Manitoba Committee Hansard — 6 June 1985 (Legislative Affairs Committee, Sitting 2, 32nd Legislature, 4th Session)

32-4-la2

Manitoba — Debates (Hansard)

LEGISLATIVE ASSEMBLY OF MANITOBA THE STANDING COMMITTEE ON LAW AM ENDMENT S Thursday, 6 June, 1985 TIME - 8:00 p.m. LOCATION - Winnipeg, Manitoba CHAIRMAN - Mr. P. Ey ler (River East) ATTENDANCE - QUORUM - 10 Members of the Committee present: Hon. Messrs. Cowan , Desjardins, Eva ns, Harapiak Hon. Ms. Hemphill Hon. Messrs. LecLJyer, Parasiuk, Plohman, Storie Messrs. Adam , Ashton, Corri n, Eyler, Filmon, Fox Mrs. Hammond Messrs. Hyde, Joh nston, Malino wski, Manness, Mercier, Nordman Mrs. Oleson Messrs. Orchard, Santos, Scott, Steen WITNESSES: Bill No. 2: Dr.

Paul Shu ckett, Association of Ind ependent Physicians Dr. Richard Matkaluk, private citizen Dr. Henry Krahn, Association of Independent Physicians Dr. Jeremy Gordon, Associa tion of In dependent Physicians Mr. Waiter Kuch arczyk, private citizen Dr. Henri Marcoux, private citizen Dr. Gilbert Bohemier, Manitoba Chiropractors' Association MATTERS UNDER DISCUSSION: Bill No. 2 -

An Act to amend The Health Services Ins ur ance Act. MR. CHAIRMAN: Comm ittee, come to order. We are hearing representations from the public on Bill No. 2,

An Act to amend The Health Services Insur ance Act. I have a list of approximately 10 people. The first person on the list is Dr. Paul Shuckett. DR. P. SHUCKETT: Mr. Chairman, before I begin, will it be permissible to add an additional name to the end of the speaking list? MR. CHAIRMAN: Certainly, the Clerk will get the extra name to make a presentation. 22 DR. P. SHUCKETT : Dr. Gordon will have the name, okay? Mr. Chairman, I am an ophthalmologist, an eye doctor, and I have a su bspecialty in Pediatric Ophthalmology. I deal in my practice with children.

I was born in Manitoba and educated at the University of Manitoba, both at an un dergradua te level and in medical school. For four years I was a gradua te student in Economics at the University of Minnesota prior to entering Medicine. After completing my residency in Ophthalmology at the University of Manitoba, I did an additional year's training in Pediatric Ophthalmology at the Eye and Ear Ins titute in Pittsburgh. At the time of the completion of my training in 19 80, I contemplated returning to Canada, and specifically to Winnipeg.

Although I knew that the financial rewards for my work were far greater in the United States and in other parts of Canada, I felt I had a du ty to the people of Manitoba, as well as a desire to return to my family and roots, and come home. I knew that the rewards here were circums cribed, but I felt that I could provide the kind of practice that I had been trained to do and provide the rewards that I knew were available in other parts of Canada and in the United States by practising outside the Medicare scheme and extra billing those patients with the ability to pay.

In point of fact, I extra bill about two-thirds of the patients that I actually see. The amount that any patient may be extra billed over a year might range from $10 for one visit up to $40 for several visits over the course of a year. I automatically waive my full fee for those who are on Social Assistance, those whose fees are being paid by a third party, etc., etc., etc. Since the patients pay directly to the clinic business manager, I, in fact, do not know what the patients end up paying, as some patients merely remit their MHSC claim cheque.

In fact, our clinic has a practice of not submi tting its bill to the patient un til six weeks after the patient is seen, so they have received their MHSC cheque before our bill is received by them. I continue to see patients who have kept the money that MHSC has paid them and fail to remit their fees to us. In fact, we do not fail to see patients who have kept hundr eds of dollars from our clinic. I cannot see how this practice in any way represents a barrier to access of appropriate health care.

In point of fact, any patient who is making an appointment with us is informed of the extra fees that we charge and if they cannot or will not pay, we waive the extra fee. My patients have the freedom of seeing me or not seeing me. There are other ophthalmologists who are not practising outside the scheme. The patient gets a bill and knows what my fees are and is well aware of what the true cost of medical visits are because of this. I cont rast my practic e to that of the Provincial Government. Several months ago, they instituted a $1 5.25 extra billing fee for patients in chronic care facilities.

Their definition of the ability to pay was an income of greater than $1, 825.00. The Pro vincial

Thursday, 6 Jun e, 1985 Government is short of cash, so they can extra bill anyone and this is "okay," but if a private practitioner does this, there is a "barrier" to health care. lt is obvious to me that extra billing is permitted when it is to the benefit of the government's own pocketbook, but is opposed when the proceeds go to another party. As an opted-out physician, I am always aware of the fact that the public may have some adverse feelings toward my practice and toward physicians in general. As you recall, the Hall Commission, in its review of Medicare, found that people were opposed to extra billing.

This is much akin to asking people if they would like to have a free lu nch or pay for it. The answer is obvious. In another su rvey, people were asked whether they wou ld be willing to pay an extra fee if they had the freedom of choice in terms of physicians. With the appropria te phrasing of this su rvey, people were in fact positive with their response to the practice of extra billing and opting out. We are well aware that lawyers have a tariff fee, but some choose to charge less than that, and some charge significantly more.

People are willing to pay more because certain lawyers have better skills and expertise in certain areas. As physicians, we are to be denied this und er the rule s to be instituted by this bill. lt should be noted that Britain has had a two-tiered medical scheme for the last 30 years. I refer, of cou rse, to the National Health Service which provides free "medical care" to its popula tion.

In particul ar, with regard to Ophthalmology, they provide cataract surger y. lt is a joke that in the Na tional Health Service, the patient is booked for cataract su rgery, but the long waiting list redu ces the queue by a sign ificant percentage because the patients die before they get their su rgery. The response in Britain has been the setting up of private insu rance and private health schemes. I find it ironic that labour unions in Britain are fighting for private medical insu rance as part of their fringe benefits in settlements.

This is a direct result of the inability of the closed health system to provide adequate care. I fear that this same type of und erfunding will develop in Canada with time, as it has developed in the United Kingdom , but un fortuna tely the second route, the ability to use outside funds for health care, is to be closed by this bill. The constraints of financing have already reared their ugly heads in the provisions of health care in Manitoba.

There is no doubt in my mind that certain decisions, made even in the last few years, have restricted the availability of first class health care to Manitobans and the sole criteria, of cou rse, has been cost. Recently the Health Sciences Centre in Winnipeg pur chased a new computer ized tomographic x-ray machine paid for by the government, of cou rse. This is a very expensive machine and it consists of two parts, a compu ter and a scanner. The patient sits in the scanner and the computer develops the x-rays.

The Health Sciences Centre obtained outside funding from a donation for a second scanner which could be hooked up with a computer , as the computer was designed to be used with two scanners at once. The Health Services Commis sion rejected the use of the second scanner because it said it wou ld cost too much to operate the machine. 1t is known from other national su rveys that Manitoba is tremendously behind the national average in terms 23 of the provisions of computerized tomography. The costs considerations alone have prevented this machine from being util ized fully at the Health Sciences Centre.

I work in a large mult i-specialty clinic in which we have the largest group of obstetricians practising in the city who are responsible for almost 1, 000 deliveries, births a year. They, as well as our internal medicine experts, have need of what is called a diagnostic ul trasou nd machine. This machine is available only at a few hospitals in Winnipeg, and the waiting list for its us e are too long, months at a time when it's elective.

We felt it wou ld be advantageous to our patients to provide this service and we have, at our own cost, pu rchased a machine. lt has been in use for several years, filling an obvious need for the people of Manitoba. To date, the Health Services Commis sion refuses to compensate our clinic for this service. lt is flagrantly obvious the only reason for this is cost, and the un willingness for the province to pay for it bodes ill for the futur e of medical care in Canada and in Man itoba, in par ticul ar, when patients are denied adequa te access to proper facilities.

I practise in a very fast moving, highly-technological area of medicine. Ophthalmology has seen sign ificant advances in the treatment of various diseases with procedu res which save or restoree vision and enhance the qual ity of life for all Manitobans. In particul ar, the treatment of glaucoma has changed radically in the last few years. The introduction of laser glaucoma surgery has made profound inroads in preserving vision, decreasing the need for hospital ization, expensive su rgery inside the eye and long-term use of mul tiple potentially hazardous drugs.

We, as a group, have been negotiation with the government, through the Manitoba Health Services Commission, for adequa te fees for these procedu res. The government has been very hard-nosed about this to the point of lud icrousness. They are willing to compensate us performing a potentially risky, highly skilled procedur e for the sum which is un believable - $57.00. Manitoba has been very lucky to have one of its ophthalmologists spend several years training as a glaucoma specialist in the United States and England. This person returned to practice in Manitoba three years ago with great hopes and expectations.

Unfortuna tely, he has been hamstrung by the inabil ity of the Commis sion and the MMA to come to any fruitful agreements. Because of this stalemate, and because his futur e is tied to glaucoma work, he has made arrangements to leave the province within the next six months. Manitoba is a have-not province with regard to ophthal molog ists. We have a relative shortage of ophthalm ologis ts and those who are in pra ctice demographically are relatively old.

The relatively low level of fee schedules, in terms of office practice, compared to other areas of Canada, can be attested to by the relatively high percentage of ophthalmologists in Manitoba who have opted out of the Medicare scheme. Approximately 40 percent of the fully qu alified active ophthalmologists are opted out. A second factor to bear in mind is the fact that the University of Manitoba has lost its accreditation in the training of new ophthalmologists. Because of problems at the Health Science Centre and other inadequate facilities for training, this has come about. When we

Thursday, 6 Jun e, 1985 combine the combina tion of a loss of extra billing and the relative lo wering of attractiveness of fee schedul es in Manitoba, and a loss of a training facil ity for new ophthalmolog ists, we ma ke Manitoba a relat ively unattractive pla ce for the future of ophthalmolo gy. My expectation is, without changes in both these regards, 10 years from now we'll be facing an untenable position in which Manitoba will have very lo w expenses for ophthalmolo gy because there won't be any. Thank you very much. MR. CHAIRMAN: Are there any questions for Dr. Shuckett? Mr. Mercier. MR . G. MERCIER: Dr .

Shuc kett, what was th e recommended fee for the proc edure you were discussing with the laser beam? DR. R SHUCKETT: Ini tially , when the procedure was introduced in Manitoba, there was an interim fee recom mende d - and I can't remember the exact num ber, but I think $250 rings a bel l. That was when the fee was first introduced provisionally about four years ago, but then the Comm ission decided that was much too high and they countered with a fee of $1 13 .00. The fee of $1 13 was to include six weeks of post-op erative care.

A cal culation done by my col league who does this procedure, who is the glaucoma expert, concluded when one took into account the numb er of visits which are required post-operatively with this $1 13, inclu ding six weeks of post-o perative care, the fee for the procedure worked out to about $25 and he felt, because of the risks and the paperwork invo lved, he would do the procedure for nothing. So the problem has been one of negotiation with the Comm ission and it's been stalema ted for several years now. MR. G. MERCI ER: Did a group ophthalmologis ts purchase a laser ma chi ne? DR.

R SHUCKETT: There is one la ser owned privately in the Province of Manitoba. MR. G. MERCIER: What is going to happen to that with the fee

schedule that is being set by the Health Services Commission? DR. R SHUCKETT: it's in teresting becaus e tha t ma chine ha s been paid for by private funds, by a clinic through a Foundation, and they will be maintaining their facility, but there will probably be no other facilit y provided at this point, privately. MR. G. MERCIER: Is there any guarantee that mach ine will be retained and not sold, in view of the fee

schedule that ha s been app roved by the Health Services Commi ssion? DR. R SHUCKETT : Well, fortunately for the users of that ma chi ne, it has another use, and that's in terms of laser surgery for retinal detachments. Now, the fee for the laser surgery for retinal detachments, which required probably equal amount of time and less post operative care, is significantl y greater than the fee that 24 has been prop osed for glaucoma. The probl em has not been the fee for the laser surgery, as existed in the fee

schedule in the past, the prob lem has arisen because of these new procedures and the very very hard-nosed app roach tha t the Manito �a Health Ser vices Commission has approached it. Now the problem arises when you have physicians, such as a glaucoma expert, who confine their practice to a certain area and find that they're stonewalled in their practice because they can't get adequate fees for their work. MR. CHAIRMAN: Mr. Orchard. MR. D. ORCHARD: Dr. Shucke tt . DR. R SHUCKETT: Can I add some thing to that?

