Features
Canadian Medical Association Journal 1997; 156: 65-66
[en bref]
© 1997 Canadian Medical Association (text and abstract/résumé)
A particularly glaring example of this waste of medical energy is the Canada Pension Plan (CPP) application for disability benefits. Refusing to complete these forms, however unrealistic the claim, is generally considered a form of professional misconduct that is subject to disciplinary action by licensing bodies. Yet completing forms for patients after you have advised them they do not meet the eligibility criteria seems almost fraudulent. In those cases, the automatic form-completion fee of $50 is certainly a waste of public money. [Earlier this year, after an internal review process and in consultation with the CMA and its divisions, CPP administrators raised the fee for completing a narrative report from $50 up to $150, although the maximum fee will be paid only in certain instances.-- Ed.]
In 199596, the 90 449 new disability applications, up 47% from 198889, resulted in physician payments totalling more than $4.5 million. It is sobering to realize that 59.7% of these applications were rejected. While some applicants no doubt had reasonable grounds for pursuing a claim, it is certain that others were making frivolous applications.
How do these wasteful applications arise? One common source is economically marginal workers such as older employees who have been rendered redundant and unskilled labourers who are no longer able to do hard work. Indeed, CMAJ reported last year that almost 1 in 5 Canadian men aged between 60 and 64 are now receiving CPP disability payments.[1]
There are also applicants who have no medical disability but rather social handicaps such as substance abuse, and their cases should be handled in quite a different manner. Yet when advised of their lack of medical eligibility, a disappointing number insist on pursuing an application on the off chance they will succeed. This imposes a cost on the system that is of no concern to them.
Another common source of doomed applications is the insurance industry. Private insurance plans often refuse to process a claim for long-term disability benefits until the patient has applied for CPP disability payments. Many patients may meet the criteria of their private plans but clearly fail to match the CPP's requirements, yet in the hope of reducing their own payout insurance companies will force the CPP to process and pay for useless applications.
A third source of trivial claims is municipal and provincial governments, which also encourage CPP applications from people who clearly fail to meet the necessary criteria. They fail to show any concern for the resulting costs.
The final source of frivolous applications is physicians, whose attestations about patients' disabilities are all too often based more on empathy than medical accuracy.
How do such errors in medical judgement arise? It is certainly not an exercise in deliberate deceit. Rather, it grows from an unpleasant paradox within the doctor's role. A central pillar in the family physician's credo, long articulated by the College of Family Physicians of Canada, is that the doctor must act as "the patient's advocate." In a medical context this is a thoroughly necessary and appropriate role. The family physician ensures that patients are seen as quickly as possible by specialists, that they receive ready access to necessary testing, that their treatment in hospitals and nursing homes is appropriate and that their wishes regarding terminal care are respected. It is a role of trust and responsibility in which patients' needs are the paramount concern.
But into this comfortable relationship intrudes the dreaded disability pension application. The patient pleads entitlement. In many cases the issue is social, not medical. A patient with limited skills who is hampered by a minor physical or emotional problem is searching for a nonexistent job in a downsizing economy. The plight is real enough, but the cause is not medical incapacity.
But what are doctors to do? Schooled as patient advocates, they are now being asked to act as pension adjudicators. It is a classic example of role strain and a disappointing number of physicians fail to resolve it satisfactorily. There are simply no obvious incentives for the physician to confront patients, because refusing their requests leads to disappointment, anger, accusation and, frequently, the loss of a patient.
Signing the disability form solves all that without the need for the doctor to acknowledge directly the tremendous long-term cost to the system occasioned by even one illegitimate disability pension. Socially responsible behaviour is an abstraction which, in the intimate confines of the examining room, easily takes second place to the time-honoured role of compassionate patient advocate.
How can we change this sorry situation? Independent medical examiners are an option, but the additional cost would be high and their ability to assess patients fairly during a single encounter would be limited. Perhaps, incredibly, we could learn a lesson from Revenue Canada. Every spring brings a fearsome wave of patients clutching applications for the disability tax credit. These are usually given to them by the hastily trained employees of firms that complete income-tax forms. A simple glance at the back of the form clearly outlines the meaning of disability for income-tax purposes. A disability, even when already recognized by a disability pension, is not a guarantee of entitlement. Rather, the form clearly states that a condition must be "prolonged" -- present for 12 months or likely to be so -- and severe enough to "markedly restrict" the ability to perform "activities of daily living" such as dressing, preparing food, etc. When confronted with such relatively concise definitions, most patients quickly concede that their status does not -- mercifully -- qualify them for the credit.
Why not include such guidelines on the CPP form? It would be a simple matter for physician and patient to check off the activities the patient cannot perform and provide a statement on the duration of the impairment, and then jointly sign the list. This is an objective and nonjudgemental task that should cause problems neither for physician nor patient. Evidence of a high level of functioning on the list of activities should be stated clearly in order to terminate the application at that stage, saving both medical time and public money.
No doubt some illegitimate applications will continue to be pressed forward, and this should lead to a second administrative change. Application forms should carry two brief questions. First, has the physician advised the patient he/she does not qualify? If the answer is affirmative and this indeed proves to be the case, the patient should be billed the $50 cost of the medical report. Second, applicants should be asked if they are applying at the insistence of an insurance company or another level of government. If this is the case, and the physician has already advised the patient he/she is ineligible for CPP disability benefits, the insurance company or other government should be billed the cost of pursuing unsuccessful claims.
Some may object that these suggestions are mere bureaucratic tinkering, but a number of scholars have already argued persuasively that work as we have known it is quickly becoming obsolete.[2-4] It follows that existing support programs will be inundated with applicants.
Measured against this type of social change, revision of the CPP disability-benefits form may seem a pedestrian concern indeed. However, at present Canada's social safety net is as much a web of red tape as a matrix of lofty principles. If that bureaucratic tape proves weak, the entire system may collapse before it becomes naturally obsolete.
We should remember the battle lost for want of a horseshoe, which holds a clear message for the CPP disability form: fix the form and, at least for now, save the kingdom.