical insurance program must "provide for reasonable compensation for all insured50health services rendered by medical practitioners;" and rights guaranteed by the CanadianCharter of Rights and Freedorøs (specifically mobility rights, rights to life, liberty andsecurity of the person, and equality rights (Barer and Wood, 1997) The case (Waldman v.British Columbia (Medical Services Commission) was heard in 1996, with the decisionbeing filed in June 1997. Details of the decision, and the reasoning, can be foundelsewhere (Barer and \ilood, 1997; McNamara, 1998), and are discussed briefly in themain text of this report. Suffice to note here that the PPSM were found to violate rightsunder each of the two Aøs and some of the rights guaranteed under the Charter; withrespect to the Charter the judgement also found no relief from s. 1. In particular, I¡vineJ. agreed with Hanvelt (1996) that the PPSM were unlikely to achieve their statedobjectives, because most physicians confronted with the PPSM choice were opting forlocums, and because there were, in fact, no regions where new general practitioners couldbe granted I007o billing numbers (a fact which was reported to have come as a surprise,after the fact, even to the province's Deputy Minister of Health; Borsellino, 1998c). It isinteresting to juxtapose this judgement, based on the PSP which was developed by thePhysician Supply Advisory Committee (with representation from the profession), with thesubsequent dispute between the Ministry and northern rural physicians over workloadsand on-call relief. If, in the judgement of those who developed the PSP, there were nocommunities with shortages of general practitioners, why only a year later were so manyrural/northern physicians 'going to the wall'over workloads and call?Also troublesome for Levine J. was the apparent contradiction between identifying regionswith established needs, and entitling existing physicians in those regions to determinewhether a new physician would be accepted. From July 1997, there have been no explicitfinancial or regulatory/administrative 'macro' policies intended to influence the distributionof physicians in B.C. The decision is being appealed by the Medical Services Commission(Kent, 1997) with the BCMA having intervenor status (Borsellino, 1998c). The case isnot expected to be heard until later this year, with a decision not likely before spring 2000.In February 1996, at about the same time as the PPSP was being approved, the "CentralPhysician Recruitment Assistance Program" was set up. It was operated by the HealthEmployers Association of BC (FIEABC) to help rural communities recruit physicians.Between 1996 and 1998 the program assisted in the placement of 43 permanent and24Iocum physicians in underserved communities. The program also provides locum servicesto larger communities such as Quesnel and Creston. The same group at I{EABC also puttogether an extensive advertising campaign in July 1998 as their services expanded in 1998to include recruitment (8.C. Ministry of Health, 1998b). On the training/continuingeducation front, the province has established a number of initiatives. Physicians practicingin NIA communities are now eligible for up to $4,400 per year to support access tocontinuing medical education opportunities. This is in addition to the $1,600 available toall physicians (whether or not in NIA communities) under the terms of the most recentagreement between the BCMA and the Ministry of Health and Ministry Responsible forSeniors (MOH). The faculty of medicine at UBC also has 6 residency positions which areused to provide skills upgrading for gplfps in situations where there is a community needfor particular skills. Over half of the physicians who took up these training posts between5l1982 and 1997 are currently practicing in rural locations (8.C. Ministry of Health,1998b).The Department of Family Practice, Faculty of Medicine, University of BritishColumbia developed a community-based rural training program for family practiceresidents in t982. This program involves placing residents in rural and regional settingsfor large segments of their two year program, mentored through an extensive group ofcommunity-based faculty (Whiteside and Mathias, 1996).The program selects likely candidates on the basis of personal background andpersonal/family factors, and then provides them with a full year of rural residencyexposure. Currently the program requires all family practice residents to complete at leastone month of training in a rural or regional location, and,"l2 of the 26 second yearresidents spend 9 months of their training" in one of these locations (8.C. Ministry ofHealth, 1998b). Apparently over 50Vo of the physicians who took advantage of thisprogram during the 1982-91 period are practicing in remote rural areas, and a further 20Voare in non-metropolitan areas of British Columbia (Whiteside, 1996). Between 1982 and1997 this proportion has stayed well over 50Vo (8.C. Ministry of Health, 1998b). Inaddition, the UBC medical school organizes undergraduate medical student summeremployment opportunities in rural communities. These range from 4 to 8 weeks duringthe summer after completion of second year; in 1997198 108 of the 118 second yearstudents took up placements in 59 different rural communities. The Department of FamilyPractice has organized rural family practitioners who serve as preceptors, and funding isprovided by the MOH through its Alternative Payments Branch. The Department ofFamily Practice has also established a'northern satellite'teaching unit in Prince George,which offers a two year residency in family medicine in a northern setting. This programwas established in 1995.4nd finally, the province is running a "teleradiology" pilotprogram involving l1 communities in the northwest of the province.52Appendix 2Alberta53AlbertaAlberta Hospitals and Medical Care first made funds available for encouraging ruralphysician recruitment and retention in the mid-1980s. The Incentive Payment Program,beginning in 1985, provided incentive allowances to "eligible physicians" in "eligiblecommunities". A total of at least 30 'eligibility points'had to be amassed; these wereassigned on the basis of the number of physicians in the community (and relative to thecatchment population), the number of specialists in the area, and the proximity ofhospitals to the physician's office and on the basis of a number of "living factors" (distancefrom the main urban centres; population of the community; recreational potential).Eligible physicians received a minimum incentive of 5.07o, plus 0.57o for each eligibilitypoint in excess of 30 points, to a maximum total incentive of 207o (i.e. maximum'eligibility points' of 60).Incentives payable under this program were intended for physicians whose total billings tothe Alberta plan were not more than $200,000. For each $1,000 in payments in excess of$200,000, any incentive entitlements were reduced by l7o. There was a ceiling on thetotal incentive payments, equal to 20Vo of plan payments to the physician.If a community had no resident physicians, it would not be listed as an eligible community(since eligibility was based on a combination of physician and community characteristics).A community could be listed as eligible but, were a prospective physician to move there,could become ineligible irrespective of where the physician set up practice (relative to thelocation of hospitals).This program underwent an 'internal'evaluation in 1989. Performed by the IncentivePayment Steering Committee (1989; with representatives from Alberta Health, the AlbertaMedical Association, and the Rural Health Care Association) this evaluation used bothqualitative and quantitative methods. The qualitative element surveyed two groups ofphysicians: one that had received incentive payments for 1983 to 1985 (155), and oneconsisting of physicians who had not received such payments, but who resided incommunities having between 10 and 29 'eligibility points'(104). The responses indicatedthat lifestyle and professional factors had much greater weight in location/relocationdecisions than did monetary incentives, with the latter being significant factors for onlylTVo of the group receiving incentive bonuses. (A similar finding was reported by a laterevaluation of the Rural Physician Action Plan; see below.) However, the incentiveprogram did appear to have had a positive affect on retention:34Vo of the group receivingincentive payments indicated that the payments had influenced their decisions to continueto practice in an eligible community.The quantitative component of the evaluation compared the recruitment and retention offee-for-service physicians in rural communities from 1983 to 1987. The movement ofthese physicians was tracked using Alberta Health Care Insurance Plan (AHCIP) billingsinformation. The results showed that the proportion of always-eligible communities which54gained at least one new physician did not change before and after the introduction of theprogram, and the proportion of sometimes-eligible communities which recruitedsuccessfully actually declined (while things improved for never-eligible communities).This led the authors to conclude that the "Program has not increased physicianrecruitment and retention in communities eligible for incentives compared to ruralcommunities which were not eligible." But those always-eligible communities did enjoysome success with recruiting because the growth in physician supply in always-eligiblecommunities was more rapid between 1984 and 1987 than in the never-eligiblecommunities.The incentive payment program underwent considerable amendment during 1990 and1991. Effective January l, 1991, a community became eligible for the program if it had apopulation in excess of 500 residents, was more than 160 km from Edmonton or Calgary,and was more than 80 km from one of five other regional centres. Eligibility of individualphysicians was reviewed quarterly, and required the physician to practice primarily in aneligible community, and to be relatively active (bill >$10,000 in the quarter) (personalcommunication, Sandra Woodhead-Lyons, February 1997). Incentive payments were thesum of any "Isolation Payment" (based on the distance in kilometres of an eligiblecommunity from Calgary or Edmonton), and a "Practice Payment" (based on acommunity's physician:population ratio, relative to a target of 1:1000). As with theoriginal plan, incentive payments were reduced for high income (>$50,000/quarter)physicians.In 1990, the External Advisory Committee on Physician Manpower completed andapproved a Proposed Action Plan for Addressing Rural Physician Recruitment andRetention Issues, which focused largely on initiatives designed to address the professionaleducation and professional practice-related determinants of practice location decisions.The Plan was approved by Cabinet in December of that year, and funding for the RuralPhysician Action Planbegan in April 1991. The plan provided for:. rural rotations for medical students. rural experience during postgraduate training. expansion of programs that could provide extended skills trainingfor already practicing physicians (e.g. in anaesthesia,general surgery, obstetrics). increased and more convenient opportunities for continuingmedical education for rural physicians currently inpractice. increased availability of temporary medical relief or locums forrural practitioners wishing to further their educationas well as for vacation, sickness or other reasons.Details on each component can be found elsewhere (Woodhead-Lyons, 1993). A ruralphysician recruitment fair program was added in 1994.The Plan was developed and coordinated through the collaboration of the Ministry ofHealth, the provincial medical association and College, the Alberta Healthcare Association55(representing hospitals and other health care institutions), the two provincial faculties ofmedicine, the Northern Alberta Development Council, and Alberta Municipal Affairs. Thecomposition of the Plan's Co-ordinating Committee continues to be in flux - in 1995 theNorthern Alberta Development Council dropped off, but three regional health authoritieswere added, along with two rural physicians and a representative of the ProfessionalAssociation of Interns and Residents of Alberta. The newly created AMA Section ofRural Medicine was added in 1996 (personal communication, Sandra Woodhead-Lyons,February 1997). As of June 1998, the Co-ordinating Committee was composed of threerepresentatives from regional health authorities (a Board chair, a CEO and a regionalMedical Director), as well as the College of Physicians and Surgeons of Alberta, theAlberta Medical Association, the two provincial faculties of medicine, practicing ruralphysicians, the AMA's section on Rural Medicine, medical students, Alberta Health, andthe Professional Association of Internes and Residents of Alberta (personalcommunication, D. Kay, Rural Physician Action Plan, June 1998). The Plan included astudent loan remission program. This program provided newly graduated physicians whoagreed to take up practice in designated communities with a $10,000 remission of already-held student loans. In 1993194 this loan remission component of the program wasmodified to target family medicine residents interested in rural practice. Such residentscould enter into a return-of-service agreement, at which time a remission of $10,000 wasmade on the resident's outstanding student loans, with a further $10,000 available at theend of a two year period of service in a designated community. Eligible communities weredefined by physician to population ratios of less than l:1000.A formal evaluation of the Plan was commissioned in late 1995, and reported out in early1996 (MacDonald and Associates, 1996). The report is largely descriptive, based for themost part on the opinions of physicians, residents, and students, who were interviewed aspart of the project. The evaluation did report data indicating that, if anything, rural areashad become less successful at recruiting and/or retaining physicians in the 1993-95 periodrelative to 1987-89 and 1991-93. The authors of the evaluation suggested that thephysician recruitment fairs had not been particularly successful, and that the student loanremission program had had very limited effect. In general, the rotations for residents werefelt to be more effective than those for medical students. With respect to the special skillsyear for family practice residents, it appeared to be too early to evaluate comprehensivelythe effects of this opportunity. While survey respondents thought it was effective inrecruiting rural physicians, very few rural physicians indicated it as being influential in theirown recruiting decisions. As for the locum program, this was reported to be the mostwidely-known component of the Plan, and apparently a relatively successful component.It had had some effect both on retention and recruitment. However, it has come to beused primarily to provide some physician coverage for communities unable to recruit anew physician, leaving it short of funding for short-term coverage locums. The continuingmedical education programs were "not seen as particularly effective, by most ruralphysicians" (p. 84), in part because of the time off, and/or locum coverage, required inorder to take advantage of the opportunities.56The authors of the evaluation conclude that "[t]here is no evidence to show that the RuralPhysician Action Plan initiatives have materially increased the overall recruitment rates inAlberta over the last five years. There is evidence which suggests that without the RuralPhysician Action Plan programs, recruitment rates would have decreased, particularly overthe past few years." (p. 105). They reached a similar conclusion with respect to retention.In short, the primary effect of the Plan, in the opinion of the authors, had been as a defenseagainst likely erosion of rural physician supply in Alberta in its absence.Also in 1995, the province constituted the Physician Resources Planning Group (PRPG),composed of representation from the regions, the two faculties of medicine, the AMA, theCollege, the Professional Association of Internes and Residents of Alberta, the MedicalStudents' Association and Alberta Health. Its deliberations drew on the work of threebodies: the Coordinating Committee of the Rural Physician Action Plan, the Post-Graduate Medical Education Working Group, and the Physician Database WorkingGroup. The PRPG presented a report to the Minister of Health in February 1997. Thisreport, like so many before it (although not in Alberta specifically), suggested that Albertadid not currently have an oversupply of physicians, but did have serious geographicdistribution problems and that, furthermore, it was likely to face an overall shortage ofphysicians in the not-too-distant future. The group's assessment of the Rural PhysicianAction Plan was that its activities had produced "measurable successes for recruitment torural Alberta" (p. I), but that considerably more attention needed to be paid to professionaland lifestyle matters bearing on retention (PRPG, 1997). The report also noted a numberof areas worthy of considerable future attention. These included the development of"physician specialist extenders", telehealth networks, and standardized return-in-serviceagreements (PRPG, 1997).The student loan remission program was phased out as of the end of fiscal year 1998(owing to persistent low uptake). In its place the province established a "signing bonus"program, whereby a rural regional authority provided a $10,000 signing bonus (matchedby the RPAP) to any medical resident who signed a return in service agreement of at leastone year. Together with other available incentives, provided by regional authorities, somenew physicians prepared to settle in rural areas were securing incentives worth as much as$75,000 (Walker, 1997),As of 1997,family physicians interested in a third year of training became eligible for a"signing bonus for additional skills", upon signing a return in service agreement with arural regional health authority (D. Kay, June 1998). The value of the bonuses, and thematching provision, are the same as for residents'bonuses (personal communication, S.Woodhead-Lyons, February 1997;D. Kay, June 1998) Here, too, the required return inservice is a minimum of one year. As of 1997198,18 of the 24 available additional skillstraining program (AST) slots for family physicians or residents require a return-of-serviceaffangement with a rural health authority or with the rural locum program. The 18positions are for upgrading in areas such as anaesthesia, general surgery, obstetrics, andpalliative care (Paetkau,1999). Currently because of the timing, there are some problemswith the return-of-service arrangements. The program begins in July, but the candidate57has until December of the same year to secure the arrangement with the locum service or aRHA. A number of participants have failed to make such arrangements, and are ending uptaking advanced skills training in emergency medicine, and then ending up in urbansettings. There has, to date, been no enforcement of the requirement to secure a ruralreturn-of-service arran gement (Paetkau, 1999).The incentive payment program underwent another review in 1997 and was terminated asof 31 March 1998. It was replaced with a rural "on-call" program, which is a programwith funding separate from the Medical Services Budget. The on-call plan pays $17.00/hrto on-call physicians serving in eligible rural facility emergency departments.2e The on-call fee is in addition to any fee-for-service billings, for eligible on-call hours. This ratewill be in effect until March 31, 2000, at which time the rate will increase to $2lleligibleon-call hour. Eligible on-call applies to weekends, statutory holidays, and weekdays from1700 until 0800 (Alberta Health, 1998b). If more than one physician is on-call during thesame period, only one hourly payment is provided. Funding for this program was inaddition to funds negotiated in the 1998 agreement with the AMA (personalcommunication, D. Kay, January 1999; Alberta Health, 1998b; personal communication,Thorsten Duebel, April 1999).Thus, by mid-1998, several aspects of the original Rural Physician Action Plan had beenmodified or eliminated. IVhat remained had been judged to be of special value.Undergraduate educational initiatives have tended to remain in place (with the exceptionof the loan remission program); for example, rural rotations were still available to medicalstudents at both provincial medical schools and rural residency rotations were optional atthe University of Alberta,3o and compulsory at the University of Calgary. In addition, thePlan currently includes the provision of travel/accommodation allowances for studentsundertaking rural/remote area placements, as well as honoraria for their clinicalpreceptors. The Enrichment Program, a package of 1991 initiatives designed to provideskills enhancement opportunities for already-practicing rural physicians (including thelocum pool), is also intact. It initially provided $80,000 in annual honorarium (proratedfor length of enhancement training); the amount of the honorarium was reduced to$76,000 in 1993 (and continues at that level).The fall of 1997 saw the start of a special two-year recruitment initiative (separate fromand intended to complement the longer term objectives of the Rural Physician ActionPlan) designed to address the shortfall in physician numbers in rural Alberta over an18-month time frame. During 1998, placements were sought for over 100 vacancies; about90 physicians (mostly gplfps) were recruited (personal communication, Alberta Health,April 1999) Just over half of these were Canadian graduates; the vast majority of the2e Eligible facilities are acute care hospitals