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The AMPs require physicians to work an average of 12 hours per week in a "priority" service, such as an emergency room, a hospital ward, a rehabilitation centre or home care. Every hour that physicians spend fulfilling AMP requirements is an hour that they are not available at their primarycare clinic seeing their own family medicine patients. In addition to AMP hours and family medicine patient care, family physicians are also called to assume administrative duties and engage in medical teaching, both of which take time away from patient care. Bill 20 requires family physicians to register patients to their clinic with the intent of offering continuity of care, known as "prise-en-charge." This offers the patient a home base from which to seek health care, always first contacting that particular physician or group, as opposed to going to a walk-in clinic or emergency room, but physicians are to be penalized if too many of their patients choose to seek health care elsewhere, such as a colleague's clinic, a walk-in clinic or an emergency room. The law provides no exceptions if patients who live and work in two different areas seek health care from two different clinics, one near their place of work and one near their place of residence. Part-time physicians will be specifically punished, as they will not be able to provide continuity of care to the required number of patients. This includes physicians who are in the process of retiring and downsizing, working parttime due to personal or family reasons, on maternity leave, or on sick leave or disability.

Canadian medical schools have expanded their annual enrolment by 80% over the last 13 years

major increase in physician supply per capita, from 1970 to 1990, did not result in underemployed physicians. Utilization of physicians' services adapted to the increased supply. Whether the additional physicians were "needed," and what impact their activities might have had on the health of Canadians, are good and debatable questions

In the last decade, medical expenditure per physician has also risen, by nearly 35% above general inflation.

Each of these waves of expansion responded to widespread perceptions of a looming "physician shortage." How accurate were those perceptions? In the case of the first wave, they rested on assumptions that were simply wrong, and by a wide margin. Medical schools were built to serve people who never arrived.

it is politically extremely difficult, almost impossible, to cut back on medical school places once they have been opened.2

Does all this increased diagnostic activity among the very elderly actually generate health benefits?

(Population has grown by about 14%.)

Table 1. Canadian health spending, percentage increase per capita, inflation-adjusted   1999–2004 2004–2009 1999–2009 Hospitals 19.1 11.7 33.0 Physicians 16.4 24.4 44.8 Rx drugs 46.1 19.0 73.7 Total health 22.2 16.5 42.3 Provincial governments 21.2 17.7 42.6  

Over the nine-year period, there were very large increases in the per capita volume of diagnostic services – imaging and laboratory tests. Adjusting for fee changes, per capita expenditures on these rose by 28.4% and 42.1%, respectively.

much greater among the older age groups – 59.4% and 64.4%, respectively, for those over 75

money has been poured into reimbursing diagnostic services for the elderly and very elderly, but access to primary care for the non-elderly appears to have been constrained

insofar as more recently trained physicians tend to be more reliant on the ever-expanding arsenal of diagnostic technology, overall expenditures per physician will continue to rise as their numbers grow

As in the case of the previous major expansion, the impact on the total supply of physicians will unfold slowly, but relentlessly, over decades.

a lot of money is going out the door and no one has a clear picture of what it is buying

The question of Canadian physician supply is now moot. The new doctors are on their way, and whether or not we will need them all is no longer relevant. It may be that as cost containment efforts begin to bite we will again see renewed limits on the inflow of foreign-trained physicians, but we will not be able to turn down the domestic taps as supply increases.

Growth in diagnostic testing has to be brought under control, both in how ordering decisions are made and in how tests are paid for.

Much of the rhetoric thrown around today in scuffles between governments and physicians might ring a bell for students of medical history. More than 50 years ago, doctors were also accused of being too stubborn to accept changes to pay structure, and a provincial government was also charged with putting fiscal concerns before patient needs. Of course, if that old saying holds any merit — “Those who cannot remember the past are condemned to repeat it” — perhaps a refresher is in order. There seems, after all, to be a little bit of history repeating itself.

The origin of conflict between provincial governments and physicians can be summed up in one word: medicare. It therefore dates back to midnight of July 1, 1962, when the Saskatchewan Medical Care Insurance Act passed into law, introducing the first universal, government-run, single-payer health system to North America. All of one minute later, most of Saskatchewan’s doctors went on strike.

tually, to be precise, the fighting between the government and doctors in Saskatchewan began a couple of years earlier, during the 1960 provincial election. Premier Tommy Douglas had made universal health care the main peg of his re-election campaign. The College of Physicians and Surgeons of Saskatchewan fiercely opposed the idea, contending that government interference in medicine would do far more harm than good.

A public battle ensued, pitting doctors against politicians. Debates were held, pamphlets were circulated, pledges were signed. Did the whole affair stay civil and free of propaganda? Well, you could say that. But only if you enjoy being wrong.

Let’s start with some of the literature circulated by opponents of medicare. One pamphlet, Political Medicine is Bad Medicine, was chockablock with scary warnings and seasoned with a liberal sprinkling of words in all-caps for emphasis. Red Tape! Skyrocketing costs! Inferior care! The premier’s plan “proposes a PERMANENT INFLEXIBLE GOVERNMENT SCHEME at a high cost” that would subject medicine “to POLITICAL considerations bearing no relation to your NEEDS.”

Then there was the infamous flyer — later used by Premier Douglas to shame his opponents, according to Saturday Night magazine — that suggested many doctors would flee the province if the medicare bill passed. “They’ll have to fill up the profession with the garbage of Europe,” read one excerpt, a quote from an anonymous doctor taken from the Toronto Telegram. “Some of the European doctors who come out here are so bad we wonder if they ever practised medicine.”

Later, some in the anti-medicare camp acknowledged that mistakes were made, passion had trumped reason, and the medical profession had suffered for engaging in political mudslinging. “Many doctors concede privately that they went too far, that the campaign lost them prestige in their communities,” reported Saturday Night magazine.

Part II: Today’s contentious negotiations echo those from the battle over medicare a half-century ago Doctors refuse to compromise, says one side. The government cares more about its budget than patients, says the other side. Doctors have rejected a “very fair offer,” says a provincial health minister. Patients can’t wait for the government to balance its books, says a medical association. You know, this all sounds mighty familiar.

In the end, Douglas and his party, the Co-operative Commonwealth Federation, won the election and pushed ahead with their health system plan. The doctors and government set aside their differences and all lived happily ever after. Yeah, right.

Medicare was coming to Saskatchewan — that battle was over — but physicians still weren’t cooperating with the government. They focused their efforts on changing sections of the proposed medicare act, specifically those that granted the government almost unlimited power to control the practice of medicine.

There was no provision for negotiation. The doctors would simply have to do what the government told them to do, and be paid what the government said they would be paid,” Dr. Marc Baltzan (1929–2005), a Saskatoon nephrologist and former president of the Canadian Medical Association, wrote in a 1984 article in Canadian Family Physician entitled, “Doctor/Government Fee Negotiations in Canada.”

After the act became law, unchanged, the province’s physicians closed their offices, though they still provided emergency services in hospitals. The standoff lasted 23 days, ending only after both sides compromised and signed the Saskatoon Agreement. The deal amended the act to ensure doctors would maintain their independence and could, if they wanted, opt out of medicare and bill patients directly.

The deal was brokered by Lord Stephen Taylor, a British doctor and politician who helped implement the National Health Service in the United Kingdom. Later, reflecting on his Saskatchewan adventure, Taylor wrote that much of the animosity between the two parties arose because they did not understand each other at all. The government did not anticipate how much their plan would threaten the autonomy of a proud profession. Physicians “could not believe that the government was composed of honest and responsible people.”

Taylor, a man of both medicine and government, chose to take a dispassionate view of the conflict. “I see honest men on both sides, well motivated but mystified by the actions of their opponents.”

Decades later, debate over another act — the Canada Health Act, federal legislation adopted in 1984 — again showed just how differently government and physicians can view a change to how doctors are paid. This time, the government was putting an end to extra billing by physicians. But according to Baltzan, as mentioned in his Canada Family Physician article cited above, this was merely a “political euphemism” for banning a patient’s right to be reimbursed by the government when billed directly by a doctor.

In his lament over the passing of the “deceitful bill,” Baltzan suggested that it was important to revisit the original fight over medicare in Saskatchewan because “it shows that there is nothing new under the sun: it contains all the elements of physician–government confrontation that have been replayed again and again during the Canada Health Act debate.”

Now, more than 30 years later, it might not be a stretch to say there is still nothing new under the sun regarding negotiations between doctors and government. When things go bad, as they have in Ontario, both sides sometimes resort to a little time-tested rhetoric. Then again, though some of the messages sound familiar, other elements of physician–government showdowns have changed since 1962. For one, doctors back then didn’t have Twitter accounts.

This put nursing groups in an awkward position. After saying publicly for years that PAs are a danger to patients because they are unregulated, now they would have to make the opposite case: that regulating PAs is unnecessary because there is no evidence they have harmed the public.

HPRAC, and the Minister of Health agreed with the RNAO. PAs, said HPRAC’s report, do not pose sufficient harm to patients to require regulation, although as their numbers grow, that may change.

What’s really broken is the relationship between physicians and nurses, at least at the organizational level. PAs, whose practice of medicine depends entirely on collaborating and consulting with physicians, are just collateral damage in a century-old war.

There are signs that in the US, where PAs are one of the fastest-growing professions and in high demand, some PAs want to break out of their “assistant” shackles to practice more autonomously, which many of them already do in underserviced areas where physicians choose not to practice.

Maureen Taylor is a Physician Assistan

"I go help mothers with their sick children while I leave mine at home," Saoud said. "I can't see how I can do more." Saoud has three young children. She devotes 60 per cent of her workweek to a Montreal hospital's emergency department - irregular hours that include evening and weekend shifts - while the rest of her schedule is split between a walk-in clinic and what's known as "dépannage," replacing doctors in Quebec's more remote regions at least once a month. What she wants is more time for her job as a mother - helping with their homework and sharing meals - and not have to meet "an impossible" quota of following 1,500 patients, as the original Bill 20 would have required of each family doctor.

