[Show abstract][Hide abstract] ABSTRACT: There is a widespread perception that the increasing proportion of female physicians in most developed countries is contributing to a primary care service shortage because females work less and provide less patient care compared with their male counterparts. There has, however, been no comprehensive investigation of the effects of primary care physician (PCP) workforce feminization on service supply. We undertook a systematic review to examine the current evidence that quantifies the effect of feminization on time spent working, intensity and scope of work, and practice characteristics. We searched Medline, Embase, and Web of Science from 1991 to 2013 using variations of the terms 'primary care', 'women', 'manpower', and 'supply and distribution'; screened the abstracts of all articles; and entered those meeting our inclusion criteria into a data abstraction tool. Original research comparing male to female PCPs on measures of years of practice, time spent working, intensity of work, scope of work, or practice characteristics was included. We screened 1,271 unique abstracts and selected 74 studies for full-text review. Of these, 34 met the inclusion criteria. Years of practice, hours of work, intensity of work, scope of work, and practice characteristics featured in 12%, 53%, 42%, 50%, and 21% of studies respectively. Female PCPs self-report fewer hours of work than male PCPs, have fewer patient encounters, and deliver fewer services, but spend longer with their patients during a contact and deal with more separate presenting problems in one visit. They write fewer prescriptions but refer to diagnostic services and specialist physicians more often. The studies included in this review suggest that the feminization of the workforce is likely to have a small negative impact on the availability of primary health care services, and that the drivers of observed differences between male and female PCPs are complex and nuanced. The true scale of the impact of these findings on future effective physician supply is difficult to determine with currently available evidence, given that few studies looked at trends over time, and results from those that did are inconsistent. Additional research examining gender differences in practice patterns and scope of work is warranted.
[Show abstract][Hide abstract] ABSTRACT: About 3,600 Canadians are currently studying medicine abroad (CSMAs). Most hope to return to practise in Canada. But the road back is not easy. These graduates must complete postgraduate residency training in Canada and alas, there are less openings than there are aspirants. One might have thought, amid the endless rhetoric of "physician shortages," that an obvious solution would be to increase the number of residency positions. But provincial governments are well aware, even if the media are not, that Canada is in the early stages of a dramatic expansion in physician supply fuelled by increased domestic training capacity. Last time the physician supply outpaced population growth, as it is doing today, governments choked off the entry of international graduates. It could happen again.
[Show abstract][Hide abstract] ABSTRACT: ABSTRACT This article describes British Columbia's regulatory model for assisted living and used time series analysis to examine individuals' use of health care services before and after moving to assisted living. The 4,219 assisted living residents studied were older and predominantly female, with 73 per cent having one or more major chronic conditions. Use of health care services tended to increase before the move to assisted living, drop at the time of the move (most notably for general practitioners, medical specialists, and acute care), and remain low for the 12-month follow-up period. These apparent positive effects are not trivial; the cohort of 1,894 assisted living residents used 18,000 fewer acute care days in the year after, compared to the year before, their move. Future research should address whether and how assisted living affects longer-term pathways of care for older adults and ultimately their function and quality of life.
Canadian Journal on Aging / La Revue canadienne du vieillissement 05/2013;
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Laboratory testing is one of the fastest growing areas of health services spending in Canada. We examine the extent to which increases in laboratory expenditures might be explained by testing that is consistent with guidelines for the management of chronic conditions, by analyzing fee-for-service physician payment data in British Columbia from 1996/97 and 2005/06. METHOD: We used direct standardization to quantify the effect on laboratory expenditures from changes in: fee levels; population growth; population aging; treatment prevalence; expenditure on recommended tests for those conditions; and expenditure on other tests. The chronic conditions selected were those with guidelines containing laboratory recommendations developed by the BC Guidelines and Protocol Advisory Committee: diabetes, hypertension, congestive heart failure, renal failure, liver disease, rheumatoid arthritis, osteoarthritis and dementia.Result: Laboratory service expenditures increased by $98 million in 2005/06 compared to 1996/97, or 3.6% per year after controlling for population growth and aging. Testing consistent with guideline-recommended care for chronic conditions explained one-third (1.2% per year) of this growth. Changes in treatment prevalence were just as important, contributing 1.5% per year. Hypertension was the most common condition, but renal failure and dementia showed the largest changes in prevalence over time. Changes in other laboratory expenditure including for those without chronic conditions accounted for the remaining 0.9% growth per year. CONCLUSION: Increases in treatment prevalence were the largest driver of laboratory cost increases between 1996/97 and 2005/06. There are several possible contributors to increasing treatment prevalence, all of which can be expected to continue to put pressure on health care expenditures.
