Sustainability of health care in Canada

We strongly support Mark Fruitman's point that “[a] sustainable system must both control costs and provide appropriate health care.” Our purpose1 was to identify the key components in physician billings as a means of isolating both what was and what was not happening. The observation of major changes in the patterns of contact between patients and general practitioners is, we think, quite new: we found that GPs are increasingly sharing their patients, yet the net impact on costs is minimal. It appears that neither patients nor physicians are abusing the system or, if they are, that abuse has not been increasing. This situation might raise concerns about continuity of care, but such concerns take us beyond these data.

In contrast, the care of elderly patients after they pass the GP “gatekeeper” and enter the specialty system is much more expensive. As Fruitman points out, our data cannot say whether these dramatic increases in cost are appropriate. But if one is truly concerned about both the appropriateness and the cost of care, these sectors and this patient group would seem obvious places for further scrutiny.

Fruitman suggests that our conclusion regarding sustainability had its basis in costs for physicians, whose real fees declined over the period in question. But even if fees had increased at the rate of inflation, the average annual increase in expenditures would have been 6.8% rather than 5.8%, hardly enough difference to support claims of “unsustainability.” Furthermore, this calculation presumes that the change in (age-specific) utilization per capita would have been the same, irrespective of the change in real fees. It seems conceivable that faster growth in fees would instead have been associated with slower growth in utilization — the fact that the increase in use almost precisely offset the decline in fees may be more than coincidence. In any case, physician fees in British Columbia have been the highest, or among the highest, in the country for decades.

Morris L. Barer Robert G. Evans Kimberlyn McGrail Centre for Health Services and Policy Research University of British Columbia Vancouver, BC