I am already at my maximum," said Saoud. And so, she has applied for a licence to practise outside Quebec. Nearly 24 per cent of Quebecers are on a waiting list or desperately searching for a family doctor. The crisis is rooted in a 1990s provincial government plan to save money by encouraging doctors to retire early. Staffing shortages ensued, and family doctors were obliged to fill the gaps by working outside their clinics in hospitals and far-flung regions. Quebec has attempted, with little success, to improve primary care over the last two decades by expanding community health clinics (CLSCs) and creating pools of doctors known as Groupes de médecine de famille (GMF) but both limped along under budget constraints and heavy bureaucracy. Barrette contends that the province has more than enough physicians to meet its needs, but that a profound structural change is needed.

He presented Bill 20 last fall as his road map to ensure that every Quebecer has a regular doctor. But the bill's punitive measures sparked widespread discontent among doctors against what they called a one-size-fits all, state-controlled, conveyor-belt approach to medicine. Doctors were further incensed at Barrette's assertion that doctors are not productive enough - which they saw as being accused of laziness - and frustrated at being blamed for a broken health system.

Like Saoud, many doctors prepared exit plans - from retiring to leaving the province. Some med students, many of whom were actively recruited to shore up Quebec's supply of family doctors, began reconsidering family medicine - or simply leaving to do their residency out-of-province, according to the Fédération des médecins résidents du Québec. Saoud was heading home to her sick daughter on Monday when Barrette announced he had cut a deal with the provincial federation of family physicians to exempt them from Bill 20 - temporarily. There would be no quotas and no penalties, Barrette said, as long as family physicians were able to collectively ensure that 85 per cent of Quebecers had a family doctor by the end of 2017. But Saoud says the change will not keep her here. And she's not alone.

The buzz among disillusioned physicians is that "everyone has a Plan B." And while the bill's delay has eased tensions a notch, some doctors are saying the two-year delay simply means they now have until 2017 to prepare a better exit. Bill 20 remains a guillotine above the heads of doctors. "Most definitely, there are physicians investing in Ontario licences and poised to leave if Bill 20 passes. I myself may have to leave," family physician Maggie O'Dell, who works at the Wakefield Family Medical Centre near the Ontario border, said before the bill was modified. And after Barrette backtracked, she had this to say: "It's nice to have reprieve, so it's a relief - for now ... a reason for many to hold back on pulling up stakes in the short term."

Montreal family physician Fahimy Saoud hated leaving her sick 5-year-old in someone else's care this week, but it was her turn to staffa walk-in clinic and she didn't want to let those patients down. But as the day wore on, Saoud kept hearing her daughter's plea when she left the house: "Who will take care of me?" So on Monday, after seeing everyone in the waiting room, Saoud left the clinic early; her daughter needed her as much as her patients did.

The group's recent survey - 204 of its members responded - indicated that Bill 20's sanctions would backfire. While the survey was taken three days before Barrette modified Bill 20, Duong said the results reveal that doctors, in particular those whose mother tongue is English, are at risk of leaving the province. Among the 134 francophone doctors polled about their intentions if Bill 20 were applied, 32 per cent said they would resign from hospitals, 12 per cent said they would leave Quebec and another nine per cent would go into private care.

Among the 70 anglophone respondents, seven said they already sent letters of resignations to their hospitals (it's not clear whether they are keeping their office family practice) and among the remaining 63 doctors, 34 - more than half - said they planned to leave Quebec. Another seven said they would retire early, seven would move to the private system and three would stop working as family doctors. It's a small sample, Duong conceded, but the study is nonetheless alarming.

We are worried that doctors will leave," Duong said, noting that every year, more doctors are opting out of the provincial insurance board (RAMQ), meaning they are no longer on the public payroll, though it's not clear whether they went to private practice or left Quebec. RAMQ representative Marc Lortie confirmed this week that 246 family physicians dropped out of RAMQ between May 2014 and May 2015, up from 204 the previous year and 187 in 2012-2013.

In the wake of Monday's announcement to put offBill 20's sanctions, many doctors remain skeptical of Barrette's 85-per-cent target, Duong says, "because it's far too ambitious a goal." Whatever doctors' efforts, Duong says, the reform will fail if the government doesn't help them do their jobs - for example, by abolishing mandatory hospital work. Others suggest the crisis between the province's doctors and Quebec's health minister is over. Bill 20 was heavy-handed, they argue, but if it leads to doctors taking on more patients it will have been a successful negotiating tool. Dr. Yoanna Skrobik, a critical care researcher and adjunct professor at McGill University's department of medicine, is among those who wholeheartedly support the Barrette reform.

It's the most dramatic change in the history of Quebec's health system, and the best thing that's ever happened to patients," said Skrobik, who worked side by side with Barrette at Maisonneuve-Rosemont Hospital in the early 2000s, when Barrette was chief of radiology and she was an intensivecare physician. She said that if 85 per cent of Quebecers have a family doctor, the quality of health care in the province will be much improved. Doctors may be offended by Barrette's manner, and by what they see as an attack on their autonomy, Skrobik said, "but it's also true that he puts patient care in the forefront."

But Saoud also has priorities. She earned her first medical degree in Haiti, then had to obtain it again after emigrating to Montreal. There's a saying among those who work in the ER, she said: "We know when we go in, but we don't know when we will leave." Saoud, who won the Nadine St-Pierre Award for her research as a resident in family medicine in 2009, still loves being a doctor. "It can be frustrating, but it's really gratifying work. Helping someone is really the cherry on the sundae. But my priority is not that." She would rather not force the children to uproot, but she's skeptical doctors can meet the demands of the health reform. And possible sanctions in two years could force her to to make a tough choice.

"My male colleagues don't have that issue. The bill is discriminatory. I'm just asking for the right to be a mother and not simply a doctor." With her permit application process in motion, Saoud says she will go wherever her licence takes her. cfidelman@montrealgazette.com twitter.com/HealthIssues

Medical students from four major Quebec universities demonstrate against Bill 20 in March near the legislature in Quebec City. • VINCENZO D'ALTO, MONTREAL GAZETTE / Dr. Fanny Hersson-Edery, left, at a diabetes clinic she runs with nurse Jen Reoch. Hersson has a full schedule, from research to teaching and seeing patients.

the 1990s saw a perception of widespread physician shortages though only a handful of provinces had declines in the per capita number of physicians (Ontario, BC, Alberta, PEI and Nova Scotia), and by 2010 these declines have turned into marked increases in most of these provinces

The recent increase in physician numbers more than makes up for the small decline of the 1990s

a positive correlation between physician numbers and health spending is not automatic. In other words, a high per capita number of physicians is not always associated with high per capita health spending. Quebec, for example spends the lowest amount per capita on public health care spending and yet has one of the highest number of physicians per capita. Manitoba, on the other hand has the second highest per capita public health spending in the country but is one of the lowest in terms of physicians per capita.

While the access agenda has been the central focal point of the 2004 health accord, it is time to have the 2014 health accord focus on quality, of which access is one important dimension, with the others being effectiveness, safety, efficiency, appropriateness, provider competence and acceptability.

we also propose three specific funds that are strategically focused in areas that can contribute to improved access and wait time

Can the 2014 health accord act as a catalyst to ensure appropriate post-hospital supportive and preventive care strategies, facilitate integration of primary health care with the rest of the health care system and enable innovative approaches to health care delivery? Is there an opportunity to move forward with new models of primary health care that focus on personal accountability for health, encouraging citizens to work in partnership with their primary care providers and thereby alleviating some of the stress on emergency departments?

one in five hospital beds are being occupied by those who do not require hospital care — these are known as alternative level of care patients, or ALC patients

the creation of an issue-specific strategically targeted fund designed to move beyond pilot projects and accelerate the creation of primary health care teams — for example, team-based primary health care funds could be established — and the creation of an infrastructure fund, which we call a community-based health infrastructure fund to assist in the development of post-hospital care capacity, coupled with tax policies designed to defray expenses associated with home care

consider establishing a national health innovation fund, of which one of its stated objectives would be to promote the sharing of applied health system innovations across the country with the goal of improving the delivery of quality health services. This concept would be closely aligned with the work of the Canadian Institutes of Health Research in developing a strategy on patient oriented research.

focus the discussion on what is needed to ensure that Canada is a high performing system with an unshakable focus on quality

of the Wait Time Alliance

Dr. Simpson

the commitment of governments to improve timely access to care is far from being fulfilled. Canadians are still waiting too long to access necessary medical care.

Table 1 of our 2011 report card shows how provinces have performed in addressing wait times in the 10-year plan's five priority areas. Of note is the fact that we found no overall change in letter grades this year over last.

The WTA has developed benchmarks and targets for an additional seven specialties and uses them to grade progress.

the lack of attention given to timely access to care beyond the initial five priority areas

all indications are that wait times for most specialty areas beyond the five priority areas are well beyond the WTA benchmarks

we are somewhat encouraged by the progress towards standardized measuring and public reporting on wait times

how the wait times agenda could be supported by a new health accord

governments must improve timely access to care beyond the initial five priority areas, as a start, by adopting benchmarks for all areas of specialty care

look at the total wait time experience

The measurements we use now do not include the time it takes to see a family physician

a patient charter with access commitments

Efficiency strategies, such as the use of referral guidelines and computerized clinical support systems, can contribute significantly to improving access

In Ontario, for example, ALC patients occupy one in six hospital beds

Our biggest fear is government complacency in the mistaken belief that wait times in Canada largely have been addressed. It is time for our country to catch up to the other OECD countries with universal, publicly funded health care systems that have much timelier access to medical care than we do.

The progress that has been made varies by province and by region within provinces.