There is another la ser ma chine which I should menti on, it's called a yag (ph onetic) laser ma chine, which I did not specifically mention in my presenta tion. Tha t's a machine that's used after cataract surgery to open up a membrane, let's put it that way, and the same private Foundation that provided the group of ophthalmo logists with this mach ine has provided them with this yag la ser machine. There is no other yag laser in the province; no public facil ity has the yag laser at the present time.

Again, the fees pro posed by the Health Services Commis sion for the yag la ser are so ludicrously lo w the clinic is actively looking for a purchaser and getting rid of it. MR. D. ORCHARD: Dr. Shuckett, on the first machine that you were describing, are services provided, in the clinic with that machine, currently covered under the MHSC fee schedul e? DR. R SHUCKETT: The machine itself is being covered for retinal surgery, with an adequate fee; but for glaucoma surgery, the fee that's been proposed is $113 .00.

Now the Commis sion has been trying to negotiate an extra fee, and to be perfectly frank the Commission has been trying to propose an extra fee to help those who own the mac hine to pay for it. But, again, when you add up the professional com ponent to this it's entirely inadequate. MR. D. ORCHARD: Now, the glaucoma procedure at $113 is deemed to be inadequate, has the MMA suppor ted the ophthalmologis ts' position that that is an inadequate fee? DR. R SHUCKETT: We've been negotiating, through the MMA, for three years on this item , and we have gotten nowhere. MR. D.

ORCHARD: And the MMA is indicating to the Health Services Commis sion that the fee of $1 13 is inadequate and should be raised? DR. R SHUCKETT: Right, we've been negotiating this. MR. D. ORCHARD: You've expressed some concern about the lo ss of the training facili ty at the Health Sciences Centre for ophthalmo logy. What im pact will that have in terms of recruitment of ophthalmolo gists in Manitoba?

Thursday, 6 June, 1985 DR. R SHU CKETT: In point of fact, in the la st 10 years onl y one ophthalm ologis t has come here who wasn't, at least, partially trained here. it's a kno wn fact that physicians tend to practise where they train, especially at the end of their training. If they are in a specialty they'll stay where they train. In Manitoba we've had a relatively successful program in the past , in terms of retaining trainees, especially in the last 10 years.

With the loss of a training program this abil ity to attract ophthalmolog ists to Man itoba will be los t, and I can't see how we can attract people here unless they have social or geographic ties to Manito ba. MR . D. ORCHARD: Now, with the loss of the training facil ity, where is the next cl osest geographic school for ophthalmo logy? DR. R SHUCKETT: Geographically west, Saskatoon, it's a very very small program , they accept one resident a year, and that is in fact inadequate for their needs.

The y have had a very diff icult time retainin g ophthalm olog ists in Saska tche wan, sp ecific ally , Saskatoon. it's interesting because Saskatoon is where the training program is, and Saskatoon is not bad in terms of the numb er of ophthalm ologists. Regina, which is not tha t much smaller than Saska toon, has a tremendous shortage of ophtha lmo logists. And, again, it's a sim ple reason the trainin g program exists in Saskatoon and there's a relative attractiveness to it; here in Manitoba we have the same problem.

Brandon which, even of itself, is not a huge city but services a large portion of the population of Manitoba, has onl y th ree ophthalmolog ists who are activ ely practising, and need a significantly la rger num ber but, because it's not a centre, it's had difficulty in attracting ophthalmologis ts. MR. D. ORCHARD: Then, from Saskatoon, is Al berta or Ontario the next cl osest school? DR. R SHU CKETT: Right, then we go to Al berta and then going east - my geography in Ontario is not terrific - but I think that Lon don, Ontario would be the next cl osest stop. MR. D.

ORCHARD: Now, with the loss of the training facilit y, are you aware of any loss of some of the training personnel, some of the physicians that provide the instruction and the residency? DR. R SHUCKETT: Well, one ophthalmolog ist who was a former head of the department is leaving the province. In terms of the facili ties provided at the Health Sciences Centre, at the General Hospital, some of the facil ities are being cl osed down. These facilities were providing care to patients at the Health Sciences Centre, ambula tory care.

Most of the ambu lator y care facil ities at the General Hospital will be cl osed as of this month in ophthalmolo gy. Surgery will still go on at the General Hospital, but the out-patient facili ties, the ambula tory care faciliti es are gone. MR. D. ORCHAR D : Is your clinic able to, in. some way, fill the gap on the out-patient aspect? 25 DR. R SHU CKETT: I can only speak for my personal practices in pediatric ophthalm ology and, because of the nature of the Chil dren's Hospital and the nature of its operation, we have elected to conti nue our out patient services at that hospital.

At the General Hospital, which I don't work at actively, there were several types of clin ics. There were general out-patient facili ties and very special ized clin ics. Now the very specializ ed clini cs, most of the directors of these clinics have gone to great pain to make sure that these patients have been placed, because most of them were foll owed for years in private ophthalmologis t practice.

In terms of the other out-patient faciliti es, the clinic s were disbanded and the patients were told to go to their fam il y doctor for referral to an ophthalmologist, and fight the queues into the offices from that point. MR. D. ORCHARD: You mentioned earlier on in your presentation the ultrasound mach ine that is in the clinic that you practise from. DR. R SHUCKETT: Right. MR. D. ORCHARD: Are diagnostic procedures with the ultrasound ma chine in the clinic covered by MHSC fee schedul e now? DR. R SHUCKETT: No they are not. MR. D.

ORCHARD: Now, presumably then, when that is used, the patient is paying for that directly. DR. R SHUCKETT: We had been billing the patients, and the radiologis ts who practise at our clinic, have been billing for the professional part of it, for their

interpretation of the results. In point of fact, we have not been dema nding payment from our patients at this point because the costs would be considerable for the patients and we have been absorbing it up to this point. MR . D. ORCHARD: Would you anticipate continued usage of that machine then? DR . R SHUCKETT: No, I think that it is coming to a head and the situation will have to be rectified. I think that, either we are going to have to start to get paid for the use of the ma chine, and the provision of the facil ities and the service to the people of Manitoba, or we are jus t going to get rid of it. . MR.

CHAIRMAN: Are there any further questions? Mr. Orchard. MR. D. ORCHARD: Now what is the process? Is that a negotia tion with MH SC to have tha t diagnost ic procedure included? DR. R SHUCKETT: There are fees for many things tha t phy sicians do in a fee. sched ule. Dia gno stic ul trasound nowhere exists in the fee schedule, so we can 't get paid for some thing that does not exist in the fee schedule. We have been attem pting to establish fees for ultrasound for years, but the ultrasound facilities are onl y in hospital right now, and the only way you

Thursday, 6 June, 1985 ;ou ld get paid, I gather, is on a sessional basis throug h :he hospitals. We have been un able to establish fees 'or this. IIR. D. ORCHARD: Thank you. IIR. CHAIRMAN: Are there any further qu estions for )r. Shu ckett? Seeing none, then I would like to thank you, Dr. :;huckett, for coming here tonight. I)R. P. SHUCKETT: Thank you. IIR. CHAIRMAN: The next person on my list is Dr. Richard Matkaluk. I)R. R.

MATKALUK: I'd like to thank the members of the committee for the opportun ity to speak tonight, Emd I'd like to direct my remarks to some problems that I feel exist with Bill 2, as it relates to my specialty Nhich is dermatology, and specifically as it will ultima tely relate to the entire population of Manitoba. At the present time the American Academy of Dermatolo gy recommends that there is one dermatologist for every 35,000 to 50,000 people in the general popula tion; therefore using the upper figure of one in 50,000, a province the size of Manitoba should have approximately 20 dermatologists.

At present there are 12 certified specialists in dermatology in Manitoba; three of whom are over the age of 65. Training for dermatology is not available in Manitoba. In Canada it is available only in British Colum bia, in Ontario, and in Quebec. Clearly, we're facing a critical shortage of specialists in this area, and I feel that the government at this time should be trying to provide incentives to attract more specialists into Manitoba. What the actual situation is, in terms of financial compensation, could be better construed as a deterrent for physicians to come to Manitoba.

At the present time, the fee schedul e for dermatology ranks ninth out of the 10 provinces, with only Quebec showing a less favourable fee schedule. And if we look at the fee

schedule for 1984 for the five western provinces, from British Columbia through to Ontario which may be more representative, and we pick out a couple of office categories, I'll give the illustration of a com plete examination. The fee

schedule for those five western provinces in 1984 varied from $20.60 to $40.21; the lowest fee was in Manitoba; the highest in British Columb ia. The fee for British Columbia is 95 percent above the fee that exists in Manitoba. If we combine those five provinces, the average fee in Manitoba is 31 percent below the average. Similarly, for a su bsequent visit, the fees range from $10.55 to $17.60, and once again, the fee in Manitoba is 31 percent below the mean. Clearly, without training facilities in this specialty and other specialties, such as ophthalmo logy that Dr.

Shuckett has pointed out to you , we have to do something to attract specialists to the province, as he's already alluded to.

People locate their practices, either because they're from an area, or because they're trained there and they've liked the environment, or because there are good practice opportuniti es available. 26 Although I've already told you there are good practice opportuniti es available in Manitoba in terms of demand, the situation exists that there are also pr actice opportunit ies and good ones available in Ontario, in Saskatchewan, in Alberta, and in British Colum bia, all of which provide a more favourable environment for the newly-trained specialists.

Legislation such as this, which restricts the income of highly-trained specialists, will only serve to deter people from possibly locating in Manitoba. At the pr esent time, waiting lists are long and they're continuing to grow. There's a real threat to a sup erior qualit y of health care in Manitoba and I don't see that threat being posed by the small amounts, such as $5 or $6 that are billed by myself and other specialists to the patients that can truly afford it. Once again I'd reiterate what Dr.

Shuckett said, that if somebody can't afford it, if they're on welfare, if they're on Children's Aid, if they're unemplo yed, those fees aren't charged. I can't see how that small fee I charge my patient can ultima tely be expected to limit the access of ordinary Manitobans to qualit y medical care. But I can see how a lack of manpower that legislation like this can foster and worsen can prevent access to qu ality medical care.

I think that the problems facing Medicare are much too complex to be solved by a two-paragraph legislation that singles out physicians as a group in society to be su bject to unila teral price controls and to infringe on their rights. I would encour age the government to re-examine this legislation and in the spirit of co-operation with input from not only physicians, but other health care personnel and ordinary Manitobans, to try and establish a more comprehensive solution that might fairly address some of the many problems that exist in Medicare. Thank you. MR. CHAIRMAN: Are there any ques tions for Dr.

Matkaluk? Mr. Mercier. MR. G. MERCIER: Doctor, how many years did it take you to become a dermatologist? DR. R. MATKALUK: I was . . . MR. G. MERCIER: After high school. DR. R. MATKALUK: After high school - 12 years. MR. G. MERCIER: Where did you do the final training? DR . R. MATKAWK: I did my final training in the States, in Cleveland, at the Cleveland Clinic. MR. G. MERCIER: Training in dermatology, I take it, is not available in Manitoba or . . . DR . R. MATKALUK: Just the three provinces I outl ined: Ontario, Que bec and British Columbia. MR. G.

MERCIER: This is a qu estion - if you don 't want to answer it, fine. I would qu ite accept that. I take

Thursday, 6 Jun e, 1985 it that you went through a residency period in the final years of dermatol ogy. DR. R. MATKAWK: That's correct. MR. G. MERCIER: In your final years in residency, would you care to indicate what the average sal ary was? DR . R. MATKALUK: Well, the salar y where I was was $18, 000 .00. MR. G. MERCIER: Is that for 12 years of trainin g? DR. R. MATKAWK: That's correct. MR. D. ORCHARD: Doctor, I mi ssed the num bers of derma tol ogists in Manitoba right now. DR . R. MATKAWK: At the present time there are 12, and three are over 65, so I would ima gine they probably will be retiring shortly. MR.