without contracted emergency room physicians, which offer'around-the-clock' emergency room care and which handle fewer than 25,000 unscheduled visits per year.As of spring 1999, 84 facilities were designated as eligible. Funds are allocated to facilities, and allocatedby facilities to individual gp/fos on the basis of hours of service.30 Also relevant, although not part of the RPAP, is the fact that the University of Alberta designates twomedical school entry slots per year for qualified Aboriginal candidates.58remainder were the product of aggressive recruiting in South Africa, with the next largestcontingent being from the United Kingdom. Regional health authorities handled their ownrecruiting in about 557o of the cases, although the efforts of some authorities clearlypredate this special initiative (Canadian Press Newswire, 1996; Alberta Health, 1998a;Walker, 1998).Alberta has a program to accommodate FMG physicians with special licenses tied tospecific practice locations. The Alberta Medical Register has two parts; Part 2 is theSpecial Register, and part 5 of the Special Register permits a Regional Health Authoritywhich cannot recruit a Canadian-trained physician to its area to apply to the Minister ofHealth for an emergency designation under the provisions of part 5. If permission isreceived, the RHA can recruit someone not eligible for full licensure (e.g. a FMG). Therecruit receives a 30 month license and is restricted during that time to working in anunderserved location. The expectation is that the FMG will pass the LMCC I and IIexaminations during that period. Assuming this occurs, at the end of the 3O-month period,the FMG moves on to part I of the Special Register if (s)he is a gplfp and,part2if aspecialist; both designations are tied to the specific underserved location. After 5 years inthe setting, the FMG gplfp can apply for a College of Family Practice certificate throughits "practice-eligible" route. Once certified, the FMG is no longer subject to locationrestrictions.The April 1998 collective agreement between the Alberta Medical Association and theGovernment sets out criteria for "Physician Resource Planning" to be undertaken jointlybetween the two parties. As part of the undertaking, a "Physician Resource PlanningCommittee" is to be constituted, a body whose constituents appear to resemble veryclosely those of the PRPG.59Appendix 3Saskatchewan60SaskatchewanSaskatchewan has no regulatory measures designed to improve the availability ofCanadian-trained physicians in rural/remote areas. However, there are policies aimed atforeign medical graduates (FMG). Through an agreement with Human ResourceDevelopment Canada (HRDC), FMGs applying to settle in Saskatchewan must receiveapproval from Saskatchewan Health. Whether an application is approved will depend onwhether the applicant would be eligible for licensure with the College of Physicians andSurgeons of Saskatchewan (CPSS), and whether the applicant's specialty and intendedlocation of practice meet the province's needs. While the FMG is in the country on a visa,he or she must practice in specific approved communities or districts.Physicians who do not meet the conditions for full licensure with the CPSS may apply fora probationary license which falls into one of the following categories: conditional,provisional, special or locum tenens. Each of these options requires a commitment towork in particular communities or districts for a variable period of time. Failure to abideby the terms of the commitment without the approval of the Council of the CPSS istreated as professional misconduct. A provisional or conditional license will be granted toa FMG who has passed the Medical Council of Canada's Evaluating Examination(MCCEE), and who has graduated from an approved undergraduate and postgraduateprogram. The physician must agree to a three- or five-year service commitment.A locum tenens permit may be granted to an applicant who has not yet passed theMCCEE. Such a permit is valid for a maximum of twelve months of supervised practice.Special licenses are granted to particular specialists in short supply (e.g. psychiatrists).These specialists must sign a service commitment to a community. (A court challenge tothe service commitments was brought in 1996, but the challenge was not successful). Inaddition, as an interim measure in response to the Royal College's June 30, 1997 policychange, the CPSS now permits other qualified foreign-trained specialists to apply for aspecial license.3rThe province has a variety of programs offering financial incentives targeted both atpracticing or prospective physicians and physicians-in-training. The Rural PracticeEstablishment Grant (RPEG) program (ointly funded by the Saskatchewan MedicalAssociation (SMA) and Saskatchewan Health) provides different opportunities each year.ln 1997, a one-time grant program was established; it provided $25,000 to any gplþ witha valid Saskatchewan license who was prepared to take up practice with one or morephysicians for at least 18 months in a community with a population of approximately10,000 or less (Driver, 1997b). Since 1998 the RPEG program has been available only to3r The Royal College's 1997 changes restricting specialty certification to physicians trained in the U.S. orCanada created significant problems for provinces such as Saskatchewan which had historically reliedheavily on FMGs other than from the U.S. In response, Saskatchewan opened up its availability of speciallicenses which had, until then, largely been available only for psychiatry and Medical Officers of Health(personal communication, Dianne Anderson, April 1999).6tphysicians who were eligible to obtain full registration under the Medícal Profession Act,and the grant amount has been reduced to $18,000 for an l8-month commitment. Theprogram is now on-going. Concern has been expressed by some that the dichotomousnature of this program (under 10,000 population communities are eligible; over 10,000 arenot) may be adversely affecting slightly larger communities such as Swift Current @river,1998b); we had no independent information with which to evaluate such alleged concems.Through the Rural Physician Enhancement Training (RPET) program (also jointly fundedby Saskatchewan Health and the SMA), the province makes it possible for up to two ruralphysicians each year to receive $80,000 so that they can take leave (not exceeding oneyear in duration) to obtain advanced training in obstetrics, anaesthesia, general surgery,geriatric medicine, psychiatry, or emergency medicine. The program also offers two$40,000 grants per year for second-year Family Medicine residents seeking a third year inone of these specialty areas. The grants are conditional on one-year (for practicingphysicians) and six month (for family medicine residents) return-in-service commitments toeligible communities. Communities with populations of approximately 10,000 or lesswhich can support a three-or-more physician practice and which have demonstrated needfor physicians with enhanced skills are eligible.In 1999, a re-entry program (funded jointly by the SMA and Saskatchewan Health) forphysicians practicing in rural communities was introduced. This program will fund up totwo physicians per year. Preference will be given to candidates who are willing to sign areturn-service commitment to practice in Saskatchewan, who agree to enter a medicalspecialty that is identified as being one of particular need, who are currently practicing in arural area or who have practiced in a rural area in the past ten years and who areSaskatchewan or Canadian graduates.There are also two initiatives targeted specifically at medical students and medicalresidents. Up to 15 bursaries per year have been available each year since 1991 to medicalundergraduates in their second, third, and fourth years of study who agree to set uppractice in an underserviced area of the province once their program is completed. Thesebursaries can be held for a maximum of three years; current value is $18,000 annually.Upon obtaining licensure, bursary recipients are allowed a six-month period to establishfull-time practice, and are then required to maintain that practice for a period equivalent tothe period for which a bursary was provided. Licensees who fail to fulfil this servicecommitment are required to repay the bursary funds (on a pro rata basis), together withinterest. (A $20,000 penalty has also, in the past, been applied; this has now beenreplaced by interest charges (Driver, 1997a). Since 1998, up to three $18,000 bursariesper year have also been available to medical residents. If approved by the Rural PracticeCommittee, a recipient may train in a general specialty. Most recipients, however, arefamily medicine residents. Family medicine recipients must establish practice in acommunity of approximately 10,000 population or less, while those who have trained as ageneral specialist are permitted to establish practice in any community in Saskatchewan,other than Regina or Saskatoon.62Through a collaborative program involving the University of Saskatchewan, SaskatchewanHealth, and Health Canada (MSB), the Northern Medical Services Division of theUniversity hires physicians to work as members of teams in a few small, remote,communities. As of 1998, these physicians serve three communities, and are paid between$121,000 and $140,000 plus benefits (including the availability of subsidized housing).In 1997 , Saskatchewan Health and the Saskatchewan Association of Health Organizations(SAHO) created the position of "Physician Resource Co-ordinator", with a mandate toundertake a number of functions designed to "facilitate the recruitment of physicians intorural Saskatchewan", including:I Workshops on effective recruitment practices;t Development of a practice opportunities database and website;t Development of a network to facilitate communication between physicians in thesecommunities, residents, and medical students;t Coordination of weekend relief placements in rural sites (see below);t Coordination (inter- and intra-provincially) with other recruitment agencies.o Recruitment fairs (Saskatchewan, 1998)On the education side, SAHO offers a summer extern program through which up to 20medical students can gain summer work experience in rural/remote communities, betweentheir second and third years of medical school. The University of Saskatchewan FamilyMedicine Department has had a 12 week rural exposure program in place for some time.Beginning in 1997, it established a pilot project which would place a limited number of itsresidents into rural communities for 40 weeks. This program was given a budget of$200,000 over a three-year period. By 1999-2000, the program hopes to have six suchrural placements available.The Saskatchewan Medical Association employs a number of physicians who can offershort term (4-14 days) locum relief for physicians in rural communities with fewer thanfour physicians. In February 1997 , a weekend relief program was established bySaskatchewan Health. This program was designed to provide relief services torural/remote communities in which the weekend call schedule exceeded 1:3. Reliefphysicians are paid $1,500 per weekend. A weekend is defined as the time from 5:00P.M. Friday to 8:00 A.M. on Monday. Travel expenses are paid at current governmentrates. Cunently there are over 50 physicians listed as willing to participate.The SMA and the Department of Health negotiated an Emergency Room CoverageProgram in January of 1998. This program provides $5.5 million in funding tocompensate physicians providing emergency room coverage in rural areas. The programis overseen by a tri-partite committee comprised of Department of Health, SMA andSAHO representatives. There are two categories of coverage. Category "A' communitiesare those with facilities serving a large catchment area, high volume emergencydepartments, providing a broad range of services and generally supporting three or morephysicians. These sites serve as primary emergency centres within a geographic region orhealth district. Payment in these centres is based on an hourly rate of $10/hr from 5:0063P.M. to 8:00 am weekdays and $25lhr from Friday at 5:00 pm ro Monday at 8:00 am.Category "B "sites are smaller acute care facilities or health centres that the health districtshave designated as requiring 24hour continuous physician coverage. These facilities servea smaller population and have low to medium emergency volumes. Generally thesefacilities have fewer than three physicians providing a limited range of emergency andacute care services. Physicians are paid $5,000 per quarter and must provide a minimumof l:3 weekend coverage to be eligible (Driver, 1998a, Saskatchewan, 1998).Districts are required to submit emergency coverage plans on an annual basis to theEmergency Room Coverage Committee. In July, 1998 achange was made to the programto allow physicians in category "B" communities to bill $1,175 per weekend to amaximum of 4 additional weekends per quarter. Physician payments in both categories arein addition to fee-for-service billings.Finally, the province is involved in a number of administrative initiatives focusing on so-called "telehealth" or "infotech". These are intended to provide remote, continuous,access to a range of health care providers (including, in some communities, diagnosticservices) for patients in rural and remote communities, and collegial support andcontinuing medical education for clinicians in such communities.64Appendix 4Manitoba65ManitobaManitoba has had geographic redistribution initiatives in place at least since 1969. In thatyear, the University of Manitoba's Faculty of Medicine established a Northern MedicalUnit (NMU) which began providing services to isolated communities the following year.The unit is funded by Manitoba Health, and currently funds about 24 fte physicians. Ithas, over the years, had difficulty recruiting Canadian graduates, although the 1996introduction of isolation incentives (see below) appears to have improved this situation.In January t996,the compensation package for the NMU physicians was augmented.Incomes currently range from about $120,000 to $168,000 for gps; NMU physiciansproviding specialty services receive per diems ranging from $605-700, depending in parton whether the physician is engaged under an employee or independent contractoranangement. As of spring l999,the NMU contract is under review.Manitoba has, for some time, operated a program of differential fees. Initially fee-for-service physicians based outside Winnipeg received a premium based on location. In 1989these premia range from 2.5Vo for physicians practicing in Brandon, to lÙVo for physicianspracticing north of the 53rd parallel, with other rural physicians receiving a 5Vo premium.The province has a program to provide income tax-free incentive grants, payable over afour year period, to physicians who establish a practice in designated under-serviced areas.Those practicing north of the 53rd parallel are eligible for $44,000, while those south ofthe 53rd could receive up to $30,000. As of.1992, only six such incentive grants orguaranteed income anangements had been established over an eleven year period. Nogrants have been provided since that time and continuation of this program is currentlyunder review. As an alternative to the incentive grants, a physician agreeing to practice ina designated medically under-serviced area may be eligible for a guaranteed net income,based on the average rural/remote physician remuneration. Approximately 83 ruralphysicians are now working under such contracts, for approximately $150,000 annually.In 1997 Manitoba committed earmarked funding for emergency on-call coverage in ruraland northern Manitoba hospitals. Payment levels are a function of the 'business' of theemergency room. For example, hospitals handling at least 10,000 ER visits annuallyprovide $70/hr, hospitals with 5,000-10,000 ER visits provide $600/day for weekday 24hour coverage or $900/day for 24 hour weekend/statutory holiday coverage, and hospitalswith 1,000-5,000 visits annually provide $500/day and $750/day. Physicians receiving thison-call remuneration cannot claim fees-for-services rendered during these periods, exceptfor obstetrical, surgical or anaesthetic procedures, or for booked hospital procedures forup to one continuous four hour block of time per day. In communities without hospitalswhere physicians are paid under contract, some of these contracts make explicit provisionfor on-call remuneration. Physicians paid by fees for services can bill a "special premium"for after-hours work (e.g. an after-hours home visit attracts a307o fee premium).66In July 1995 the College of Physicians and Surgeons of Manitoba (CPSM) established aconditional register which, as of February 1999, had been used to recruit 164 physicians torural/northern Manitoba (132 currently active, most from South Africa). The keycondition is that physicians must work in a designated medically underserviced area andthey have up to 5 years to achieve full licensure. The advantages are that FMGs fromcertain countries who have not completed the MCC examination requirements can begranted conditional registration and can work toward full licensure during this period, andrural/remote communities are able to secure physician services that Canadian graduateshave shown a long-standing resistance to providing. Between 1983 and 1992, almosttwo-thirds of physicians entering rural practice in the province were trained outsideCanada (Postl et al., n.d. 1994).During the past year, Manitoba Health imported alarge number of FMGs. A recentfollow-up survey found that most of these physicians received little or no orientation.Subsequently, an orientation manual containing information on treatment protocols,consultants, health programs such as Home Care, etc., has been developed by the Facultyof Medicine. The hope is that the provision of additional CME support will both improverecruitment and improve the record of rural/remote retention. To the latter end, ManitobaHealth recently employed a family practitioner to work with rural physicians on aphysician retention plan.Another recent licensure-related option was signaled with the recent approval in principleby the CPSM of the licensing of "physician-associates" (Love, 1997). This is modeledafter the "physician assistants" who find widespread use in the U.S. (Cooper and Dietrich,1998). Physician-associates (or "clinical assistants" - the label is not yet worked out)would work under the supervision of a physician (although how close this supervisionwould need to be is not yet clear), and would be able to prescribe medications and admitpatients to hospital. At this point it is not clear where such assistants/associates willoriginate (since there is no training program in Canada), but presumably extended dutynurses with the requisite training, or foreign-trained physicians not on the conditionalregister might fill such roles.In March 1994 the province established a "Provisional Billing Numbers" policy, pendingthe development of a more permanent physician resource policy. The PreliminaryPhysician Resource Plan under which such numbers were issued was implemented inspring 1995. Under this provisional policy, the quantity of available "active and valid"medical practitioners'billing numbers was fixed as equal to the number of physicians whowere entitled to bill, or billing, the provincial medical plan on December 31,1993.Provisional billing numbers began to be issued thereafter. Although in practice thesenumbers were no different than the "active and valid" numbers (in other words, they camewith no restrictions), the idea was that physicians with provisional billing numbers whoprovided two months of service in the North, or four months in rural southern Manitobawould then be able to obtain an "active and valid" billing number. This"Preliminary...Plan" was to have been replaced by a "Comprehensive Physician ResourcePlan" by the end of 1995. To our knowledge, that "Comprehensive" plan was never67released, and all provisional numbers were, in the meantime, converted to "active andvalid" numbers. In short, while considerable work was done on a "billing numbers" policyfor Manitoba, no such policy has, to date, been implemented.A medical student loan program has been in place since 1981, consisting of forgivableloans of $15,000 available to third and fourth year students, with an obligatory return-of-service period of one year for each year of support. As of June 1997, 102 students hadreceived loans over the fifteen years of the program, of which 22had repaid their loanswith interest; 51 had completed at least part of their northern/rural return-of-service, and29 were still in training. Between 1981 and 1992,62 students received loans/bursariesunder this program; of the 35 who had completed their trainingby L992,17 hadwithdrawn from the program and repaid their bursaries, 3 served part of their return-in-service period and then paid back the remainder of the bursary, and 15 completed the ruralpractice obligation. There was an increase in the size of the loans (from $9,000 to$15,000) in 1989. Since 1989, of those who have completed training,24 of 27 arereturning service. Criteria for the loan program will be reviewed again this year.In addition, a program to offer work experience in rural areas to first and second yearmedical students is accompanied by a stipend plus reimbursement for travel andaccommodations, totaling about $5,000 per student. All fourth year medical students arerequired to take a seven week family practice clerkship; most students select rural sites forthis clerkship (Manitoba Health Services Commission,1992). All family medicineresidents are also required to complete a rural rotation. Funding is also provided byManitoba Health for accommodation and travel