Dr. Michael Schull, Senior Scientist, Institute for Clinical Evaluative Sciences

Many provinces in Canada, and Ontario in particular, have made progress since the 2004 health accord following large investments in health system performance that targeted the following: linking more people with family doctors; organizational changes in primary care, such as the creation of inter-professional teams and important changes to remuneration models for physicians, for example, having a roster of patients; access to select key procedures like total hip replacement and better access to diagnostic tests like computer tomography. As well, we have seen progress in reducing waiting times in emergency departments in some jurisdictions in Canada and improving access to community-based alternatives like home care for seniors in place of long-term care. These have been achieved through new investments such as pay for performance incentives and policy change. They have had some important successes, but the work is incomplete.

Examples of the ongoing challenges that we face include substantial proportions of the population who do not have easy access to a family doctor when needed, even if they have a family doctor; little progress on improving rates of eligible patients receiving important preventive care measures such as pap smears and mammograms; continued high utilization of emergency departments and walk-in clinics compared to other countries; long waits, which remain a problem for many types of care. For example, in emergency departments, long waits have been shown to result in poor patient experience and increased risk of adverse outcomes, including deaths.

Another example is unclear accountability and antiquated mechanisms to ensure smooth transitions in care between providers and provider organizations. An example of a care transition problem is the frequent lack of adequate follow-up with a family doctor or a specialist after an emergency department visit because of exacerbation of a chronic disease.

A similar problem exists following discharge from hospital.

Poorly integrated and coordinated care leads to readmission to hospital

This happens despite having tools to predict which patients are at higher risk and could benefit from more intensive follow-up.

Perverse incentives and disincentives exist, such as no adjustment in primary care remuneration to care for the sickest patients, thereby disincenting doctors to roster patients with chronic illnesses.

Critical reforms needed to achieve health system integration include governance, information enablers and incentives.

we need an engaged federal government investing in the development and implementation of a national health system integration agenda

complete absence of any mention of Canada as a place where innovative health system reform was happening

Dr. Brian Postl, Dean of Medicine, University of Manitoba, as an individual

the five key areas of interest were hips and knees, radiology, cancer care, cataracts and cardiac

no one is quite sure where those five areas came from

There was no scientific base or evidence to support any of the benchmarks that were put in place.

I think there is much less than meets the eye when we talk about what appropriate benchmarks are.

The one issue that was added was hip fractures in the process, not just hip and knee replacement.

in some areas, when wait-lists were centralized and grasped systematically, the list was reduced by 30 per cent by the act of going through it with any rigour

When we started, wait-lists were used by most physicians as evidence that they were best of breed

That continues, not in all areas, but in many areas, to be a key issue.

The capacity of physicians to give up waiting lists into more of a pool was difficult because they saw it very much, understandably, as their future income.

There were almost no efforts in the country at the time to use basic queuing theory

We made a series of recommendations, including much more work on the research about benchmarks. Can we actually define a legitimate benchmark where, if missed, the evidence would be that morbidity or mortality is increasing? There remains very little work done in that area, and that becomes a major problem in moving forward into other benchmarks.

the whole process needed to be much more multidisciplinary in its focus and nature, much more team-based

the issue of appropriateness

Some research suggests the number of cataracts being performed in some jurisdictions is way beyond what would be expected to be needed

the accord did a very good job with what we do, but a much poorer job around how we do it

the accord has bought a large amount of volume and a little bit of change. I think any future accords need to lever any purchase of volume or anything else with some capacity to purchase change.

We have seen volumes increase substantially across all provinces, without major detriment to other surgical or health care areas. I think it is a mediocre performance. Volume has increased, but we have not changed how we do business very much. I think that has to be the focus of any future change.

It is at these transition points, between the emergency room and being admitted to hospital or back to the family physician, where the efficiencies are lost and where the expectations are not met. That is where medical errors are generated. The target for improvement is at these transitions of care.

I am not saying to turn off the tap.

the government has announced, for example, a 6 per cent increase over the next two or three years. Is that a sufficient financial framework to deal with?

Canada currently spends about the same amount as OECD countries

Many of our physicians are saying these five are not the most important anymore.

they are not our top five priority areas anymore and frankly never were

this group of surgeons became wealthy in a short period of time because of the $5.5 billion being spent, and the envy that caused in every other surgical group escalated the costs of paying physicians because they all went back to the market saying, "You have left us out," and that became the focus of negotiation and the next fee settlements across the country. It was an unintended consequence but a very real one.

if the focus were to shift more towards system integration and accountability, I believe we are not going to lose the focus on wait times. We have seen in some jurisdictions, like Ontario, that the attention to wait times has gone beyond those top five.

people in hospital beds who do not need to be there, because a hospital bed is so expensive compared to the alternatives

There has been a huge infusion of funds and nursing home beds in Ontario, Nova Scotia and many places.

Ontario is leading the way here with their home first program

There is a need for some nursing home beds, but I think our attention needs to switch to the community resources

they wind up coming to the emergency room for lack of anywhere else to go. We then admit them to hospital to get the test faster. The weekend goes by, and they are in bed. No one is getting them up because the physiotherapists are not working on the weekend. Before you know it, this person who is just functioning on the edge is now institutionalized. We have done this to them. Then they get C. difficile and, before you know, it is a one-way trip and they become ALC.

I was on the Kirby committee when we studied the health care system, and Canadians were not nearly as open to changes at that time as I think they are in 2011.

One thing I heard on the Aging Committee was that we should really have in place something like the Veterans Independence Program

some people just need someone to make a meal or, as someone mentioned earlier, shovel the driveway or mow the lawn, housekeeping types of things

I think the risks of trying to tie every change into innovation, if we know the change needs to happen — and there is lots of evidence to support it — it stops being an innovation at that point and it really is a change. The more we pretend everything is an innovation, the more we start pilot projects we test in one or two places and they stay as pilot projects.

the PATH program. It is meant to be palliative and therapeutic harmonization

has been wildly successful and has cut down incredibly on lengths of stay and inappropriate care

Where you see patient safety issues come to bear is often in transition points

When you are not patient focused, you are moving patients as entities, not as patients, between units, between activities or between functions. If we focus on the patient in that movement, in that journey they have through the health system, patient safety starts improving very dramatically.

If you require a lot of home care that is where the gap is

in terms of emergency room wait times, Quebec is certainly among the worst

Ontario has been quite successful over the past few years in terms of emergency wait times. Ontario’s target is that, on average, 90 per cent of patients with serious problems spend a maximum of eight hours in the emergency room.

One of the real opportunities, building up to the accord, are for governments to define the six or ten or twelve questions they want answered, and then ensure that research is done so that when we head into an accord, there is evidence to support potential change, that we actually have some ideas of what will work in moving forward future changes.

We are all trained in silos and then expected to work together after we are done training. We are now starting to train them together too.

The physician does not work for you. The physician does not work for the health system. The physician is a private practitioner who bills directly to the health care system. He does not work for the CEO of the hospital or for the local health region. Therefore, your control and the levers you have with that individual are limited.

the customer is always right, the person who is getting the health care

It is refreshing to hear something other than the usual "we need more money, we absolutely need more money for that". Without denying the fact that, since the population and the demographics are going to require it, we have to continue making significant investments in health, I think we have to be realistic and come up with new ways of doing things.

How do you help patients navigate a system that is so complex? How do you coordinate appointments, ensure the appointments are necessary and make sure that the consultants are communicating with each other so one is not taking care of the renal problem and the other the cardiac problem, but they are not communicating about the patient? That is frankly a frequent issue in the health system.

There may be a patient who requires Test Y, X, and Z, and most patients require that package. It is possible to create a one-stop shop kind of model for patient convenience and to shorten overall wait times for a lot of patients that we do not see. There are some who are very complicated and who have to be navigated through the system. This is where patient navigators can perhaps assist.

There have been some good studies that have looked at CT and MRI utilization in Ontario and have found there are substantial portions where at least the decision to initiate the test was questionable, if not inappropriate, by virtue of the fact that the results are normal, it was a repeat of prior tests that have already been done or the clinical indication was not there.

Designing a system to implement gates, so to speak, so that you only perform tests when appropriate, is a challenge. We know that in some instances those sorts of systems, where you are dealing with limited access to, say, CT, and so someone has to review the requisition and decide on its appropriateness, actually acts as a further obstacle and can delay what are important tests.

The national trend masks some regional differences. For example, the number of doctors in Alberta and Saskatchewan has increased by 20% in the last 5 years, the highest among the provinces. During the same period, British Columbia, Quebec and Prince Edward Island had the lowest increases of between 10% and 11%.

More doctors are graduating in Canada than ever before.

The number of female physicians is growing rapidly.

After more than a decade of significant growth, the proportion of total payments made to physicians through alternative payment plans (APPs) instead of fee for service (FFS) appears to have stabilized.

In 2013–2014, 28% of payments to physicians were received through APPs and 71% through FFS, which remained virtually unchanged since 2009.

Much of the data on this comes from the The Canadian Physician Health Study, which surveyed nearly 8000 of Canada’s 75,000 licensed physicians in 2007. The study reported that Canadian physician physical health is comparable if not better than that of the general population. Indeed, more than 90% reported being in good to excellent health, and leading healthy lifestyles.

Physician wellness is undoubtedly critical for the overall functioning of the health system. In fact, some experts have suggested that physician wellness is a missing quality indicator of health system performance.

The data, which were released Sept. 30 by the Centers for Medicare & Medicaid Services (CMS), a branch of the US Department of Health and Human Services that manages care for more than 100 million Americans, describe 4.4 million payments totalling $3.5 billion. The payments were from commercial sources for “consulting fees, research grants, travel reimbursements, and other gifts” made to 546 000 US physicians and 1360 teaching hospitals during the last five months of 2013.

Early analyses of the data reveal that some drug-makers spend lavishly on doctors, especially doctors from a small subset identified as “thought-leaders” who communicate with their peers most energetically in return for compensation in cash or luxury travel and other in-kind payments.