D. ORCHARD: Are you aware of how many of the 12 who are practising, how many may use the extra billing provision presently? DR . R. MATKALUK: Six of twelve. MR. D. ORCHARD: Six of twelve. Now you give a range in the fee

schedule from $20.60 to $40.21 in B.C. Do you have the other provi nces of the five western that you ... DR . R. MATKALUK: Yes, that fee

schedule was for a comple te exam and the five provinces - going from Ontario - were $28.50 in Ontario; $20.6 0 in Manitoba -t hese are 1984 figures - $27 in Saskatchewan; $2 1 .50 in Al berta; and $40.21 in B. C. The five-province average is $27.00. MR. D. ORCHARD: I think that's all the questions I have at the present, Mr. Chairman. MR. CHAIRMAN : Are there any further questions? Mr. Nordman. MR. R. NORDMAN: Doctor, what would be the average extra billing that would be made? DR . R. MATKALUK: In my practice, for a comp lete exam I bill $28, which is very cl ose to the five-province med ium of $27.00. MR. R.

NORDMAN: So actually you're extra billing about $7 and some odd cents? DR . R. MATKALUK: Yes, I'm billing less than I would receive in Ontario or British Columb ia; and more than I would receive in Saskatchewan and Al berta. MR. R. NORDMAN: Further to that, how many of these 12 are in Winnipeg? DR . R. MATKALUK: All 12 are in Winnip eg. There was recently a dermato lo gist in Brand on. He's left for New Zealand. 27 MR. R. NORDM AN: Fine, thank you very mu ch. MR. D. ORCHARD: Doctor, could you indicate whether you've made any efforts with MHSC to have the fee

schedule looked at and possibl y adjusted? DR . R. MATKALUK: We made strong efforts through the MMA to have the fee

schedule reviewed but, unfortun ately, when you're a group of 12, in a group of 1,400 with a demo cratic process, it's hard to have a very strong voice. MR. D. ORCHARD: In other words, you're saying that you haven't had any s uccess? DR. R. MATKALUK: That's correct. MR. CHAIRMAN: Are there any further questions? Seeing none, then I would lik e to thank you Dr. Matkaluk for coming this evening. DR . R. MATKALUK: Thank you. MR. CHAIRMAN: The next person on my list is Dr. Henry Krahn. DR . H. KRAHN: Mr. Chairman, ladies and gentlemen, I would lik e to thank you very much for allowing me to come here tonight.

I would like to present to you three thin gs. One, there is a great worry in my soul that if this act is passed the way it has been drafted, that our excellent Medicare system, as we have it today, will be very rapidly deteriorating. I would say the complai nts that I hear about health care services in this province are rarely anything to do with medical services, but usually have to do with hospital services, and I would lik e to contr ast with you for a second.

The type of service that is being provided by our hospita l services, which I think is inadequate; and the type of service that I think the public generally has agreed, is quite acceptable as far as the med ical services is conc erned. Finishing that, I would lik e to just present to you the difficult ies tha t you have when you have a new procedure that is brought into the health care field that is really of a revolutiona ry nature and how difficult it is in Manitoba to get a fee establi shed for such a procedure.

Lastly, I would like to make some very presumptuous, but very mode st suggestions, as to how I hope this act could possibly be amen ded. To begin with, I would lik e to take you through a day of a typical urological surgeon, which is today. A patient gets admit ted at noon yesterday for a very radical kidney operation today for a malignanc y. She has a test done on aC T Scanner at the Health Sciences Centre in October 1984, on a machine - and this is no guff - that is a relic. lt is a ma chine tha t is a mu seum piece at the Mayo Clinic.

I kno w this for a fact because my daughter is a med student over there and I've been there and I'v e seen the mach ine - and on this ma chine a wrong diagnosis was made. Finally, because she was continuing to do unwell, it was apparent that there were difficulties; she had a CT

Thursday, 6 .June, 1985 Scan done on an up-to-date machine at the St. Boniface Hospital, which took five weeks to book. There were some problems with this and then we had to repeat this so that a needle could be placed in this lesion to draw off some tissue for examination, which took about another two wee ks, and all of this was finished on May 17th. For the last while this lady has been in contact with me and the admitting office, almost on an hourly basis, hoping that she could get in and have this thing attended to. She's a 48-year-old lady with a young family. She's a nurse.

As of noon yesterday, there was still no indication from the hospital that they could accommodate her for the surgery , which I was hoping could be done today, but she finally did get in; and then there's a tremendous rush to get all the things done, the blood that's required, and so forth, to make it possible for her to have the operation this morning. The othe r case is just as bad. A 22-year-old young man with a malignancy in his testicle who, from the time that the diagnosis was made, waited five weeks before he could have a CT Scan at the St.

Boniface Hospital to find out if there was any spread and whether there should be further surgery . Again, it was noon yesterday and he still didn't know whether he was going to get in, but he did get in and he finally had his surgery today. lt's very frustrating for everybody . The surgeon is targeted as being the one that should be able to get things moving. We are very much like lawyers. Patients unload on the surgeon and he becomes their advocate and they expect us to get them through this mess, but it is extremely frustrating and very difficult.

I have umpteen patients with malignancies like that that I could show you if you like. This happens all the time. We are very cash short in our hospital system and something should be done to unjam this; even if it means that one has to bend a little bit on dogma or on one's beliefs to allow extra money to come in from other sources. The problem, as far as beds go, is purely one of blocked beds by geriatric patients which, in every hospital in the city, represents at least 20 percent of our bed allotment.

If something could be done to get these geriatric patients into the proper place, then there would be all kinds of room for patients to be admitted at least; and surely if we're having to provide such substandard service with really only one CT Scanner in the province because the other one should be forgotten, then surely we should allow some charges to those who can afford to pay to get money into the system and get this thing unplugged. In Medicine, that option has always been there, but now we are told that option will no longer be there.

I can very quickly see that the frustrations, as far as medical services are concerned, will become just as severe and just as crippling as they are in the health care system. As far as new fees are concerned, it's almost a joke. We have, in the last two years in my specialty, found a way to remove stones from kidneys and from ureters, without putting people through a mammoth operation with six weeks of recovery before they can go back to work. As far as the advantage to the public is concerned, it's an immediate economic advantage.

With this new 28 technology they can have their thing done and practically leave the hospital and go back to work. This is a very high impact economic benefit to the citizens of this province. The procedure was intr oduced by one of my colleagues at the Health Sciences Centre, a bright fellow that learned this thing at the. Mayo Clinic and since then all of us have taken courses elsewhere and this fellow, Hosking, by now must have done at least 200 such procedures and we still, in two years, do not have a proper fee for this thing. There is an interim fee which is $300.00.

If he removes the stone by making an incision, he gets somewhere around $400 to $450, depending on slight changes and variations in the operation and that takes him an hour. If he does it with this new tec hnique, it takes him three hours and he gets paid $300 and we can see no way of getting this thing unjammed. lt's not a problem of the Medical Association. The Medical Association has come out full force and said that this is unreasonable and a decent fee ought to be established for this. lt is a problem of the Hospital Commission.

When it comes to another procedure which is allied to this, called ureterosco py, which is an instrument that we can now pass all the way up into the kidney , we could operate on stones for a fee of around $375.00. The patient would be in the hospital for about seven days minimum, usually 10, and go back to work in six weeks. With this instrument we can do all of this, but the open operation takes an hour, or maybe even less, and yields $300-plus. With this, we are currently offered a fee of somewhere around $100, which is about $33 an hour. We have office expenses also.

We cannot be in the black because my office expenses exceed that on an hourly basis and there's nothing left for it, it's missionary work. This keeps going on and on and on and we cannot get anything done about it. As far as my modest suggestions are concerned, I think the intent here is that they want to control the medical profession totally. But that very often means that there will be people standing in line for the procedures, which they have to stand in line for in the hospitals but not for medical services at the present time and thereby cut costs, but that means accessability will be reduced.

I think that extra billing, in some form, ought to be allowed. I'd be very interested in what the exact definition of extra billing is going to be in this act. For instance, if I do a bladder examination in the hospital, I get paid $42.50. If I do a bladder examination in my office, where I buy the $10,000 instrument and I provide the nurse and I provide the sterilizing and the room and all of that, I get paid $42.50. Now would it be considered extra billing if I charged $15 for my instrument, for my nurse, and so forth, over and above the $42.50? As I read the act, this would be considered extra billing.

There would be no tray charge; nothing would be allowed, which would mean - and this is happening in many, many of our procedures now - that all of our procedures will end up being done in the hospital and of course you'll get the control that you want. You'll be able to say, we're only going to do this many bladder examinations in 1986 - and maybe that's what you want. I kind of think that's your intent. I think that we shouldn't hoodwink the public about this. I think there should be the opportunity for people

Thursday, 6 June, 1985 to continue to get private medical care and there should be some incentive that a lot of this could be moved out of the hospital setting and be done much faster and much more appropriately that way. The other modest suggestion is that when there is a new procedure - and we've heard of others besides the two that I wanted to bring here today - that the doctor who has this new procedure is not in the fee man ual . Let him provide this thing as an uni nsured item , if he wants to, and charge a reasonable fee.

This will put some pressure on the goldarn government to get this thing unstuck, so that they'll talk to us and make some financial arrangements with us, so that we can feel encouraged to do these things and to develop new procedures. We're all going to be very big lo sers if this doesn't happen. Final ly, just to cont rast how this can be different, I had a patient that I saw last fall who had a fair amount of difficulty with his waterworks and not enough that I thought he needed an operation.

So he visited his daughter in Lancaster, Pennsylv ania, which I understand is a town about the size of Bran don; and this patient got plugged while he was there, was adm itted to the hospital. He had some heart problems. The y did some standard x-rays and found that he had a lump on one kidney and he had a type of cardiogram - and I work out of a hospital that is noted for its cardiol ogy - I'd never seen anything lik e this, as far as the technology was conc erned.

He had his CT scan and this thing turned out to be a cyst and he had his operation and the whole thing was wrapped up in eight days, to show you what it would be like. If that very same patient had this mi shap here in Winnipeg, it would have taken me six weeks. Thank you. MR. CHAIRMAN: Are there any questions for Dr. Krahn? Mr. Orchard. MR. D. ORCHARD: Thank you , Mr. Chairman. The aspect of the bladder exam ination, Dr. Krahn, undertaken in your office. I take it that that, when done in your office, that you do cha rge some thing above the $42.50? DR. H. KRAHN: We're not all owed to.

If you are an opted-in doctor you are not allo wed to charge one cent more than $42.50. MR. D. OR CHARD: Okay, yes. I realize if you are an opted-in doctor, but right now, if you so desired, without the legisla tion, you could charge sufficient to cover off your fees. DR. H. KRAHN: That's correct. MR. D. ORCHARD: The resolution of the kidney stone fee

schedule for the new procedure, I take it, and I think you indicated in your presentation tha t you had the full support of the MMA in the negotiation with MHSC. DR. H. KRAHN: That's correct. MR. D. ORCHARD: And ho w long have tho se negotiations been going on, Dr. Krah n. 29 DR. H. KRAHJt. Two years. MR. D. ORCHARD: And are they close to settlement right now? DR. H. KRAHN: Not anywhere near cl ose. MR. CHAIRMAN: Are there any further questions ? Mr. Lecuyer. HON. G. LECUYER: Dr.

Krahn, referring to the same example and you're referring to a piece of equipm ent for bladder inspections, whereby you say if it's done in the hospit al , for instance, will cost $42.50 for that service, and you will get the same amount, whether it's done in your office or in a hospital. That's one particular exam ple of equipm ent but, of course, there are many other equipm ent for other special ized cases.

Would there not be merit, for instance, in having all of the specializ ed equipment in the hospitals so that not every doctor is requir ed to buy the se pi eces of equipm ent; but, on the other hand, the doctors, as in your case who have to use that type of eq uipment, would have slated days or hours whereby your patients would meet you there and you can have access to that equipm ent. The alternative is that you and everybody else has to buy the same piece of equipment and, understandabl y, it has to be paid. DR . H.

KRAHN: The problem is that as soon as you bring this into the hospital you very often find that your needs are not a high p·riority need as far as the hospital is conc erned. lt ma y be that some heart surgery is taking all the bucks and there will be no equipment flowing in your direction. So you're limping along with practically no equipment and you're very severely handicapped.

