Rural incentive programs: a failing report card

Peter Hutten-Czapski, MD
Haileybury, Ont.

CJRM 1998;3(4):242-7

This paper has been peer reviewed.

© 1998 Society of Rural Physicians of Canada

The "rural problem" is not new. The method of servicing rural Canada's medical needs by using "excess" urban physicians has led to great inequalities in physician distribution. There can be as much as a fourfold difference in physician-to-patient ratios between urban (1:193) and rural centres (1:797) in Canada.¹ What is new is that the problem is rapidly getting worse. Reduced enrolments in medical schools, which began in the early 1990s, have reduced the flow of family medicine residents to rural Canada. Physician net emigration of 503 in 1996² is adding to the drain.

Many factors are at work. Doctors are becoming more militant as worsening working conditions accelerate tensions. Some small hospitals are at risk of closing because of a lack of physicians. In 1995, 88 doctors were being recruited by designated Ontario underserviced areas; in 1997, 116 physicians were being sought (Underserviced Area Program Ontario, sponsored by the Ministry of Health). Places that previously had never had trouble attracting physicians are learning the new reality: the competition is tough. Towns that are within commuting distance from teaching centres are feeling the pinch. Whereas in the 1970s, building a medical clinic was enough, in the late 1990s houses, turn-key offices, income guarantees and overhead subsidies are being offered by desperate communities.

Compounding this problem is that census numbers indicate a growing rural population; many are retirees moving to the country. The increase in population and the increased health care needs of the elderly are stressing limited resources.

The provinces have a social responsibility to ensure equitable access to health care for all Canadians and have generated an impressive array of rural incentives (Table 1). What is surprising is the paucity of work done in evaluating the programs and determining trends in medical manpower, both urban and rural.

Existing data

The Canadian Medical Association (CMA) keeps a list of all the doctors in Canada. It is updated using data from licensing bodies and from mailings and surveys (CMA Masterfile). For years the CMA has taken the simple expedient of defining "rural" by the Canada Post definition: simplified it reads that if you get door-to-door delivery of mail your postal code is urban. This eliminates communities with a population of approximately 10 000 or more that get home mail delivery. Other definitions of rurality exist that may be more appropriate when discussing physicians. However, the CMA is unique in keeping a national database.

When the data are analysed for generalists, the breath-taking drop in rural GP/FP numbers is appreciated. In 1994 there were long-standing shortages. In January 1998, 15% fewer doctors were working in rural Canada than in 1994. Not a single province has maintained its numbers, and it appears that some provinces have undergone a physician attrition rate that spells rural extinction by 2006 if the rate continues unabated (Table 2, Fig. 1 [not available online, please refer to print copy], CMA Masterfile).

Whatever the limitations of a population-based definition of rurality, there are further limitations imposed by "definition drift" as the post office changes postal codes. The CMA has recently checked the validity of the postal code definition against a Statistics Canada definition of rural based on population density. Fifty-four physicians did not match. Thirty-six of those physicians were GP/FPs practising in New Brunswick who had had their postal codes reassigned, although they did not physically relocate. Factoring these 36 physicians into the New Brunswick numbers does not alter the overall rural and urban trends in that province.

Obstacles to rural recruitment

The uniform ineffectiveness of incentive programs is not because they are bad ideas. It is simply that they are not comprehensive and lack sufficient resources to have an impact on those practising in the hinterland. Implementing a successful program is inhibited by 4 obstacles: fee for service, organized medicine, governments and universities.

Fee for service

Whereas fee for service is particularly attractive to physicians who can limit their practice to high volume and low intensity, it is not well suited to the rural doctor. The rural doctor has to deal with inefficiencies arising from working in both the hospital and the office, as well as dealing with the very poorly paid work of looking after those who are truly sick. Fee for service encourages a treadmill work ethic which, combined with high community needs, leads to an unsustainable lifestyle. Paradoxically, if there were adequate personnel to service the community, fee for service would not be as big a problem.