But with the pharmaceutical industry alone spending about $30 billion per year promoting products, and with 90% of that money directed to physicians and other prescribers, the scale of inappropriate relationships aimed at distorting evidence-based clinical judgments for commercial gain is potentially significant, says Neil Kirschner, senior associate for Health Policy and Regulatory Affairs, American College of Physicians.

Not all financial relationships between clinicians should be viewed as improper, the CMS cautions. In a statement emphasizing “the importance of discouraging inappropriate relationships without harming beneficial ones” the agency underlined that many payments support research and other medically important activities.

“This is an opportunity for the public to learn about the relationships among health care providers, and pharmaceutical and device companies,” CMS Administrator Marilyn Tavenner said in a statement accompanying the release of the data on CMS’s “Open Payments” website. The release was mandated under the “Sunshine” section of the US government’s 2010 Patient Protection and Affordable Care Act.

New data from the US describe 4.4 million payments to physicians totalling $3.5 billion.

Kirschner and Wen both mix their praise for the CMS with criticism of the quality and scope of the data released so far. The information is for a partial year only, and about one-third of the records were withheld due to concerns about accuracy voiced by the American Medical Association and other groups. CMS’s decision to exempt payments within continuing medical education programs also attracted heat.

The primary beneficiaries of the CMS disclosure will be patients, Kirschner believes. “The public availability of this data will increase patients’ trust in doctors,” he says. “The evidence suggests even little things like meals can have an effect on prescribing and that there will likely be a reduction now in things you would want reduced, like free trips for doctors paid for by industry.”

These observations, Kirschner notes, are rooted in evidence after the State of Massachusetts began publishing state-wide data in 2004 similar to what CMS has released (Arch Intern Med 2010;170:1820–6).

Dr. Leana Wen, founder of Who’s My Doctor?, an advocacy group calling for full physician disclosure of all commercial relationships, agrees with Kirschner’s view that the CMS data dump will yield salutary results for patients.

These latest data are a “very good start,” but Wen would like to see far more financial data made available, including information about how physicians are paid. “It can make a huge difference to the care they receive if payment is by volume of procedures delivered.” The group is also calling for physician disclosure about their political affiliations and “philosophy of practice” concerning issues such as contraception, abortion, early breast cancer screenings and vaccination.

“Plenty of studies have shown that marketing relationships between physicians and health care companies can introduce conflicts of interest that influence prescribing, research, education, use, and ultimately patient outcomes,” says Kirschner. “And there is substantial evidence that this is often in ways that favor the company’s interests.”

Despite the shortfalls, Canadian lawmakers should follow the US lead, says Dr. Andrew Boozary, cofounder of Open Pharma, a Toronto-based group that advocates for greater medical transparency. “A province like Ontario could take up this charge. There’s no doubt that patients benefit from financial disclosure.”

Boozary notes that conflict-of-interest disclosures are now the norm in medical research and publishing. “Patients clearly deserve the same.”

Emily Nicholas, spokesperson for Patients Canada, another group that advocates for medical transparency, agrees. “It seems contradictory for a health system or government to promote patient engagement, patient-partnership, self-management and shared decision making and yet withhold certain information that they believe patients don’t need, can’t handle, or will over-react to.”

Imagine if a Canadian diagnosed with cancer were told she could receive chemotherapy paid for by the health-care system, but would have to cough up the cash herself if she needed radiation. Or that she could have a few weeks of treatment, and then be sent home even if she needed more. That would never fly. If doctors, say, find a tumour in a patient's colon, the government kicks in and offers the mainstream treatment that is most effective. But for many Canadians diagnosed with a mental illness, the prescription is very different. The treatment they receive, and how much of it they get, will largely be decided not on evidence-based best practices but on their employment benefits and income level: Those who can afford it pay for it privately. Those who cannot are stuck on long wait lists, or have to fall back on prescription medications. Or get no help at all. But according to a large and growing body of research, psychotherapy is not simply a nice-to-have option; it should be a front-line treatment, particularly for the two most costly mental illnesses in Canada: anxiety and depression - which also constitute more than 80 per cent of all psychiatric diagnoses.

Why aren't we providing evidence-based care?" .. The case for psychotherapy Research has found that psychotherapy is as effective as medication - and in some cases works better. It also often does a better job of preventing or forestalling relapse, reducing doctor's appointments and emergency-room visits, and making it more cost-effective in the long run.

Therapy works, researchers say, because it engages the mind of the patient, requires active participation in treatment, and specifically targets the social and stress-related factors that contribute to poor mental health. There are a variety of therapies, but the evidence is strongest for cognitive behavioural therapy - an approach that focuses on changing negative thinking - in large part because CBT, which is timelimited and very structured, lends itself to clinical trials. (Similar support exists for interpersonal therapy, and it is emerging for mindfulness, with researchers trying to find out what works best for which disorders.) Research into the efficacy of therapy is increasing, but there is less of it overall than for drugs - as therapy doesn't have the advantage of well-heeled Big Pharma benefactors. In 2013, a team of European researchers collated the results of 67 studies comparing drugs to therapy; after adjusting for dropouts, there was no significant difference between the most often-used drugs - selective serotonin reuptake inhibitors (SSRIs) - and psychotherapy.

The issue is not one against the other," says Montreal psychiatrist Alain Lesage, director of research at the Douglas Mental Health University Institute. "I am a physician; whatever works, I am good. We know that when patients prefer one to another, they do better if they have choice." Several studies have backed up that notion. Many patients are reluctant to take medication for fear of side effects and the possibility of difficult withdrawal; research shows that more than half of patients receiving medication stop taking it after six months. A small collection of recent studies has found that therapy can cause changes in the brain similar to those brought about by medication. In people with depression, for instance, the amygdala (located deep within the brain, it processes basic memories and controls our instinctive fight-or-flight reaction) works in overdrive, while the prefrontal cortex (which regulates rational thought) is sluggish. Research shows that antidepressants calm the amygdala; therapy does the same, though to a lesser extent.

But psychotherapy also appears to tune up the prefrontal cortex more than does medication. This is why, researchers believe, therapy works especially well in preventing relapse - an important benefit, since extending the time between acute episodes of illnesses prevents them from becoming chronic and more debilitating. The theory, then, is that psychotherapy does a better job of helping patients consciously cope with their unconscious responses to stress.

According to treatment guidelines by leading international professional and scientific organizations - including Canada's own expert panel, the Canadian Network for Mood and Anxiety Treatments - psychotherapy should be considered as a first option in treatment, alone or in combination with medication. And it is "highly recommended" in maintaining recovery in the long term. Britain's independent, research-guided scientific body, the National Institute for Health and Care Excellence, has concluded that therapy should be tried before drugs in mild to moderate cases of depression and anxiety - a finding that led to the creation of a $760million public system, which now handles therapy referrals for nearly one million people a year.

In 2012, Canada's Mental Health Commission estimated that only about one in three adults and one in four children are receiving support and treatment when they need it. Ironically, anti-stigma campaigns designed to help people understand mental illness may only make those statistics worse. In Toronto, for instance, putting up posters in subway stations in 2010 had the unexpected effect of spiking the volume of walk-ins at nearby emergency rooms by as much as 45 per cent in 12 months. Dr. Kurdyak treated many of them at CAMH. The system, he says, "has been conveniently ignoring this unmet need. It functions as if two-thirds of the people suffering won't get help." What would happen if the healthcare system outright "ignored" two-third of tumour diagnoses?

Essentially, argues Dr. Lesage, adding therapy into the health-care system is like putting a new, highly effective drug on the table for doctors. "Think about it," he says. "We have a new antidepressant. It works as well as many others, and it may even have some advantages - it works better for remission - with fewer side effects. The patients may prefer it. And [in the long run] it doesn't cost more than what we have. How can it not be covered?" ..

A heavy price This isn't just a medical issue; it's an economic one. Mental illness accounts for roughly 50 per cent of family doctors' time, and more hospital-bed days than cancer. Nearly four million Canadians have a mood disorder: more than all cases of diabetes (2.2 million) and heart disease (1.4 million) combined.

Mental illness - and depression, in particular - is the leading cause of disability, accounting for 30 per cent of workplace-insurance claims, and 70 per cent of total compensation costs. In 2012, an Ontario study calculated that the burden of mental illness and addiction was 1.5 times that of all cancers, and more than seven times the cost of all infectious diseases. Mental illness is so debilitating because, unlike physical ailments, it often takes root in adolescence and peaks among Canadians in their 20s and 30s, just as they are heading into higher education, or building careers and families. Untreated, symptoms reverberate through all aspects of life, routinely trapping people in poverty and homelessness. More than one-third of Ontario residents receiving social assistance have a mental illness. The cost to society is clearly immense.

Yet, when family doctors were asked why they didn't refer more patients to therapy in a 2008 Canadian survey, the main reason they gave was cost. For many Canadians, private therapy is a luxury, especially if families are already wrestling with the economic fallout from mental illness. Costs vary across provinces, but psychologists in private practice may charge more than $200 an hour in major centres. And it's not just the uninsured who are affected.

Although about 60 per cent of Canadians have some form of private insurance, the amount available for therapy may cover only a handful of sessions. Those with the best benefits are more likely to be higherincome workers with stable employment. Federal public servants, notably, have one of the best plans in the country - their benefits were doubled in 2014 to $2,000 annually for psychotherapy. Many of those who can pay for therapy are doing so: A 2013 consultant's study commissioned by the Canadian Psychological Association found that $950-million is spent annually on private-practice psychologists by Canadians, insurance companies and workers compensation boards. The CPA estimates t

These are the patients that family doctors juggle, the ones who eat up appointment time, and never seem to get better, the ones caught on waiting lists. Sometimes, they have already been bounced in and out of the system, received little help, and have become wary of trying again. A 40-something mother recovering from breast cancer, suffering from chronic depression post-treatment, debilitated by fear her cancer will return. A university student, struggling with anxiety, who hasn't been to class for three weeks and may soon be kicked out of school. A teenager with bulimia removed from an eatingdisorder program because she couldn't follow the rules. They are the ones dangling on waiting lists in the public system for what often amounts to a handful of talk-therapy sessions, who don't have the money to pay for private therapy, or have too little coverage to get the full course of appointments they need.