for family medicine residents involved intheir rural practice rotation.In 1992 a rural training program for family medicine residents was established by theFaculty of Medicine at the University of Manitoba. This program, based in Dauphin,provides the opportunity for six residents a year to spend their entire second year ofresidency training in this rural community. Subsequently, a second community-basedresidency program was established in a southern small community, but this wasdiscontinuedin 1997. There is some cunent discussion about re-establishing this site.Beginning in 1998, Manitoba Health began providing to each rural physician anorientation manual containing information on treatment protocols, available consultants,health programs such as home care, and other resources available to them and to theirpatients. Manitoba Health has also hired a family practitioner to work with the new ruraldoctors and assist them with practice and other issues. This individual is working in closecollaboration with the Health Authorities and the Faculty of Medicine on recruitmentissues.Continuing medical education grants provide payments of approximately $3,200 permonth for rural physicians who wish to take advantage of one-to-six month self-directededucation programs. A formal agreement to return to practice in a rural community isrequired, the breach of which requires repayment of the funds with interest. Between681980 and 1985,28 physicians received funding under a program similar to this which didnot require a formal return-of-service agreement. Of these, 13 failed to return to ruralpractice upon completion of their training and 15 complied with the programrequirements. Of the 57 physicians funded between 1985 and 1998, the period duringwhich the return-in-service provision has been in place, all but one have completed theirreturn of service. In addition, Manitoba offers longer programs for rural physicianswishing to complete an additional year to develop or upgrade specialty practice skills suchas anaesthesia, emergency medicine, gerontology or psychiatry. These programs run up to1 year and participants must return services in their community.In September 1997, the province entered into an agreement with the Northern MedicalUnit to provide alocum tenens program. For the past 18 months, locums have beenprovided for physicians working in medical practices of less than 3 physicians inruraVremote communities who wish to take vacation or educational leave. The programwas intended to be run on a cost recovery basis. However, this has not been successful.The program continues to be funded through'the NMU, although the province is presentlyexploring alternative funding approaches.69Appendix 5Ontario70OntarioThe Ontario Underserviced Area Program (OUAP) was established in 1969 to addressproblems with accessibility of physician services in northern communities. It was soonextended to encompass "underserviced" areas throughout the province. Requests fordesignations as "underserviced" are initiated by communities which felt they were in needof recruitment and retention assistance. The designation itself results from a process offormal review, involving determination of the number and type of physicians in acommunity or region, the population:physician ratios for the area (in relation to the gplfpguideline of 1:1380 established by the Council of Ontario Faculties of Medicine), thepopulation composition, availability of housing and facilities for a physician, previousrecruitment efforts, support of local health care professionals, a letter indicating DistrictHealth Council support or recommendation, and the area's health care needs andresources.By late 1997, this method of designation had resulted in more underserviced areas beingidentified in southern Ontario (37) than in the north (31); in 1995/96, in contrast, therewere 22 in the south and 4l in the north (Sibbald, 1998b). This was despite the fact thatonly northern communities may be designated as "underserviced" for physician specialists(Ontario,1998). The 68 communities were seeking a total of 116 physicians, up from the88 physicians being sought by the 63 communities two years earlier (Sibbald, 1998a). ByMay 1998, these numbers had grown further, to 43 southern communities and32 northern(Hardy, 1998). But vacant positions are not restricted to "underserviced" areas. As ofearly 1998, 235 gpfip positions were listed as vacant in a Ministry publication (Ontario,1998b; as cited in McElroy, 1998).Financial incentives in the Program include tax free grants of $40,000, paid quarterly overfour years, to general practitioners and psychiatrists prepared to locate in "underseryiced"northern communities. Smaller grants of up to $15,000 are available for gplþs whorelocate to designated southern communities, and for some other health care professionals(e.g. audiologists, chiropodists, physiotherapists) (Ontario, 1998a).The program also had another option whereby general practitioners could, instead, receivea guaranteed net professional income of $38,000 (Anderson and Rosenberg, 1990). Thisoption expired in the late 1970s.In 1979, the program was enlarged to permit a limited number of incentive grants forspecialists. Participants who establish practices in designated northern communities areeligible for a tax free grant of $20,000, payable over four years, with an additional$20,000 available to specialists prepared to participate in outreach activities for aminimum of 12 days per year to areas at least 40 km from their chosen home community(Ontario, 1998a).7tAs of 1994,the OUAP has been managed under the Northern Health Programs Branch ofthe Ministry of Health. The Branch maintains a "list of areas designated as underservicedfor general/family practitioners" which is updated quarterly. A similar list is maintainedfor specialists, and a third covers rehabilitation professionals. These lists are updatedquarterly, and the Ministry makes published versions available on request. With fundingfrom the OUAP, the Ontario Medical Association (OMA) maintains an on-line job registrycontaining opportunities in designated underserved areas. The OMA job registry isavailable only to members. (McElroy, 1998; personal communication, David Salter, Aprilteeg).In 1996, the Ministry of Health began providing a "$70 per hour sessional fee payment foron-call after-hours emergency services provided in rural hospitals" (PAIRO, 1996, p. 13) .Fee-for-service physicians practicing in eligible communities receive the sessional paymentfor ovemight, weekend, and statutory holiday coverage. They are not permitted to billfees-for-services actually provided during periods for which they are receiving sessionalpayments; if they are involved in obstetrics or extraordinary circumstances during an on-call period, but they are not the on-call sessional physician, they can bill fees for suchservices.32Eligible communities are those with emergency room volumes of less than 25,000 visitsduring 1994195; at least 40 km from a "major centre"; and having only one public hospitalemergency department. There are currently 78 eligible hospitals in the province, of which70 are actively using this sessional fee. Eligible physicians are those not already under analternative payment anangement. In some communities, physicians have chosen to billfees-for-service during some periods (weekend daytime), and take the sessional rateduring other (presumably slower) periods. The OUAP currently makes no specialprovision for gp on-call responsibilities in smaller communities without a hospital, beyondthe usual ourof-office-hours fees in the negotiated fee guide (personal communication,David Salter, April 1999).Locum tenens funding has been available for some time, both through the OUAP andthrough an Ontario Medical Association-sponsored "Rural Placement Program" alsofunded by the Ministry. These programs are intended to provide replacement physiciansfor rural and isolated practices. Locums provide services both in situations wherecommunities are in urgent need of medical services but have been unable to recruit, and asrespite for local physicians who wish to take a vacation or attend continuing medicaleducation programs.The 1996197 agreement between the Ontario government and the OMA included acommitment of $36.4 million "of new monies to implement alternative payment plans inmedically underserviced communities in the fiscal years 1997-98, 1998-99, and 1999-2000." (Gravelle, 1998) This was identified as a priority item for ongoing negotiations;32 The sessional payments are for the provision of primary care. If a specialist provides this coverage,(s)he is, in addition, entitled to bill fees for any services/procedures that would normally require specialistexpertise (personal communication, Anne Finlay, April 1999).72the significance of this being "new monies" was that it did not threaten the existingnegotiated fee-for-service global budget. Part of this new funding was used to addressrural/remote community recruiting/retention problems through the establishment ofGlobally Funded Group Practices Agreements (GFGPA). These were designed to assistsmall rural communities which require 3 to7 physicians in recruiting and stabilizing gplfpservices by providing guaranteed incomes to those who contracted to practice in approvedcommunities (Ontario, I998a, Physicians of Northwestern Ontario, 1998).The GFGPA had a short life; only four agreements were ever negotiated. The program'sdemise was precipitated by concerns particularly from representatives of PAIRO and thephysicians from northwest Ontario. There appear to have been two major concerns: a)that the terms of the GFGPA were based on insufficient numbers of physicians percommunity to create the necessary critical mass in designated communities struggling withissues such as on-call loads ("virtually none of this committed funding was spent [in thelast fiscal yearl due to the government's insistence on funding only a minimum ofphysicians per community rather than a sustainable physician complement necessary toretain and recruit needed physicians" (Gravelle, 1998)); and b) that the program's scopeand potential were restricted by the Ministry's agreement with the OMA. This agreementplaces restrictions on the funding which will be made available from the fee-for-servicebudget for this and similar alternative payment anangements, thereby limiting the potentialof such affangements to resolve the recruitment/retention problems in undersupplied areasof the province (PAIRO, 1998).As a result, the GFGPA were replaced by the Northern Group Funding Plans (NGFP).Under the terms of these plans, groups of three to seven physicians practicing in 20northern communities of under 10,000 population and more than 80 km from a "major"health centre, are eligible for a base salary of $128,000 (Borsellino,1999). The contractsunder these plans are to cover all primary care services, including palliative care andmental health.33 Participating physicians are eligible for up to $60,000 annually forpractice overhead, and those who complete the three years of the contract are also eligiblefor a $10,000 "retention incentive" bonus (personal communication, Anne Finlay, April1999; Ontario Government News Release, November 26,1998 (fromhttp:\\www.gov.on.ca\health)). The OUAP designation process and its method ofdetermining the necessary "complement" for a community are still in use with the NGFP,but as of spring 1999, appeals may be made by physicians and communities to the OntarioPhysician Complement Review Committee, which is composed of a chair, andrepresentatives from the OMA, the Ministry of Health and practicing physicians (personalcommunication, David Salter, April 1999).In addition, part of the $36.4 million was used to continue to support "communitysponsored contracts consisting of guaranteed annual incomes of up to $194,000; benefits;no overhead costs; time off for holidays and continuing education. As well, there arecompletion bonuses of $10,000 and $25,000 for two- and three-year contracts for family33 Participating physicians are, however, able to receive additional payments for specific services such asobstetrics, anaesthesia, and surgical assisting, and on-call emergency coverage.73physicians going to work in 21 northern and rural communities" (Ontario, 1996a).34 Thebonuses are payable on completion of the contracts. Funds for these contracts arise froma variety of partnerships involving the individual communities and the Ministry of Health,and the Ministry portions are taken from the OHIP fee-for-service pool, since these fundsare seen as supporting practitioners who would otherwise be billing fees-for-service(personal communication, Eileen Mahood, January 1997). By November l, 1998,30physicians had signed contracts (Ontario, 1998a). The maximum program commitment is40 contracts in 25 communities; as of spring 1999, there were 25 communities involved.The OUAP has been the subject of a number of reviews. An assessment undertaken byAnderson and Rosenberg (1990) used geographical analysis to examine physician-to-population ratios across the province over time. Their conclusion was that while thenumber of physicians available in all regions had increased between 1969 and 1990, thefundamental distribution problem that had been the prime motivation for the OUAP in thefirst place, remained largely unresolved by that program.A review of the OUAP, undertaken for the Ministry of Health by Dreezer and DreezerInc. (1992) concluded that, if the evaluation were to be based solely on the number ofhealth professionals who have taken advantage of the Program's various incentives topractice in Northern Ontario, "the program can be called a qualified success". Otherearlier evaluations (cited in Anderson and Rosenberg) also appear to have felt that theprogram had been relatively successful in improving recruitment into northern and otherrural areas.Perhaps predictably, the program continues to be controversial, with arguments botharound the process of designation, and concerning whether the embodied policies areeffective in attracting and retaining physicians in designated communities. Indeed, evenleaving aside the over-arching fact that the program relies rather centrally on financially-based tools, the more communities that become designated, the less effective the programis likely to be at solving the problems of any one of them.The Plan is also criticized by physician groups for its method of calculating "complement"( the number of physicians the MOH will provide funding for in any one community). It isasserted that this method has "time and time again . . .proven to be inaccurate, arbitraryand not reflective of the real physician need in any given community" (Physicians ofNorthwestern Ontario, 1998). An independent assessment of these claims was beyondthe scope of the present work.3a These contracts are restricted to communities requiring a complement of one or two physicians; theOUAP designation process is used to calculate the complement. Thus, the eligible communities must bethose which are northern and rural, rather than rural alone; this program does not apply to those southerncommunities recently identified as underserviced (see above, Sibbald, 1998b; personal communication,David Salter, April 1999).74One of the factors standing in the way of comprehensive and ongoing evaluations of theeffectiveness of the program is the lack of the requisite information base. The program hasnever come under the scrutiny of the province's Auditor General. Data on variouscomponents of the OUAP exist for 1991 on, but the Ministry of Health only began thesystematic collection of information on OUAP placements in 1995 (Hardy, 1998).Several studies not specific to the operation of the OUAP but examining the problem ofworkforce distribution and rural access were undertaken by the Provincial Co-ordinatingCommittee on Community and Academic Health Sciences Centre Relations in 1995(personal communication, David Salter, April 1999). But even with this information inhand, since the previous location of physicians recruited through the OUAP is notmonitored, it is not possible to net out movement of physicians between underservicedcommunities without a more concentrated research effort.In place of any recent critical evaluation, one has a litany of claims and complaints aboutthe program, many of which may be valid, some of which are not, and a few of which(largely from the OMA and PAIRO) we note here (Hardy, 1998; Quinn, 1997; Sibbald,1998a):I competing programs and lack of Ministry coordination -- the OUAP might be losingphysicians to the Community Sponsored Contracts program;o the risMhreat of a billing numbers policy which might lock rural/remote physicians inplace;I blurring, or watering down, of the original intent of the "underserviced area"designation, so that now a number of relatively large southern communities have thedesignation; this loses sight of the original intent of the program, and makes it evenmore difficult for rural/remote communities with situations in which physicians arebeing burned-out by too-frequent on-call situations, to recruit help;o "The UAP's focus on financial incentives is out of step with the wants and needs ofrural doctors. . . .[t]hey are more interested in such things as locum relief forcontinuing medical education purposes, spousal employment and educationalopportunities for family members" ;0 on the other hand, others believe it is a problem, in part of the "perks" being too small;o limited opportunities to generate the incomes sufficient to draw down education andnew practice investment loans;I alleged inappropriate use of physician:population ratios which fail to take account offull-time-equivalence of physicians, or of inter-regional patterns of care-seeking.But the feedback is not all negative. Marathon, Ontario is one community that credits thepossibility of an altemative payments plan, as well as the sessional fees for emergencywork and a local reworking of the idea of group practice as contributing to their ability torecruit 6 family physicians in one year. (O'Reilly,1997).Under a recent agreement between Health Canada and McMaster University, new fundingis being provided to hire up to sixteen family physicians to provide medical services toFirst Nations communities in a massive area north of Lake Superior. Under theagreement, these physicians would receive salaries similar to those provided through the75NGFP, and McMaster University is taking on the responsibility of hiring the physiciansand ensuring the terms of the agreement are met. As part of the agreement, the NOMP(Northwestern Ontario Medical Program; see below) has also agreed to include this areaamong the clinical education opportunities it makes available to medical students andresidents at the five Ontario schools (Kilpatrick, 1998).Turning to regulatory/administrative initiatives, under the terms of the 1993 "InterimAgreement on Economic Arrangements" between the Ontario government and the OntarioMedical Association, a supply control policy was put in place that restricted the issuanceof "provider numbers" to physicians who were graduates of Ontario medical schools orwho had completed at least one year of postgraduate medical training in Ontario. Whilethe agreement also imposed restrictions on access to practice for FMGs, exemptions weregranted for physicians interested in practicing in underserviced areas. FMGs willing tocommit to three years'service in an underserviced area would be granted an exemption.A charter challenge of the restricted billing privileges component of the interim agreementwas filed in 1995. However, the entire agreement expired March 31,1996, rendering thechallenge moot. It was therefore not pursued. This agreement was replaced by a new"Interim Agreement", dated December 15,1996, ratified in 1997, and in effect until Dec3I,1999. Under the terms of the new agreement, the earlier-proposed billing numberpolicy has been replaced with a differential fees policy. New generaUfamily practitioners35choosing to establish a practice in an "oversupplied" area receiveT0To fees to an annualmaximum of $140,000 for the first 12 months, 757o fees to a maximum of $165,000 forthe second twelve months, and807o fees to a maximum of $205,000 for the third twelvemonths, after which they are eligible for full (l00%o) fees. The same discounts with largermaxima ($175,000; $205,000; and $255,000) apply to selected new specialist groups.The individual income ceilings imposed on these new physicians are lower than those forestablished physicians. For example, in his/her third year of practice, a new generalpractitioner in an oversupply area can bill $205,000, whereas an established generalpractitioner anywhere in the province can bill up to $300,000 before any fee prorationkicks in, and can bill an unlimited amount, although subject to an accelerated proration(topping out at 25Vo fees for billings in excess of $350,000). For established specialists,fee proration does not kick in until billings of $380,000 have been accumulated, and thehighest proration (25Vo fees) affects billings over $430,000. Under the terms of one of thecomponents of the OUAP, the Specialist Retention Initiative (SRI), gpffps and specialistsin undersupplied areas may be granted exemptions to their individual annual OHIP billingcaps. Specialist applications are considered on the basis ofgeographic undersupply, orundersupplied domain of practice (e.9. a unique sub-specialty), while gplfps areconsidered on the basis of undersupplied communities designated as requiring four or35 This differential fees policy applies to gplfps who were issued a billing number any time after December15, 1996, who commenced practice in Ontario less than 36 months prior to receipt of that billing number,and who practice in a designated oversupplied area (with an exemption process available) (personalcommunication, Jane Seltzer, February 1999).76fewer family physicians, or on the basis of undersupplied specialized domains of practice,or because of "unique practice circumstances" (Ontario, 1998a).Again here, we are unaware of any independent evaluation/audit of this new initiative.Ministry figures reported in The Medical Posl suggest that only 307o of new numbersissued during the life of the agreement have been to physicians wishing to practice inoversupplied areas (Hardy, 1998).This current agreement with the OMA was negotiated within an environment influencedby the Omnibus legislation (Bill 26) introduced in January 1996 to allow the governmentof Ontario to "achieve fiscal savings and to promote economic prosperity through publicsector restructuring, streamlining and efficiency and to implement other aspects of thegovernment's economic agenda" (Ontario, 1998a). Included in this legislation wereamendments to the Health Insurance Act in the area of the setting/negotiation of fees ofphysicians, and to the Savings and Restructuring Acl which gave the Minister theauthority to restrict the issuance of new fee-for-service billing privileges to gplþs who areprepared to practice in designated areas, and to specialists who have an appointment witha hospital, independent health facility, or other health agency. This authority is to beexercised only if deemed necessary by the Minister (Ontario, 1998a).This legislation provoked intense opposition from among physicians as soon as it wasproposed (see Borsellino 1996a; Borsellino 1996b; Rich, 1996). It would appear fromthe results of a recent survey of University of Toronto family medicine residents that themere threat that the Minister would invoke billing number restrictions was a key factor inlocation decisions among these residents. Almost half the respondents indicated that theyintended, or were likely, to practice in the U.S. after completing their residencies. Almost718 of respondents rated the threat of "geographic billing restriction" as a "very important"factor in the location decision. This was by far the most important of the factorscanvassed. In contrast less than half rated "universal access" as a key consideration (Maet al., 1997).The new agreement also established a "Medical Services Corps of 20 physicians...