BMC Health Services Research 12/2012; 12(1):472. · 1.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Conventional wisdom holds that Canada suffers from a physician shortage, yet expenditures for physicians' services continue to increase rapidly. We address this apparent paradox, analyzing fee-for-service payments to physicians in British Columbia in 1996/97 and 2005/06. Age-specific per capita expenditures (adjusted for fee changes) rose 1% per year over this period, adding $174 million to 2005/06 expenditures. We partition these increases into changes in the proportion of the population seeing a physician; the number of unique physicians seen; the number of visits per physician; and the average expenditure per visit. Expenditures on laboratory and imaging services, particularly for the elderly and very elderly, have increased dramatically. By contrast, primary care services for the non-elderly appear to have declined. The causes and health consequences of these large changes deserve serious attention.
Healthcare policy = Politiques de sante 08/2011; 7(1):41-54.
[Show abstract][Hide abstract] ABSTRACT: Objective: To investigate the effect of workers' compensation policies related to expedited surgical fees and private clinic surgical setting on disability duration among injured workers.Methods: The study included 1,380 injured workers with knee meniscectomy between 2001 and 2005 in British Columbia. Using linked workers' compensation claim and surgery/clinical records, wait time for surgery (time from last surgical consult to surgery) and time from surgery to return to work were computed and compared for workers who received care in public versus private facilities, and according to whether their surgeons received fees intended to expedite care.Results: The public expedited group had the shortest disability duration from surgical consult to return to work; the expedited fee reduced the surgery wait time (~2 work weeks), and surgeries performed in public hospitals had a shorter return-to-work time (~1 work week).Discussion: An overall difference of approximately three work weeks in disability duration may have meaningful clinical and quality-of-life implications for injured workers. However, minimal differences in expedited surgical wait times by private clinics versus public hospitals, and small differences in return-to-work outcomes favouring the public hospital group, suggest that a future economic evaluation of workers' compensation policies related to surgical setting is warranted.
Healthcare policy = Politiques de sante 08/2011; 7(1):55-70.
[Show abstract][Hide abstract] ABSTRACT: Accounting for 36% of public spending on health care in Canada, hospitals are a major target for cost reductions through various efficiency initiatives. Some provinces are considering payment reform as a vehicle to achieve this goal. With few exceptions, Canadian provinces have generally relied on global and line-item budgets to contain hospital costs. There is growing interest amongst policy-makers for using activity based funding (ABF) as means of creating financial incentives for hospitals to increase the 'volume' of care, reduce cost, discourage unnecessary activity, and encourage competition. British Columbia (B.C.) is the first province in Canada to implement ABF for partial reimbursement of acute hospitalization. To date, there have been no formal examinations of the effects of ABF policies in Canada. This study proposal addresses two research questions designed to determine whether ABF policies affect health system costs, access and hospital quality. The first question examines the impact of the hospital funding policy change on internal hospital activity based on expenditures and quality. The second question examines the impact of the change on non-hospital care, including readmission rates, amount of home care provided, and physician expenditures.
A longitudinal study design will be used, incorporating comprehensive population-based datasets of all B.C. residents; hospital, continuing care and physician services datasets will also be used. Data will be linked across sources using anonymized linking variables. Analytic datasets will be created for the period between 2005/2006 and 2012/2013.
With Canadian hospitals unaccustomed to detailed scrutiny of what services are provided, to whom, and with what results, the move toward ABF is significant. This proposed study will provide evidence on the impacts of ABF, including changes in the type, volume, cost, and quality of services provided. Policy- and decision-makers in B.C. and elsewhere in Canada will be able to use this evidence as a basis for policy adaptations and modifications. The significance of this proposed study derives from the fact that the change in hospital funding policy has the potential to affect health system costs, residents' access to care and care quality.
BMC Health Services Research 06/2011; 11:150. · 1.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Most provincial governments are considering or introducing changes to hospital funding. Ten years of rapidly increasing expenditures have left them still facing complaints of waiting lists and waiting times. Activity-based funding (ABF) would supplement traditional negotiated global budgets, reimbursing a predetermined amount for each case treated - essentially, a "fee schedule" - thus providing incentives and resources to increase throughput of certain "hot button" procedures and services and to improve efficiency.Maybe. ABF-type systems in other countries date back over 20 years; the results are very mixed. What is clear is that information and reporting requirements are substantial. A host of perverse incentives lurk in ABF. Most Canadian hospitals and provincial governments do not now have the necessary data systems, so are wise to proceed cautiously.