If I have a patient, right now, that come s from rural Manitoba I can , in at least half the patients, depending on the psycholog ical ma ke-up of this person and so forth, and if it's going to be simple, I can do the whole thing, the office visit, the consulta tion, the exam ination; rap it all up; get my letter out and it's done.

Now the system that you're suggesting would m ean that he'd have to come back for a second exam ination which would then have to be booked in the hospital, which would probabl y be some thing, if it's anything like the hospitals that I'm in, at least six weeks or two months or mor e down the poke. Why do you think we are doing these things when they're losing mone y on them in the office. We are also perfectly stable people, we're not crazy. We wouldn't be doing this for $42.50 in the office if we get $42.50 in the hospital if there weren't reasons for it. And the reasons are that it's so goddamn difficult. MR.

CHAIRMAN: Are there any further questions? MR. D. ORCHARD: Mr. Lecuyer made a suggestion about having this equipment in reasonable enough supply tha t all doctors woul d have access to it, presumably , and be able to provide the patient rapid service; but you've indicated , earlie r on in your presentation, Dr. Krah n, that such is not the case, that the hospital system is backlog ged and, in effect, is

Thursday, 6 Jun e, 1985 rationing the level of service to your patients and presumably to other physician's patients. DR. H. KRAHN: That's right. MR. D. ORCHARD: Now, we mentioned an average figure of 20 percent in terms of block beds in the hospitals, I presume those are chronic care patients, or chronic stay patients that are occupying acute care beds, so that your access to a bed, hence to the surgical theatres, is restricted by that chronic care patient in the acute care bed.

So that your suggestion is that if you're going to deliver a quality level of medical service to your patients, that if you rely on the hospital to do it, you may be able to provide a quality service, but not in a quality time.

And your suggestion to the committee tonight then is that if you are willing to invest in the equipment, the space, the manpower and, presumably the knowledge of providing some examination, such as, the bladder examination in your office, that there should possibly be two fee schedules; one for the hospital scene where the space equipment manpower to support your practice is paid out of hospital budget, and another fee

schedule which would recognize the investment and the additional cost to you as a physician, if you do it in your clinic? DR. H. KRAHN: And that is not a unique thought either , because the fees are broken down in many fields, like radiolo gy, and I think in lab also, to a professional component, and an overhead component. All that would have to be done is that there would be a professional component which, if this legislation passes, that would be something that couldn't be extra-billed, but that the overhead component, that that would not be considered extra-billing. MR. D. ORCHARD: I missed that.

You're saying that the overhead portion wouldn't be considered extra billing? DR. H. KRAHN: That would have to be a definition that would allow this overhead component, that it could go ahead. MR. CHAIRMAN: Mr. Desjardins. HON. L. DESJARDINS: Dr. Krahn, it is a fact isn't it that you're on the Executive of the MMA? DR. H. KRAHN: Yes. HON. L. DESJARDINS: Isn't it a fact that the MMA has always resisted the concept of a two-fee structure; a higher fee when the physician had a major capital expenditure, and a lower fee when the equipment is supplied by the hospital? DR . H. KRAHN: I do not recall that.

We've had a differential in fees in some specialties, like radiology, which happened during the time of the price controls and ... HON . L. DE SJ ARDINS: We're talking about now though, presently . 30 DR. H. KRAHN: I don't believe so. HON. L. DESJAR DINS: Maybe we should both check, that's not the information that I have. MR. CHAIRMAN: Mr. Steen. MR. W. ST EEN: Dr. Krahn, you made reference a few moments ago to having a patient visit you in your office and you received a fee of 42.50, I believe. You mentioned that you required a nurse to assist you on that.

If you did the same procedure at the hospital, what type of personnel would you need, just a single nurse? Could you give me an example of what you think it is costing the taxpayer of Manitoba to have you do that procedure at the hospital as opposed to your office? DR . H. KRAHN: That same procedure in the hospital is staffed with at least two nurses, a clean-up person who is not full time in that room, but there are enough of them that as soon as the patient is taken out of the room that they are in that room in a very short time to make place for the next one.

There are people who look after the instruments there, at least four or five people involved in such a thing;

whereas in the office it is one person, that is, myself and the staff that I have. MR. W. ST EEN: But perhaps, Doctor, with the procedure in the hospital, it can be done so much quicker because there are two nurses rather than one. There are clean-up people where your nurse would have to clean up your office and so on, or do you say that it is still much more expensive to be done in the hospital? DR . H. KRAHN: Oh, an awful lot more expensive to be done in the hospital. MR. W. ST EEN: That's fine. MR. R.

NORDMAN: When it is done in the hospital, is there a hospital charge besides to the patient, or how does that work? DR. H. KRAHN: Well, if there is a patient who is going to have a procedure done equivalent to this and it is an uninsured service, it's a person who comes from south of the line, something like that. They charge what the hospital levies, and I presume this is based on something that has been worked out and not just a figure out of thin air. it's somewhere around $175 and then the professional component is added to that. That's probably a good way of showing you the difference in cost. MR.

CHAIRMAN: Are there any further questions? Seeing none, I would like to thank you, Dr. Krahn, for taking the time to come tonight. The next person on my list is Dr. Jeremy Gordon. DR . J. GORDON : I, too, would like to thank the committee for allowing me, on behalf of the Association of Independent Physicians, to have the opportunity to address you with our concerns about Bill 2.

Thursday , 6 Jun e, 1985 Our group is a group of 94 physicians who have come together to defend the rights of independent physicians. Some of us are specialists, some generalists, some urban, and some rural ; all of us un ited by a desire to preserve what is best in medicine and Medicare. We strongly believe that the independent contract between a doctor and his patient for delivery of medical services should be maintained. We believe the best way to preserve this cont ract is to encourage its continuation. The passage of Bill 2 in our opinion will begin the destruct ion of this independent contract.

The freedom of a physician to charge a fee for his services is a cornerstone of the contract. The state, in the shape of the NDP Government of Manitoba, has argued that in order to protect the weak and give them proper access to a physician that Bill 2 mus t be passed. The state has said that in order to be fair to everyone, there mu st be no mor e freedom for an individual to make his health a financial priority and purcha se the kind of treatment that he or she thinks he needs. The state has decided that in passing this law that promises made to all physicians only 16 years ago are to be broken.

The state has decided that the new value for medical services will be whatever fees the state determines. What began as an inducement for doctors to join the insur ance plan, that is Medicare, that is discounted fees for services, at the time in 19 69, 15 percent less than the going rate. This was an inducement because the government was going to pay the tab for the services rendered. What began as an inducement is now becoming a manda tory fee. Doctors who are not in the plan set their own fees based on mar ket values. For example, right now my fee is $87 an hour for those who can afford it.

The government, as soon as this bill is passed, has decided that my value is $69 per hour . I can tell you that is 9th out of 10 in the provinces of Canada. Only Quebe c is lower than us and that is largely because they've got captive doctors - pur ely French speaking.

In our view, instead of increased access to doctors and lowered costs and protection of the Medicare system, the opposite will occu r with their deteriorating medical system, lowered morale of health care pra ctition ers in the general public and general dissatisfaction as has occurr ed in other countries, such as Sweden and U.K., that has adopted state medicine. Bill 2 is the opening but very necessary gambit in the plans of the state to control medicine, in particula r, to control everything to do with doctors and their services. There is an old proverb: he who pays the piper calls the tune.

I wou ld like to illus trate with two little vignettes, what I believe to be the problems besetting Medicare at this time, and the dilemma facing those politicians who are charged with the responsibility of ru nning Medicare. Mr. Jake Epp, the Federal Minister of Health, was talking to me about a problem. He described a problem last week to me. He described a small town, and he said, "Look what happens. A new doctor comes into a small town and starts working. Pretty soon he's earning about two-thirds of the income of his colleagues. What happens to the old doctor already in the small town?

His income goes up, too. The incum bent has increased his workload and the new doctor is earning a very satisfactory kind of income. There was no 31 increase in the patient population, ju st an unexpected increase and a demand for medical services." Second story: the patient goes to the doctor for a trivial complaint, for the ump teenth time. The doctor tells the patient, "Look, I can't do anything more for you , why do you persist? Why are you coming to see me for these services?" The answer came back, "Why shouldn't I?

After all, the service is free." The doctor has told the patient, "N o, these services are not free." I think these difficult ies that I have ju st illustrated can be summa rized in a few sentences. The demand for medical services has grown to a point where governments no longer can afford to sup port them financially, and there does not seem to be a natural limit to this demand. Unless governments come up with new resources they will be forced to tackle the problem of increasing demand and try to find solutions to curbin g it.

If one adds to the above the coming problems attendant on the expected burdens of an aging popula tion, then we can all clearly see what a pretty pickle the government finds itself in at this time. The AlP believes that the Government of Manitoba has avoided the central issues of mutual responsibility for the costs of medical services between a patient and doctor. Medicare, as we all know, is not, nor ever has been, free. There is a finite limit on the amount of government money available for Medicare through taxes or other sou rces.

We feel that there has to be a public debate on these issues, in order for do ctor s and public alik e to un derstand for themselves, and resolve their concerns about this disturbing truth. Are people afraid to face the fact that Medicare is not a limitless resource? Is this simply a m yth propagated by people in the past, by politicians and , to some extent, by the medical profession itself? What is needed? We think government task forces just will not do. We think that this is something that has to be brought out into the open and that the popu lation of this province has to be told.

We think that you should all trus t in the natural cou rage and common sense of the people of this province. This is not a time to be cowardly and hide behind public opinion su rveys that tell you what everybody wants. Believe me, if you ask people if they would like to have a free autom obil e, you 'll get 99 percent sayi ng yes. If everybody was asked, do they want to have medicine free from any kind of extra charge, everybody will say, yes. So using that kind of information is absurd .

No one likes bad news, but if it is bad news, then I think it's better to hear it and then get down to facing the problems and trying to solv e the difficulties co operatively. Now, let's get back to the example that I introduced. The new doctor in the small commu nity generates enough work for himself to make a good living. Before he arrived the needs of the town were apparently being met by the incumb ent. What is going on? Is the increased demand due to the actions of the new doctor? Is he causing the increased need for services; or are the causes un clear at present?

Perhaps more research needs to be done to establish the facts. lt would seem obvious to any common sense person that the causes probably lie in the interaction between

Thursday, 6 June, 1985 the doctor and the people of that town, between the expectations of the townspeople for medical services and the doctor's expectation of providing these services and making a comparable income to his colleagues. The AlP thinks it's clear that, at this time, neither the doctor, nor the patients, are concerned about the costs of the services that are demanded and rendered. A reasonable man might enquir e as to why there is no sense of responsibil ity for the costs involved.

The answer seems to be clear; there has been a deliberate policy of presenting to the general public the idea Medicare is free and unlimi ted. We have to admit to all that this is not true. As long as the GNP of the countr y remained high, then we all cou ld get away with this deception, but now when the national money pie is shrinking in size, then the slice representing the costs of Medicare is proportionately larger. At the same time, the costs of repaying the huge loans governments have borrowed on our behalf, has grown to a point where they consume a qua rter of every dollar raised by the tax system.

No w we have respected politicians expressing their concern about runa way costs and pointing to potential cru nches in the near futu re when the Medicare system has to cope with an increasingly aging popula tion. The AlP, and by now every interested person in this province, realizes the NDP government has already decided on its solution to the problems of providing medical services to the general public with shrinking resources. The answer is to control doctors. If you control doctors from working hard, then bingo, all our problems will be over.

Stop doctors from seeing so many patients; stop them from ordering tests to make their diagnosis; stop them from admitting the sick to hospitals as much as they do; stop them from using the latest equipment; discou rage new techniqu es; stop training as many medical students; reduc e the numb er of specialists in training. The government wants to be able to tell doctors where to practise and how to practise. All this in the name of solving the Medicare problem. The AlP applauds the government for trying to tackle a difficult situa tion.

However, the propo sed solutions must properly be evaluated for their effects before being accepted holus-bolus. With all due respect, it's hard to have complete confidence in the solutions made by the same gu ys that put you in the manur e in the first place. The AlP has serious reservations to the propos ed changes in the delivery of Medicare. They can be summa rized as follows: firstly, establishing controls over doctors means abolishing certain rights of doctors and patients. The right to make decisions with the patient about his/her treatment will be eroded by the demands of the state.

Secondly, the right of a doctor and patient to make a contract for services requested and rendered is to be abolished. This is a fundamental right practised by every Manitoban every day of their life. Would any other group in society put up with the loss of this traditional right? Mr.