[to] ..fillservice gaps in hard-to-place coÍrmunities; provide support to nursing stations; providelocums to those in alternative payment plans...", a job registry, and expanded opportunitiesin underserved areas for alternative payment arrangements (Ontario, 1996b). Theseinitiatives formed part of a commitment of about $45 million in new geographicdistribution-related financial incentive programs, over and above the funding for newpayment affangements. As of October 1998, this funding covered the OMA job registry(see above), a Health Professionals Recruitment Touf6, and a program establishingCommunity Development Officers (CDO). As of 1998, the Ministry funds CDO positionsin Northwestem, Northeastern and Southwestern Ontario. Their objective is to "develop36 For many years, the Ontario Ministry of Health has been involved in an annual health professionalsrecruitment tour, which involves a tour by representatives of communities designated as underservicedcommunities, of the five academic medical centres. This tour has been in place since 1978, and iscurrently co-sponsored by the Ministry of Northern Development and Mines..77a collaborative effort on many fronts to improve on independent efforts, primarily by thecommunities in need, to attract and retain doctors and their families". The CDO programwas introduced through a two year pilot project run by the Ministry of NorthernDevelopment and Mines. During the Northwest Ontario program's first two years ofpiloting, it apparently reduced the number of communities designated as underserviced tonine looking for 19 physicians in 1997 from 14 communities looking for 2I physicians in1995 (Medical Post, 1997; personal communication, David Salter, 1999).The province is currently embarking on a number of pilot/demonstration projects based ona non-fee-for-service model of primary care. Five potential sites for primary care pilotprojects had been identified by Ministry officials as of April 1998, but as of April 1999,they had still not been confirmed. There was, at the time of the initial announcement,some disagreement between Ontario Health and the OMA around the details of the modelto be piloted. The pilot projects are to involve population-based (capitated) funding,supplemented by incentives for care co-ordination and preventive care, and will includethe availability of 24-hour access to expertise, including through a new after-hourstelephone triage service. The pilots are expected to run 18 months to two years, and theintent, as in British Columbia, is to undertake an independent evaluation of the projects. Itis not at all clear what, if anything, will be done thereafter in terms of broaderimplementation.Ontario recently passed into law the Expanded Nursing Services for Patients Acr. Underthe terms of this Act, so-called "Extended Class" nurses are permitted to perfoûn anexpanded range of duties, some of which, prior to this, could be performed only by MDs.These duties can only be performed when the nurses are working as parts of multi-disciplinary health care teams, although it is not clear what (or in what circumstances)direct'supervision'is required. In addition, the province has committed to funding forover 100 new nurse practitioner positions, most of which will be targeted for underservedareas of the province.In addition to these financial, regulatory and administrative policies, Ontario has a largemix of education-related policies intended to encourage future physicians to set uppractice in rural areas and to provide continuing medical education opportunities for thosealready practicing in such settings. These include programs that provide travel assistanceto medical students to travel to northern facilities for clinical placements, as well as ruralelectives in a number of northern Ontario sites for both medical students and residentsfrom the five Ontario medical schools. These electives are aranged through theNorthwestern Ontario Medical Program (NOMP) in Thunder Bay, and the NortheasternOntario Elective Program (NEP) in Sudbury. Other similar programs are based atCollingwood General and Marine Hospitals (McMaster affiliation) and Goderich(University of Western Ontario affiliation).The Ministry of Health also recently announced funding for a 3 year program to providerural-oriented medical education and training to undergraduate medical students at theUniversity of Western Ontario. The Southwestern Ontario Rural Medicine (SWORM)78Program is structured to provide clinical rotations in rural southwestern Ontario towns;funding will provide support for a rural placement co-ordinator, teaching fees, studentgrants, administrative, transportation and accommodation costs. The program will includea week of rural exposure for all first year students, 10 eighrweek summer studentshipgrants for second and third year students; a four week year 3 rotation for up to 60students in "general specialty" areas; 3 month specialty rotations for up to 10 year 3students, and2 month rural rotations for up to 10 year 4 students.On the specialty training side, the SWORM Research and Development Unit, Ied by theUniversity of Western Ontario, provides rural exposures and experiences through a multi-specialty community training network. There are also two family practice residencytraining programs geared to providing rural exposure. McMaster University runs aprogram out of Thunder Bay, while the University of Ottawa administers the Sudbury-based "North Eastern Ontario Family Medicine Program". Sajgalik (1996, p. 2) cites anadministrator with this latter program as indicating that "the majority of graduates fromthe programs are establishing practices in small northern towns...[h]o\ryever, it is still toosoon to measure retention rates." Of the 131 graduates from these two programs to date,20have carried on with additional training, and almost 607o of the rest are currentlypracticing in northern Ontario (personal communication, Jane Seltzer, February 1999).The OUAP also administered, from 1969 until 1996, a bursary program through which theMinistry of Northern Development and Mines provided $7,500 (taxable) for each of thelast two years of medical school. Students were required to commit to provide one yearof service in a designated northern community for each year of bursary support.Repayment of the bursary with interest was the penalty for non-compliance. We areunaware of any data or analysis pertaining to return-of-service rates, but one might inferby the fact that the program is no longer in place that it was not an overwhelming success(or had become less so over time).Beginning in the current (199912000) fiscal year, the Ministry of Health will providesupport for implementing some of the components of the recently developed NorthernAcademic Health Science Network's (NAHSN) program to improve recruitment andretention of primary care health care professionals to/in northern communities. A jointinitiative of the Northeastern Ontario Medical Education Corporation (NOMEC; Sudbury)and the Northwestern Ontario Medical Program (NOMP; Thunder Bay), the full programwill include northern high school science program enhancement, aboriginal andfrancophone initiatives, telecommunication and library service development, increasednorthern medical training, development of regional locum/specialist services, and increasedsupport for research and continuing education of northern doctors (personalcommunication, Jane Seltzer, February t999).Under the terms of the current agreement with the OMA, the Mnistry is also providingfunding for 25 "re-entry" training positions. This funding is for up to l0 3rd year familymedicine slots, and up to 15 new specialty re-entry enhanced training positions. Allpositions come with return of service conditions. Physicians accepted into re-entry79positions must return one year's service for each year's training (or pay back a proratedproportion of the salary and benefits, plus interest, dependent on the return-of-service notcompleted) and must agree to locate in an underserviced area, facility or agencyacceptable to the Ministry (Ontario, 1998a); Suhadolc, 1998). Early evidence suggests ahigh rate of return-of-service, although indications here, as elsewhere, is that very fewrecipients stay beyond the service-return obligation period (Paetkau, 1999).There has been some analysis of the relative success of the five Ontario medical schools'recent attempts at encouraging their graduates, through recruiting, training exposures orother means, to locate in non-urban settings. The most successful appears to be theUniversity of Western Ontario "by a wide margin" (Peter Coyte, as quoted in Hardy,1998); the University of Ottawa has been the least successful. Queen's University's familymedicine residency program claims thatT5Vo of its graduates locate in "communitiessmaller than Kingston", and one-third of those in "truly rural settings with populations of10,000 or less" (Godwin et al., 1998)The province currently has capacity in place to train approximately 75 nurse practitionersannually.The Ministry of Health recently began funding a telehealth project for Northern Ontario.The Northern Ontario Remote Telecommunications Health (NORTH) network isdeveloping two-way video technology to upgrade telemedicine services and reducespecialist travel.80Appendix 6Québec81QuebecQuebec was the first province in Canada to implement a policy of differential fees; it datesback to June 1982. Initially, fees were reduced to70Vo for the first three years inuniversity areas and the urban periphery, for gps and most specialists beginning practice(in fact, specialists within nineteen of thirty+wo specialties were so affected; for theothers, there was no proration, even in university areas). Payments equal to ll57o (forgp's) or l20%o (for specialists) of the prevailing fees (or sessional fees or salary) wereavailable to practitioners (new and already established) in areas away from major centres.At the same time, an isolation premium began to be offered, along with reimbursement ofmoving expenses, and reimbursement of costs of trips out of the rural/isolated regions.Each region of the province was designated as either "university", "intemediate","remote", or "isolated", with the distinction between the last two being based on difficultyof access (e.g. James Bay, and Isles de la Madeleine were categorized as "isolated"). Theisolation premium was intended only for isolated areas, while the líVo and20Vo feebonuses were available to both remote and isolated areas. New monies were allocated tothe upgrading of medical facilities in isolated regions to assist those regions withrecruitment.In 1984, the government established an earnings floor for physicians who had to take callin facilities with few emergency cases. In addition, a maximum of 910,000 (non-taxable),available over a four year period, was made available to assist with the setting up of newpractices in designated isolated communities, and new monies were allocated to theupgrading of medical facilities in isolated regions to assist those regions with recruitment.At the same time, the llíVo rate of pay for gps practicing in isolated regions was madeconditional on practice in a hospital centre or other facility with on-call responsibilities,and the fee reductions to $.25 on the dollar, which would come into effect once a gp hadhit the quarterly income ceiling (Contandriopoulos, 1986), were waived for servicesprovided "in an institution within a designated territory", but not for private practice(Quebec Department of Social Affairs, 1934).Many of these measures, or minor modifications thereof, were still in place as of July1998. General practitioners working in institutions in designated regions are exempt fromthe757o fee reduction over the trimestrial ceiling, and activities carried out as part of a gpreplacement program, or medical services provided in a fronçline emergency departmenton a Saturday, Sunday or statutory holiday, or between 10 p.m. and 8 am any day, are notincluded in the determination of whether a physician has hit the quarterly ceiling. Also, inthe determination of whether a gp has hit the ceiling, any fee premia (i.e. the I57o indesignated regions) are not counted.Starting in 1982, specialists locating in the three urban areas (Montreal, Quebec City andSherbrooke) were paid707o of billings, increasing to 1007o after three years, while thosewho selected the outskirts of Montreal received 70Vo for office-based practice and I007ofor hospital-based practice. Those locating in intermediate areas received l00%o, and82specialists who settled in remote/isolated areas were paid 1207o of billings. BetweenOctober 1995 and October 1998, new specialists setting up practice in designatedunderserviced regions received 957o of basic payments during their first three years ofpractice, and 1007o from the fourth year on, with these payments eligible for the 20Vopremium noted above. IVhile it may seem strange that physicians establishing practices inunderserviced areas would be subject to any fee discounting, the 95Vo does exceed the857o of basic payments for the first three years and I007o in the fourth year paid tospecialists settling in intermediate regions, and the 707o of basic payments paid in the firsttwo years, followed by 807o in the third and fourth years, and 1007o in the fifth year andbeyond, for specialists locating in university or urban areas. As of spring 1999, fees forspecialists settling in urban areas are subject to a discount of 707o for the first two years,and 80Vo for the third year; full fees are paid from the fourth year on. Specialists in office-based practice in the outskirts of Montreal are subject to the same discounting, but if theyare hospital-based, they will receive 1007o of billings. Specialists choosing to practice inintermediate areas now receive l00%o of billings, and those who select remote/isolatedregions are eligible for the bonus, thus receiving l20%o of billings (personalcommunication, José Velasco, April 1999).The discounting for general/family practitioners has not changed since 1982. Thoselocating in urban areas are subject to discounts to 707o for three years, while those settlingin the outskirts of Montreal receive 70Vo if in office-based practice and 1007o if inhospital-based practice. GPs locating in intermediate regions receive 1007o of fees billed,and those who choose remote/isolated areas are eligible for the bonus, thus receivingllíVo of billings. At this time, negotiations are underway to increase the gpremote/isolated area bonus to 207o from ISVo (personal communication, José Velasco,April 1999).Between 1982 and 1995 it was possible for some specialists locating in urban areas toreceive exemptions from the discounting, provided they were working as a professor ofmedicine and were connected with a teaching hospital and a faculty of medicine. Thisexemption was removed in 1995, as it had led to increases in the supply of urban-locatedspecialists. After a three-year hiatus, the exemption was renewed in 1998 for newlycertified specialists who obtain fellowships outside Quebec; such physicians will be paidl00%o of billings for twice the length of the fellowship, once they return to Quebec.(personal communication, José Velasco, April 1999).A settling-in premium has been payable (since 1984) by regional boards to physicianslocating in designated regions. Until 1991, the premium had a maximum annual value of$10,000 for non-salaried and $25,000 for salaried physicians and was non-taxable. It isnormally paid for a maximum of four years from the date of settlement. Whileconsideration was being given in late 1995 to eliminating the distinction based on mode ofremuneration, as of July 1998 the difference remained. A physician can only takeadvantage of this premium once, and cannot previously have practiced in the region.83A generaVfamily practitioner who has settled in, and chooses to stay in, a designatedregion may be eligible for a retention premium which can extend a settling-in premiumthrough a second four-year period upon evaluation by and approval from the regionalboard. This premium has the same value as the settling-in premium for physicians workingin certain isolated areas, and a maximum value of $5,000 or $12,500 in other specifiedregions, depending on the region.Specialists are eligible for a retention premium after at least three years in a "remote"region. These premia are paid to new and established specialists. A new specialist istherefore eligible for both the settling-in and the retention premium in year 4 in a remoteregion. The actual retention premium is I07o of earnings up to a maximum of $10,000 peryear in the fourth to sixth year; thereafter it is increased to l27o of earnings, up to amaximum of $12,000 per year.For those specialists who already had long-established commitments to these designatedregions, the government introduced a "revalorization" (compensation for low income)premium at the time that the retention premium was introduced; the revalorizationpremium was available in addition to the retention premium. The premia range from$4,000 to $20,000 annually, and the level in each case is determined by the distance of thepractice from Montreal or Québec City, the income of the specialist (with those with thehigher incomes being eligible for smaller premia), and the type of specialty. These premia,too, are grossed up by the207o remote/isolation fee bonus. In addition, specialists locatedanywhere in the province who are members of designated specialties (e.g.anaesthesiology, internal medicine, and general surgery) may become part of a"replacement pool" for remote or isolated areas, thereby receiving $50 per day in additionto any other remuneration for which they might be eligible.Other sources of supplemental funding include isolation premia, travel expenses andmoving costs. In addition, some specialists (e.g. anaesthesiologists, internists, and generalsurgeons) can anange to be paid on a sessional basis for work in remote or isolated areas,and at the same time are eligible for part of what would otherwise have been billed, hadthey been billing fees for service. These specialists are eligible for $550/day for a (7 am to7 pm) weekday 'shift' with a minimum presence of 7 hours on hospital premises; but inaddition, they receive20To of the fee value of the services actually provided. Both thesessional fee and the 207o of fee-for-service are grossed up by the 20Vo remote/isolationfee bonus ( i.e. $660/12 hour shift plus 247o of basic fees-for-service). Those samespecialists (e.g. anaesthesiologists, internists, and general surgeons) located in"intermediate" areas can also be paid on a sessional basis, but are not able to bill the20Vofees in addition, and are of course not eligible for the 207o remote/isolation bonus.Specialists in remote/isolated areas and in selected hospitals in " intermediate " regions canreceive a (12 hour) "on call" sessional fee of$50 during weekdays and $350 for weekendsand statutory holidays. This is in addition to the usual fees for any services actuallyprovided during these periods, and both the "on call" sessional fees and the service feesare also grossed up by 20Vo for those specialists in remote/isolated regions.84Quebec distinguishes between emergency room (ER) coverage and on-call remuneration.GP who provide ER coverage anywhere in the province between 0800 and 2400 of anyday must choose between billing fees-for-services in the usual manner, or receiving a lumpsum (this varies according to a variety ofcriteria) plus 