Organized medicine

Because most doctors practise in urban areas, inevitably the power structure of most medical organizations (with the obvious exception of the SRPC) will be based in the cities. This doesn't make them unsympathetic to the plight of rural physicians, but it renders it difficult for them to fully support measures that inject more fiscal and physician resources into rural areas that might have been applied to urban areas, especially if urban physicians have bought into the divisive government concept that the size of the budget is fixed.

Governments

Current fiscal and political constraints make substantial rural programs difficult to enact. If a third of our population is significantly underserviced, how can one imagine that a token program, with even as much as 1% of the budget, will do the job?

Universities

Although many teaching programs claim to turn out a "stem cell" physician, most of the time they tend to put the stem cell in a broth modelled after big city medicine. Rural GP/FPs constitute about 14.3% of all GP/FPs (CMA Masterfile) but, using the same definition, only 8.8% of members of the College of Family Physicians of Canada (CFPC) are rural (CFPC membership database, 1998). With the demise of procedure-orientated, generalist training programs such as rotating internships and the decline in others such as GP-anesthesia programs, this trend will worsen unless family medicine training programs are further improved to address the needs of rural practice.

Clearly a solution to the "rural issue" is complex and will require significant resources applied at various levels of the infrastructure. However it can be done.

Positive examples

Some lessons can be taken from Manitoba. Although it, too, lost rural doctors between 1994 and 1998, its attrition rate was limited to 6% by a comprehensive rural package (CMA Masterfile).

Guidance counsellors promote rural medicine as a career choice to rural high school students. Several "rural experience" programs for medical students start in the first year. A medical student bursary of $15 000/yr is available for 3rd and 4th year students. It requires a return of service in rural areas. Rural family medicine rotations are supported financially, as is the Parklands second-year rural residency program. Six to 12 months of anesthesia or obstetrics training (including cesarean section training) is available. Additional residency slots for specialty training in psychiatry are also available for physicians prepared to serve in rural and northern communities. Recruitment grants of $30 000 to $44 000 tax free over 4 years are available for setting up practice in designated areas (Table 1). The Northern Medical Unit, as an example, places physicians in remote areas. They are paid a salary of $150 000 (Table 1). The same organization provides a rural locum program for communities with 4 or fewer physicians.

This is not to say that the Manitoba model is perfect. After all, that province has also had rural attrition, and the health minister admits that there are at least 20 physicians required to help relieve chronic rural and northern shortages. The numbers have had to be propped up by the recruitment of rural doctors from overseas who are "ghettoized" into underserviced areas by restrictions imposed on their licensure.

Quebec's programs have been almost as successful as Manitoba's, with only 7% rural attrition since 1994 (CMA Masterfile). The province has not relied on importing physicians. The Quebec system sponsors both fee-for-service and salary models (the latter usually at the CLSC [community health centres]) with La Régie de l'assurance maladie being the payer in both cases (provincial Ministry of Health). Quebec's basic fee-for-service schedule tends to pay better than does Ontario's for office work but not as well for hospital work. However, in Quebec, doctors in rural areas receive a premium of 15%, and emergency fees are supplemented by a sessional component (Table 1). In Quebec's emergency rooms, rural doctors get paid 50% of the schedule plus $140 from 2000 to midnight and 75% of the schedule plus $402 from midnight on (Table 1). If the night happens to be very busy, doctors can choose to bill straight fee for service instead.

Even the disincentive of being paid less than 100% of the fee schedule for urban practice appears to be a little better designed in Quebec. If a physician sets up practice near Montreal and wishes to do just office work, the Régie will pay only 70% of the standard fee-for-service rate. The physician's rate can be bumped up to 100% if s/he :

• Has worked there long enough. Initially the time period was 3 years, now it may take 10.
• Does enough designated community work, for example, work a shift a week at the CLSC, work in the (underpaid) emergency room, work at the home for the aged, do a rural locum (say in Val D'or).
• Sets up practice just on the outskirts of the designated urban centre (provincial Ministry of Health).