Green, the other day, who helped to bring in this Medicare to this province, said that he's fought all his life for the rights of electricians and plum bers and the working man, but tie thinks that these people should have the same rights as doctors and lawyers, and vice versa. 32 In our opinion, this government feels it can do this to doctors because it experiences doctors, as a group, as already civil servants. Already, as the boss, they feel they can do whatever they want. After all, he who pays the piper calls the tune, as I have said before; hence, the arrog ant disregard of our rights as fellow citizens.

Why not portray us as bad people, greedy and unc aring, with distortions about our salaries and our motives? To hell with our rights. All that is necessary is the appropriate smear in the press. What we are aware of is the erosion of our rights today, which is un challenged, will make it easier for other groups to lose their freedoms in the future. History has many tragic examples of this. Trying to solve problems by trampling on the rights of a minority is always wrong, whether the minority group is temporarily unpopular or not.

The AlP was shocked that no one in the Legislatur e voted against such a proposal on these grounds. Thirdly, the solution proposed by the NDP, namely, state medicine - that is doctors as state employees with regionalization, strict control over the numb ers, locations, services of doctors - this kind of solution has been tried in other countri es and found wanting. With that failur e inevitably comes the developments of a two-tier system. A significant numb er of the population eventually get fed up and rebel against such a system and demand a better system even if they have to put money towards paying for it.

We think that this is unne cessary; we think that the present kind of system wou ld avoid that. Fourthly, the solution proposed in Bill 2, namely, control over the medical activity of do ctors, will undermine the professional independence of physicians. The tradional role of the doctor as the servant, advisor and advocate for the patient will be lost. Our primary allegiance as doctors will be expected, by the government, to be to the funding agency. The name of the game will be to control costs and the kingpin will have to be the bureaucrat in charge of carrying out government policy.

We will become the gatekeepers, the apologists for other people's decisions. We predict the cu rrent experience of a deteriorating system will continue. Fifthly, the solution proposed by the NDP is an ideological one. We respectfully point out that rigid adherence to ideology runs the risk of being a complete failure. A wise man does not keep all his eggs in one basket. We have already tried to make these points to the government. What we have polled for is a more prudent approa ch.

We sug gest that a smor gasbord of approaches be considered in a public forum where all parties concerned have the opportun ity to contribute. We're in favour of solutions that emphasize flexibility, pragma tism and competition between various methods of delivering medical services, including preserving a direct contract between doctor and patient where it's requir ed.

Sixth, the solution avoids confronting people with the qu estions about how much medical attention do we want; how much do we want the state to control medical treatment; what constitu tes health care; what are the costs of a service that offers health care, meaning the pur suit of health, whatever that means; what are the costs of a service that offers care of sickness? How can we afford the system we want? Do we have to

Thursday, 6 June, 1985 accept higher taxes to pay for it? Is there an upp er limit to the support we can expect from government in our pursuit of health? Do we have to divide the pur suit of health, which is obviously an adm irable pursuit, from the treatment of sickness? Can we accept the principle that much of the work of doctors shoul d be done by other professionals? Will this resu lt in a cheaper and more effective service, or not? The AlP membership has always been willing to

part icipa te in such an exha us tive inquir y. These questions are too important to be left to the biases of gov ernment officials or go vernm ent domina ted committees. Will the passage of Bill 2 contribute to this particular process of investigation of public inqu iry, of a resolution in the pu blic's mind as to what is Medicare and what it can do, what it can't do, what are its limitations in these days of a shrinking dollar? I think not. Will the bill affect the introduction of new techniques and treatment into Manitoba? We feel that this will be underm ined.

Alr eady you have heard that entrepreneurs, people who take risks, will be di scoura ged. lt will be up to the bu reauc racy to introduc e new ideas, and this is always a risky busi ness. Without trying to blame or put down the bur eauc racy, their kind of decision making is slow and caut ious. What of the $1. 2 million qu oted as being sequestered in Ottawa? We feel it's a small price to pay to save Medicare. Medical care will deteriorate at the expense of fostering the delusion that Medicare provided univ ersality of care.

Only if you suffer from a common illness or live in Winnipeg or a big city, can you hope to get equal attention. If you live in a remote place or suffer from a rare illness requiring specialized care, you will not. If you live in Brandon and requir e a CAT scan, you will not receive as good attention as if you lived in Rug by, North Dakota, a much smaller centre.

The fine imposed in the province is highly qu estionable in its legality and if this was any other area of provincial jurisdic tion, there wou ld be screams of protest from the provinces and determined efforts to contest its legality in the courts. $1. 2 million compared to the sums the state spends everyday to pay in interest on debts on past borrowings is very sma ll. How much is the NDP prepared to spend on an advertising campaign to advertise its su ccesses in the hop e of electoral advantage? How much has the state spent on projects like McKenzie Seeds or Manfor or Flyer Bus es?

What promises or reassurances that if the government's policy is proved disastrous, that they will take any personal responsibil ity for them? lt is our conc ern that new technologies and procedures are being developed at the inverse speed at which bu reaucracy proceeds. New illnesses spring up all the tim e - AIDS, legionnair es' dis ease, environmental illnesses come to mind. Doctors and all governments can't stop developments of new illnesses or the developments of new technologies to deal with them. This is a most rapidly moving time. Medical knowledge, all knowledge, seems to doubl e every five years.

Can we keep up with this? How are we going to find the money to keep up with this and give the people of Manitoba the kind of medical services they deserve if there isn't going to be a chance for new money to come into the system? These events that I have described will not slow down in order to oblige slo w-mo ving go vernment 33 bu reaucracies to catch up with them. Everything in future is going to go through the Manitoba Health Services Commission which will control all. By necessity, it's cautious and has to be constricted by considerations weighted against risk. Entrepreneurs are needed to take risks.

You have to create a climate where these people are welcome in medicine as well as in busi ness in this province. We are worried about such things as the implications of our medical insu rance against malpractice. If our hands are tied in prov iding the mo st appropria te medical care, will the state protect us from lawsuits that prove that the patient did not receive the best and the most up -to-date care? The AlP feels like a fish in a lake contaminated by PCBs, acid rain or mercu ry. Our vitality, initiative and will to continue is being sapped by this act, but no one seems to pay any attention.

We know we are the first victims, but no one appears to be able to hear our warnings. Our ob jections to this act are that it's unf air, discriminating, and limits our basic freedoms and those of our patients. As Mr.

Green said, the same rule should apply to plum bers and working men as to lawyers and do ctors. it's the forerunn er of chan ges that will undermine the independence of all doctors and their patients; it's the forerunner of state medicine which has produc ed un wanted results in other cou ntries and which we advise against producing here. lt won't prod uce the described results, rather the opposite; it won't enhance accessibility or decrease costs; it'll discourage innovation; product ivity, supersp ecialization, new techniques and technology; it's anti-physician in its bias, which is in concert with cu rrent bur eaucratic thinking that doctors are what is wrong with Medicare.

I think that's an extremely day for Manitoba when this kind of thinking is allowed to become law. Thank you . MR. CHAIRMAN: Are there are qu estions for Dr. Gordon? Mr. Mercier. MR. G. MERCIER: Dr.

Gordon, to the best of your knowledge, is any consideration being given in this whole extra-billing debate that has gone on federally and provincially as to the possibility of establishing a committee that might be composed of doctors, of government officials, of even laypersons, who could rule on the acceptability of the amount of extra-billing, as to whether or not the extra-billing proposed is excessive, as a possible solution to this pro blem, because we continuall y hear from doctors who make very strong and what appear to me to be valid argu ments that fees established by the Health Services Com mission do no t cover the cost of certain procedures.

I suppose, in their defense, they don't have the money to do that in every case. Is that type of procedur e being discussed ; is that type of procedur e a process one that you think would be an acceptable solution to this problem? DR. J. GORDON: We wou ld be glad to do that. The answer is, no, that has not been our experience, but it's something that we would welcome. We sympathize

Thursda� 6 June, 1985 ery much with the government's dilemma in this articula r situa tion, having to find the money to fund tedicare, and looking down the road is very worrying, nd we absolutely sympathize. However, what we've alled for is an analogy to a mixed economy; in other rords, let's not just go down one road , because what ' we're wrong.

Let's look at a variety of approaches 1 order to try and solve these kind of problems, very ery difficult and phony problems, and why shut one loor at the moment when you may be glad, in fact, want to open that door again in a few years time when he funds simply aren't there? IIR. G. MERCIER: Is there a procedure now Dr. Gordon or a patient to complain about excessive over billing? >R. J. GORD ON: No, there isn't. We would certainly r�elcome such a provision.

You know, the patient can 1ave the freedom to jus t simply not pay the bill and, )bvious ly, if there was a dispute though between )hysician and patient, we will be glad to have something ,ike the lawyers do, where there is someone that you �an go to and have the bill checked out. We would be extremely willing to do that. We certainly don't want to be apologists for any wrongdoing or any rotten apples in our barrel. In my experience, people follow in my practice very widely, and that is that we charge according to people's ability to pay without any qu estion.

I mean it's really a very easily conduc ted and fair way of trying to establish the fee and I, in my own practice, find that if people have overestimated themselves that pretty soon that shows up, in either their ability to pay, or things that are said, and the fee is then adjus ted again. MR. CHAIRMAN: Are there any further qu estions? Mr. Orchard. MR. D. ORCHARD: Dr.

Gordon you mentioned earlier on that if you ask - public opinion is the point you were making - that public opinion is basically against extra billing and when you ask an individual, do you want to pay extra for medical services, the que stion naturally begs the answer that you 're going to get a, no. No w, given your opposition and some of the problems you foresee with this legislation, what should the qu estion be to the citizens to make them aware of the problems that you perceive with the ban on extra-billing? DR. J.

GO RDON: Well, I wou ld sug gest that the public sim ply hasn't been presented with the facts and that, once it was presented with all the facts, there wou ld be a tremendous debate in the public with all sorts of different shades of opinion. But what I wou ld hope for, at the end of it all, wou ld be some kind of mixtur e of solutions to be tried out in order to try and un derstand what might be the best way. So I think that if people were given choices, some of them would opt for a completely covered situa tion as there is now, and some wou ld want the opportu nity to make health care a priority.

Some citizens might even call for an increase in insurance schemes to allow them to insur e against their medical services in the future. I mean there's all sorts of possi ble schemes being tried out in different 34 count ries. The HMO's are being tried out in Ontario. There are things called DRG's , Diagnostic Related Groups, which are being tried out in the States where there is a fixed fee for a procedur e and that, when this is applied, it does encou rage efficiency because that is all that a person would get for doing, say, a herniorrhaphy or something like that.

So that there are a whole bunch of possi ble solutions, including commu nity clinics, nu rse practitioners, and everything else under the sun to try and solve these difficu lties. What we say is, let's have a mixtur e of things and, if you like, give the job entirely to the state, when the state could be flush and we'll get everything we want; or the state could be broke, in which case you know we're going to have some problems.

The kind of things that I think of are surely things that would warm the hearts of someone who believes in a welfare state and in socialism, because it wou ld, of necessity, mean that the rich are going to su bsidize the poor. Those people who can afford to pay a bit extra wou ld pay so, and that would lighten the burden for those people who don't have the money. MR. D.

ORCHARD: You made reference to countries that have a two-tier system where theoretically the system we may well be moving into now, with the ban on extra-billing, doesn't provide the level of care that the citizens demand, that a change to the sytem be made. Under this legislation, I believe that would be im possi ble because there is no abil ity under this legislation to practise outside of the plan and charge anything in addition to the preset fee schedule. DR. J. GORDON: Well, I'm very concerned about this. I started my medical practice in 19 63 with my father. He's a family doctor back home in Wales.

I spent six years in Wales un der the national health system. In those days, I could see a change happening. My father and people like him, who started the whole thing going in 19 48, worked their butts off. I mean, he would do 30 hous e calls a day and to offices every day, and work on Saturda ys and go out on house calls. I joined him and we started to introduce things llke appointment systems and some sense of limitation - I mean, my generation began that. We were saying: hey, wait a minute. We jus t don't think that the kind of money warrants this.