357o offee-for-service billings. Ifthe gp is covering the ER between 2400 and0800, (s)he may choose on a daily basis,before or after the fact, between straight fee-for-service billing, or a lump sum of $450plusT5Vo of fees-for-services billed. These arrangements are available only to gpsOn-call coverage payment anangements are available to gps or specialists in remote andisolated areas only; the remuneration anangements for each group have the sameframework - only the details differ. For example, gps providing on-call coverage inremote areas receive 50Vo of the current hourly rate ($57.60) while on-call, and in additionmay claim full fee-for-service billings for any activities performed if called in.Since 1985 the entitlement of physicians practicing in designated regions to time forrefresher courses was increased from 10 to 20 days per year, complete with compensatoryallowances for remuneration, living expenses, and transportation.A few recent policy initiatives not primarily aimed at remote/isolated supply issues may,however, represent indirect threats to, or potentially undermine some of the effects of, thispackage of policies. In particular, in 1996 the province began a new program to run overthree years to 1998 -- the "end-of-career allocation program" -- through which gps aged55and over in 1996,55-64 in 1997 and 55-63 in 1998 could contract to receive 40Vo oftheir mean income from the previous five years (the mean subject to a maximum of$ 190,000 per year) for the next 3 years, and 30Vo of the mean in the fourth year, for atotal of l50%o of average annual income, over 4 years. A similar program was establishedfor specialists in 1997, running for 1997 and 1998 only, whereby practitioners aged 65-67could receive 200Vo of their average income from the previous 3 years, up to a maximumof $150,000, spread over 5 years, while practitioners aged 68 were entitled to 1807o over4 years, those aged 69 to I60Vo over 4 years, and those 70 and older to 1407o over 4years.The "assisted-departure program" was instituted in 1997 as a replacement for the gpportion of the end-of-career program, which had experienced a poor subscription duringits first year. Applying only to gps and only to the two years remaining to the "end-of-career" program timing, those practitioners who were between the ages of 50 and 64could contract to receive 2007o of their mean income from the previous five years,allocated over 4 years, while gps aged 65-69 could receive I507o over 4 years and thoseaged7O and older l00%o over 4 years. As this anangement was sometimes moreattractive than the provisions of the gps' end of career program, special affangements hadto be made for those who wished to transfer (personal communication, José Velasco,April 1999).85These policies may have had perverse effects in chronically undersupplied areas, in manyof which a few gps would have been serving a community for many years, and may havebeen approaching retirement. They would seem likely to have hastened retirements insituations where communities have not yet established replacement arrangements.The other recent (1997) policy with potentially perverse geographic distribution effects isthe daily patient limit. This was agreed to by the Fédération des médecins omnipraticiensas a means of assisting the process of keeping global billings within the cap. It involvedsharply reduced fees for patient visits beyond 50 per day. Again, this is likely todifferentially affect regions with chronic problems of finding sufficient physicians, sincethose in place will often need to work long hours and see large numbers of patients, simplybecause they are the only game(s) in town (Wanamaker, 1998) The program wasterminated in 1998 as it was deemed to be too controversial in view of the Iimited savingsaccruing from its implementation.As with most other provinces with medical schools, Quebec has over the years developedan extensive affay of education-related financial incentives designed to encourageexposure to rural community medicine, the establishment of practices in such communitiesafter the completion of post-MD training, and retention of physicians already practicing inthese areas. Beginningin 1982, the government of Quebec agreed to increase the level ofbursaries for medical students (first introduced in 1978) from $6,000 to $10,000 per one-year commitment in a designated area. The $10,000 bursaries are available in each of thefinal two years of medical undergraduate training. For students choosing family practice,an additional two years of $10,000/year in residency bursaries are available. Between1978 and 1985 return of service was mandatory; failure to comply meant the graduate wasunable to secure a billing number. Since 1985, a repayment option has been available.The proportion of bursary-holders fulfilling the return-of-service requirement has fallenconsiderably since the repayment option was introduced (Paetkau, 1999).For those choosing the return of service option, each recipient agrees to provide insuredservices in an area designated by the Minister of Health and Social Services for a numberof years equal to the number of annual bursaries received. Individuals may indicatespecific regions in which they wish to practice (up to three regions) but the student has nocontrol over the region to which (s)he is assigned. The number of bursaries available tomedical students and family practice residents was increased from 90 to 180 in 1985because it was thought that no more than 50Vo of those who took bursaries would keepthe commitment to return of service. However, there are usually only 50 candidates eachyear, and of those who do begin their return of service, about 50Vo repa! the remainderafter one year of such service (personal communication, José Velasco, April 1999).As of 1984, bursaries of between $10,000 and $25,000 per year have been made availableby regional boards to residents in the final two years of training for designated specialties.Residents are required to reimburse the region for the value of the bursary, anyaccumulated interest, and any settling-in allowance, in proportion to the time not served, ifthey do not take up or complete the return-of-service obligation.86Alternatively, medical students and residents may apply for bursaries from the Ministry ofEducation, which have no return of service requirement. In addition, medical students areeligible for the ordinary student loans available to any Canadian undergraduate. It is alsoapparently relatively easy for even new physicians to secure loans. The result of thesevarious alternative sources of funds seems to be that most who do receive Ministry ofHealth bursaries with return of service obligations choose to 'buy them out' rather thanreturn the service. This seems to have been especially true for specialists. Anotherproblem that has emerged with "return-of-service" requirements arises when medicalstudents receive conditional (return-of-service) bursaries, but then go on to do specialtyresidencies in specialties where there are no needs in isolated/remote regions. They are,under the terms of the bursaries, required to provide return-of-service, yet there are noopportunities for them to do so (this has been particularly true in the past four years(personal communication, Québec Ministry of Health, 1998). This has affected bothQuébec and non-Québec students.In 1984, there was a major multi-party review of initiatives to improve geographicdistribution of medical services. As a result of this review, 20 new rotating internshipswere created for graduates of faculties of medicine located outside of Canada and the US.The number of positions allocated thus increased from 30 to 50, but the additional 20were required to make a formal commitment to practice for three years in a locality orfacility designated by the government.The provincial physician resources plan for the years 1995-96 to 1998-99 includes aprovision that 51 of the 457 authorized annual first year medical school places in theprovince may be filled by students drawn from two quotas: 20 from New Brunswick andone (1) from PEI, all of whom must agree not to remain in Quebec to practice; and 30 forforeign students with visas. In addition, up to 10 of the remaining 406 positions can betaken by Canadian students from provinces other than Quebec. These latter 61 positionsin the foreign and other-Canada quotas are available provided that the students agree inwriting to practice for four consecutive years in a facility designated by the Minister if theyshould settle in Quebec after graduation. Failure to comply can leave the recipient subjectto a penalty of $200,000 (reduced by number of years of designated service that have beencompleted).An internal study undertaken for the Ministère de la Santé et des Services Sociaux(MSSS) in 1995 found that gp/fps and specialists who had agreed to "return of service"contracts between 1985-86 and 1993-94 were considerably more likely than those withoutcontracts, to remain in isolated regions. Among gp/fps, 42.47o with contractualobligations and who also benefited from regional bonuses, were found to have left isolatedregionswithinthefirstthreeyearsof practice. Thiscontrastswith 48.77o of gplþswhohad not benefited from any incentives and were not under contractual obligations, and58.8Vo of those who had only taken advantage of isolated area bonuses. Within fiveyears, however, there was virtually no difference between the three groups of gplþs in"departure" rates (Velasco, 1995).87A different picture emerged for specialists, where almost 787o of those under contractualobligation had departed from the isolated regions within the first three years of practice.This was virtually identical to the experience of specialists over this period who had nottaken advantage of any bonuses, and who were not under contractual obligation. What isparticularly interesting about the specialists is that only 40Vo of those without contracts,but who took advantage of bursaries or other regional bonuses, had departed within thefirst three years. Within the first five years, the third group showed the highest rate ofdeparture (887o), withTSVo of the other two groups who had benefited from bonuses orbursaries (with or without return of service obligations) having departed. (Velasco, 1995).Based on this analysis, the study concluded a) that contractual obligations were far moreeffective than bonuses/bursaries alone, in encouraging retention in isolated regions; b) thatrelocation bonuses in particular appear to be largely ineffective in getting those withoutcontractual obligations to practice in isolated regions; and c) that relocation and otherbonuses for those under contractual obligation were largely wasted, since those undercontract would have likely fulfilled the obligations in any event. What was not clear tothese observers was how one could determine whether fewer contracts might have beenhonoured (rather than bought out) in the absence of the bonuses.Some programs provide rural/remote training to residents in family medicine and in a fewspecialties. Since 1985186, family practice residents have had to spend eight weeks duringtheir two year training period, doing remote area rotations. In addition, required remotearea rotations of 8-12 weeks have recently been introduced for residents in anaesthesia,general surgery, internal medicine, obstetrics/gynaecology, paediatrics, and psychiatry. Inaddition, there are remote area opportunities for summer employment for medical studentsin the first three years of school, including allowances for the costs of moving andaccommodation.Ten specialty resident I (first year residency) training positions (of a total of 330 in1996197, and 308 in 1997198) canied with them a commitment to practice condition.These positions were allocated across eight generalist specialties (those likely to besupportable in smaller communities): general internal medicine, general surgery,anaesthesia, psychiatry, paediatrics, obstetrics/gynaecology, anatomic pathology, andorthopaedic surgery. Four of these ten positions were reserved for non-Canadian andnon-American-trained residents. Graduates were required to commit in writing to servingat least four consecutive years in a facility approved by the Minister. Failure to complyleft residents subject to the same penalty as for the medical students who fail to comply($200,000). Because of insufficient applications, the program was eliminated at the end of1997. Beginning in 1998, foreign medical graduates are required to undertake medicaltraining in Quebec if they wish to practice in Quebec.The Quebec government has also instituted a series of measures designed to ensure thatclinical fellows (residents paid other than through the usual route based on the agreementbetween the Fédération des médecins résidente du Québec and the government of Québec)are not able to settle in Québec after their residency period, unless specifically authorized88by the government, or unless they agree to a similar return-of-service arrangement withthe attendant penalty for non-compliance. In particular, there are limitations on theauthorized training period for FMGs, because their likelihood of obtaining landedimmigrant status increases with the time in the country.Since the introduction of the policy of differential fees by the Ministère de la Santé et desServices Sociaux (MSSS), the MSSS has evaluated and monitored its effects on an annualbasis. Recent data suggest that there has been some increase in the proportions of newgeneral practitioners who decide to set up practice in a remote or isolated region. Thisincreased from l l.STobetuteen 1978 and 1981 to203Vo between 1982 and 1994, and to23.37o between 1995 and 1997 . For specialists over the same periods, the comparablerates have been 4.67o (in the four years before the beginning of the policy), I0.97o, and15.77o ( unpublished data provided by J. Velasco, 1998).Of course the proportions of new physicians who settle in remote/isolated regions is onlyone part of the overall distribution story. If more are leaving than are settling, thendistribution could still theoretically be getting worse, despite these increasing proportions.However, an examination of net flow for remote/isolated regions during the years 1982-94indicates that between 1.982 and 89 there was a net addition of 21 specialists per year inthese regions. The net increase slowed to l8/year between 1989 and 1997. For gps, thenet increase was 35lyear between 1982 and 89, but only 23/year in the later period. Thedrop in gp net in-flow to these regions may be related to the reductions in post-graduatetraining slots implemented in the early 1990's. While maintaining the same total number ofpostgraduate training seats, Quebec began in 1992-93 to expand specialty-training intake,which led in turn to reductions in the number of seats available for family practiceresidencies. As a result, by 1994-95, there were reductions in the number of graduatesfrom family medicine programs. About the same time, there was considerable discussionby government about new policies designed to restrict the location choices of newphysicians. This led some physicians who might otherwise have contemplated practicingin rural/remote areas to establish practices in non-remote areas as soon after completion aspossible, so as to avoid permanent'rustication'. These two factors may have worked intandem to reduce the flow of gp/fps to remote and isolated regions (personalcommunication, José Velasco, April 1999).89Appendix 7New Brunswick90New BrunswickThe first significant government policy intended to influence geographic distribution ofphysicians came with the 1987/88 "Physician Recruitment Incentive Program". ThisProgram provided settlement grants, guaranteed minimum incomes, and guaranteedincomes for locums. The settlement grants were $10,000/year for up to three years, andwere available to physicians making a commitment to practice for three years in adesignated area. Designated areas for general practitioners were those in which theaverage population/physician ratio was at least 1500 (or those containing a particularlinguistic sub-population which was deemed to be under-served, even if thepopulation/physician ratio for the region overall was less than 1500:1). For specialists,designated areas were those in which hospital services master plans indicated a need forthe specialist in question. In addition to the settlement grants, eligible physicians wereentitled to up to $3,500/year to cover expenses and foregone income for continuingeducation, and up to $8,000 (one time) to assist with relocation expenses. The incentiveswere not intended for "physicians relocating within the province [or for] physicians whohave been away from the Province for less than a year" (New Brunswick, 1988).The guaranteed minimum incomes provided an income floor for the first year of practiceof eligible physicians. The level of income varied with type of physician (gp, medicalspecialist, surgical specialist) and by region. The eligibility criteria were the same as forthe settlement grants except that, for general practitioners, the community in questionneeded to have less than four full-time physicians in practice. The guaranteed incomes forlocums were intended for those willing to replace solo physicians in designated areaswhere the replaced physician was the only practicing physician within the area andspecialty. They provided locum incomes for a maximum of four weeks annually (based onthe income of the physician who was being replaced), as well as reimbursement of travelcosts and reasonable other expenses.At the same time, the New Brunswick Department of Health began offering someeducation-related financial incentive packages, including assistance for medical studentswho were prepared to work in New Brunswick hospitals during the summer, funding forresidents to pursue specialty training in shortage specialties, or who were prepared topractice in regions with shortages, in return for a commitment to a particular hospital oncethe training was completed, and return-of-service bursaries for psychiatric residents.In 1989 the McKelvey-Levesque Commission on Selected Health Care Programsproduced a report "... on how the health care service [could] be better structured,organized and distributed so that the various components of the system can function in themost efficient and cost effective manner" (McKelvey et al., 1989, p. l). TheCommissioners noted that "[w]hile there are still physician requirements in the provincewhich have not been met there is no longer need for overall recruitment...areas of needshould be identified and provincial resources directed to recruitment in these areas" (p.64).9lIn 1990, two significant new initiatives were introduced. One of these was intended tocontrol overall expenditures on physician services through the application of a globalexpenditure cap. The other, directed specifically at the objective of improving physiciangeographic maldistribution, replaced the "Physician Recruitment Incentive Program". Thiswas motivated by the fact that about 407o of new physicians who were taking advantageof the grants or minimum incomes under that Program, were leaving the regions during, orshortly after, their three year commitment, and very few were taking up the offer in theleast well-supplied regions of the province (personal communication, Lyne St. Pierre-Ellis,1996). This new policy involved fee levels differentiated according to practice locationand specialty. However, it was intended only for new physicians (already practicingphysicians were grandfathered at l00%o rates, irrespective of location). Under the terms ofthe policy, any new general practitioner choosing to practice within 40 km of Moncton,Fredericton, or Saint John would be paid atlí%o of the prevailing fee schedule. But newphysicians setting up practice anywhere else in the province (whether gp or specialist)would receive IlÙVo fees. These fee prorations were to be effective for the first threeyears of each new practice.In 1991, the Physician Resources Advisory Committee (PRAC), which had representationfrom the licensing authority, the medical society, the association representing hospitals, thenurses association, advanced education, the public, and the Department of Health andCommunity services, delivered a comprehensive physician resource plan (henceforth thePRAC Plan) to the Minister (Physician Resources Advisory Committee,1991). The PRACPlan set out provincial full-time-equivalent (fte) practicing physician targets to the year2001, based largely on the fte methodology developed earlier by the Federal-ProvincialWorking Group on Medical Care Statistical Indicators, as part of its development of anational physician resource database (see New Brunswick (L992, Appendix B). It wasmodified for this exercise to take account of a number of shortcomings (such as the factthat the methodology is generally not applicable to certain specialties, and cannot easilytake into account physicians paid other than by fees-for-service).PRAC concluded that certain specialties, and certain regions of the province, continued tobe in need of additional physicians. Its Plan set out targets for the year 2000-2001 which,if met, would eliminate or reduce those net requirements. These targets were based ondeveloping an overall fte specialist target by synthesizing other reports (e.g., Health andWelfare Canada, 1989; Royal College of Physicians and Surgeons of Canada, 1988),expert opinion, and experience within the province. PRAC then chose to assume that a50:50 gplspecialist ratio was reasonable, from which it was able to develop an overallsupply target.The overall province-level targets for each specialty were developed by taking the existingfte supply, and setting it against a number of 'checks and balances'. These included someinter-provincial