A signing bonus of $40 000 over 4 years and moving expenses are paid for rural relocation by the regional authorities (Table 1). However, at least one doctor found out later that this was understood by his region to mean paid as funds permit. In his case he was told by the region that the budget had run out, 4 years in a row, and he only got partial payment of his bonus!

Nonetheless Quebec's graduated fee schedule of 70%, 100% and 115% of payments, sessional emergency room work premiums and other programs have been partially successful in both rural and urban areas in providing medical care.

Less positive examples

The other end of the spectrum is Alberta. Although it has touted its Rural Physician Action Plan³ extensively, by 1998 the number of rural GP/FPs had dropped 34% from the 1994 baseline figure (CMA Masterfile).

The Rural Physician Action Plan (RPAP) in Alberta is poorly understood by many rural doctors. This might be because most of the money goes to the universities (approximately $2 million)³ and is never seen by most rural doctors. Although training doctors to practise and offering information services and continuing medical information has been a traditional role of the university, these programs now have dedicated rural funding. Looking at the type and size of the programs being offered, I am surprised that there is such a huge demand for full time CCFP(EM) doctors in 3-doctor towns rather than for GP-anesthetists, GP-"cesareanists" or GP-surgeons. I am sure that the universities were similarly surprised by the 1996 review of the program,⁴ which pointed out that most of the emergency room doctors who were trained ended up practising in the cities.

Unless serious attempts are made to make rural medicine attractive, even the best-trained rural physicians may end up in urban practice. On the other hand, the rural locum program that was established in Alberta has been viewed as helpful. It has been copied by many other Canadian jurisdictions (Table 1). The program is administered by the Alberta Medical Association and has a budget of $0.6 million.³

A more typical example is New Brunswick. It had the worst attrition rate of all the provinces: 39% since 1994 (CMA Masterfile). Allowing for postal code "definition drift," the attrition is only 21%, a rate that is in keeping with that of many other provinces.

New Brunswick has taken the novel approach of requiring doctors to obtain privileges at the hospital in order to get a billing number. The province tells the hospitals how many physicians and of which type they need. Government officials quickly tell me that this is "charter proof" and that provision is made to cover rural areas that lack hospitals, but other sources don't believe them and we will hear from the courts soon. Despite 2 weeks of vacation pay (supply your own locum) after 3 years' service, rural work has not been made more attractive than in the city. In fact other than British Columbia (0.1% growth), New Brunswick is the only province where urban GP/FP numbers rose (by 26% gross, 18% after allowing for "definition drift") since 1994 (Table 2). British Columbia at least has had significant immigration in that time.

Other factors

Factors other than the incentive programs also come into play. One interesting comparison involves fee schedules. Newfoundland has the lowest rate for fee-for-service payments of all the provinces: typically 20% or more below the national average.⁵ Ignoring arguments over definitions of rural it has had the greatest attrition of FPs, both urban and rural, of any region. In comparison, the North West Territories and Yukon Territory have depended on a fee schedule over 50% higher than the provincial average to attract and retain doctors.⁵

The microenvironment also affects the ability of communities to attract and retain physicians. For really small, isolated rural communities standard fee for service often can support only one physician. Then there is the onerous burden of being on call. Community-sponsored contract positions in Ontario serve as another interesting approach to deal with the problem of communities too small to sustain physicians in the usual fashion. Interested communities first had to get themselves on the list for these contract positions. They then interviewed dozens of candidates for each position and paid the overhead. The fact that there were dozens of candidates for each position is because these towns, at most, were used to seeing one doctor. With this new arrangement the workload was usually split between 2 physicians. Furthermore the contract was for $174 000 to $194 000 plus benefits and other incentives, as applicable (Underserviced Areas Program $40 000 for 4 years plus remuneration as per the Scott Report if there was an emergency room⁶).

