Features
Nicole Baer
Canadian Medical Association Journal 1997; 156: 61-64
[en bref]
© 1997 Nicole Baer
So, could doctors do anything to control the cost of the CPP disability program? More significantly, should they?
There's little doubt that family physicians wield substantial influence because they complete the medical reports that form the basis for pension applications. Doctors could, theoretically, serve as the program's frontline enforcers -- discouraging the undeserving from applying or urging that frivolous applications be penalized by special fines.
However, few would thank them for their efforts. First, because the problems affecting CPP disability payments run deep, and mostly they lie elsewhere. Second, because legitimate claimants may become the inadvertent victims of the crackdown. And third, because the last thing CPP administrators want is physicians volunteering opinions about an application's merits.
"The word 'disability' could mean a thousand things to a thousand different people," notes Dr. Alex Romaniuk, the plan's senior medical adviser. "Doctors may know what disability is, but they don't work for CPP and they don't know all the intricacies of our exact program. So if we ask for medical information, we're asking for medical information -- we're not asking for an opinion on disability from someone who doesn't know our definition."
Such a neutral approach would suit most physicians. Filling out forms is tedious work at best, and is generally not well compensated. The current CPP disability-benefits form was revised recently following extensive consultations with the CMA. The plan has long paid doctors $50 per form (provided the patient actually submits it to CPP administrators) but following an internal review and discussions with the CMA (in consultation with its divisions) the fees are being raised to a maximum of $150, depending on the time required to complete the paperwork.
Some observers believe physicians should advocate on behalf of their patients to ensure that they get benefits to which they are entitled. Sherri Torjman, vice-president of the Caledon Institute, a social-policy think tank in Ottawa, argues that physicians have a humanitarian obligation to help patients with mental or physical impairments obtain such financial assistance, particularly in tough economic times.
Harry Beatty, staff lawyer for ARCH, a legal resource centre in Toronto that helps the disabled, is reluctant to call on doctors to act as outright advocates. At the same time, he worries that physicians may be unwilling to go to bat for people with psychiatric problems or multiple disorders because the application process in such cases is unmercifully tangled -- all the more so when medical records are incomplete. "If the physician doesn't fill out a supportive report, or [fills out] one that doesn't document the actual disability, then [the patient] is not going to get the pension."
Last September the 26-year-old income-security program came under the auditor general's intense scrutiny. In a report to Parliament, Desautels found that the cost of CPP disability benefits had climbed from $841 million in 198687 to almost $3 billion last year, with the number of beneficiaries nearly doubling to 300 000.
Desautels was unable to pinpoint a single cause for the astounding increase, but listed a number of influences, none of which are precisely quantifiable. Overall, the report was highly critical of CPP management, describing in particular a flawed system for collecting and analysing data, subjectivity in the adjudication process and shortcomings in the reassessment procedure that is supposed to ensure pensioners continue to be entitled to their disability benefits. Moreover, Desautels said comprehensive quality-control programs are lacking from the time a claim is accepted until it is terminated.
Are too many people getting CPP disability pensions? It can certainly seem that way. "A very significant number of people that I see who come into my practice already on a disability pension -- I'm really hard-pressed how to explain how that happened," observes Dr. Samuel Shortt, a Kingston family physician and vocal critic of the program [see accompanying article]. "Either things have changed [since the patient started receiving the pension], or things were 'misstated' in a way that made that pension achievable at the time."
One study done for Human Resources Canada, the federal department responsible for the CPP, estimated that the cost of overpayments to disability claimants is $14 million a year. Desautels states flatly that this estimate is too low and that eliminating unwarranted duplication among the CPP, workers' compensation plans and private insurers could save the CPP $42 million a year.
Such criticisms aren't new. Canada's chief actuary, who oversees the financial soundness of the CPP, warned 2 years ago that "higher than expected" disability benefits were undermining the viability of the entire retirement plan. In June 1996, federal and provincial finance ministers agreed to protect the CPP by finding ways to trim its disability component.
One key distinction is that the CPP is the first insurance plan to pay out to disabled beneficiaries; workers' compensation programs and even private insurers deduct the payments from their own benefits, and top up where necessary. In contrast, the QPP is the payer of last resort. Quebec's workers' compensation plan, the Commission de santé et de sécurité au travail, pays out first, reducing costs to the QPP by about 4%. In other words, there aren't fewer disabled Quebeckers -- they simply turn up in other statistics.
There are at least 8 other significant legislative and administrative differences between the 2 plans that, in recent years, widened the fiscal gap between them. One example: the QPP doesn't cover certain diseases, such as chronic fatigue syndrome and fibromyalgia, while the CPP does. These conditions don't account for a large proportion of CPP cases, but the number is growing. Between 1987 and 1993 there was a sixfold increase -- from 743 to 4575 -- in the number of people with fibromyalgia who were receiving CPP disability benefits.