Canada's investment does not match that burden. Only about 7 per cent of health-care spending goes to mental health. Even recent increases pale when compared to other countries: According to a study by the Canadian Mental Health Association, Canada increased per-capita funding by $5.22 in 2011. The British government, meanwhile, kicked in an extra 12 times that amount per citizen, and Australia added nearly 20 times as much as we did. Falling off a cliff, again and again

In Winnipeg, Dr. Stanley Szajkowski watched for months as his patient, a woman in her 80s, slowly declined. Her husband had died and she was spiralling into a severe depression. At every appointment, she looked thinner, more dishevelled. She wasn't sleeping, she admitted, often through tears. Sometimes she thought of suicide. She lived alone, with no family nearby, and no resources of her own to pay for therapy. "You do what you can," says Dr. Szajkowksi. "You provide some support and encouragement." He did his best, but he always had other patients waiting.

hat 30 per cent of private patients pay out-ofpocket themselves. When the afflicted don't seek help, the cost isn't restricted to their own pocketbook. People with mental-health problems are significantly more likely to abuse drugs and alcohol, and to become physically sick, further increasing health-care costs. A 2014 study by Oxford University researchers found that having a mental illness reduced life expectancy by 10 to 20 years, roughly the same as did smoking and obesity. A 2008 Statistics Canada study linked depression to new-onset heart disease in the general population. A 2014 U.S. study found that women under the age of 55 are twice as likely to suffer or die from a heart attack, or require heart surgery, if they have moderate to severe depression. The result: clogged-up doctors' offices, ERs, and operating rooms. And an inexorable burden for the patients' families forced to fill the gaps in caregiving - or carry on when they lose a loved one.

Patients refer to it as falling repeatedly off a cliff. And they can only manage the climb back up so many times. Family doctors interviewed for this story admitted that they are often "handholding" patients with nowhere else to go. "I am making them feel cared for, I am providing a supportive ear that they may not get anywhere else," says Dr. Batya Grundland, a physician who has been in family practice at Toronto's Women's College Hospital for almost a decade. "But do I think I am moving them forward with regard to their illness, and helping them cope better? I am going to say rarely." More senior doctors have told her that once in a while "a light bulb goes off" for the patients, but often only after many years. That's not an efficient use of health dollars, she points out - not when there are trained therapists who could do the job better. However, she says, "in some cases, I may be the only person they have."

Family doctors aren't the only ones struggling to find therapy for their patients. "I do a hundred consultations a year," says clinical psychiatrist Joel Paris, a professor at McGill University and research associate at the Montreal Jewish General, "and one of the most common situations is that the patient has tried a few anti-depressants, they have not responded very well, and from their story it is obvious they would benefit from psychotherapy. But where do they go? We have community clinics here in Montreal with six-to-12-month waiting lists even for brief therapy." A fractured, inefficient system

"You fall into the role that is handed to you," says Antoine Gagnon, a family doctor in Osgoode, on the outskirts of Ottawa. He tries to set aside 20-minute appointments before lunch or at the end of the day to provide "active listening" to his patients with anxiety and depression. Many of them are farmers or self-employed, without any private coverage for therapy. "Five of those minutes are spent talking about the weather," he says, "and then maybe you get into the meat of the problem, but the reality is we don't have the appropriate amount of time to give to therapy, even to listen, really." Often, he watches his patients' symptoms worsen over several months, until they meet the threshold of a clinical diagnosis. "The whole system could save on productivity and money if people were actually able to get the treatment they needed."

But these issues aren't insurmountable, as other countries have demonstrated. Britain, for instance, has trained thousands of university graduates to become therapists in its new public program, following research showing that, as long they have the proper skills, people don't need PhDs to be effective therapists. Australia, which has created a pay-for-service system, also makes wide use of online support to cost-effectively reach remote communities.

Except for a small fraction of GPs who specialize in psychotherapy, few family doctors have the training - or the time - to provide structured therapy. Saadia Hameed, a GP in a family-health team in London, Ont., has been researching access to psychotherapy for an advanced degree. Many of the doctors she has interviewed had trouble even producing a clear definition of therapy. One told her, "If a patient cries, than it's psychotherapy." Another described it as "listening to their woes." A 2007 survey of 163 family doctors in Ontario found that almost four out of five had not received training in cognitive behavioural therapy, and knew little about it. "Do family doctors really need to do that much psychotherapy," Dr. Hameed asks, "when there are other people trained - and better trained - to do it?"

What further frustrates treatment for physicians and patients is lack of access to specialists within the system. Across the country, family doctors describe the difficulty of reaching a psychiatrist to consult on a diagnosis or followup with their patients. In a telling 2011 study, published in the Canadian Journal of Psychiatry, researchers conducted a real-world experiment to see how easily a GP could locate a psychiatrist willing to see a patient with depression. Researchers called 297 psychiatrists in Vancouver, and reached 230. Of the 70 who said they would consider taking referrals, 64 required extensive written documentation, and could not give a wait-time estimate. Only six were willing to take the patient "immediately," but even then, their wait times ranged from four to 55 days. Psychiatrists are in increasingly short supply in Canada, and there's strong evidence that we're not making the best use of these highly trained specialists. They can - and often do - provide fee-for-service psychotherapy in a private setting, which limits their ability to meet the huge demand to consult with family doctors and treat the most severe cases.

A recent Ontario study by a team at CAMH found that while waiting lists exist in both urban and rural centres, the practices of psychiatrists in those locations tend to look very different. Among full-time psychiatrists in Toronto, 10 per cent saw fewer than 40 patients, and 40 per cent saw fewer than 100 - on average, their practices were half the size of psychiatrists in smaller centres. The patients for those urban psychiatrists with the smallest practices were also more likely to fall in the highest income bracket, and less likely to have been previously hospitalized for a mental illness than those in the smaller centres.

And those therapy sessions are being billed with no monitoring from a health-care system already scrimping on dollars, yet spending a lot on this care: On average, psychiatrists earn $216,000 a year. There is nothing to stop psychiatrists from seeing the same patients for years, and no system to ensure the patients with the greatest need get priority. In Australia, Britain and the United States, by contrast, billing for psychiatrists has been adjusted to encourage them to reduce psychotherapy sessions and serve more as consultants, particularly for the most severe cases, as other specialists do.

As the Canadian system exists now, says Benoit Mulsant, the physician-in-chief at CAMH and also a psychiatrist, the doctors in his specialty "can do whatever they please. If I wanted, I could have a roster of actor patients who tell me entertaining stories, and I would be paid the same as someone who is treating homeless people. ... By treating the rich and famous, there is zero risk of being punched in the face by a patient." Left out in all this, by and large, are other professionals who can provide therapy. It doesn't help that the rules are often murky around who can call themselves psychotherapists. While psychologists and social workers are licensed under their professional associations, in some provinces a person can call himself a marriage counsellor or music therapist with no one demanding they be certified. In 2007, Ontario passed a law to regulate psychotherapists, requiring them to register with a provincial college that would set standards and handle complaints. Currently, however, the law is in limbo, although the government has said it will finally bring it into force by December. The brain keeps many secrets

Science, however, has yet to find depression's equivalent of insulin. Despite being scanned, poked and stimulated over and over and over again, the brain keeps its secrets. The "chemical imbalance" theory is now viewed as simplistic at best. It may not do much for patients, either: A 2014 study published in the journal Behaviour Research and Therapy suggested that, rather than reassuring them, focusing on the biological explanation for depression actually made patients feel more pessimistic and lacking in control. SSRIs work by increasing the amount of serotonin, a chemical that helps deliver messages within the brain and is known to influence mood. But researchers aren't sure why the drugs help some patients and fail with others. "Basically, it's like we have a bucket of water and we pour it over the patient's head," says Dr. Georg Northoff, the University of Ottawa's Michael Smith chair of Neurosciences and Mental Health. "But you want a drug that injects the water in a very specific brain regions or brain system, which we don't have."

Critics of therapy have argued that it's basically "good listening" - comparable to having a sympathetic friend across the kitchen table - and that in the real world of mercurial patients and practitioners of varying abilities, a pill just works better. That's true in many cases, especially when the symptoms are severe and the patients is suicidal: a fast-acting medication is safer, and may even be necessary before starting talk therapy. The staunchest advocates of therapy do not suggest it should be the first course of treatment for psychosis, or debilitating chronic depression, or mania - although, in those cases, there is evidence that psychotherapy and medication work well in tandem. (A 2011 meta-analysis found that patients with severe depression who received a combination approach had higher recovery rates and were less likely to drop out of treatment.) But drugs also don't work as well as the manufacturers would like us to think. Roughly one-third of patients given a drug will see no benefit (although they often respond to a second or third medication). In randomly controlled trials, drugs often perform only marginally better than sugar pills.

Yet it's talk therapy that the public often views most skeptically. "Until you go to a therapist, or a member of your family has a serious psychological problem, people are unsympathetic [about therapy]," says Dr. Paris, the Montreal psychiatrist. "They are very skeptical, and they don't believe the research. It's amazing, because pharmaceutical trials will get approval for a drug on the basis of two clinical trials that they paid for. And we have 100 clinical trials and no one believes us."