Healthcare policy = Politiques de sante 05/2011; 6(4):14-21.
[Show abstract][Hide abstract] ABSTRACT: To explore the redistributive impact of two different pharmaceutical financing policies (age-based versus income-based pharmacare) on the distribution of income in British Columbia (B.C.), Canada.
Using household-level data on all payments that are used to finance prescription drugs in B.C. (including taxation and private payments), we performed a redistributive analysis to indicate how much income inequality in the province changed as a result of payments made for prescription drugs. We also illustrated changes in vertical equity (different treatment according to ability-to-pay) and horizontal equity (equals, according to ability-to-pay, being treated equally) between the two years separately through a pre-post policy examination.
We found that payments made to finance prescription drugs increased overall income inequality in the province. This negative impact was larger after the move to income-based pharmacare. Our results also show increasing horizontal inequity after the policy change, and suggest that the increased reliance on out-of-pocket payments was a major source of the negative impact on the B.C.'s overall income distribution. We also show that the consequences of the move to income-based pharmacare would have been less severe had the level of public financing not decreased substantially between the two years.
The increase in income inequality in B.C. following the policy change was an unintended consequence of the move to income-based pharmacare. This finding is worth consideration as countries and jurisdictions weigh pharmaceutical policy alternatives.
Health Policy 01/2011; 101(2):185-94. · 1.51 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: When Pharaoh refused to supply straw, productivity plummeted in the Egyptian brick industry. But Pharaoh had other concerns. Anyway, the costs fell on Israelites, not Egyptians. Productivity improvement in the health sector is similarly constrained by competing objectives, and by the distribution of resulting gains and losses. Furthermore, health services have value only insofar as they improve health outcomes. Increased output of ineffective services is not productivity in any meaningful sense. Yet most of the literature on health human resources productivity focuses on outputs, not outcomes, ignoring serious questions about effectiveness. Proposals to refine the treatment of the health sector within the national accounts are similarly flawed. Proliferation of beneficial, harmful or simply unnecessary services would all be recorded as "productivity growth."
Healthcare policy = Politiques de sante 02/2010; 5(3):17-26.
[Show abstract][Hide abstract] ABSTRACT: The book Why Are Some People Healthy and Others Not? The Determinants of Health of Populations represented a milestone in our evolving understanding of the determinants of population health. Building on Marc Lalonde's earlier A New Perspective on the Health of Canadians, it created a theoretical framework that could incorporate emerging evidence from a wide range of disciplines. Central to its authors' approach was the observation of heterogeneity, of the systematic differences in health observed when populations are partitioned on characteristics such as income, education, geographic region, etc. The universal observation of a social gradient, of a strong correlation between socio-economic class and health, led to a focus on how the social environment might influence health. Social position strongly influences both the stresses to which individuals are subject, and the resources available to cope with them. Furthermore, healthy and unhealthy responses to stress become "embedded", learned or conditioned both behaviourally and biologically, thus influencing health over the whole life course. The book's impact has been remarkable, not merely in academic citations but through its authors' subsequent work and strategic positions in Canadian health research organizations. The concept of "Population Health" has become part of our shared intellectual heritage.
Canadian journal of public health. Revue canadienne de santé publique 01/2010; 101(6):433-5. · 1.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A national formulary has been proposed as a priority element of Canada's National Pharmaceuticals Strategy. We review a variety of formulary-based policies that might be used in conjunction with a national formulary, drawing on the policies and practices of the Pharmaceutical Management Agency of New Zealand. We consider the potential price impact of an actively managed national formulary by conducting a Canada-New Zealand price comparison for equivalent products in the four largest drug classes: statins, angiotensin-coverting enzyme (ACE) inhibitors, selective serotonin reuptake inhibitors (SSRIs) and proton pump inhibitors (PPIs). The results suggest that potential price savings for Canada in these drug classes are on the order of 21% to 79%. Such price differences would translate into billions of dollars in annual savings if applied across Canada, potentially offsetting the costs of the expansion of pharmacare coverage necessary to achieve both equity and efficiency goals in this sector.
Healthcare policy = Politiques de sante 09/2007; 3(1):e121-40.