However, the CPP repealed some of its more permissive administrative changes in September 1995, and this resulted in the lowest rate of new claims approvals since the late 1980s. Desautels is cautiously optimistic that the corner has been turned, but won't declare victory until a raft of rejected claims wend their way through the lengthy appeals process.
Meanwhile, there is plenty of evidence that the cost increases that were seen in the CPP in the first half of this decade were paralleled throughout the industrialized world, and simply reflected certain global realities.
The recent recession forced many companies to dump older or injured -- and therefore less productive -- workers whom they might otherwise have retained for compassionate reasons. Similarly, as the financial strain on provincial and municipal welfare programs grew, social workers began urging clients to apply for a federal disability pension.
And finally, in response to human-rights rulings substantiating the rights of the disabled, rules governing CPP disability payments were relaxed. For example, the number of years a person had to have been employed before becoming eligible for payments was decreased, and claimants could apply retroactively. Adjudicators were also directed to take into account factors relating to claimants' likelihood of finding work, given factors such as age, education, language and the regional unemployment rate.
Those provisions, first adopted in 1989, were formally repealed in 1995 after the number of applicants soared from 60 000 a year to an unprecedented peak of 109 000 in 199394. Even now, however, the CPP's Romaniuk notes that decisions are rarely based exclusively on the medical report. "To piece a person together, it's not just a medical thing. There's a whole lot more to a person than an arm and a leg."
Ten million workers and 1.2 million employers pay annual CPP premiums. Disabled workers can receive benefits ranging from $326 to $871 a month. Their children are also entitled to flat-rate benefits, which are currently being collected by 100 000 dependants. More than 60% of disability recipients receive additional income from workers' compensation plans or other public or private programs; even so, 40% live below the Statistics Canada poverty line.
CPP program administrators vary their interpretation from time to time, much to the frustration of physicians and others. Thus far they have resisted following the lead of the US -- there, all possible pensionable disabilities are listed in a thick reference book that is used by adjudicators.
"It's always been a bit of a criticism, because people who don't do this work keep saying, 'Well, how can you possibly make a good decision if you don't have a stick with little markers on it to measure the person by?' " notes Romaniuk.
Dr. Guy Gokiert, a family practitioner in Westlock, Alta., and immediate past president of the Alberta Medical Association, wishes he knew how adjudicators made their decisions so he could tailor his applications accordingly.
"There is that concern: Are they seeing the patient in the light that we see the patient, or are they seeing the patient in the light of the dollar signs? I really don't know whether it's a person who has a black book and who just goes down -- tick, tick, tick -- and says, 'Well, this patient doesn't [meet the criteria].' Sometimes we need to know what the questions are that will trigger them to be sympathetic towards the patient."
Gokiert says some of the plan's problems may be traced back to "the worried well" -- city dwellers who find themselves out of work and marginally ailing. But that's hardly the case in his small farming community. "Our patients are really down and out -- physically, mentally and economically -- before they make these applications."
Desautels had his own litany of complaints about the adjudication process. His report noted that pension awards are too often made with inadequate information and recommended that adjudicators more often consider soliciting independent assessments from outside specialists. On the other hand, the report found that requests for additional supportive evidence are sometimes rejected by CPP administrators because of the upfront costs.
In one example cited in the report, an adjudicator had recommended that an applicant consult a specialist to supplement the information on file. CPP administrators cancelled the appointment because the anticipated cost -- $1000 for travel and $300 to $2000 for professional fees -- seemed too high. The applicant was thus awarded a pension solely on the basis of information the adjudicator had deemed inadequate; by last September, the CPP had already paid out $24 296 in disability benefits to this one applicant, plus $4681 for a dependent child.
Romaniuk argues that the vast majority of forms are completed properly by family doctors and provide the basis for accurate and verifiable adjudications. Moreover, CPP administrators routinely go directly to specialists for additional details that were referenced but not included in the original report.
"A lot of physicians are either not reading the question or not understanding the question, or just doing their own thing in spite of whatever questions we have listed. But I think physicians are not helping us by trying to go the extra mile for some of their patients."
He conceded that many doctors believe they are advocates for their patients or feel vulnerable to pressure from patients demanding a favourable report. But, he argues, by listing only clinical observations and readings and lab test results, no physician should feel discomfort or pressure.
"If I was the patient, I'd probably tell my doctor, 'And can ya tell them that I'm totally disabled?' The doctor may tell them they are, or that they totally are not, but we're not asking for either one of those kinds of interpretations. What we're asking the doctor to do is simple: 'Just tell us what you see -- don't tell us what you think.' "