Dr. Ajantha Jayabarathan, an assistant professor at Dalhousie University's medical school, spent her early years as a family doctor in Spryfield, N.S., trying to manage an overload of mental-health cases. Most of her patients had little insurance; there was one reduced-cost counselling service in town, but the waiting lists were long. In 2000, her group practice became a test site for a shared-care project, which gave the doctors access to a mental-health team, including weekly in-person consultations with a psychiatrist. "It was transformative," she says. "We looked after everything in-house.

Over time, Dr. Jayabarathan says, she learned how to properly assess mental illness in patients, and how to use medication more effectively. "I just made it my business to teach myself what to do." It's the kind of workaround GPs are increasingly experimenting with, waiting for the system to catch up. Who would pay - and how?

The case for expanding publicly funded access to therapy is gaining traction in Canada. In 2012, the health commissioner of Quebec recommended therapy be covered by the province; it is now being studied by Quebec's science-based health body (INESSS), which is expected to report back next year. A new Quebec-based organization of doctors, researchers and mental-health advocates called the Coalition for Access to Psychotherapy (CAP) is lobbying the government.

In Manitoba, the Liberal Party - albeit well behind in the polls - has made the public funding of psychologists one of its campaign platforms for the province's spring 2016 election. In Saskatchewan, the government commissioned, and has since endorsed, a mental-health action plan that includes providing online therapy - though politicians have given themselves 10 years to accomplish it. Michael Kirby, the former head of the Canadian Mental Health Commission, has been advocating for eight annual sessions of therapy to be covered for children and youth in need.

There are significant hurdles: Which practitioners would provide therapy, and how would they be paid? What therapies would be covered, and for how long? Complicating every aspect of major mentalhealth change in Canada is the question of who should shoulder the cost: the provinces or Ottawa. In a written statement in response to questions from The Globe and Mail, federal Health Minister Rona Ambrose lobbed the issue back at her provincial counterparts, pointing out that the Canada Health Act does not "preclude provinces and territories from extending public coverage to other services or providers such as psychologists."

One result can be overloaded family doctors minimizing mental-health problems. "If you have nothing to offer someone," asks Dr. Anderson, "how much are you going to dig around to find out what is going on?" Some doctors also admit that the lack of resources can lead to physicians cherry-picking patients who don't have mental illness. And yet family physicians alone bill about $361million a year for counselling or psychotherapy in Canada - 5.6 million visits of roughly 30 minutes each. This is a broad category, and not always specifically related to mental health (some of it includes drug counselling, and a certain amount of coaching is a necessary part of the patient-doctor relationship). When it is psychotherapy, however, doctors admit it's often more supportive listening than actual therapy.

So how would Canada pay for access to such therapy? It wouldn't be cheap, in the short term. The savings would come from what Canadians would not have to spend in the long term: in additional medical and drug costs, emergency-room visits and hospital stays, and in unnecessary disability payments, to say nothing of better long-term health outcomes for patients given good care earlier. Some of the figures being tossed around sound staggering. Rolling out a version of Britain's centre-based program across Canada would cost $950-million. Michael Kirby's plan would amount to $1,000 annually per patient. A 2013 report commissioned by the Canadian Psychological Association calculated that, based on predicted need, and assuming no coverage from private health-care plans, providing an average of six sessions of therapy a year would cost an estimated $2.8-billion annually.

But any of those figures would still be a fraction of the roughly $210-billion that Canada spends annually on health care. Figuring out how to make the system most costeffective is, according to sources, currently delaying the INESSS report to the Quebec government. "You need to facilitate the government," says Helen- Maria Vasiliadis, a professor of community health at the University of Sherbrooke. "You can't be going to policymakers and showing them billions and billions of dollars. People start having heart attacks. With evidence in hand, we have to present possible solutions."

An insurance-based plan is the proposal that has emerged from the Quebec-based CAP group, which sent its proposal to Quebec's health minister last month. In its design, the system would work much like Quebec's public drug plan - Quebeckers not covered through work plans would contribute to a provincial insurance program for therapy. That would be similar to the system that Germany has used for decades. One step forward, one step back

Last year, the Sherbrooke clinic where Marie Hayes works received provincial funding for a part-time psychologist and a full-time social worker. With a roster of 25,000 patients, the clinic team laid out clear guidelines for the psychologist, who would consult on cases and screen patients, and be limited to a mere four sessions of actual counselling with any one patient. "We wanted to be careful she didn't become a waiting list - like everything in the system," says Dr. Hayes. The social worker helps guide patients into services such as housing and addiction counselling. They have also offered group sessions for depression management at the clinic. As stretched as those new professionals are in such a large practice, Dr. Hayes says the addition of that mental-health team is improving the care she can provide patients. Recently, for instance, the 32- year-old mother with anxiety attended sessions with the psychologist. "She is making progress," says Dr. Hayes, "slowly."

At Women's College Hospital in Toronto, Dr. Grundland is not so lucky. Asked to describe a difficult case, the family-practice physician mentions a patient suffering from depression after a lifechanging accident. Every month, doctor and patient would repeat the same conversation they'd already had more than a dozen times - and make little real headway. Her patient, says Dr. Grundland, needs a trained therapist: someone she can see regularly, to help her move past her frustration, counsel her about addiction, and ease the burden on her family.

But there's no extra money in the patient's budget for a psychologist. "I do my best," Dr. Grundland says, "but it's not my area of expertise." Meanwhile, the patient isn't getting better, and in the time that it takes to make it through one appointment with her, Dr. Grundland could see three other people with problems she was actually trained to treat. "But," says Dr. Grundland, "she has nowhere else to go." Erin Anderssen is a feature writer at The Globe and Mail. OPEN MINDS How to build a better mental health care system

The Centre for Addiction and Mental Health has purchased advertisements to accompany this series. While CAMH professionals are quoted in this story, the organization had no involvement in the creation or production of this, or any other story in the series. $20.7-billion The cost, according to a 2012 Conference Board of Canada report, of lost productivity each year due to mental illness. What else does $20-billion represent?

$20B: Canadian spending on national defence, 2012-13 $20B: Market valuation of Airbnb, 2015 $21B: Kitchener-CambridgeWaterloo region's GDP, 2009 $21B: Amount food manufacturing contributed to the economy, 2012

The latest Intergovernmental Panel on Climate Change report, released in 2014, outlined more clearly and with greater certainty than ever before how both climate change and pollution from the combustion of fossil fuels have killed thousands of people and will threaten the lives of many more.2

In 2010, a position statement from the Canadian Medical Association3 called for physicians to take action, but it focused largely on developing strategies to deal with the impending effects of climate change on health and health systems. In 2013, a CMAJ editorial4 discussed the role of physicians on the front line of climate change and examined how they can make a difference at the political, professional and individual levels. These recommendations remain pertinent.

Prompt action on reducing fossil fuel emissions in the near term, to prevent irredeemable downstream effects, is just as important as responding to current and imminent threats. An emergency medicine physician based in Yellowknife summed it up well when she likened the relatively small window for action to the urgency following a myocardial infarction or the onset of sepsis. “We either get the job done in the next decade or so or we prepare for palliative care.”5

Yet achieving international binding agreements seems to be happening at a slower pace than that of receding glaciers. When world leaders convene, issues related to saving the world from economic collapse, terrorist threats and oil crises seem to come before those related to saving the world from the threat of climate change. However, things are changing at the macro-economic level. The World Bank has made strides in coordinating international efforts to develop renewable energy, develop globally networked carbon markets and “enhance the flow of finance toward the ongoing effort to limit global warming.”6 One can perhaps see the influence of the current president of the World Bank, who is a physician and social anthropologist, in these recent actions.

Humans are bad at envisioning or appreciating the long-term consequences of behaviour. Behavioural scientists call the phenomenon “delayed reward discounting.” In short, we need salience now. In developed countries such as Canada, many of the adverse effects of climate change will only affect future generations. Although we may believe the science and many of us may support our government in making binding agreements to reduce carbon emissions, changing our personal behaviours may be costly, inconvenient and difficult. How do we galvanize to combat global warming?

Health promotion campaigns are most effective when delivered on multiple levels at once, combining information on the health benefits of a behaviour change with modelling of the behaviour, reduced barriers to its adoption, a good system of social support for those who adopt it, and person-to-person promotional initiatives and media campaigns.7

We need such a multipronged campaign to drive real action on climate change. Physicians are agents for change at all levels, and we can do more to bring climate change to the forefront of people’s consciousness. With our unique comprehension of stages of change and skill at intervening to help individuals make lifestyle changes at whichever stage they may find themselves, we can make a big impact.

We have managed to effect social change regarding smoking despite the power of industry, and we are beginning to turn the tide against the anti-vaccine lobby. Our approach to overcoming the stalling tactics of climate-change deniers should be no different. A few years ago, it was unusual to ask patients about how much physical activity they engaged in or how much sitting their job demanded. Now, we counsel about the risks of being underactive and write exercise prescriptions. It is time for physicians to talk about the effects of climate change routinely in daily practice. We should not forget that we are respected, influential advocates.

"It's now up to the government to act and decide whether it will cover the cost of certain services and the use of medical equipment in private practice, or if it wants to revise the agreement on the accessory fees with the medical federations." Under the Quebec Health and Social Services Act, doctors who work in hospitals cannot bill patients for medically necessary services. These same physicians must abide by certain conditions in their private practice, since they have not opted out of medicare. They can only charge for "medications and anesthesia agents" in private, and they are not allowed to bill patients for the use of medical equipment. However, there is one exception to the rule: private radiology clinics in Quebec can bill patients for MRI scans - a sore point with Health Canada, which has argued that the exception violates the accessibility provisions of the Canada Health Act. In addition, Quebec did negotiate with the medical federations a list of fees that are permitted, such as the use of liquid nitrogen to remove moles ($10) or the use of a topical anesthetic for a minor eye wound (also $10). Over the years, many physicians in private practice have started billing for many more items and services, sometimes prompting investigations by the Régie de l'assurance maladie du Québec (RAMQ).

DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): Well, I think it's probably not divided properly and I also think that we need to be very mindful of the ways in which advertising and marketing, whether it's direct to patients or consumers as we often consume from the American media on our television screens, or whether it's direct to physicians. So, you know, in fact, even in the U.S. under the Affordable Care Act, physicians are now required to declare any amount of money that they take from the pharmaceutical industry. We have no such sunshine law here in Canada. Don't Canadian patients want to know if your doctor has had their vacation or their last meal or their speakers' fees paid by the company that makes the drug they have just prescribed for you? WENDY MESLEY (HOST): Well, we saw in those ads they'll say: Ask your doctor. Is there a lot of pressure and is that contributing to the number of pills on the market? SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK):

WENDY MESLEY (HOST): What are you seeing, David? DAVID HENRY (PROFESSOR, DALLA LANA SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO): I think this is right and it's a surprise to somebody from outside of Canada to find that in a country with a good comprehensive care system, there is not drug coverage. So patients with chronic disease, for instance diabetics, ironically in the city where insulin was discovered, are relying on free handouts from their physicians to provide what is really an essential medication; it's keeping them alive. WENDY MESLEY (HOST): Who do you think is falling through the cracks? What are you seeing?

CARA TANNENBAUM (GERIATRIC PHYSICIAN, PHARMACY CHAIR, UNIVERSITÉ DE MONTRÉAL): The vulnerable population in my mind are older adults with multiple medical conditions who are taking 5, 10, 15 medications at the same time and have to pay the deductible on that. And that adds up for a lot of them who don't have a lot of money to begin with, so they start making choices about will I take my drugs until the end of the month? Will I take every single medication that I have to? Do I really need those three medications for my high blood pressure, or can I let one go? And that could have effects on their health. WENDY MESLEY (HOST): Well, you mentioned diabetes, David. We heard earlier on "The National" this week from a woman in B.C. She has diabetes. That's a life-threatening disease if it's not looked after. This is what she said.

SASHA JANICH (PHON.) (DIABETES PATIENT): Roughly about 600 to 800 bucks a month. I don't get any help until I spend at last 3500 a year and then they'll kick in, you know, whatever portion they decide to cover. WENDY MESLEY (HOST): So, David, that's really common? People on diabetes aren't fully covered?

DAVID HENRY (PROFESSOR, DALLA LANA SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO): Well, they're covered to a degree in B.C., but it's what we call the co- payment level that they have to make even under an insurance program. In Ontario, they don't have any insurance at all. They're going to pay the full market price if they don't have insurance through their employer, and they may lose that if they're out of work. WENDY MESLEY (HOST): What are you seeing? What's not covered? Give me an example. DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL):

Well, actually, one thing that I think is surprising to a lot of people is the variability in coverage among public drug plans in Canada. So something that's covered, even if you're covered under a public drug plan, for example if you have cancer and you have to take chemotherapy outside of the hospital, in many Canadian provinces that's taken care of. In Ontario, for example, it's not. And I think that many Canadians are surprised to discover, imagine the, you know, enormous stress of a cancer diagnosis, that on top of that you're going to have to pay out of pocket at least to very… sometimes to very, very high levels, in fact. WENDY MESLEY (HOST): Samir? SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): And even just the other day, I just was debating with a pharmacy about the cost of some vitamin D. I have a person who's under house, he's on social assistance, and they said: We'll give you a free blister pack, you know, so he can sort his meds. We'll give you this. And we were actually, you know, working out a pricing system so this guy could even afford something so that he wouldn't break bones and actually have a fracture down the road. So it's amazing how some of the basic things we think are important aren't even covered. WENDY MESLEY (HOST):

Well, we saw that the drug costs have almost doubled in the last 11, 12 years. Is part of the problem… there's only so much, it seems, money to go around for prescription drugs. Is part of the problem that there's too many… some drugs are too easily available while people who really need them are not getting them? And there's marketing playing into that. We see a lot of ads in the last ten years. Check this out. VOICE OF UNIDENTIFIED WOMAN (ANNOUNCER): (Advertisement) We know a place where tossing and turning have given way to sleeping, where sleepless nights yield to restful sleep. And Lunesta can help you get there.

UNIDENTIFIED MAN #1: (Advertisement) Anyone with high cholesterol may be at increased risk of heart attack. I stopped kidding myself. VOICE OF UNIDENTIFIED MAN #2 (ANNOUNCER): (Advertisement) Talk to your doctor about your risk. VOICE OF UNIDENTIFIED WOMAN (ANNOUNCER): (Advertisement) Ask your doctor if Lunesta is right for you.

WENDY MESLEY (HOST): It's funny, you know, we hear our health plan discussed in the United States and now you talk about our socialized medicine and it's sort of until you have a health problem, you assume everything is covered. But who falls through the cracks that you see, Samir? SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): Yeah, I mean, I treat a lot of older patients and those who are 65 and older generally are covered by a provincial drug plan. But, you know, I'm seeing more and more, especially after the recent recession, we have people who are closer to that age who lose their jobs and if they lose their jobs and they were relying on private drug coverage plans, they are not covered. And then they find themselves they can't afford their medications, they get sicker and they literally have to wait and be sick until they can actually get their medications.

Well, it's a huge amount of pressure, I think, you know, for… you know, if you're a doctor that relies on information or supports from pharmaceutical representatives, for example, then there is that pressure that you're put under, there is that influence that you have. But also, we know that if your patient asks you specifically and says, you know, what about this medication, you may say, well, it's easier to prescribe you that medication if that's what you really want. But there's actually five things you can do to improve your sleep and actually avoid being on that medication, but we don't get asked for that. WENDY MESLEY (HOST): But I want to be like the lady with the wings.

SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): And that's what I hear: Why can't I be like that? But I think it's important to think about the other options. WENDY MESLEY (HOST): David, what do you think? DAVID HENRY (PROFESSOR, DALLA LANA SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO): I would like to focus a little bit on the prices that are being paid. We talked about usage and whether drug use is appropriate. There's also the price that is paid. Canada is paying too much. And if we can just return for a second or two to the idea of a national program, there's a huge advantage in being the sole purchaser on behalf of 35 million people, as it would be with a national program in Canada. And we know from experience you can reduce drug prices by 30, 40 percent. That's billions of dollars a year. WENDY MESLEY (HOST):

That's a political debate that you have launched and I hope that it gets taken up by the politicians. Who is buying these drugs? We have seen that there are more people having trouble getting drugs, more people using drugs. Who is it? DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): That are taking prescription drugs in Canada? WENDY MESLEY (HOST): Yeah. DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL):

Well, you know, interestingly over the last decade, we have seen an increase in prescription drug use in every single age category. So the answer is we all are. We're all taking more drugs than our equivalent people did a decade ago and I think… WENDY MESLEY (HOST): Teenagers? DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): Absolutely, teenagers and the elderly and everybody in between. And so the question really becomes: Are we any healthier as a result? You know, in some cases we're talking about truly life-saving treatment that are medical breakthroughs and, of course, we all want to see every Canadian have unfettered access to those important treatments. In other cases we may actually be talking about overdiagnosis, overprescription and as you say, Cara, sort of chemical coping of all different kinds. And I think that's what we need to kind of get at and try to tease out. WENDY MESLEY (HOST):

Well, and the largest group of all on prescription drugs right now, Cara, are the seniors. CARA TANNENBAUM (GERIATRIC PHYSICIAN, PHARMACY CHAIR, UNIVERSITÉ DE MONTRÉAL): The seniors, yes, and I'm very passionate about this topic because sometimes I see patients come into my office on 23 different drug classes, and that's when we don't talk about what drugs should we add but what drugs can we take away, and the concept of de-prescribing. And imagine if we could get people who are on unnecessary drugs, because as you get older you get added this drug and a second drug and this specialist gives you this and that specialist gives you that, but then there starts to be interactions between the different drugs that could cause side effects and hospitalization. And maybe it's time to start asking, well, what's the right drug for you at this time, at this age, with these medical conditions? And personalized medicine is something that we have been talking about. It would be nice if we could introduce that conversation into therapy and not just drug therapy, but all therapy. Maybe the drug isn't needed. Maybe physiotherapy is needed or a psychologist or better exercise or nutrition. So I think it's really a bigger question. WENDY MESLEY (HOST): Samir?

SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): Exactly. I mean, in my clinic the other day I had a patient who was on eight medications when she came with me, and… WENDY MESLEY (HOST): This is a senior? You deal with seniors as well. SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): Absolutely. And when she left my office, she was thrilled because she was only on two medications, mainly because some of the medications are prescribed to treat the side effects of other medications, for example, or the indications for those medications were no longer valid in her. But we added some vitamins and we just balanced things out appropriately. And she was thrilled because, as Cara was saying before, the co-pays, the other payments that one needs to pay for medications you don't want to take, that's a problem as well. WENDY MESLEY (HOST): We're going to take a short break, but we have one more discussion area which is: What are the next challenges that Canadians might face with prescription drugs? We'll be right back.

(Commercial break) WENDY MESLEY (HOST): Welcome back to our "National Checkup" panel. Danielle Martin, Samir Sinha, Cara Tannenbaum and David Henry are all here to talk about the next frontier. So we're hearing all of this exciting new science marches on and there's all of these new drugs, new treatments. Everyone wants them or everyone who needs them wants them, but they're expensive, right, Danielle? DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): They can be extremely expensive. So, you know, what we call these blockbuster drugs coming onto the market, some of them truly do represent breakthroughs in medical treatment and in some cases they can cost tens or hundreds of thousands of dollars a year. So they really are very expensive. But what I think many people may not realize is that the number of drugs coming out, even the expensive ones that are truly breakthroughs, is still a very small portion of the drugs coming out on the market. Many, many drugs that are being released and are expensive are marginally, if at all, really any better than their predecessor. So just because it's new and fancy and costs a lot doesn't necessarily mean that it's all that much better.