comparisons; regional supply validation by members of PRAC;consistency with the Hospital Services Master Plan, which set out the province's intentwith respect to the distribution of primary, secondary, and tertiary services; comparisonagainst earlier hospital staffing guidelines, and the Royal College of Physicians and92Surgeons of Canada (1988) recommendations; and the views of the specialty sections ofthe New Brunswick Medical Society and the Mental Health Commission (PRAC, 1991,4l-44). On this basis, the Committee developed provincial and, where possible, regional,requirements estimates, which became the Plan "targets", for each specialty. A keystatement in the overall planning process was that "established regional services should notbe enhanced or expanded in excess of the regional targets set by PRAC, until such time asunder-serviced regions reach their targets" (PRAC, 1991,39).In March 1992," A Health and Community Services Plan for New Brunswick" (NewBrunswick,n.d.l992a) was introduced. This document presented a major restructuringof the governance of health care in the province (from 5l hospital and health servicecentre boards, to 8 regional boards), a number of other new organizational initiatives, anda physician resource plan for the province.This was all formalized later that year with the release of the province's PhysicianResource Management Plan (henceforth "the provincial PIan") (New Brunswick,1992),which remains in place as of April 1999). The Plan drew heavily on the work of thePRAC. The overall goal of the plan was "[t]o achieve an appropriate number andequitable distribution of general and specialized physician services throughout theprovince by the year 2001, through a process of managed growth." The "appropriatenumber" was those supply targets that had been recommended by the PRAC, and the"equitable distribution" was, similarly, based on the region-specific targets established bythe PRAC.The Plan set a medium-term planning horizon of eight years (to the year 2000-2001); itestablished target population/physician ratios for each specialty (with the exceptions ofcommunity medicine, emergency medicine, and medical genetics, for which specialaffangements were made) for 1992-1993 and 2000-2001; and it gave authority formonitoring of progress toward those targets in each region, to the PRAC. Furthermore, itdesignated the hospital corporations in each region (RHCs, established in April of 1992)as the groups responsible for implementation; hospital corporations were thus given thepower to approve, or deny, applications of new physicians wishing to establish practices intheir regions, according to whether the regions required additional physicians of any givenspecialty in order to meet their interim targets at any given stage in the planning period.The Plan also provided a phase-out period for the earlier-established differential feespolicy. This policy remained in place during 1992-93. In addition, the Plan left open theoption of issuing special licenses for regions which were unable to attract certifiedspecialists. A separate policies and procedures document (New Brunswick,1994), set outthe specific roles and responsibilities of regional hospital corporations and offered moreimplementation details.The hospital corporations were made responsible for granting privileges to thosephysicians deemed to be needed by the region, and whose addition would be consistentwith the targets for the region. All additions and un-replaced reductions were to bereported by each corporation to the Department. The policies and procedures also set out93an "exceptions" process, whereby a corporation that felt it could justify additions beyondtarget, was able to submit a request to the Department, for review by PRAC.A number of powerful disincentives are embodied within the Provincial Plan. Acorporation that grants privileges, without authorization, to a physician where doing sohas the effect of taking the region over target for the specialty, is responsible for bearingthe cost of that physician's fee-for-service billings to the Medicare Branch. Thecorporation is required in the first year of the physician's practice, to reimburse theMedicare Branch, in advance, an amount equal to average yearly payments to physiciansof the same specialty. In subsequent years the Corporation is responsible for reimbursingthe actual payments made by the Medicare Branch.The Medicare Branch is responsible for issuing billing numbers to those physicians grantedprivileges by a regional hospital corporation. A physician without privileges (privilegesare granted in the form of a list of procedures that the physician in question is authorizedto perform in the hospital in question; New Brunswick, n.d.l992b) could, in theory,practice in the region, but would not have access to the hospital, and would not be issueda billing number.A number of other initiatives intended to encourage physicians to locate in less well-supplied areas continue as part of the current physician resource management strategy.These include the reimbursement of moving expenses, up to $10,000, for physicians whosettle in designated regions, and reimbursement of tuition and travel expenses, plus 507o'salary'coverage, for attendance at continuing or extended education courses approved bythe relevant specialty College. A physician who has practiced in a designated shortagespecialty/geographic area combination for five years is eligible for support for a threemonth course; after ten years of service, a course of from 3-6 months can be attendedunder these terms. All such course support comes with a post-course return-of-servicerequirement: I year for each month of course attended (New Brunswick, 1994). Finally,after three years of practice, eligible physicians can apply for paid vacation (2 weeks at40Vo of average previous year's weekly billings; after five years of service, this increases to3 weeks).The "Phase-Out Program" is intended to allow a physician to sell his/her practice withoutsimultaneously having to relinquish his/her billing number. This 'pre-retirement' phase-outpermits a physician to transfer his/her practice to a new physician, while at the same timeleaving the pre-retirement physician able to engage in a limited amount of clinical servicefor up to five years. This anangement is only possible in regions which are at or under the2000-2001target in the physician's specialty. To compensate for the fact that allowingpre-retirement physicians to retain part of an fte could hinder recruiting, regions are ableto recruit a new physician even if they are not below target by a full fte (personalcommunication, Bonny HoyfHallett, February 1997).Effective with the 1996/97 fiscal year, New Brunswick has also had in place individualincome thresholds. General practitioners receive 707o prorated fees for fee payments in94excess of $275,000, to a maximum of $325,000, after which they receive 40Vo proratedfees. For specialists, the proration rates are the same, and the trigger levels are $400,000and $450,000.There has been some evaluation of these policies (Reamy, 1995, 1996), which examinedone year prior to implementation, and the first few years of operation under the newprovincial Plan. The author found that the population:fte physician range wentfrom 477 -1012 in t991192, to 504 - 842 in 1994/95, suggesting a considerable 'evening out' of theoverall distribution (although most of this was attributable to an improvement in thesupply situation in the least-well-supplied region of the province). However, a moredetailed examination of the underlying data suggests that much of this evening out effectwas the result not of more physicians practicing in the least-well-supplied region, butrather of higher fee-for-service billings among the physicians already practicing in thatregion. And in the second least-well-supplied region, there was actually a substantialdecline in the number of discrete physicians reportedly in the region in 1994195 relative toI99ll92 (based on data reported in Reamy, 1995).Reamy (1995, Table 14) reports data from the Department of Health showing that thenumber of fee-for-service physicians entering the province declined over the three years ofthe Plan that he examined. One could surmise that most, if not all, of the declinerepresented physicians who would have settled in regions that were already at, or over,their physician:population targets. As for movement in the other direction, the datareported by Reamy suggest some decline in out-migration of fee-for-service physicians in1993194 and 1994195, relative to the previous 5 years. However, the differences aresmall, and cannot be attributed to the provincial Plan, since these decisions will be affectedby policies in other provinces (and other potential sites such as the U.S.). On balance, onecould reasonably conclude that the provincial Plan did not cause any significant increasein movement out of the province, but this is not surprising, in light of the fact that thosephysicians already practicing were not materially affected by the Plan. The key question iswhether physicians who might have set up practice in adequately or over-supplied regionsin the absence of the provincial Plan chose, instead, to do so in regions which were under-supplied relative to target. A survey was sent to the eight region hospital corporations,seeking information on physicians denied privileges, and whether those physicianssubsequently settled in other regions of the province. This is at best impressionisticinformation, because regions would not necessarily have tracked the subsequent decisionsof physicians denied privileges in their region, nor would they necessarily have known theprior application history of physicians to whom they granted privileges. The data reportedby Reamy (1995) indicate that over the three years 56 physicians were denied privilegesbecause granting them would have put the region/specialty under its population:fte target(or, equivalently, over the targeted number of fte physicians). Of those 56, the regioncorporations reported knowing of 12 who were subsequently granted privileges elsewhere(either in the same region, or in another region). The region corporations also reported 5physicians to whom they had granted privileges, who had previously been denied in earlierapplication (these earlier denials would, in all likelihood, have been part of the 56). Whatwe do not know is what happened to the other 44 physicians who were denied privileges.95These data are, however, the most direct evidence that the Plan was having some of theintended effect.In 1994 a Statement of Claim was filed against the province by four physicians and theProfessional Association of Residents and Interns - Maritime Provinces. The petitionersclaimed that "the restriction of billing numbers, the placement of regional and specialtyquotas on full-time-equivalent physicians, combined with restrictions on the privilegeshospital corporations may grant, and the refusal to reimburse for services delivered by aphysician without a billing number, violate the Charter's freedom of association (s. 2),theright to pursue the gaining of a livelihood in the province of New Brunswick (s. 6), rightsto liberty and security of person (s. 7), and sex equality (s. 15)" (Barer and Wood, 1997,352). Unlike the B.C. (Waldman) case, the plaintiffs here are arguing violation of equalityrights on the grounds that "the current supply of physicians in urban centres is male-dominated, and the Plan has the effect, (if not the intent) of perpetuating that situation justas the supply of new physicians entering to practice has become more 'gender-balanced'(ibid.). Like the B.C. case, the plaintiffs are also alleging violations of the Canada HealthAct. The legal machinery has been dragging along for a number of years now; as of thetime of writing, it is the opinion of those closest to the case that it will not see the inside ofa courtroom until some time in the year 2000.Meanwhile, in April 1997, PRAC delivered a new report to the Minister (PRAC, 1997)reviewing and updating the methods and targets underlying the provincial Plan, andreporting on the then current supply, distribution and working conditions situation aroundthe province. The report contained 59 recommendations, including that some method befound for combining fee-for-service payments with sessional payments for calculation ofphysician ftes, that on-call issues be addressed by the PRAC, that the notion of criticalmass be employed when specialist targets were under development, that each hospitalcorporation be encouraged to develop and maintain a physician resources plan, thatrevised FTE targets for gplfps and specialists be adopted, and that the original target datefor the provincial Plan be extended to 2003-2004. The Department of Health andCommunity Services supported most of the recommendations made by the PRACSubcommittee (Nova Scotia, 1997). At the time of writing, a new provincial Plan withrevised targets is expected, presumably drawing on the recommendations from the 1997PRAC report.One measure which has been implemented is the establishment of 'on-call'payments. Insmaller facilities of less than 90 beds, physicians can choose to be paid $8O/hour foremergency room coverage between 6pm and midnight seven days a week, and between 8am and 6pm on weekends and statutory holidays, in lieu of fees-for-services (exceptobstetrics), and only if the physician is on site. Between midnight and 8am, physiciansreceive a $400 fTatfee plus any fees for services, for being on-call but not necessarily on-site.The PRAC has also recently recommended changes to the province's "re-entry" program,whereby physicians prepared to return to medical school for additional training in areas of96defined need, are eligible for some support. Applicants must already be practicing, andhave a minimum of two years service in the province. The training for which re-entry isbeing sought must be in an area of current or projected need, the training site must be inNorth America (Canada, if available) and the applicant must have the support of an RHC.A return of service clause with the sponsoring RHC will be part of each agreement. If atthe point of return to the province to practice there is no vacancy within the sponsoringRHC, then a vacancy in a designated region elsewhere in the province must be accepted.If no vacancy in the area in which the physician has specialized is available anywhere in theprovince, a physician will be released from the return of service obligation (personalcommunication, Donna Mulholland, April 1999).The Department of Health and Community Services, the Department of Labour, the NewBrunswick Medical Society and various medical education co-ordinators have recently re-established a rural summer employment program for second year medical students, inwhich job-shadowing by a preceptor is provided for up to l0 weeks. The program will betaking 12 students in the summer of 1999 (Borsellino, 1998d).In 1995 the province began to phase out its purchase of undergraduate medical seats atMemorial University. By 1997 the process was complete, and the final Memorial studentsfinished In 1998199. However, New Brunswick continues to sponsor two postgraduatetraining seats at Memorial. Some argue that this has exacerbated the problems ofattracting new physicians to rural New Brunswick (Mcleod, 1998b).In April 1998 à Health Services Review Committee was established. Included in thematters to be reviewed was access to physician services. The Committee's report wasreleased in early April 1999. It contains extensive recommendations bearing on policiesthat could affect access to services for residents of rural and remote areas in the province.Included are a number of recommendations bearing on the potential for training advancedpractice nurses (see: http://www.gov.nb.calhcs-ssc/english/publications/hsrc/).9''tAppendix INova Scotia98Nova ScotiaNova Scotia's geography means that it has no "isolated areas" the likes of which can befound in provinces to the west of New Brunswick. This is not to say that there are notvariations in physician supply, or that there are not communities where'isolation'becomesa factor in the determination by physicians of where to establish a practice. But with mostcommunities in the province being a relatively short drive from a significant community orregional hospital, the distribution problems confronting Nova Scotia are qualitativelydifferent from, say, those in Saskatchewan. The 1993 report, "Creating a Climate forChange" (Nova Scotia, 1993) noted that "...shortages in family practice are, generallyspeaking, confined to a relatively small number of areas....often remote and experienceongoing or recurring shortages of physicians. Apart from this, maldistribution of familypractitioners is not a major problem", although there was also general agreement that"there is an oversupply of family practitioners and undue concentration of some specialtiesin the Metro Halifax area" (p. 18). The Department of Health continues to believe "thatthere are sufficient doctors in the province to provide for the medical needs of NovaScotians", but also acknowledges that "some rural areas of Nova Scotia have experiencedlong standing problems attracting and keeping doctors." (personal communication,Department of Health, Sept. 1998). To that end, the Medical Society of Nova Scotia(MSNS) and the Department established a full-time Physician Recruitment Co-ordinator anumber of years ago (Robb, 1996). This position became a provincial appointment inDecember 1997. The recent focus for that position has been working with communitiesand with interested physicians (particularly gpÆps), to place the latter into rural and underserviced areas.In 1997, the College of Physicians and Surgeons of Nova Scotia began to issue "defined"licenses to physicians who are not eligible for full registration with the College; most suchsituations involve international medical graduates or medical residents (who wouldreceived an educational defined license) who are not yet eligible for Royal College orCFPC certification (e.g. are in their last six months of family practice residency, or lasttwo years of other specialty residencies) (Moulton,1997; personal communication, BrianTaylor, April 1999). The defined licenses permit these physicians to practice undermedical supervision. While those with "defined" licenses are not required to work inrural/remote areas, more often than not they do so because this is where they find theopportunities. In particular, allowing the family practice residents to practice wasintended to provide opportunities to gain experience while providing needed locum relief.Rather predictably, there have been strong opinions on both sides of this initiative. Somephysicians protested at the introduction of "physicians whose qualifications may not be thematch of those trained in this country or others with equivalent training", while othersnoted that the measure was useful as a means of filling vacancies in "doctor-starvedcommunities" (Borsellino, 1997 ).99Nova Scotia instituted a policy of restricted issuance of billing numbers in 1995. Underthe policy, new numbers were not issued to family practitioners interested in establishingnew practices in Metro Halifax, until the population per gp/fp in that area approached1170. More generally, issuance of new billing numbers was restricted to areas of need asagreed by the Joint Management Committee (although in practice the only appliedrestrictions were in Metro Halifax), and existing billing numbers were restricted to then-current geographic areas and domains of practice, to prevent practitioners from moving tothe larger urban centres if they were not already there. These policies came into effect withthe March 1995 agreement.Under the terms of a new four year agreement between the Department of Health and theMedical Society of Nova Scotia (MSNS), signed in July 1997, this general billing numberspolicy was rescinded, with the exception of Halifax, where no new billing numbers will bemade available for the Halifax Regional Municipality (HRM) "except in those sub-regionsor practices designated by the Billing Number Committee as under serviced" or in caseswhere replacement billing numbers are required "for physicians pefinanently leaving apractice in the IIRM due to illness, retirement or other reasons" (personal communication,Department of Health, September 1998; MacKinlay, 1997).In addition to this administrative approach, a number of financial incentives are in place.An allowance of up to $12,000 is made available to supplement fee-for-service income'shortfalls'in selected remote areas, and a fixed compensation package has been developedto encourage small groups of physicians to establish practices in underserved locations.This package has been used in four sites to date. The Department of Health also funds alocum service which is available to physicians in selected rural communities for shortperiods (vacation, illness, CNß). These initiatives are part of a comprehensive ruralincentives program.The rural incentives program was developed as part of the March 1995 Agreementbetween the Department of Health and the MSNS, and was continued by the July 1997agreement. It provides a package of financial incentives to any physician who agrees to afive year service contract in a region designated by the Department as an "UnderservicedArea". Among the features of the Rural Incentive Contracts are:. a 'signing bonus' of $50,000, payable in five annual installments beginning atthe end of the first completed year of service;. reimbursement of relocation expenses to a maximum of $5000, pro-rated overthe five years of the contract, based on completed years of service;. guaranteed minimum annual gross income of $146,704 or other comparablearangement to be worked