[Show abstract][Hide abstract] ABSTRACT: In 1958, Reuben Kessel published Price Discrimination in Medicine. It applied intermediate-level price theory to physician behaviour, providing an explanation, in pre-insurance days, of charging fees geared to patients' incomes. Such fee-setting behaviour is consistent with a sophisticated form of income maximization, and offered an alternative to the standard view of sliding fees as a form of charity. It could thus be fitted into the more conventional economic framework of behaviour based on self-interest rather than altruism, leading to Kessel's analysis of the medical profession's interest in limiting entry to practice as a way to consolidate market power. Overall, the paper was a nice example of observed behaviour interpreted through economic theory but rooted in an explicit institutional context. Five years later, Kenneth Arrow published Uncertainty and the Welfare Economics of Medical Care. This extraordinarily influential paper re-directed economists' attention from the supply side to the demand side of the medical market. This shift in focus led directly to the Welfare Burden school of analysis that has so deeply influenced health economics since then. Optimal-insurance coverage could be analysed in terms of a putative trade-off between the benefits of reduced uncertainty and the costs of excess use, where excess is defined relative not to impact on health but to willingness to pay. Arrow recognized the significance of informational imperfections and asymmetries, but his followers largely ignored those qualifications. They have spent a generation playing happily with supposedly exogenous demand curves and the well-defined horizontal supply curves that are generated only by profit-maximizing firms in perfectly competitive industries without specialized factor inputs. Arrow himself adopted this framework unmodified in his 1976 paper on the Welfare Analysis of Changes in Health Coinsurance Rates, where he also makes explicit the assumption necessary to derive welfare conclusions from this framework the population must be made up of identical clones. In that paper, Arrow states: The basic function of health insurance is the reduction of uncertainty. As an empirical statement, this is incorrect. In practice, health care payment systems perform three functions. They do reduce uncertainty, but they also transfer significant amounts of wealth, not just ex post but ex ante, both from individuals at low risk of illness to those at high risk, and from higher to lower income individuals. Insurance systems also serve as a sort of (highly imperfect) consumers' cooperative that creates countervailing power to balance that of suppliers of care. Private insurance is incapable of performing these additional and critical functions and, absent public subsidy or regulatory promotion, is non-existent outside the academic literature. In this presentation we shall show that Kessel's understanding of the dynamics of markets for health care is consistent with this reality, while Arrow's is not. Kessel's framework provides economists with a perspective for recognizing and analyzing issues such as the public-private debate. Arrow's seminal paper leads us away from reality, into a world of theoretical abstractions and distractions. It is unfortunate that iHEA has chosen to offer a prestigious Arrow prize rather than a Kessel prize.
[Show abstract][Hide abstract] ABSTRACT: Fifteen years ago, it was widely believed that Canada had a surplus of physicians. In the early 1990s, several provinces reduced their medical school enrollments. Almost immediately spokesmen for medical schools were claiming that these moves had created an emerging physician shortage, which would grow steadily more severe, such that enrolment expansion was an immediate priority.Yet the Canadian physician-to-population ratio has remained relatively stable for the past 15 years. And, as Chan (2002) pointed out, it would be mathematically impossible for enrolment cuts in the early 1990s to have had any significant effect on physician numbers over the following decade. Furthermore, average rates of billings per physician, adjusted for fee changes, were not falling and for many specialties were rising - an apparent increase in "productivity". Medical shortage claims did, however, resonate with the media and the experience of some members of the public - "I can't find a doctor" and "Waiting times for specialist consultations are too long." So "[w]hy does it feel like a shortage?" (Chan 2002), despite the lack of evidence in the aggregate data? Watson et al. (2003) found, for general/family practitioners in the province of Manitoba, that the relationship between physician age and average billing rates had twisted, falling for more recent cohorts of younger physicians but rising among older physicians with established patient rosters. This would reconcile the stability of average billings with public perceptions of difficulty in finding physicians willing to take on new patients. It would also suggest that as older physicians retire, the relatively stable rates of average physician "productivity" or at least fee-adjusted billings, might drop quite sharply.This paper will present preliminary results from a new project designed to explore the sudden transformation of a "surplus" to a "shortage" by analyzing (anonymised) individual-level billing data for the province of British Columbia, for both general practitioners and specialists, over the period 1990/91 to 2005/06. Billings in each year will be adjusted to a single base-year fee schedule, to yield a measure of "real" output by year, region, and specialty that can be examined relative to both full-time equivalent physician supply and age-adjusted patient population. We will be able to test the Watson et al. findings over the full range of physician services. More generally, if there is now a "shortage" of physician services, what kinds of services are now in reduced supply relative to the population, in which regions, and when during the past decade and a half did this reduction occur? Are reductions traceable to reduced full-time equivalent physicians, or reduced billing activity per full-time equivalent? And if, as other national work is suggesting, physician hours of work are falling, is this reflected in reduced service volumes? If so, which ones?