I made $5,0 00 the last year I was in Britain for my year's work. Now, the point that I am making is that even in those days the doctors worked damn hard to make the system work, but as time went by and the younger generation came in, the doctors began to act in a different kind of way. What they started to demand was lower working hours, overtime, holiday pay, state help with their staff, and pretty soon people started to say, "Well, wait a moment, I don't even get to see the doctor any more.

The receptionist tells me what to do, tells me to take two aspirins or something - or the nurs e." Graduall y, over a period of time, something that I believed when I left Britain was absolute ly impossible to happen, there began to develop a very extensive insu rance scheme in Britain involving 20 percent of the popu lation and largely involving not just specialists, because there were obviously a few specialists available right off the bat. I mean it was two-tier system always,

ThursdaJ, 6 June, 1985 but gradually it went from, say, people having their operation done, because they simply couldn't wait four or five years on the waiting list to have it done. What happened was that people started to use family doctors also in this scheme because of the service that deteriorated, which was something that I found really remarkable, because there was no sign of that on the horizon when I left in 1969.

So I am saying to you that gradual ly, as government funds dried up, as hospital facilities became deteriorated and less money was put into them, so the development of private hospitals, money from the state came into the system; that now 20 percent of the population of Britain is covered by private insurance and trade unions are asking for it as part of their package. IIR . CHAIRMAN: No further questions. I would like to thank you, Dr. Gordon, for coming tonight. Before pr oceeding, I would like to remind the members of the committee that questions are for clarification.

The details of the brief has been presented. I have been fairly lenient tonight on the procedure so far, but I would ask the members to restrict their qu estions to more of the detailed nature of the presentations. Mr. Mercier . IIR . G. MERCIER: Mr. Chairman, if I could make a comment. I believe the committee can only deal tonight with Bill 2. The Attorney-General isn't present with respect to the other bills before the committee, and I note that Mr. Evens from the Land Titles Office is patiently waiting to deal probably with a couple of the bills later on.

I wonder if it would be in order for the committee to perhaps allow Mr. Evans to leave and indicate that anybody else who is here with respect to any of the other bills, other than Bill 2, could probably leave; that those matters won't be dealt with tonight. IIR . CHAIRMAN: Is it agreed? (Agreed) We will be dealing only with Bill 2 tonig ht for presentations. The next person on my list is Mr. Waiter Kucharczyk. MR. W. KUCHARCZVK: What happened to you, Mr. Chairman? I see, for the first time, smiling since you were elected. MR. CHAIRMAN: Order please. MR . W. KUCHARCZVK: Mr.

Chairman, esteemed members of the Executive Council, it is very rewarding to see that there are nine Cabinet Ministers here. That means it is open season on the doctors as it was on the oil industry in 19 74. Ladies and gentlemen of the committee, I will not go into the details of Bill No. 2 from the point of view of the medical profession, per se, since they know they are pains. However, I know the pain as well; what happens when government in its "own wisdom" has an open season on certain groups. I will refresh your memo ry.

There is a gentleman here who had been in the House at the time. 35 Back to April 1, 19 74, the Government of the Day came to the conclusion that the petroleum industry was making too much money, so they implemented very nice wording, "p rovincial incremental tax." Waiter's income, including Chevron and California Standard and others, gone through the window 28 percent per month. lt doesn't matter how small we were, how big some were. That's how we got heat. Mr. Turner, of course, he wasn't behind Mr. Schreyer.

He fell immediately in his steps and said, "Well, we are not getting enough money , so we'll make it deductible from income tax." So Waiter has to pay again to Her Majes ty, in the right of the Dominion of Canada at the time, income tax on the money that Mr. Sctireyer already collected in the name of Her Majesty the Queen provincially. Now, why I am I mentioning that? Then, of course, Income tax came. You , today, have power, as Mr. Schreyer had. However, very unfortunately we peasants, back in the old country, used to say, "Whoever has a rake always rakes towards himself, never away." Then what happens?

Mr. 4'on comes with a big promise - (Inte rjection) - to power MR. CHAIRMAN: Order please. MR . W. KUCHARCZVK: Mr. Chairman, would you call to order the Member for St. Johns, please? I don't mean that seriously , of course not. When we became buried in industry through the · wisdom of the government, I felt very sorry for the medical profession, even though it is only about 5 percent of the total who are being affected, more or less, of your proposed bill.

Perhaps since there are members of the Executive Council right here know what will be discussed in caucus, you give thought that you are not a God-given gift to humanity. People know what is good for themselves in a way that sometimes Is pretty hard to grasp. So give people a chance. After all, If you don't put that bill through for the next election it's not going to decide anything one way or another . However , you will be in the history of Manitoba, of Canada, one who continues democracy, and I will come to it.

Because when you really look at this bill, what you're trying to do here is to paint all of the medical profession, in the form of the fees, with the same brush. Mr. Schreyer tried to do it, and Mr. Lyon didn't do any better either . A number of the industry, small guys, couldn't survive, didn't have enough money behind them, and besides legislation was retroactive, pulled out and went to Alberta. By the way, it later came back. Howev er, at the time, it was a mistake made by the Crown, very regrettable indeed. Now we all, I assume, are supposed to learn by mistakes, at least that's what I was told.

A partly hypothetical example: Assuming that you will make another mistake and go ahead and proceed with the implementation of Bill No. 2, think for a second, please. Ye ars back some of you might remember Dr. Pinfield, one of the outstanding pride of Canada, internationally recognized neurosurgeon. When a member of the Polish Bureau of the Soviet Union took sick, the Soviet medical profession came to the conclusion that it was only Dr. Pinfield who could do the job. Can you imagine how quickly they organizad a direct \1!gr t o ' a military plane

Thursday, 6 Jun e, 1985 to Moscow, and a successful operation had been performed? Now, for a second, as I said before, heaven forbid, if your Bill No. 2 will be passed, if you wou ld have a doctor here of his calibre, and you used the same paint brush and the same qu ality of paint, I don' t think you cou ld bur y yourself deep enough from the embarrassment of your mistake of the power. Now, the Minister of Educa tion is here and I have to be very careful what I'm saying. I think it's self explanatory, she's a most gracious lady besides being Minister of Educa tion.

Now, time and time again, I see we have young Cabinet Ministers, I think they have a gui lty conscience, they expect that their statements pertaining to the Highways Department wou ld have to be censored by the Minister of Educa tion, but she's too busy. Now, when it comes to phone calls, there is something I took up with a gentleman of government and, up to now, you here in Manitoba - and I don't think anywhere else in Canada - give credit to the medical profession for assisting the patients, or hu man beings, whatever the case might be, on the phone.

Now, I have been told it is very hard to control un ethical doctors. Well, my God, after all, that word is burn ing because I take for granted that every doctor is ethical.

Time and time again you have examples, well-known or publ icized - at least the press is not too bus y then - when some doctor directs, without the case of military, or case of RC MP, or some other police force, how to assist an individual, over the phone, whether that be delivery, whether that be extreme bleeding through an accident and yet, in this cou ntry of Canada, in this Province of Manitoba, being realistic, that's a capitalist state; and you don't expect people to be patriots, to do something for nothing, or deliver their services because of the colour of the eyes. And I respectfully submit that Mr.

Minister won't be interru pted right now by the Minister of Energy and Mines, so he would give und ivided attention to it. Mr. Minister, I will repeat again, Sir. HON. L. DESJARDINS: No, I heard you. MR. W. KUCHARCZYK: Oh, thank you very kind ly, I'm very sorry, I forget your ability, Sir, that you pay attention even to simple people like me. Thank you . Maybe you give und ivided attention because, as I have been told. well, nobody else does it. Well, Manitoba is proud to be in Canada first in many ways, and I am known to say that politically.

I remember the days when the toda y Min ister of Health came out with his experience on a numb er of the issues, but if I would start to talk about the issues I might get a black eye from somebody - and they told me it's non-political. Now then, I hope that point of the telephone, the issue is well made. I see some of you are impatient, so I will come to a further point that I made out. I heard a quo te- I forget the name of the outstan ding lawyer of Great Britain - by saying, "Power tends to corrupt and absolute power corrupts absolut ely." SOME HONOURABLE MEMBERS: Oh, oh! MR. CHAIRMAN: Order please. 36 MR. W.

KUCHARCZYK: Mr. Chairman, with due respect, sir, it's in modern days that one of the lecturers who comes from England to Canada. No, sir, it's not that far back, no. Now then, if you try to create a util ity out of the medical profession, then you are going to wipe out something that you worked so hard up to now to achieve. People hold you in high esteem, so why are you attempting to commit suicide through Bill No. 2? Jus t think about it.

Time and time again we are criticizing the Soviet system - after the Second World War, of course, because we don't need them anymore- and I tell you , the medical profession is held in the Soviet Union on a much higher pedestal than you demonstrate by drafting even this Bill No. 2 which is, in my hum ble opinion, an insult - an insult to yourself, whoever experienced that road, and an insult to the medical profession. Jus t to give you some points that maybe some day you will be thinking before you have a third reading of it - I hope never.

If you permit doctors to charge outside but the same rate, say, which is something to think about, as you are giving right now to the medical profession, and some doctors will not charge as much as your rate is, what are you going to do with the difference in the money? A figure of speech - $20 an hour - and the doctors say, no, I'll just charge you $10 , but Medicare has to pay $20.00. What are you going to do with the difference? Have you thought about it? No, because you were too bus y with Bill No. 2 to take complete control. I will be very brief; just be patient for a minute.

I only know that in principle, not exactly, but in principle, what you are trying to do through this Bill No. 2, there is only one countr y, to my knowledge, in the world - that's Afghanistan - that has a ratio 1 to 2. The Cabinet Minister gets twice as much as a working man. That's a very un ique position down there. At one time the people steared wrong with Mr. Schreyer, but our situation here is just entirely different - that wasn't applicable - but indirectly you r Bill No. 2 supports indirectly Afghanistan, and we are too far away from every point of view; I don't need to give you a lecture on that su bject.

Time and time again, when you walk into the Legislative Assembly, you see the sign in the Latin language. lt says, "Patria cara carior libertas," which stands for fatherland is dear; freedom is dearer. I repeat - patria cara, carior libertas- fatherland is dear; freedom is dearer. Mr. Chairman, you are here, so am I, sir, because of the philosophy of Caesar way back, right? And the Minister of Urban Affairs - and may she ever remain as a guideline for people of Manitoba and Canada - Mary Beth Dolin, she also came here and contributed un mercifully to this country the highest esteem I can ever pay to her.

I wish my English would be better and a richer vocabul ary. And yet by choosing the countr y with the freedom, as such, you turn arou nd and you are denying, through your power, the freedom that you choose here and yet you weren't able and neither was I - Stalin was in power then, eh? Well, there is the Member tor St. Johns, he can deliver you a lectur e, maybe tor six months constantly, as long as you have something to drink, right? SOME HONOURABLE MEMBERS: Oh, oh!

Thursday, 6 .lune, 1985 A MEMBER: He already gave that speech at the nominating meeting . . . MA. CHAIRMAN: Order, order please. MA. C. MANNESS: Come on Waiter, let's go. MA. W. KUCHARCZVK: I'm finished, Mr. Manness, in about two or three minu tes, that's all. I feel kind of hurt. Somebody said that the Member for St. Johns gave a speech at the nomina tion meeting. Well, I was going to come. That statement that was made which will linger in many minds, eh, I feel sorr y for those people that belittle the issue, what the Member for St. Johns said.

I don't think he meant to be derogatory because today in the Globe and Mail, on Page 10, you have the horrible stor y about the alcoholism situation right here in Canada. The Soviet Union set the precedent; they increased the drinking age to 21 and the liquor commission opens at 2:0 0 p.m. dur ing the working days. No w, what is more important, health or profit? Maybe the Cabinet will decide about it, etc., I thought, since the sugges tion developed on the spur of the moment.

In conclusion, I will only say that despite the fact that we live in a capitalist system, be gu ided by welfare of people, physically and mentally, and those dedicated people from the medical profession, I think I have to trust them the way unfortu nately I have to trus t some elected members, not all of them - some.

Without any doubt, seeing that the Minister of Health is in an excellent mood , even though he has two portfolios, I'm pretty sur e that he one day will say I was on the beginning of the nightmare known as Bill No. 2, but I just woke in time and the nightmare disappeared like a fog when sun and winter comes. Thank you. MA. CHAIRMAN: Are there any que stions for Mr. Kuch arczyk? MA. W. KUCHAACZVK: I gu arantee you there will be no questions at all. A MEMBER: You'v e covered everything. MA. CHAIRMAN: No qu estions?