out between the individual physician and theDepartment;. locum replacement for continuing medical education and vacations, wheneverpossible, through the rural locum service;. reimbursement of continuing medical education expenses to a maximum of$1000;. reimbursement of moving expenses, to a maximum of $5,000;100. prefelred access to a billing number in the [IRM, for physicians who completethe five years' service.There are now 30 contract positions in22 communities across the province (personalcommunication, Department of Health, September 1998).In addition, the Department has made available the option of non-fee-for-servicealTangements for communities where there are too few patients to support a reasonablegeneral practice. As of September, 1998, the Department and the MSNS continue toexplore and develop alternative funding anangements, with individual and groups ofphysicians. About 20Vo of physicians in the province are now remunerated through non-ffs payment arrangements The provision of paediatric services in tertiary centres and ruralareas has been a focus of recent discussions (personal communication, Department ofHealth, September 1998). But as in other provinces, negotiations over new paymentarrangements remain contentious. Less than a year into the 'new deal', the president of theMSNS suggested that progress on "alternative funding and special projects" had been a"total disaster". He implied that, despite many proposals, a number of them relativelystraightforward, there had been no movement to create new funding affangements withthose submitting proposals (Borsellino, 1 998e).The July 1997 contract also provided for a Rural Physician Stabilisation Fund, which isdesigned to pay physicians who provide emergency room'cover'and services in ruralregions of the province, and who provide 'on-call' services in remote regions (defined asany area greater than 45 km from a hospital with emergency facilities). This appears to bea compromise in response to recommendations from the Scott report (Scott, 1996). Thecunent policy providest category A emergency on-call remuneration for larger volume rooms (over13,000 unscheduled ER visits per year), at $65/hr in lieu of ffs billing fornights, weekends and statutory holidays;t category B emergency on-call remuneration for mid-volume rooms (< 13,000visits per year), at $600 for a 12 hour shift (a total of $3,000 is available for allweekend on-call coverage), in lieu of ffs billing;In order to be eligible for this alternate payment, all physicians providing cover atlfor thefacility in question must'sign-on'. Otherwise, the physicians are paid only fees for servicesactually provided while on-call.Physicians in remote areas not serving in designated ER's receive $20,000 per year inaddition to ffs billing for being on-call (Martel, 1998). In these regions, the physicians inquestion can also continue to claim fees for services provided (personal communication,Department of Health, September 1998; April 1999).3?37 Remuneration for all on-call services is based on a "unit value system". One "Medical Service Unit" iscunently valued at $1.84; physicians in remote areas receive an annual payment equivalent to I1,628MSUs; physicians in category A facilities receive 38 MSUs per hour, and so on.101The province is also developing telemedicine linking rural areas with regional and tertiaryhospitals. This serves a number of purposes in addition to making specialized servicesavailable to ruraVremote areas. It provides an opportunity for ongoing continuing medicaleducation for physicians in those areas. It can also be used to provide back-up fordiagnostic interpretation, and to offer periodic consultation services. All the facilities inone health region have been linked to the tertiary and paediatric facilities in Halifax, andthere is funding to extend the linkage to three other health regions. (personalcommunication, Department of Health, September 1998).A number of other initiatives are apparently under current consideration. Among these isthe deployment of nurse practitioners to assist in primary care delivery in more isolatedrural areas,38 and the incorporation of a return-in-service option for physicians who havepracticed for at least two years in the province and wish to improve their prospects ofbeing accepted for re-entry to residency training at Dalhousie Medical School.38 A Health Transition Fund primary care demonstration project expected to commence this fall willinvolve the deployment of nurse practitioners.t02Appendix 9Prince Edward Island103Prince Edward IslandA tripartite Physician Resource Planning Committee (PRPC) with representation from theMedical Society of PEI, the Health Association and the Department of Health and SocialServices, was established in 1988 to manage the supply, mix and distribution of physiciansfor the province.Until recently, PEI had few geographic distribution problems. However, in the last fiveyears the province has experienced more difficulty in recruiting physicians for some of themore 'remote'areas. The Medical Society, in particular, believes that the province issuffering from an overall shortage of physicians, resulting in "limited access to primarycare physicians" (Mcleod, 1998a). In an effort to address retention of those in suchareas, the PRPC established a program that provides locum replacement for vacation andcontinuing medical education leave.In June, 1998 a three-year Master Agreement was reached between the Department ofHealth and Social Services and the Medical Society. Relevant changes under the MasterAgreement include increases in the sessional rates for emergency call at the five ruralhospitals, and various provisions regarding salaried physicians, including matters related toon call coverage.The current Master Agreement also provides for the continuation of a policy of 507o feeproration for physicians who obtained a billing number on or after April l, 1993, who arenot part of the approved complement in any given region of the province.While there are several salaried specialists in Prince Edward Island, consideration iscurrently being given to the development of salaried arrangements for family physicians.A set of guidelines/formulae for the conversion of practices from fee-for-service toalternate payment (including salary), and vice versa, is currently under development.Physicians providing coverage in five rural hospitals are eligible for on-call evening/nightfees ranging from $38.20 per hour to $58.20 per hour in lieu of fee-for-service claims.Times range from 8:00 p.m. - 8:00 a.m. to 10:00 p.m. - 8:00 a.m. depending on thefacility.The province has provided financial assistance for specialty training in areas of definedneed, with return-of-service commitments attached. To date, four such fundingarrangements have been made.r04Appendix L0Newfoundlandll,abrador105Newfoundlandll.abradorEffective July 1993, family practitioners who established a practice in St. John's whichexceeded a quota for that region developed by the province's Joint ManagementCommittee (JMC), were paid at 50Vo of the fee schedule. In May 1994, sixteen otherregions in the province became subject to this same fee proration. Existing physicianpractices were not affected. As of January 1997 , only one family practitioner hadestablished a position in St. John's that attracted the 507o pro-rating (personalcommunication, Jeff Young, January 1997), and that physician has since left the province.A number of other family practitioners had settled into specific situations in St. John's,without attracting pro-rated fees (e.g. salaried positions as emergency room physicians, orat psychiatric or cancer treatment facilities). Four family physicians jointly launched alegal challenge to this system in August 1994, but there was little action for a number ofyears and the case was considered dormant. In early 1998 the association representing theappellants appeared to be reviving the action, and a separate civil action was launched(Gushue, 1998); shortly thereafter (October 1998) the 507o fee proration policy for newphysicians locating in the St. John's area was discontinued as a result of negotiations withthe Newfoundland and Labrador Medical Association. At issue was the determination ofreasonable catchment areas; some of the small communities on the outskirts of St. John'swere caught within the policy, yet apparently had too few, or no, physicians. There iscurrently no fee prorationing being applied in the province.ln 1994, the province's Physician Resource Advisory Group (PRAG) (a subcommittee ofthe JMC) tabled a report which included recommendations for a'points'system not unlikethat recently halted by the Waldman judgement in B.C. It would have involved theaccumulation of points for service in rural areas, toward the eventual granting of anunrestricted 'billing number'. The proposal involved a combination of fee incentives (up to30Vo premia for practice in certain areas) and disincentives (reductions of up to 257o infees paid to practices in well-supplied areas such as St. John's), and points accumulationwhich would eventually entitle a physician to 1007o fees irrespective of practice location(Squires, 1996; PRAG, 1994). While most of the PRAG recommendations were acceptedby the government in principle, the proposal was never adopted by the province, and thePRAG appears to have disintegratedin 1997 (allegedly in part due to frustration amongmembers of the medical profession who served on PRAG at the lack of progress towardimplemented certain recommendations which they considered of utmost importance(Gushue, 1997)).In recognition of the fact that some sparsely populated regions cannot support a fee-practice physician, the government has come to rely rather more heavily than otherprovinces on salaried positions. A t994 report suggested that approximately 347o of allthe province's physicians were at that time salaried, and 5L7o of those located in ruralareas were paid by salary (Reamy, n.d. 1994). The province has recently increased ruralphysician salaries substantially (Gray, 1998a). Because of its particular difficulties withr06providing physician services in rural and remote areas, this province has relied, andcontinues to rely, heavily on FMGs. It has been estimated that as many as 407o of allphysicians in the province were trained outside Canada, and the proportion in rural regionsis likely even higher (Reamy, n.d.1994, citing data from the National Physician Database).Subject to meeting the licensure requirements of the Newfoundland Medical Board,foreign medical graduates are eligible for provisional licenses. These licenses require thephysician to have a sponsor (e.g. a regional health board) and are only issued ingeographic and/or specialty situations where it has proven impossible to recruit aCanadian physician. Such provisional licenses are subject to annual renewal/review.Foreign graduates who have been out of practice for more than two years and who wouldnot otherwise be eligible for provisional licensure, may be assessed through the recentlydeveloped Clinical Skills Assessment and Training Program (CSATP) run by MemorialUniversity's Faculty of Medicine (Gray, 1998b). Up to six months training can beprovided to assist the physician to meet license requirements following this assessment.Under the terms of a recently ratified "Micro Allocation Agreement" (Newfoundland,1998), physicians providing on-site primary care emergency coverage in category Afacilities (those offering full-time specialist services) are paid $71-$88/hr (depending onwhether the physician had office practice overhead expenses; emergency room physiciansget $71; community gps get $88) for twelve hour on-call shifts. The language of thecurrent agreement reads that this sessional arrangement "will continue to be available".Our understanding is that physicians can determine, at the conclusion of each shift,whether to take the on-call hourly payment, or stick with their fees for services providedduring the shift. In other words, the hourly rate is intended to establish an income floorper shift to reflect the need to be on-call. Fee-for-service gps providing on-call coveragefor other 24-hour emergency facilities (smaller acute care facilities, or health care centres,designated as category B facilities), may bill $10/hr (increasing to $15/hr next year) overand above any fees billed during the on-call period.Physicians engaged in 'escort duty' (i.e. accompanying a patient by (air or ground)ambulance to a health care facility) receive supplementary remuneration for that service.In situations where a salaried physician is required to fill in for another salaried physicianwho, however, is receiving a higher salary, the former receives remuneration at the rate ofthe latter, for the entire period of fill in. The Department has, in the recent past, alsofunded four locum positions to allow salaried physicians to take educational and otherleave that they accrue. Because of difficulty staffing these positions, this is not offered atpresent. The Department provides compensation for additional workload resulting fromvacancies (through payment of part of the salary from the vacant positions to thosesalaried physicians remaining in the group, where the group is composed of four or fewerphysicians, and the vacancy extends beyond 7 or 14 days; Squires (1996)). It also beganpaying isolation bonuses of $10,000 to $20,000 in 1997. These Rural Salaried PhysicianRetention (RSPR) bonuses are payable after two years'service in a designated rural area,with the level depending on relative isolation. For other details of the newly introducedretention bonuses for gps and specialists, see Newfoundland (1998).107Subsequent to the introduction of the RSPR bonus, a second rural recruitment incentiveprogram was established to supplement the incomes of physicians providing service in arural community designated eligible for the RSPR bonuses. This additional program, theRural Salaried Physician Geographical Supplement, provided annual supplements rangingfrom $15,600 to $31, 200, depending on the isolation of the area (personalcommunication, Keith Dyer, September 1998). This program was, however, recentlyterminated. In addition, the government has recently struck an agreement wherebymilitary medical personnel could provide necessary care in some cornmunities which wereunable to find civilian sources of physician services (Tompkins, 1998).There are also many areas of the province without adequate, or any, local specialistservices. Between ten and fifteen specialists ayear, upon Departmental approval, mayreceive a guaranteed annual income for the first year of practice, as well as a one-monthpayment advance (the latter to be recovered from future income), if they are prepared topractice in designated areas.As in most provinces with medical schools, a wide variety of education-related initiativeshave been developed, although Newfoundland appears to have done more than otherprovinces in its attempts to 'reach into the rural communities' for potential rural physicians.In 1990, the Memorial University Faculty of Medicine began "MedQuest", which providesthe means for rural area high school students to go to Memorial University for a weekduring the summer for an orientation to the health professions (including medicine). Themedical school also runs a rural outreach program which provides information to studentsin rural areas, and physicians from rural communities participate in high school careerdays.All Memorial medical students spend two weeks in a rural practice during their first yearof medical training, and complete a four week rural family practice rotation (usually withinthe province) in each of third and fourth year. In the third and fourth years there are alsoeight and four week electives, respectively, which can be in any specialty or locationapproved by the undergraduate education office. Some students use these opportunitiesto receive additional rural practice exposure. All family practice residents spend at least16 weeks in a rural family medicine rotation. Residents who choose the Northern Optionenroll in the Northern Family Medicine Education Program (NorFaM) and spend 7 monthsbased in Goose Bay, Labrador (Gray, 1997). As well, residents can complete a number ofrural rotations in disciplines such as obstetrics (twelve weeks), paediatrics, generalsurgery, internal medicine and orthopaedics in secondary care centres (defined ascommunities with fewer than 25,000 people).In a 1995196 pilot project, seven additional students were admitted to the enteringMemorial class under the condition that they pay a higher-than-usual tuition, with theunderstanding that if they ended up settling in an underserved area, these additional feeswould be reimbursed. V/ith similar intent but a different target, approximately fivepositions that could be used by provisionally registered physicians to 'train-up' to fullr08licensure were made available with return-of-service conditions. Both programs havesince been discontinued.As of 1995, the Newfoundland Department of Health increased bursaries from $12,500 to$20,000 per year for six students for their second, third, and fourth years of medicalschool, in return for which the students had to undertake to provide service as a familypractitioner in a designated rural area. Students who accepted these bursaries wereobligated to sign a contract with a health care board agreeing to one return-of-service yearfor each funded year. Each year various boards were designated to sponsor studentsunder the program. Students who failed to complete their commitments (through failureto graduate, to complete a family medicine residency, or to complete the return of servicerequirement) were required to repay, on a pro-rata basis, all funds advanced to themalong with interest.As of spring 1998, the $20,000 per year undergraduate medical student bursaries wereincreased to $25,000 and redirected to the final year of family practice residency (with thesame year-for-year return-of-service expectation), through a new Medical StudentPractice Incentive Program.3e The program was fully subscribed for 1998/99 (personalcommunication, Keith Dyer, September 1998; April 1999),In addition, up to twelve bursaries of $12,500 per year are made available at any one time,to residents in their later years of residency training (seven of the twelve are designated forpsychiatry), again with a year-for-year return-of-service commitment; and five out-of-province residency posts are available, through the province's Travelling FellowshipProgram, for students who wish to receive specialty or sub-specialty training not offeredat Memorial University (Squires, 1996; personal communication, Jeff Young, January1997). Most residents taking advantage of these two programs have completed theservice return (Paetkau, 1999). Additional funding in 1999-2000 will increase thesebursaries to $17,500 per year.Memorial University has also recently been involved in developing pilot projects intendedto establish primary care service and teaching units in small communities. These serviceand teaching units are multidisciplinary in nature, and are intended to extend thecapabilities of solo practitioners in these communities. The University also maintains anoffice for professional development that coordinates continuing medical educationinitiatives and opportunities. The Centre for Nursing Studies established a nursepractitioner program for experienced registered nurses in 1997 (Gray 1998a); the provincehas since passed legislation permitting graduates to meet some of the rural/remote areaprimary care needs. (personal communication, Keith Dyer, April 1999). Twelve graduatesof the program's first (1997198) intake are already practicing in eight communities aroundthe province, and the program has thirteen students currently enrolled.3e Discussions are cunently underway, however, about re-establishing undergraduate $20,000 bursariesfor 4th year medical students.109The Newfoundland/LabradorHealth and Community Services Association employs acentral recruiter among whose responsibilities is the coordination of physician recruitmentfor "Board positions". Among the sponsored activities is an annual informal networkingand social event intended to facilitate dialogue between Boards and postgraduate trainees.In August 1998, the Mnister of Health and Community Services established a new adhocPhysician Recruitment Co-ordinating Committee to advise on matters related to physicianrecruitment. The Committee's mandate included monitoring physician recruitment needsfor each region of the province, developing programs to enhance regional recruitment, co-ordinating provincial and regional recruitment activities, and maintaining contact withmedical students as they work their way through their medical training (personalcommunication, Keith Dyer, 1998). This committee reported to the Minister in early1999.Communications technologies are used extensively in the province, for both education andcare provision.ll0Appendix LLThe Northwest TerritoriestllThe Northwest TerritoriesThe Nothwest Territories are charactenzed by small populations widely scattered acrossmostly very small communities (only a few centres with more than 2000 residents, manyquite isolated, and accessible only by air). In such circumstances it is not feasible toattempt to have physicians available in every community. Instead the Territories havemaintained a different model of primary care, centred around the community health nurse.In the larger communities with populations between 2,300 and 17,000, the physician is theentry point for primary care. In the smaller communities, a health "team", comprised ofnurses, dental therapists, aboriginal health workers, and interpreters, among others,provides the source of first health care contact. The teams work out of health