WENDY MESLEY (HOST): So what's going to happen, David? DAVID HENRY (PROFESSOR, DALLA LANA SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO): We need to find a plan. These drugs may cost hundreds of thousands of dollars. Nobody can afford that individually. Tens of thousands, rich people can afford them but the average person cannot. So there's really no way we can cope with these unless we've got a plan and, in my view, it has to be a national plan. And the advantage of that are that when you're buying or you're subsidizing on behalf of 35 million people, you're going to get better prices and your insurance pool that covers these costs is much greater. So the country can afford drugs that individuals can't.

WENDY MESLEY (HOST): Samir, what do you see as the new frontier here? SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): I think the new frontier is going to be more personalized treatments in terms of how do we actually treat cancers, how do we treat certain rare conditions with more personalized treatments. WENDY MESLEY (HOST): Because it's very exciting, right? You have this cancer that's not that common and then you hear that there's a treatment for it and you want it. SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): And it has the possibility of alleviating a lot of suffering from unnecessary treatments that may not actually be… you know, be effective. But I think this is the challenge. If we want to be able to afford these, if we actually work together we're actually more able to afford them when we bulk-buy these medications. But the key is going to be that, you know, this is where the future is going and we're going to have to figure out a way to pay for them.

WENDY MESLEY (HOST): What are you looking forward to? CARA TANNENBAUM (GERIATRIC PHYSICIAN, PHARMACY CHAIR, UNIVERSITÉ DE MONTRÉAL): I'm really looking forward to seeing all these new treatments that we have spent decades researching. You know what the investment in health research has been in order to find new targets for drugs, in order to increase quality of live, in order to cure cancer, and then to send a message, oh, sorry, we're not going to give them to you or you can't afford to pay for them, then I think there is a lack of consistency in the messaging that we're giving to Canadians around equity for health care. So you could get your diagnosis and you could see a physician, but we way not be able to afford treating you. So I think this is something we need to think about it. It's very exciting, I think we live in exciting times, and looking at different funding strategies to make sure that people get the appropriate care that they need at the right time to improve their health is really what we're going to be looking forward to. WENDY MESLEY (HOST):

Tricky, though. It's a provincial jurisdiction, you've got to get all the provinces to agree to a list, and the list is getting longer. DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): Absolutely. I mean, I think actually one of the big myths out there about drug plans is that higher-quality plans are the ones that cover everything. And, in fact, that's not true. You know, we can use a national plan or a pan- Canadian plan or whatever you want to call it to target our prescribing and guide our prescribing in order to make it more appropriate, and that's another way that we're going to save money in the long run. WENDY MESLEY (HOST): Well, I learned a lot tonight. I hope our audience did too. Thanks so much for being with us. DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): Thank you.

My story is relatively brief. Six years ago, shortly after completing my residency in Rochester, N.Y., I opened a solo family medicine practice in what had become my adopted hometown. I had a vision of cultivating a practice where patients felt heard and cared for, and where I could provide a full-spectrum of family medicine care, including obstetrics. My practice embraced the principles of patient-centred collaborative care. It employed the latest in 21st-century technology. After five years of constant fighting with multiple private insurance companies in order to get paid, I ultimately made the heart-wrenching decision to close my practice. The emotional stress too great. My spirit was being crushed. It broke my heart to have to pressure my patients to pay the bills their insurance companies said they owed. Private insurance never covers the whole bill and doesn't kick in until patients have first paid down the deductible. For some this means paying thousands of dollars out-of-pocket before insurance ever pays a penny. But because I had my own business to keep solvent, I was forced to pursue the balance owed.

Doctors deal with this conundrum in different ways. A recent New York Times story described how an increasing number of doctors are turning away from independent practice to join large employer groups (often owned by hospital systems) in order to be shielded from this side of our system. About 60 per cent of family GPs are now salaried employees rather than independent practitioners. That was a temptation for me, too. But too often I've seen in these large, corporate physician practices that the personal relationship between doctor and patient gets lost. So I looked for alternatives. I spoke with other physicians, both inside and outside my specialty. We invariably ended up talking about the tumultuous time that the U.S. health care system is in - and the challenges physicians face in trying to achieve the twin goals of improved medical outcomes and reduced cost.

I knew Canada had largely resolved the problem of delivering affordable, universal care with a publicly-financed single-payer system. I also knew Canada's system operates more efficiently than the U.S. system, as outlined in a landmark paper in The New England Journal of Medicine. So I decided to look at Canadian health care more closely. I liked what I saw. I realized I did not have to sacrifice my family medicine career because of the dysfunctional system on our side of the border. In conversations with my husband, we decided we'd be willing to relocate our family so I could pursue the career in medicine that I love. I'll be starting and growing my own practice in Penetanguishene on the tip of Georgian Bay this autumn. I'm excited about resuming my practice, this time in a context that is not subject to the vagaries of backroom deals between monied, vested interests. I'm looking forward to being part of a larger system that values caring for the health of individuals, families and communities as a common good - where health care is valued as a human right.

I hope the U.S. will get there some day. I believe so. Perhaps Canada will help us find our way. Emily S. Queenan, MD, resides in Rochester, N.Y. She is an adviser with EvidenceNetwork.ca.

Doctors have already made it clear that they don’t want centralization of services to detract from the needs of local communities. “Physicians want administrative feet on the ground. They want local support,” says Harrigan. “Any model we come up with will have to reflect this.”

The government has made four commitments, including developing a multi-year health plan for the province that will set targets for improvement. There is also a legal requirement for the IWK Health Centre in Halifax and the provincial health board — the two authorities created by the new legislation — to prepare annual public-engagement plans to ensure community voices are heard.

Physicians’ response to the merger, which was a prominent 2013 election promise from the Liberal government, has been cautious but supportive. “We’re looking at it as an opportunity to work with government so patients are better served,” says Kevin Chapman, director of Health Policy and Economics with Doctors Nova Scotia.

The new physician bylaws, now being developed by the health department and Doctors Nova Scotia, are also expected to change credentialing and privileging in the province. “We want to streamline this,” says Patrick Lee, CEO of the Pictou County Health Authority who is currently serving as co-lead of the provincial consolidation project.

Privileging is not now required in Nova Scotia, and physicians who want to be credentialed to work in more than one health facility must repeatedly go through the administrative process. Under the consolidated system, all physicians will likely have to be privileged, and credentialing will be simplified. Doctors Nova Scotia applauds both approaches but expressed concerns these systems could be used to restrict physicians to specific geographical locations.

That worry is unfounded, says Lee. “We have no plans to make any of those changes.”

One of the major — and controversial — changes the government has made is to reorganize the way health care workers are unionized. Four existing unions will continue to represent health workers, but they will represent only one group each. The Nova Scotia Nurses’ Union, for example, will represent all nurses in the province. The move is intended to reduce the rounds of bargaining from 50 to 4, according to the government.

The implications are already significant for the health care system, says Joan Jessome, president of the Nova Scotia Government and General Employees Union, which stands to lose 10 000 members under the restructuring. “It’s affected patient care today. [Staff] are all distracted.”

The Quebec government has negotiated with the medical federations a list of fees that are permitted, such as the use of liquid nitrogen to remove moles ($10) or the use of a topical anesthetic for a minor eye wound (also $10). Over the years, many physicians in private practice have started billing for many more items and services, occasionally prompting investigations by the Régie de l'assurance maladie du Québec (RAMQ).

In a statement made public Tuesday, College president Charles Bernard countered that the researchers based their conclusions on "impressions and partial data ... without taking the time to analyze in depth an issue so complex." Bernard noted that the College produced a report on accessory fees in 2011, and in January, it modified its code of ethics warning doctors that they cannot bill patients "disproportionately high" fees and that they must produce detailed invoices.

In April, the College called on the provincial government to modernize its system of accessory fees. In November, the National Assembly adopted Law 20, which gave the health minister the power to expand the range of fees now charged in private practice and to limit certain amounts. "We need to calibrate the expectations of pressure groups that would wish that the College - through its code of ethics - defend the public coverage of fees for medical services," Bernard added.

The number of Quebecers filing complaints about excessive fees soared by 374 per cent during the past five years, according to a report by the College in April. The complaints jumped from 31 in 2010-11 to 147 in 2014-15. To date, two cases over abusive fees have gone before the College's disciplinary board. In one of those cases, a Westmount physician was fined $10,000 in 2013 for charging patients "excessive and unjustified fees."

An Oct. 1 report by Quebec's Ombudsman found that some private clinics have billed patients $300 for eye drops; $100 to freeze offa wart; $40 to apply a four-centimetre bandage; and $200 to insert an intrauterine device. aderfel@montrealgazette.com Twitter.com/Aaron_Derfel

Dr. Charles Bernard, left, president of the Quebec College of Physicians, seen at a February news conference with college secretary Dr. Yves Robert, says researchers based their conclusions about accessory fees on "impressions and partial data."

Hoskins said he wants to follow through on Winkler's recommendation to create a task force to make recommendations for improving and funding physician services. "One of the things Winkler spoke to was putting together a team from the OMA and from the ministry and other stakeholders, to really, in a serious way for quite frankly the first time, look at the issue of physician compensation and the delivery of health services by physicians," Hoskins said. "(It would address) how they can and should be best compensated, how to create a sustainable way of doing that, how to frame it within the reforms that are taking place in the health-care system. There's a lot we can do together," he added.

The OMA has so far issued no public response. The organization's board of directors is gathering on Wednesday and plans to discuss the Hoskins' meeting. In an email update sent to doctors on Monday, OMA president Dr. Mike Toth said board members plan to discuss next steps, including possible legal action. The update hints that doctors may be preparing to take some sort of job action. Toth wrote that 200 physician leaders met on Sunday and held a "brainstorming exercise designed to test and confirm innovative and impactful actions that members might undertake in various clinical settings and geographic areas across the province."