On behalf of the committee then, I wou ld like to thank you for taking the time to come here tonight, Mr. Kuch arczyk. MA. W. KUCHAACZYK: And I thank you for the new title, although I have a Ph.D., pr ofound hater of deadbeats. Thank you very kindly. MA. CHAIRMAN: The next person on my list is Mr. John Nicolson. Dr. George Habib. Dr. A. Macrodimitris. Dr. Henri Marcoux. DR. H. MAACOUX: Mr. Chairman, Honourable Ministers, Leader of the Opposition and members of this committee, concerning chiropractors, Bill 2 is a tip of an iceberg in the continuing shoddy treatment of my profession and our patients.

Recent history supports this fact and this history has repeated itself many times before, so I will repeat some of the recent history concerning this. A lot of Manitobans have been seriously affected and are pretty angry by the decision the government has made in reducing MHSC benefits un der pretext of correcting the inequiti es in chiropractic care. Every Manitoban now has a single benefit limit of $14 4 a year. The intent, we know, is to save approximately $1 million or mo re per year.

This su bsequent increase following the 20,0 00 letters this government received, is inadequa te and our patients are not appeased as yet, although the sin gles seem to appr eciate the increase. The un derhan ded manner in which this was perpetrated on our patients and on my profession has left us with a strong determination to regain the little control we have, not only as a profession but also as guardians of chiropract ic. We also have the responsi bility to represent our patients in this manner because the government has not. On Febru ary 1, 19 85, Mr.

Harvey of MHSC sent a letter to all chiropractors advising them, that as of Janua ry 1, 19 85, chiropractic benefits would be cut back to make things more equal for Manitobans. Limits as they existed, $10 2 for a single, $204 for a family of two or three, $306 for a family of four or more, to be used as a family saw fit, no longer applied. Our Pr esident, Dr. Du nn, was noti fied by Mr. .

McCaffrey of MHSC, approximately four weeks before and told that the go.vernment wou ld cut back to the limits, change the policy on chiropractors opting out of Medicare where these would, by law, not be permitted to charge more than what MHSC pays per visit - that's extra billing. 37 Further , Dr. Dunn was asked to keep this absol utely qu iet and not to react publ icly until it was annou nced openly by this government. Dr.

Dunn reluc tantly agreed in keeping with the Manitoba Chiropractors' Association traditional spirit of co-operation - an obvious naivety, I might add - in our dealings with this government and its agencies. The MCA Board thought is was an un usual request. We did not un derstand it at first, no consulta tion, no chance to get feedback, no opportun ity for contributing other possible solutions, and no choice was given to us to help this government decide on what is best for everyone, given the profound impl ications for chiropractic and our patients. But this is not new.

MHSC has never negotiated in good faith for the good of all, but instead has always told us, after the usual mak e-believe motions of negotiating, that what we wou ld get, period, and this is not only as it applies to fees. Consequently we have fallen seriously behind, not only in fees, but in a natural growth of the profession and in patient benefits. Ins tead of being recognized by NDP governments as contributing significantly to the health of Manitobans, we continue to be treated as if we are a burden. I find this incredib le.

In my home province, where my profession and I work hard to help restore the health and maintain healthy Manitobans, we are treated with profound disr espect, a disrespect that I for one will no longer endur e, nor will I tolerate. Manitoba chiropractors are the lowest paid in the world while they treat the largest percentage of the

Thursday, 6 June, 1985 'pu lation per capita than any other area or jurisdiction the world. MHSC fee increases have not even kept 't o the rate of infla tion. Exam ple: 19 69 - $4.25 from Jr $6.00 fee; 19 85 - $8.77 per visit from our $19 fee; 10 percent increase in fee in 15 years and a 300 �rcent increase in infla tion. Although we started on par with the MD s in 19 69, tey are currently about $4 ahead of us per basic visit 1 which they can add other fees. Further, our fee ;hedule for exami nations in other procedures are not "en considered as these relate to the realities of ract ice.

This is no t the case with the medical rofession . This relates very poorly to high overhead :>sts, 60 to 75 percent of gross income. Costs for ension plans, holidays, semi nars and expenses typical f any other small business professional and then one tust pay taxes. Chi ropractors are staying in Manitoba )r reasons other than mone y. Chi ropractors are hurt and angry at this deplorable ituatio n. Chi ropractic work is very exact ing, very emanding and is a strong effort physically and motion ally . We deserve to be paid fairly for the work re do, a principle this government mus t respect and as not.

Whenever we ask for more mone y, we are !ways accosted with the cold fina ncial statistics that take us look lik e we are mo ney hungry, that com pared :> the average Manitoban , we are doing extremely well, , manipula tion further rei nf orced by sho wing hirop ractic revenue at higher levels per year with no ccounting for high overhead costs. No mention is made about how we are not average tnd of the long hours, the hard work and the awesome esponsi bili ty of caring for people who are sick. No :onsideration is given to our right to fee for service tS small business enterprises.

Furthermore, we are tlways aligned to the medical pr ofess ion in our ncreases and yet we are paid considerably less and tot fully insured under MHSC. The situation would be nore tolerable if the government would allow extra 1illing given the li mitations impo sed upon us, or at least 1ay decent fees for the services we render Manitobans. Manitobans who util ize chirop ractic health care do ;o mos tly at their own expense, while those who util ize nedical care do so totally with MHSC support; a true liscrimina tion in a provi nce that advocates universal 1ealth care.

My profession has always acted with ·espect, integrity and pol iteness in dealing with the �overnment and its agencies. The MCA has been ;onscientious in resolving its probl ems and keeping an �xcellent standard of professionalism in Mani toba. Because of ina pp ropria te fee sched ules, the ;hiropr actors of Manitoba have financed not onl y the �overnment in its health care, but also financ ed the nedical profession to the tune of millions of dolla rs :>ver the last 15 years. This has been done at our �xpense and detriment. We have no mor e to give.

Further, this government and its agencies have rarely, if ever, consulted us prior to making decisions affecting the future of chiropractic care and our patients. This must come to a stop and it will. In the current situation, the government has broken its part of the contract with the Manitoba Chiropractors' Association and the people of Manitoba three months prior to its expiration. The legal and politi cal impl ications speak for thems elves.

In 19 80, when I opted out of Medicare, I met with the Leader of the Opp osition, who is now the Premier 38 of Manitoba, I made him aware of the seriousness of our situation. I also informed him about how our patients in the chiropractic profession had been neglected by the Schreyer and Lyon governments. Mr. Pawley agreed tha t this situation was depl orable and yet his government continues with the same pol icy towards us and our patients. This governm ent and its agencies act as if they are not accountable to anyone for their actions.

The num ber of Ma nitobans who ha ve uti liz ed chiropractic care since 19 69 mu st num ber well over 70 percent of the popu lation . Many famil ies employ chiropractic as their main source of health care because of our holistic approach. These thousands of people will now find thems elves forced to do without or to emplo y medic al practitioners, who in turn, will charge MHSC, Pharma care, use hospitals, refer to surgeons, etc., thus incurring costs far greater than the $1 millio n this governm ent is trying to save.

The in dependent New Zealand Comm ission on Chir opr act ic in 19 79, an independent study, international and chiropr actic, found that chiropractic was not onl y an im portant health care profession, but that chiropractors were indisputably the experts on spinal manipu lat ive therapies. This repor t further establi shed chiropractic as an essential service in any health care scheme. Canada's Royal Commis sions on Medicare and on health care, have all strongly recommende d proper inclusion for chi ropractic care.

This imp lies consideration and respect and like Justice Hall, have called for an end to discrimi nation against chiropractic. When will this government start handling its responsibili ties towards chiropr actic health care? Removi ng the right to extra bill for chiropractors causes the profession to be locked into a system functioning on bla tant discrimina tion , inadequate fees and continuing government inconsi deration. This does not allo w us our survival clause for a situation which, in the last 15 years, have proven can and do happen. Especially ludicrous is the fact that

Section 12 of The Canada Health Act does not include chi ropractic. The Federal Go vernment gives no moni es towards chiropr actic care. Allowing extra billing in no way reduces federal mo ney to Manitoba. Are we being sacrificed to keep the medical profession in their place politic ally? This government does not have the ma turity, the capabil ity, and the abili ty to be the guardia n of chir opractic. Including us in Bill 2 is a discrimi nation of the hig hest order and spells a very severe bl ow to chi rop ractic care in this province.

Furtherm ore, it renders us comple tely vulnerable to any agency discrimi nation and we would have no recourse. Why does this government insist on including us in its polic y of universal health care by the removal of extra billing, when we are not universally covered or insured by MH SC? In my opinion, univ ersal Medicare is not advanced by Bill 2. Bill 2 is a desperate attempt to deal with rising costs and is useless in dealing with the real issues facing health care in Manitoba.

Do you think that removi ng extra billing and saving a few mill ion dolla rs in provincial mon ies will make a big difference in health care expenditures when Medicare spending is absolutely out of control? The truth is, that universal Medicare is pie in the sky, as long as Medicare spending is out of control

Thursday, 6 June, 1985 and tha t's what it is in Manitoba, and in Canada for that matter. As long as our society fights disease and mai ntains the attitude of ignoring health, we will be the losers. The present attitude this government has penalizes health care pr ofessionals and patients, especially chiropractic patients, by survival cutbacks instead of reducing usage of Medicare by Manitob ans. I realize that cutbacks are often necessary in governments, but what's wrong with creating healthy Manitobans who will not require Medicare to any great extent, but instead will use Medicare for health purposes?

The fact rem ains that there is no relationsh ip between the health and welln ess level of Manitobans and the amount of mo ney spent for so-called health care through Medicare. And also, there is no relationship between the sophistication of medical care and a level of health care anywhere in the world. The U.S. and Canada have the most sophisticated med ical facilit ies in the world and yet at least 18 th down the list of healthy countries. Medical sophistication saves liv es, that's quantity; but does not contribute significantly to health as a resource, I mean qualit y.

Medicare supports primarily one side only of the health care picture, the necessary crisis intervention of sick people by medic al practition ers. Nothing is done to maintain health and to prevent diseases. Coming back on expenses for Medicare and other changes will do little to alter the ultima te dem ise of universal Medicare. Medical expenses for Medicare have no alternative but to keep escalating as our society gets sicker and sicker. Increasing the numb er of medical graduates has not changed this picture. In fact, society wants to cut back on new medical graduates.

The transformation of this situation resides in a firm commitment to alter the direction of health care so that disease care is no longer in control. For this to happen, you need to look at health care in the true sense, that of caring for health as opposed to caring for disease. Medicine, unfortun ately, does very li ttle for the care of health. Governments need to look elsewhere to find solutions for the creation of healthy citiz ens, and finding means of hel ping people create health as the natural resource that it is.

Chi ropractic can pla y a major role in developing a plan to maintain health and prevent disease, so can other prof ess ions. This gov ernment, or the next government, need to look into this very soon if we are going to benefit from universal health care, if we don't go bankrup t first. lt is im portant to change our appr oach to the current problems and include all the healing arts for their input into developing a concrete plan. This is especially true about chi ropractic.

Chir op ract ic is hol istic and concerns itself with correcting and straightening the human frame, the body's state of nutrition, the body's fitness and a person's attitudes toward life. These are the essentials for good health in the human body. Any plan to create healthy Manitob ans mus t and would have to include these essentials. Not using chir op ractors to help in this problem is not realistic. In fact, we are the second largest healing art in the world. We don't use drugs or surgery and we are here to stay. We are scientific; we are well-trained; we are very effective in our area of health care.

Any plan to save Medicare must make 39 people healthy. That means the empha sis would have to be on health, not diseases, and that must include chir opractic. Incl uding chiropractic health care, the governm ent mu st do so in a fair and just manner. Services available to our patients must be in keeping with what public facilit ies are availabl e for the proper diagnosing and treatment of chi ropractic patients. Fees paid must be fair, equitable and relate realistically to the economy .

Binding arbitr ation for chi ropra ctors is certainl y necessary to com pensate for the pas sing of this im ma tur e legislation as it is now written . If this Legislature insists on pursuing this course, it mu st remove chiropractic from its grip and give the profession strong protection against unfair . government control. This government must finally make its move to right the wrongs it has imposed on the chiropractic profession and our patients since 19 70. Thank you, Mr. Chairman. MR. CHAIRMAN: Are there any questions for Dr. Marcoux? The Member for Burrows. MR. C. SANTOS: Dr.