centres,which are equipped with basic laboratory and x-ray facilities and which stock a smallselection of pharmaceuticals to deal with emergency needs. The nurses provide routineand emergency services, including outpatient treatment, and public health services such ascommunicable disease control. They are also responsible for managing chronic conditions,and for health promotion. They consult with physicians based in regional centres (or theassigned settlement physician where available) as required. Consultation is by telephone,and the Department of Health has developed guidelines which are used to ascertainwhether patients require air med-evac.In addition, the Territories rely on a number of models of 'rotating physicians'. Mostcommunities will receive a visit from a primary care physician at least once every 6 weeks,some more often. Each region of the NWT either has some resident physicians, who arerequired to serve a number of communities under agreement with a regional or hospitalboard, or contracts for physician services. For example, the Keewatin region has a long-standing agreement, and contracts, with the University of Manitoba's Northern MedicalUnit (NMU; see discussion under Manitoba, Appendix 4). Under the terms of thiscontract, two physicians are based in the Churchill Health Centre in Northern Manitoba,and one in the NWT at Rankin Inlet. These physicians are recruited, and funded, by theNMU. The Kitikmeot region contracts with Yellowknife for two of its westerncommunities, with the other three communities being serviced by a regional physicianbased in Cambridge Bay. The Baffin region receives specialist services (other than thoseprovided by a general surgeon based at the regional hospital) through contractanangements with McGill University in Montreal, and with the Clarke Institute (forpsychiatry). Under these arrangements, specialists make pre-arranged annual visits to holdclinics at the hospital or to visit the communities in the region, and they will often beaccompanied by residents who are thereby given exposure to conditions in thesecommunities. Under these arrangements, specialists make pre-arranged annual visits tohold clinics at the hospital or to visit the communities in the region, and they will often beaccompanied by residents who are thereby given exposure to conditions in thesecommunities.tt2Health and social services boards are responsible for physician 'staffing' where there is noprivate clinic or where the boards supplement existing physician resources. In suchsituations, they provide (resident or visiting) primary care and consultant services for thecommunities for which they are responsible. Services in smaller communities are providedthrough a combination of rotating visits by physicians, and arrangements to bring patientsfrom the most isolated communities to the locations where physicians visit, or are resident.Many communities in which there are resident physicians are vulnerable because of thelack of relief for those physicians. In addition, many of the physicians with general surgeryskills are nearing retirement age, and no new recruits are presently 'on the horizon'.Virtually all specialist services are concentrated in the capital (Yellowknife), and patientsare still sent south when the necessary expertise, or complementary clinical facilities, arenot available.In terms of initiatives to improve the supply and distribution of physicians in theterritories, there is a rather limited set of policy levers available to them. Many of thecommunities do not have sufficient populations to support two physicians, yet one wouldfind the on-call an impossible burden without regular relief. The physician in smallTerritories'communities is called on to play many roles (from back-up to local healthteams, to involvement in health education medevac, audit, and even development ofclinical guidelines). Communities have a very limited fiscal base from which to attempt todevelop financial incentives (and based on experience in the rest of the country, thesewould not likely be particularly effective in the far north). More regulatory/administrativepolicies would likely have the effect of reducing the overall supply of physicians in theTerritories. However, the regional rotation model, providing physician support forcommunity health nurses, appears to serve the Tenitories'needs relatively well.The Territories are innovating in their approaches to recruiting, but it is too soon to knowhow effective new initiatives will be. For example, the Baffin Regional Health and SocialServices Board plans mail-outs to all physicians in the country who have graduated in thepast2-3 years, particularly targeting provinces such as Alberta which have seen relativelysignificant recent constraints on or reductions in funding for physician services. A numberof boards also have long-standing arrangements in place whereby medical students andresidents at the Universities of Alberta, Calgary and Manitoba, as well as McGillUniversity, can gain experience with practice in the north. As of late 1996, these hadapparently had little, if any, effect on subsequent recruitment (personal communication,Margaret Dunn, November 1996).As of 1996, Stanton regional hospital was employing funding from the TenitorialDepartment of Health and Social Services to pay the salaries of residents prepared toprovide return in service. In other regions, such as Inuvik, the medical directornegotiated with a teaching hospital (traditionally in Alberta) to provide training/exposurestailored to the region's hospital and service mix.113The NWT Medical Association has a physician education fund, financed by theDepartment of Health and Social Services, which provides funding for physicians seekingadditional training, provided the applicants have been practicing in the NWT for at leasttwo years.There is a general loan relief program administered by the Territories'Department ofEducation, Culture and Employment, available to students who return to the Territories tolive after completing their university or college training (irrespective of discipline). This isaccessible to medical students who return to set up practices in the Territories.The Department of Health and Social Services has recently developed a new recruitmentand retention strategy in response to critical staffing shortfalls and high turnover inmedicine, nursing and social work. This strategy includes:I a recruitment officer available to all boards to address immediate staffingshortages;o the creation of a common locum/relief pool accessible to all boards;I conducting a workload analysis to surface short and long-term problems;I the development of standard physician contracts so as to avoid inter-regionaland inter-personal competition ;I strategies to encourage more Northern residents to study in the health andsocial services areas; strategies include scholarships, employmentopportunities, and mentorship.Lt4Appendix L2Yukon Territory115Yukon TerritoryLike the NWT, the Yukon's policies are less dependent on a physician-centred primarycare model. In Whitehorse, where approximately two{hirds of the Yukon populationresides, primary care is delivered by physicians. Outside of Whitehorse, primary care isdelivered by a variety of combinations of extended-role nurses and family physicians.Approximately 30Vo of communities outside Whitehorse have resident physicians.The Yukon developed a physician resource plan (PRP) in 1995), and a regulation underthe 1994 Health Care Insurance Plan Act sets out the terms and conditions under whichnew physicians may enter practice in the territory. The central feature of the regulation isa financial disincentive amounting to the payment of 507o prorated fees to any physicianwho is not granted I00Vo billing privileges by the physician resource planning committee(PRPC).Under this regulation and Plan, any new physician applying to practice in the Territory ispaid 5070 fees unless (s)he receives PRPC approval for a 1007o number (Yukon, 1994).Routine exceptions include certain locum arrangements, when a physician can demonstratethat he/she has special skills or attributes needed in the territory, and the temporary orpermanent replacement of a physician. Fee-for-service physicians with 1007o billingnumbers at the time the policy was put in place have full intra-territorial mobility. Butnew physicians granted 1007o billing numbers for communities outside Whitehorse do notthereby gain the right to move to Whitehorse and carry that full-pay number with them.Under the terms of the Plan, consideration is given to adding a 1007o fees physician in theTerritory if the population increases by at least 836, or if there are significant changes inthe physiciansÆTEs ratio (which would signify a change in active status of some of thepracticing physicians in the Territory). All applications, even in situations of permanentreplacement, are reviewed by the PRPC.In addition, the Territory periodically makes contractual anangements whereby aphysician will provide service to a particular community (and that community only).Physicians practicing outside Whitehorse receive $1,000 annually to offset higheroverhead costs, and some physicians are able to make office space arrangements withingovernment health care facilities.General/family practitioners and some specialists based in Whitehorse also haveresponsibilities to visit outlying communities, as needs may dictate. Included in thephysician supply based in Whitehorse are specialists in paediatrics, general surgery, andobstetrics/gynaecology. A number of the gps in the Territory have developed special skillsin certain areas (e.g. anaesthesiology, obstetrics, ophthalmology). The remainder ofspecialist care is provided by specialists from outside the Territory (mostly Vancouver)who make periodic visits to communities in need. 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(1997) "Incentive moves Alta. Doctors to fill rural spots" Medical Post33(6):38.Walker, R. (1998) "'Scouring the world'to find physicians for rural Alberta" Medícal Post3aQ):68.Wanamaker, G. (1998) "Spring of discontent looming for Quebec FPs", Family Practice10(9):14.Watt IS, AJ Franks and TA Sheldon (1993) "Rural health and health care", British Med J306:1358-9.Watt IS, AJ Franks and TA Sheldon (L994) "Health and health care of rural populations inthe UK: is it better or worse?" Journal of Epidemiology and Comrnunity Health 48:16-21.Whiteside C and R Mathias (1996) "Training for Rural Practice: Are graduates of a UBCprogram well prepared?", Canadian Family Physician 42(June):I II3-ZL.Whiteside C (1996) "Regional Review - Focus on British Columbia", paper submitted tocanadian Journal of Rural Medicine, UBC: Department of Family Practice.Woodhead-Lyons SC (1993) "The Rural Physician Action Plan: A Summary of Alberta'sInitiatives", presented at Redressing the Imbalance: Health Human Resources in Ruraland Northern Communities Conference,Thunder Bay, Ontario, October.World Organization of Family Doctors (WONCA) (1995), Policy onTrainingfor RuralPractíce, Melbourne, Australia: WONCA.lVright DS (1985) Factors Influencing the Location of Practice of Residents and Internsin British Columbia: Implications for Policy Making, M.Sc. thesis, Department of HealthCare and Epidemiology, Vancouver: University of British Columbia.Xu G, J. Veloski, M Hojat, RM Politzer, HK Rabinowitz and SL Rattner (1997) "FactorsInfluencing Primary Care Physicians'Choice to Practice in Medically Underserved Areas",Acad Med 72(10):5 109-5 1 1 1.t33Yukon (1994) Memorandum of understanding between the Minister of Health and SocialServices and the Yukon Medical Association for Development of a Physician ResourcePlan, unpublished.134Health Human Resources UnitCentre for Health Services and Policy ResearchThe University of British Columbia#429 - 2194 Health Sciences MallVancouver, BC V(Î lZ3rerePhone: iffirï;lï,iwebsite: www.chspr.ubcca/Some of the early reports may not be available for distributionHHRU 99:2 ROLLCALL TJPDATE 98. A Status Report of Selected Health Personnel in the Provinceof British Columbia. May 1999. ISBN l-894066-97-9. ISSN 0828-9360.HHRU 99:1 Regional Health Human Resources Planning & Management: Policies, Issues AndInformation Requirement January 1999. (A. Kazanjian, M. Herbert, L. Wood, S.Rahim-JamaD. ISBN t-894966-98-7 .HHRU 98:4 Proceedings of the SecondTrilateral PhysicianWorkforce Conference, November 14-16,1997, Vancouver. Derember 1998. (M.L. Barer, L. Wood). ISBN 1-894066-99-5.HHRU 98:3 PLACE OF GRADUATION 97. A Status Report on Place of Graduationþr SelectedHealth Personnel in the Province of British Columbia. August 1998.ISBN 1-896459-99-4. ISSN 1200_0701.HHRU 98:2 INVENTORY 97. A Regional Analysis of Health Personnel in the Province of BritishColumbia. June 1998. ISBN 1-896459-98-6.HHRU 98:1 ROLLCALL 97. A Status Report of Heatth Personnel in the Province of BritßhColumbia. July 1998. ISBN l-896459-97-8. ISSN 0707-3542.HHRU 97:4 Common Problems, Dffirent'solutions': Learningfrom International Approaches toImproving Medical Services Access for Underserved Populations. October 1997. (M.L.Barer, L. Wood). ISBN 1-896459-96-X. Also listed as Health Policy Research UnitReport IIPRU 97:12D.HHRU 97:3 INVENTORY UPDATE 96. A Regional Analysis of Heatth Personnel in the Province ofBritishColumbia. July 1997. ISBN 1-896459-95-1. ISSN 1196-9911.HHRU 97:2 ROLLCALL IJPDATE 96. A Status Report of Selected Health Personnel in the Provinceof Brítish Columbia. Júy t997. ISBN t-896459-94-3. ISSN 0828-9360.HHRU 97:1 PLACE OF GRADUATION 95. A Status Report on Place of Graduationfor SelectedHealth Personnel in the Province of British Columbia. April 1997.rsBN l-896459-93-5. rSSN 1200-0701.HHRU 96:5 INVENTORY 95. A Regional Analysis of Heatth Personnel in the Province of BritishColumbia. December 1996. ISBN t-896459-92-7.HHRU 96:4 PRODIICTION 95. A Status Report on the Production of Health Personnel in theProvinceof BritishColumbia. October 1996. ISBN l-896459-91-9. ISSN 1199-4010.HHRU 96:3 ROLLCALL 95. A Status Report of Health Personnel in the Province of BritishColumbia. October 1996. ISBN l-896459-90-0. ISSN 0707-3542.HHRU 96:2R ldentifying the Population of Health Managers in one Canadian Province: A Two-StageApproach. April 1996. (4. Kazanjian, N. Pagliccia). ISBN l-896459-89-7.HHRU 96:1R Key Factors in Physicians' Choice of Practice Incation - Level of Satisfaction andSpousal Influence. March 1996. (4. Kazanjian, N. Pagliccia). ISBN 1-896459-88-9.HHRU 95:6E Fee Practice Medical Services Expenditures Per Capita, and Full-Time-EquivalentPhysicians in British Columbia, 1993-1994. December 1995. (A. Kazanjian, P. WongFung, L. Wood). Only available in an electronic format at: www.chspr.ubc.calfeepract/.HHRU 95:5R The Impact of Professional and Personal Satisfoction On Perceptions of Rural andUrban: Some Analytic Evidence. December 1993. (N. Pagliccia, L. Apland, A.Kazanjian). ISBN l-896459-87-0.HHRU 95:4 PRODUCTION UPDATE 94. A Status Report on the Production of Selected HealthPersonnel in the Province of British Columbia. May 1995, ISBN 1-896459-86-2.ISSN 1199-4010.HHRU 95:3 Health Personnel Modelling 1975-1994: An Updated Bibliography with Abstracts.March 1995. (N. Pagliccia, K. McGrail, L. Wood). ISBN 1-896459-85-4.HHRU 95:2 INVENTORY UPDATE 94. A Regional Analysis of Health Personnel in the Province ofBritishColumbia. March 1995. ISBN l-896459-84-6. ISSN 1196-9911.HHRU 95:1 ROLLCALL UPDATE 94. A Status Report of Selected Health Personnel in the Provinceof BritishColumbia. March 1995. ISBN l-896459-83-8. ISSN0828-9360.HHRU 94:5 PLACE OF GRADUATION 93. A Status Report on Place of Graduationfor SelectedHealth Personnel in the Province of British Columbia. October 1994. (K. McGrail, K.Kerluke, A. MacDonald, L. Wood). ISBN l-896459-82-X. ISSN 1200-0701.HHRU 94:4 PRODUCTION 93. A Status Report on the Production of Health Personnel in theProvince of BritishColumbia. August 1994. ISBN 1-896459-81-1. ISSN 1199-4010.HHRU 94:3 ROLLCALL 93. A Status Report of Health Personnel in the Province of BritishColumbia. May 1994. ISBN 1-896459-80-3. ISSN 0707-3542.HHRU 94:2 Interpreting the Historical Dfficult+o-Fill Vacancy Trends - A Multivariate Analysis.April 1994. (N. Pagliccia, A. Kazanjian, L. Wood). ISBN 1-896459-79-X.HHRU 94:1 Social Work Personnel in British Columbia: Defining the population and describingdeployment patterns in i,993. January 1994. (J. Finch, A. Kazanjian, L. Wood).rsBN l-896459-78-1.HHRU 93:8R Health Care Managers in British Columbia Part I: Who Manages Our System?, Part II:Exploring Future Directions. December 1993. (4. Kazanjian, N. Pagliccia).ISBN l-896459-77-3.HHRU 93:7 Fee Practice Medical Services Expenditures Per Capita, and Full-Time-EquivalentPhysicians in British Columbia, I99l-1992. December 1993. (4. Kazanjian, P. WongFung, L. Wood). ISBN l-896459-76-5.HHRU 93:6 Social Workers in Health Care in Brirish Columbia, l9gl Jluly 1993. (L.E. Apland,L. Wood, A. Kazanjian). ISBN l-896459-75-7.HHRU 93:5 Dfficuk-to-Fill Vacancies in Selected Health Care Disciplines in British Columbia,1980-/99i,. June 1993. (4. MacDonald, A. Kazanjian). ISBN I-896459-74-9.HHRU 93:4 ROLLCALL UPDATE 92. A Status Report of Selected Health Personnel in the Provinceof British Columbia. April 1993. ISBN 1-896459-73-0. ISSN 0828-9360.HHRU 93:3 Nursing Resources in British Columbia: Trends, Tensions andTentative Solutions.February 1993. (4. Kazanjian, L. Wood). ISBN 1-896459-72-2. Also listed as HealthPolicy Research Unit Report HPRU 93:5D.HHRU 93:2 Nursing Resources Models: Part I: Synthesis of the Literature and c¿ Modelling Strategyfor B.C. February 1993. (N. Pagliccia, L. Wood, A. Kazanjian). ISBN l-896459-71-4.HHRU 93:1 Study of Rural Physician Supply: Perceptions of Rural and Urban. January 1993.(N. Pagliccia, L.E. Apland, A. Kazanjian). ISBN l-896459-70-6.HHRU 92:8 Diagnostic Medical Sonographers in British Columbia, /,99/,. December 1992.(L.8. Apland, A. Kazanjian). ISBN l-896459-69-2.HHRU 92:7 Fee Practice Medical Service Expenditures per Capita, and Full-Time-EquívalentPhysicians in British Columbia, i,989-i,990. November 1992. (A. Kazanjian, P. WongFung, M.L. Barer). ISBN l-896459-68-4.HHRU 92:6 PLACE OF GRADUATION 9l,. A Status Report on Place of Graduationfor SelectedHealth Personnel in the Province of British Columbia. November 1992,(4. MacDonald, K. Kerluke, L.E. Apland, L. Wood). ISBN 1-896459-67-6.ISSN 1200-0701.HHRU 92:5R Health "Manpower" Planning or Gender Relations? The Obvious and the Oblique. June1992. (A. Kazanjian). ISBN 1-896459-66-8.HHRU 92:4R A Human Resources Decision Support Model: Nurse Deployment Patterns in OneCanadian System. November 1992. (A. Kazanjian, I. Pulcins, K. Kerluke).ISBN 1-896459-65-X.HHRU 92:3 PRODUCTION 91. A Status Report on the Production of Health Personnel in theProvince of British Columbia. May 1992. ISBN 1-896459-64-1. ISSN 1199-4010.HHRU 92:2 ROLLCALL 9l . A Status Report of Health Personnel in the Province of BritishColumbia. May 1992. ISBN 1-896459-63-3. ISSN 0707-3542.HHRU 92:1 Information Needed to Support Health Hutnan Resources Management February 1992.(4. Kazanjian). ISBN l-896459-62-5.HHRU 91:4R A Single Stochastic Model For Forecasting Nurse Supply and For Estimating Life-CycleActivity Pauerns. May 1991. (4. Kazanjian). ISBN l-896459-61-7.HHRU e1:3 :f;":,#:"i::î::#*"f ij;lî,tü'i"{f;líi:l,i:'i!,ií';;#;!u::o'* provinceHHRU 91:2 Study of Rural Physician Supply: Practice Location Decisions and Problems inRetention. Volume /. March 1991. (4. Kazanjian, N. Pagliccia, L. Apland, S. Cavalier,L. Wood). ISBN 1-896459-59-5.HHRU 91:l Registered Psychologists in British Columbia, |,990: A Status Report March 1991.(C. Jackson, L. Wood, K. Kerluke, A. Kazanjian), ISBN l-896459-58-7.HRU 90:7 Pløce of Graduationfor Selected Health Occupations - 1989.(HMRU 90:7) November 1990. (S. Cavalier, K. Kerluke, L. Wood). ISBN l-896459-57-9.HHRU 90:6 Health Managers in B.C. Part II: Who Manages Our System? - Sociodemographic(HMRU 90:6) Charqcteristics, Employment Patterns, Educational Background and Training of HeatthManagers. June 1990. (A. Kazanjian, C. Jackson, N. Pagliccia). ISBN l-896459-56-0.HHRU 90:5 Health Personnel Modelling: A Bibliography With Abstracts.(HMRU 90:5) June 1990. (N. Pagliccia, C. Jackson, A. Kazanjian). ISBN l-896459-55-2.HHRU 90:4 PRODUCTION 89. A Status Report on the Production of Health Personnel in(HMRU 90:4) the Province of British Columbia. March 1990. ISBN l-896459-54-4.ISSN 1199-4010.HHRU 90:3 ROLLCALL 89. A Status Report of Health Personnel in the Province of British(HMRU90:3) Columbiq. March 1990. ISBN l-896459-53-6. ISSN 0707-3542.HHRU 90:2 Proceedings of the Workshop on Priorities in Health Human Resources Research in(HMRU 90:2) canada. March 1990, (4. Kazanjian, K. Friesen). ISBN t-8964s9-s2-8.HHRU 90:1 Nurse Deploymenl Patterns: Examples for Health Human Resources Management.(HMRU 90:l) February 1990. (4. Kazanjian, I. Pulcins, K. Kerluke). ISBN 1-896459-51-X.HHRU 89:4 Providers of Vision Care in British Columbia: A Report on the Status of(HMRU 89:4) Ophthalmologists and Optometrists, and On the Iltilization of Ophthatmological andOptometric Services, i,975-l,988. July 1989. (I. Pulcins, P. Wong Fung, C. Jackson,K. Keduke, A. Kazanjian). ISBN 1-896459-50-1.HHRU 89:3 Fee Practice Medical Service Expenditures Per Capita, and Full-Time-Equivalent(HMRU 89:3) Physicians in British Columbia, 1987-88. August 1989. (4. Kazanjian, P. Wong Fung,M.L. Barer). ISBN 1-896459-49-8.HHRU 89:2 Health Managers in B.C. Part I: Methods and Preliminary Findings From Survey of(HMRU 89:2) Chief Executive Officers. July 1989. (4. Kazanjian, N. Pagliccia, C. Jackson).ISBN 1-896459-48-X.HHRU 89:1 ROLLCALL UPDATE 88. A Status Report of Selected Health Personnel in the Province(HMRU 89: l) of British Columbia. March 1989. ISBN l-896459-47-1. ISSN 0828-9360.


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