[Show abstract][Hide abstract] ABSTRACT: The first set of evidence-based benchmarks for medically acceptable wait times, announced in December 2005, were developed, in part, through a novel partnership between the Provincial and Territorial Ministries of Health, the Canadian Institutes of Health Research (CIHR) and Canada's health services research community. Responding to a direct request for assistance and demanding timelines from the Provincial and Territorial Ministries of Health, CIHR mounted a rapid-response funding process and supported eight Canadian teams to synthesize evidence to inform the development of the first set of benchmarks. This experience demonstrated that both the research funding process and research syntheses themselves can rapidly inform policy making in even the most heated of environments.
Healthcare policy = Politiques de sante 03/2007; 2(3):56-62.
[Show abstract][Hide abstract] ABSTRACT: Canada is strongly influenced by US cross-border direct-to-consumer advertising (DTCA) and has held consultations to discuss introduction of DTCA since 1996. This article describes a survey of Canadian drug policy experts carried out in 2001, during one such legislative review. The survey results are compared to more recent DTCA policy developments.
We recruited key informants on pharmaceutical policy to complete a faxed questionnaire that queried their opinions on DTCA information quality, effects on drug and health care use, and regulatory issues. Respondents were asked about the evidence they had used to back their opinions. Analysis was descriptive.
Of 79 identified potential participants, 60 (76%) participated, 40% of whom were from federal and provincial government; 3% were private insurers; 18%, 15%, and 8% were from health professional groups, consumer groups, and patient groups, respectively; 8% and 7% were from pharmaceutical and advertising industries, respectively. Opinions were highly polarized on the effects of DTCA on drug and health care use. Advertising and pharmaceutical industry respondents were generally positive, public sector, health professional and consumer groups generally negative. Over 80% believed DTCA leads to higher private and public drug costs and more frequent physician visits. Fewer judged billboards or television to be appropriate media for DTCA than magazines or the Internet, and most believed that children and adolescents should not be targeted.
Given the polarization observed within this survey, we examined how DTCA policy has evolved in Canada since 2001. The federal government has legislative authority over DTCA, but bears few of the additional costs potentially incurred through policy change. These fall to the provinces, which provide an eroding patchwork of public coverage for prescription drugs in the face of rapidly increasing costs. No new federal legislation has been tabled since 2001. However, considerable shifts in administrative policy have occurred, all supportive of expanded advertising. Thus, the law continues to be restrictive but its application less so.
Research in Social and Administrative Pharmacy 07/2005; 1(2):310-30. · 2.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Justice Emmett Hall's landmark 1964 Royal Commission report is remarkable as, among other things, a very early Canadian example of successful knowledge brokering. It predates by about three decades even the earliest discourse in Canadian health research circles about knowledge translation, knowledge transfer, knowledge exchange, knowledge brokers, and the like.
[Show abstract][Hide abstract] ABSTRACT: Health services and population health research often depends on the ready availability of administrative health data. However, the linkage of survey-based data to administrative data for health research purposes has raised concerns about privacy. Our aim was to compare consent rates to data linkage in two samples of caregivers and describe characteristics associated with consenters.
Subjects included caregivers of children admitted at birth to neonatal intensive care units (NICU) in British Columbia and caregivers of a sample of healthy children. Caregivers were asked to sign a consent form enabling researchers to link the survey information with theirs and their child's provincially collected health records. Bivariate analysis identified sample characteristics associated with consent. These were entered into logistic regression models.
The sample included 1,140 of 2,221 NICU children and 393 of 718 healthy children. The overall response rate was 55% and the response rate for located families was 67.1%. Consent to data linkage with the child data was given by 71.6% of respondents and with caregiver data by 67% of respondents. Families of healthy children were as likely to provide consent as families of NICU children. Higher rates of consent were associated with being a biological parent, not requiring survey reminders, involvement in a parent support group, not working full-time, having less healthy children, multiple births and higher income.
The level of consent achieved suggests that when given a choice, most people are willing to permit researcher access to their personal health information for research purposes. There is scope for educating the public about the nature and importance of research that combines survey and administrative data to address important health questions.
Canadian journal of public health. Revue canadienne de santé publique 01/2005; 96(2):151-4. · 1.02 Impact Factor