David R. Henderson  

Price Controls Cause Doctor Shortage in Canada

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So I used the Health Care Options Directory on the same government website.This allows you to plug in your postal code and find all family doctors listed within a certain radius. It is a particularly soul-destroying experience.

The opening page lists no names or phone numbers, just the number of doctors at each address. It takes more clicks to get the contact information. And after you go through those steps and make the calls, you find that none of the doctors are accepting patients.

I phoned all 84 doctors who were listed as practising within 10 kilometres of my home. Some of their receptionists were polite. Some were surly. All rejected me.

This is from Gloria Galloway, "The Soul-Destroying Search for a Family Doctor," Globe and Mail, August 21, 2011. Read the whole thing.

The one part that surprised me was this:

Then I found another Web-based service called HealthAware.ca. It allows you to search for doctors who are accepting patients. Skeptical, I gave it a try. Lo and behold, there was a doctor listed at a clinic called ExecHealth located right behind my office. Hallelujah!

When I called I was directed to their marketing department. And yes, said the man on the other end of the line, they would be glad to take me as a patient. For $3,000 a year. I actually gave it some thought before declining the offer.

As I have understood Canada's single payer system, it is one in which the government is the only payer: thus the word "single." But it sounds as if Ms. Galloway could have had a doctor for $3,000 a year. Does this mean that the clinic was breaking the law? Or does it mean that, possibly in response to the Chaoulli v. Quebec decision in 2005, things are loosening up? If the latter, I wonder what the other terms of the deal were. Was it like concierge care? Was one guaranteed up to x number of visits per year?

See here for an earlier discussion.

HT to Pierre Lemieux.

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COMMENTS (13 to date)
Karen Selick writes:

The CCF recently had an inquiry from an Ontario pediatrician who was facing disciplinary proceedings because she also operated a separate facility that provided supplementary health services for parents and babies, for an annual membership fee. Pursuant to the Medicine Act regulations, she could have faced revocation of her medical licence. She caved and shut down her supplementary business.

My guess is that the firm mentioned in the Globe article might be located in Quebec, or is just flying under the radar at the moment (i.e. nobody has yet thought to complain to the College of Physicians & Surgeons).

David MacRae writes:

It is legal in Canada for a doctor to have a private practice. However, there are several severe restrictions. The two most important probably are:

1) No kind of health insurance is not allowed. All payments must be in cash.
2) The doctor may not take any Medicare patients. He or she must work entirely outside the system.

The case Karen Sellick cites is one in clear violation of the second regulation. Given the facts as stated, it is possible that ExecHealth is operating legally although, as Karen says, it certainly could simply be flying under the radar. In any case, it seems to be located in Ontario and Chaoulli v. Quebec only applies to Quebec.

Steve Roth writes:

Did you see any mention of price controls in that article? I missed them.

Isn't it equally likely that family doctors aren't paid as well as specialists, as is true in the U.S.?

And as a result there's a shortage of family doctors in some areas, as there is in the U.S.?

Is it also possible that it's partially a result of a shortage of medical schools and/or difficulty of foreign doctors getting work visas, as is the case in the U.S.?

Also from the article: "In 2010, 4.4 million Canadians, or 15 per cent of the population aged 12 and older, reported they did not have a regular medical doctor."

I wonder what the percentage is in the U.S. I'm guessing considerably higher.

"Of the Canadians without a doctor in 2010, more than 8 in 10 said they have a place they usually go when they need medical care or health advice. "

Is the number that high in the U.S.?

Of course any shortages in the U.S. would be Medicare's fault. That's just obvious, right? No need to think any deeper than that.

This is supposed to pass for an incisive critique?

Pierre Honeyman writes:

Steve, the price controls are an inherent part of the Canadian medical system. The Provincial governments determine how much money goes into their respective health care systems (funded partially, but not entirely, from Federal transfers) and most, if not all, Provinces determine Physician's fees - on a per service basis, in B.C. Unlike an uncontrolled system, the pool of money available for health care is fixed per unit time - typically one year - independent of the actual demands for services in that same unit of time. In times of high demand that fact alone practically guarantees shortages, and, in Canada, shortages there are. Not just shortages of family doctors, that's just the shortage du jour.

I got sick in South Africa, Johannesburg, and I had to use their system, and use it on a purely private basis. I was able to get two housecalls to my hotel, from two different physicians. I got a clinic visit, for free - because the physicians were unable to diagnose my problem - and a referral to a neurologist.

Now, the absolutely amazing thing to me, as a Canadian, is that I saw the neurologist within 3 hours of making the appointment. This occurred in 2000, and I am only half-joking when I joke that if my illness had occurred in Vancouver, I'd still be waiting to see the neurologist. The serious answer is that I would have had to wait many months to see a neurologist for a condition that was not immediately life-threatening in Canada.

Which brings up another point, one which David has brought up before: wait times make life in Canada absolutely miserable if you're waiting for necessary, but laughably referred to as elective, surgery, or if you have to wait for tests. I was sent to have an echocardiogram for a heart murmur. From a physician friend, the recommended maximum wait time for an echocardiogram, based on an asymptomatic murmur, is 1 week. My wait time was just over 3 months. That's 3 months of anxiety, thanks to Canada's "free" healthcare. My brother was injured at work and needed an MRI. His wait time, for just the MRI, was 13 months.

So he had his MRI privately, since he was in agony. He definitely violated the spirit of the law to do this. Once his MRI results were back he was able to prove that his injury was work related, and thus he was able to bypass the waitlist for elective back surgery, and get the Worker's Compensation Board of BC to pay for his surgery at a private clinic (it's OK to jump queues if another government department foots the bill.)