This did fulfil the need of these small communities for medical care and in a sustainable fashion. However, since the manoeuvre was made in isolation it had the effect of drawing other rural physicians from less attractive settings. In some instances the incumbent physician stopped commuting to clinics that served adjacent communities because there was no incentive to continue doing that in the package. In the typical Toronto fashion it was assumed that all politically active small communities had to be treated similarly. Community-sponsored contracts offered the same money for physicians within commuting distance from Sudbury or North Bay as those in, say, Pickle Lake a full day's drive from Thunder Bay. The Ontario Ministry of Health is also surprised that almost nobody wants to sign the latest version of contracts for larger towns that are based on the northern Ontario GP average of $169 000 gross fee for service. The ministry still expects doctors to pay overhead and maintain the high "rural patients per physician ratio" that was not sustainable under fee for service.

What is needed

The solution in simple terms is to make the entire spectrum of rural practice attractive. Although numerous suggestions have been made,^6­8 all that is needed is money and people.

From Canada-wide experience we should recognize that a substantial additional capital involvement of 5% to 10% of the physicians' services budget is required. More will be required for provinces that are further behind. Much of this money will need to be used as direct incentives for rural physicians.

Special efforts will have to be made to mitigate the ongoing costs that rural generalists incur when taking on required, but low-volume work such as obstetrics, inpatients, casualty work, anesthesia call, and when they cannot be as efficient as they would be in larger centres with more resources. Recently it has been recommended in British Columbia that doctors who provide services, such as GP-anesthesia, be rewarded a token amount for being on call — a first for Canada. These accommodations need to be extended to rural specialists as well, who share the high-call and low-volume problems. There are also substantial costs for continuing medical education where 2 days of travel are typically required.

It should be recognized that direct incentives are only part of the solution. The burnout issue will only be solved by an adequate source of appropriately trained rural physicians. Additional monies of at least 10% of medical school and residency budgets need to be brought to bear on physician training: current monies are insufficient to train enough physicians to sustain even existing services, with the exception of some urban specialties. The fact that provinces are recruiting over 75 physicians from abroad (data supplied by provincial ministries of health) indicates that we are not training enough doctors.

Of course simply training more doctors won't help if they train to become urban specialists or urban family physicians: the bias of the current educational system. Getting around this bias requires proactive selection of medical students with rural origins, and rural modelling to students and residents in their training. Unless a physician is comfortable practising in a rural environment s/he won't choose rural medicine regardless of financial incentives or disincentives.

Finally, these programs will need to be evaluated to ensure that the public good is being served. This will require accurate definitions of rural and careful monitoring of population-to-physician ratios to ensure equitable distribution of this important resource across the rural­urban spectrum.

References

1. Skelly A. BC decision removes restrictions — doctors want bright lights of cities as underserviced areas stay in the dark. In: 1997: A year in Canadian medical politics. Supplement to the Medical Post [Toronto]; 1998 Jan. 13. p. 4.
2. Supply, distribution and migration of Canadian physicians, 1997. Ottawa: Canadian Institute for Health Information, 1997.
3. Wilson DR, Woodhead-Lyons S, Moores DG. Alberta's rural physician action plan: an integrated approach to education recruitment and retention. CMAJ 1998;158(3):351-5.
4. MacDonald CA. Evaluation of the Rural Physician Action Plan. Edmonton: Alberta Health; 1996.
5. Payment schedule comparison: all Canada (excluding Quebec) statistics. Ottawa: Health Canada; November 1993.
6. Report of the fact finder on the issue of small/rural hospital emergency department physician service. Graham W.S. Scott, QC, Mar. 22, 1995.
7. Canadian Medical Association. Report of the advisory panel on the provision of medical services in underserviced regions. Ottawa: The Association; 1992.
8. Professional Association of Interns and Residents of Ontario. Towards an effective recruitment and retention program for communities and physicians in Ontario's underserviced areas. Toronto: The Association; 1996.