Marcoux, you made a link between chiropr actic med icine and hol istic approach to health. DR. H. MARCOUX: Yes. MR. C. SANTOS: In what sense is this link establi shed? DR. H. MARCOUX: The word hol istic is a chiropr actic word. The authenic spelling is with a "w," not h-o-1-i s-t-i-c. Holis tic is spelt with a "w." Hol istic means that inevitably the work that you do with patients who are sick or well relates to the entire human being.

For instance, when you work on the skeletal system, the spine and the skeletal system of the body, you affect 70 percent of the human being, especially as it relates to the nervous system. So what happ ens is the body generally functions better. If, on top of that, you add a sound nutrition and a level of physical fitness, and a way of dealing with li fe thr ough attitudes and counselling and so on, people automatically regain their health if there is not an irreversible process. So our concerns are with the whole man, and always have been, and always will be.

We have no choic e, this is how it is with chiropractic. MR. C. SANTOS: Mr. Chairman, it has been said that people become what they eat; in other words, our diet has some thing to do with our health. If you are training for chiropr actic medicine, are these people required to take some courses in nutrition and diet? DR. H. MARCOUX: Yes, chiropractors are very well trained in nutrition.

We are not nutrition ists, but we are trained in clin ical nutrition and in the appl ication of diet and things of that nature for the correction of the disorders in the human body, as well as, the use of vitam in th erapies and other such ..l1erapies . MR. C. SANTOS: Viewing the wtv:,'e huma n being as not merely the ma terial part of ou. physical body, but

Thursday, 6 June, 1985 there is a moral aspect or a spiritual aspect to the human being, do you have other preparations for dealing with the spiritual side of man? DR. H. MARCOUX: The basic training in chiropractric college is the same, essential ly, as it is in medic al tra ining. Ther e is a cou rse in psy cho logy and in psychiatry. Although we are not trained to be counsellor s in relation to psychiatric problems, we are trained in the kn owledge and in the general couns el ling procedures involved in li festyle counsel ling and, in general, related to attitudes.

If we run into someone who needs psy ch iatric care or more profe ssional couns elling from, say, a psy chologis t or a family therapist or some of that nature, we don't hesitate at all to refer those people for that type of professional care. Plus some chiropr actors take an avid interest in cous el ling and other things tha t rela te to the psyc hological mechanisms of the hu ma n bei ng, especially as it exists In the psychosomatic concepts.

The mind and the emotions rela te together qui te distinctly and, in fact, all emo tions are physical , so a great numbe r of our patients who come in with mus cular skeletal problems are, in fact, com plaining about emotional probl ems that are man ifesting physical ly. We need to be very aware of this and we need to deal app ropria tely with those situations from a hol istic position and we do that very well. MR. C. SANTOS: In Latin they have a saying: mens sana en corpore sano - a sound mind in a sound body. DR. H. MARCOUX: I agree. MR. C. SANTOS: Thank you. MR. CHAIRMAN: Are there any other questions? Mr.

Storie. HON. J. STORIE: In your remarks, Dr. Marcoux, you had talked about the rela tionship to chirop ract ic medicine and the other heal ing arts. I'm wondering whether in you r presentat ion you are making an argum ent, or making a case, for having others of the heal ing arts inclu ded as insured services, talking about nurse practitioners, about naturopaths and herbalis ts and nutrition ists and ph ysiotherapis ts and psychologis ts. If tha t were to happen, would it be your view that the costs of our medicare system would eventually be less onerous than under the present system? DR. H.

MARCOUX: Your question is vipercated - it speaks with forked tongue. Pardon my language, it's two questions you might be sayi ng. First of al l, I was not eluding to the . . . MR. CHAIRMAN: Order please. DR. H. MARCOUX: I was not eluding, in any way, to the inclusion of other discipli nes under Medicare, I don't think that is my doma in to decide.

But I was referring specifically to the inclusion of other health professionals in developing a plan for developing healthy Manitobans. 40 Every discipline in the heal ing arts has some thing to contribute - every displine - that includes reflexologists, massage therapists, physiotherapy, nurse practitioners, everybody has some thing to say about how we prevent. The prevention of disease and the maintenance of health is a far bigger challenge than to treatm ent of disease, especially since we do very li ttle of it, except in the holis tic professions. MR. CHAIRMAN: Are there any further questions? Mr. Storie.

HON. J. STORIE: Just one further question, Mr. Chairman . Do you see any inconsistency, any inequity in the fact that chi ropractors are at least partly insured, and that yet other of the healing arts are not insured at all? DR. H. MARCOUX: Well, you are referring to those healing arts that are not involv ed medically? The medical pr ofes sion, as a hea ling art, with all its auxili aries and adjunctive therapists, is basically covered by Medicare. Nursing is looked after and so on. What are you referring to specifically? HON. J. STORIE: Well, friv olous nutr ition ists, reflexolog ists. DR. H.

MARCOUX: You kno w, if there is adequate training and they are contri buting some thing, I would see no objection to any government looking into the feasibili ty of including them if they are providing a good service, especially as it relates to mai ntaining people's health. But I am not sure what the direction of your questioning is because I haven't referred to any of those things. HON. J. STORIE: Well, I suppose the direction of my question was that you talked about the med ical model as the sole model for the insuring of health care services.

You are making the point, and I think there are certainly merits to your argument that we profess a concern for an interest in preventative medicine. My question was simply whether it would be your view that, including all kinds of other preventative therapies would, in eff ect, lower the cost eventuall y of the Medicare system. DR. H. MARCOUX: You are asking me to outline my plan for what would be cost-reducing for MHSC or Medicare, any kind of Medicare system.

Well, I will tell you some thing, I have a book coming out in about six months exactly on that subject. lt will be called "The Survival of Health" and it deals with that, a comp lete plan. I hope you buy the book. MR. CHAIRMAN: Are there any further questions? DR. H. MARCOUX: I will even give you a complimentary copy. HON. J. STORIE: And you autograph it for me. MR. CHAIRMAN: Order please. Are there any further questions? Mr. Scott.

Thursday, 6 Jun e, 1985 MR. D. SCOTT: Thank you, Mr. Chairman. A question to Dr. Marcoux. lt's my understanding, and this is a fol low-up to your comm ents where you are saying that in no other provinc e do chi rop ractors receive .s uch terri ble treatment as they have in Manitoba. Are chi ropractors covered under Medicare in any province east of the Province of Ontario? Are they covered in Nova Scotia, New Bru nswick, Prince Edward Isla nd, Newfoundland? DR. H. MARCOUX: No, nor in Quebec. MR. D. SCOTT: Nor in Quebec.

So how do you come up with an accusation that they are so terribly treated here in Manitoba when you are one of five provi nces that even all ows coverage for chiropr actors under Medicare? DR. H. MARCOUX: In Ontario, chiropr actors get a basic fee from OHIP for which they can balance -bill to their fee schedule. In Saska tchewan, the chir op ractors, appa rently, or 50 percent opted out, but I understand ther e is going to be a change simi lar to what's happen ing here, and chiropr actors there are getting $10 a visit - I think it may be a little mor e.

In Al berta, chiropr actors can balanc e-bill or extra bill. In B. C., they do not extra bill ; I understand there are also some changes taking pla ce there that would have allo wed them to extra bill, but apparently it will not come through, but they are getting over $10 a visit. We are getting $8.77 a visit. Their fees are shoddy, as well, but ours are worst than theirs are. Outside of Medicare, our fee

schedule is considerably different. lt has kept up with infla tion and it's basically realis tic. Manitoba has traditionall y kept Manitoba chiropr actors at a very low salary on the basis - and some of it is a pretence - that we can make up the difference when the pat ients ha ve expi red their Medicare visits, which in some cases took a long time. But just how much can you tax those normal fees that we were charging? So it waters the whole thing down.

Any chiropr actor in Manitoba practising outside of Man itoba would immedia tely , without any other consideration, double his income immedia tely, triple it if you were going to Ontario and Quebec, and even up to quadruple it in the Unit ed States, depending on the area you work in and how much you charge for your fees. I am saying there is a leverage there that allo ws for fees to fluctuate. We are not asking here, I mean , I am not speaking for the profession, I am speaking for myself. For me, I am not asking for exorbitant fees, I am asking for a fair fee.

I think that a fair fee would be approxi mately 75 percent of my fee schedule, or at least some thing that I could negotiate with, but there has never been any negotiating because we have never been taken seri ous ly. My feeling is tha t we are consciousl y, purposefully put down or kept down as a profession, and I think that's comp lete bias, comple te prejudice and not acceptable. In fact, from my position , that is so unacceptable that this is going to stop. That's my commitment, this is going to stop for sure. MR. D. SCOTT: You mentio ned chiropr actory at the forefront, I guess, of holistic medicine.

I wonder what 41 'kind of controls you have in your society or organizatio� to, I guess, monitor , one could even say, in other medical professions virtually pol ice the activities of the memben as to what they are serving people, what kind o1 qual ifications they have to be able to claim to offer medical services which they are offering. DR. H. MARCOUX: Well, I will answer your question, but I just want to clarif y a term. The word "preventative medicin e" belongs to the medic al profession; we use "preventative health care." To just make the distinction, medicine is a discipline and chi ropractic is another.

So within tha t con text, �hiropr actors are traine d in chi ropractic institutions. Before coming to Winnip eg, or to Manitoba, or in any jurisdiction, you have to write a li censing board which is governed by the university. lt's the same basic science boards that medical doctors write, plus essentially the same type of exams for cli nical sciences. Then a provi ncial associa tion, which is governed by

an act, such as it is in Manitoba, further exam ines this new graduate, or this incoming graduate, to grant them a li cenc e at which point the y are acquainted with the rules and regulations of practice in the province. The act that we have in Manlotba, and I am proud to say the act that we have now, is undoubtedly the best act in Canada governing chiropractic practice, and the act gives us, as an association, a very good leverage into handling disci plina ry problems, which we occasionally have as any other profession does.

But we handle our probl ems astutely, and we handle them comp letely, and we handle them very well. So the level of unethic al behaviour and discipli nary problems in Manitoba is very low and, furthermore, has always been low. MR. D. SCOTT: How many persons in the past, say, five years, have you refused permission to practice, or taken your li cence away for practising? DR. H. MARCOUX: In the past five years? MR. D. SCOTT: Yes. DR. H. MARCOUX: To the best of my kno wledge, there has not been one practitioner in Manitoba who has been suspended. MR. D. SCOTT: Thank you. MR.

CHAIRMAN: Are there any further questions? Mr. Orchard. MR. D. ORCHARD: Dr. Marcoux, you mentioned in your presentation the recent change to your numb er of visits that you are covered under Medicare to your patients. Could you give me an indication, in your practice, an appr oxima tion, as to how. many of your patients are affected by the change in the numb er of office visits where it's been lowered for the individual and the fam ily package has been changed, and they now have to pay for those visits themselves? DR. H.

MARCOUX: Given the type of practice that I have - and there are different types of practices, there

Thursday, 6 June, 1985 re acute care short-term care practices and there are mg- term care practices - my practice is a lo ng-term are practice, and so about 80 to 90 percent of my atients are affected. Some other practices, where they treat only with acute roblems, like a person come s in with pain in their ack, you get a cursory exami nation - and I will explain 1at - you get a cursory examina tion and local treatment l relieve the pain of the back . The problem in the pine is still there. it's basically unaltered, but there's ympt oma tic relief. That's like giving an aspirin.

That fPe of care is the type of care that a lot of chiropractors ave been doing in this provi nce - like I suspect over ·0 percent of the practitioners - so in their practices hey would not be too effective. But in my type of 1ractice which is corrective lon g-term care, like getting ,t the cause and working with nutrition and lif estyle 1nd fitne ss and all that kind of ,thing, it's 80 to 90 1ercent. IR. D. ORCHARD: Then obviously your patients will tot be terribly pleased with that change in bill ing, 1ecause th at took anywhere from 16 visits away 1resumabl

Document details

Collection	Manitoba — Debates (Hansard)
Citation	32-4-la2
Type	hansard
Volume / chapter	32nd 4th hansardpdf la2.pdf
Language	en
Format	pdf
Source	PROVINCIAL
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