But many, if not most, Canadians in need of pain relieving, life enhancing, necessary "elective" surgery have to wait. Years, sometimes. And while they wait, and wait, and wait, often their conditions - deteriorating spines, hips, knees, for instance - get worse, and worse, and worse. Often they end up on the Canadian Pension Plan's disability coverage, or on disability coverage from the jobs they used to be able to do, because they can no longer work. But, they wait.

I digress.

Canada's single payer universal health care coverage is the very definition of price controls. If there is only one payer, there is only one party with the ability to set prices.


kurt writes:

But the shortage is not across Canada I guess? It's probably harder to operate a profitable practice in some rural area than in the urban areas of Toronto or Vancouver, where you are almost guaranteed patients with the right kind of reimbursement rates.

Kyle writes:
As I have understood Canada's single payer system, it is one in which the government is the only payer: thus the word "single."

I actually correct people when they say that to me. Canada's system has federal legal foundations, but it is administered and largely (66-75%) paid for on a provicial basis. The details of how the system work and even the benefits provided vary between provinces. Access and quality does as well.

For this reason both whole-country statistics and individual anecdotes can be misleading.

Shangwen writes:

I'm a hospital administrator in Canada. I've visited many hospitals in the US and other countries and seen how they operate. I've also personally used US health care a number of times when I could not get care fast enough in Canada.

Whenever the government intervenes in health care, shortages arise; these are either shortages of availability (as in the article discussed), shortages of affordable care (because prices are distorted by monopolies and public-choice dynamics), shortages of affordable insurance (as in the US), or shortages of valuable information about the quality of care and where to access it. I do not buy the argument that Arrow's information asymmetry theory applies universally to health care systems. Yes, he won the Nobel and I did not, but I think technology could bypass much of the asymmetry if the system was less regulated.

There is one great way to get better service out of the Canadian health care system: get a job in it. When my father was very ill, I got him into a specialist in three days, bypassing the normal 12-month wait (he would have been dead or in severe distress by then), and I know lots of people who do the same. Regular folks occasionally try this by complaining loudly to politicians, whereupon they are deemed troublemakers (for impersonating a civil servant??). I agree that is wrong for all kinds of reasons, but getting quicker care for my dad was the morally right thing to do. As I like to tell staff when we are discussing quality, "just because you work for the government doesn't mean you have to act like it."

Unfortunately, the great romance about public health care is about as inspiring as a Soviet-era bread line-up.

Pierre Honeyman writes:


I live in Vancouver. Wait times, and shortages of family physicians, make your health care experience a thing of misery here.


Shangwen writes:

Kurt (via Pierre):

Rural doctors are typically provided with stipends or other incentives to try and increase availability of services in rural areas. As a result, there are many services that are actually more readily available than in urban areas (usually those not dependent on sophisticated technology).

luispedro writes:

But in Canada, there are no uninsured!

(only partially tongue-in-cheek)

Methinks writes:

Unfortunately, the great romance about public health care is about as inspiring as a Soviet-era bread line.

Speaking of which, I was gravely ill for several years in the Soviet Union before immigrating to the West. My uncle was a high ranking military surgeon and I got into the right hospitals and to the right doctors. But for him, I would have died.

Now, that uncle and his wife (also a surgeon) live in Canada and I've learned from their experience the horror of that system. The wait times for something as simple as an MRI is ridiculous.

My aunt had symptoms that could have meant kidney cancer. After waiting 12 hours in the ER, she was told that they have an MRI, but no technician and no idea when one would arrive. They advised she find her own MRI facility. After much searching, she found one several hours from Toronto with only a 4 week wait. Upon arrival, she found something that could have been plucked from a Soviet era clinic. No computers, but the posters on the wall begged for mercy from the patients as it was not the staff's fault the conditions are bad - they appealed to the Canadian government and were turned down for equipment. The MRI was done, but the guy who reads it is on a rotating schedule and won't be back for two weeks. Two weeks later, she found out it wasn't cancer, but she needed surgery. Three months later she was able to see a urologist. Four weeks after that, surgery. The whole time (months!) she was on pain killers that would have prevented her from working were she not retired.

A friend in California had exactly the same thing and he his whole process from start to finish took less than two weeks.

The loss of productivity from such a hideous system is astounding. The pain and suffering is intolerable.

Angus MacAskill writes:

I'm a young Canadian without a regular doctor: I go to walk-in clinics whenever I need anything, which is not often. But my parents have been after me to get a family doctor who knows my medical history, so I tried signing up for the province of Ontario's "Health Care Connect" program, which is supposed to help you find one.

The process involved visiting a website and providing my mailing address. Several weeks later, I received a letter by mail stating that a "Care Connector" was working on my case. This is someone employed by the province of Ontario who calls doctors on your behalf trying to find one who will accept you as a patient.

That was about six months ago. I have since received two separate letters stating that my Care Connector is still working (diligently I'm sure) toward finding me a doctor.

Meanwhile, I've kept looking on my own; according to the HealthAware website Ms. Galloway mentioned above, there are all of of two doctors accepting new patients within a 12-mile radius of the major urban area where I live. One of those is asking a $2500 annual fee. The other is taking no appointments until October.

I heard that in some industries, people actually want customers.

Methinks1776 writes:

I heard that in some industries, people actually want customers.

In fairness, those are industries without price controls.

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