Death of phone service indicates Canadians not willing to pay for medical advice
Nancy Robb
CMAJ 1997;157:433-4
[ en bref ]
Nancy Robb is a freelance writer living in Halifax.
© 1997 Nancy Robb
In brief
The two physicians who started Canada's first national pay-per-use medical-advice line closed the service after determining that Canadians are not willing to pay directly for their medical services. The issue of public versus private payments will likely be raised during the CMA's annual meeting later this month.
En bref
Les deux médecins qui ont lancé la première ligne téléphonique nationale de conseils médicaux rémunérés à l'acte au Canada ont fermé le service après avoir déterminé que les Canadiens ne sont pas prêts à payer leurs services médicaux directement de leur poche. La question des paiements par les secteurs public et privé sera probablement abordée au cours de l'assemblée annuelle de l'AMC plus tard ce mois-ci.
Canadians' reluctance to dig into their own pockets to pay for health care may have doomed any chance for success for the national dial-a-doctor service called Doctor Direct, says a physician who cofounded the service.
Dr. Brian MacKinnon, a family physician from Fredericton, and an associate, Dr. Jim McKim, launched their "900 line" pay-per-use service in November 1995 but shut it down a year later. "Canadians aren't used to paying for most of their medical care," MacKinnon explains. His experience is of interest as the CMA holds its 1997 annual meeting, which begins Aug. 17 in Victoria. The last 2 meetings have focused squarely on the potential role of private insurance and private payments in health care.
With Doctor Direct, callers from across Canada paid $4 a minute to talk to a New Brunswick family physician about nonemergency medical matters. Although the service got off to a ringing start, MacKinnon says the number of calls decreased and plateaued at the lower level after a few months.
He says the service was still receiving 150 to 200 calls a month when it shut down, but in the end it wasn't worth the effort. "The service ran itself financially," he says. "It did not go under for financial reasons, but we were busy with our other lives."
MacKinnon says he and McKim got the idea for Doctor Direct from their after-hours clinic in Fredericton. The first physicians to set up such a clinic in Atlantic Canada, they employ about 20 doctors at night and on weekends.
MacKinnon says the clinic has always been popular and has even helped ease patient demand at local emergency wards. Still, he and McKim saw room for more. "People were very appreciative of [the clinic] but continued to demand our attention and service," MacKinnon recalls. "That's why we thought we could put together another way to service the public by allowing them access to us via the phone."
He says a market survey "showed quite overwhelmingly that people would use the service." Around the same time, New Brunswick Telecare (CMAJ 1997; 156:1009-13 [full text / en bref]), a toll-free line set up by the province to reduce the number of emergency visits by providing telephone access to nurses, was being "used fairly heavily."
However, MacKinnon and McKim wanted to establish a national service without any help from government. "We wanted to do it . . . privately and not have anyone dictate how to run it or what to do," says MacKinnon, noting that the provincial health minister was supportive. "We thought we could run a very good service."
They didn't have any qualms about charging for its use. "I don't believe in a two-tiered health system," MacKinnon stresses. "But this was an extra service. It wasn't taking away from anything that was offered. . . . It would be drastically different if we tried to replace something."
MacKinnon says 10 to 12 physicians worked rotating shifts fielding calls until midnight each day. He says about one-third of the calls were requests for medical information, and the rest involved acute illness.
"There was a big mix of elderly and people with children at home during the day. Those were the population groups that used it a lot," says MacKinnon, who added that most calls came during the evening. "There weren't too many surprises. People used the service anonymously for certain things, which they [cannot] do on a call system."
MacKinnon says Doctor Direct received calls from every province and the Yukon. He thinks the calls revealed that rural and urban Canadians alike are having difficulty gaining access to doctors.
"We would talk to people in rural Saskatchewan, the coast of Labrador, who were 3 hours from a doctor . . . and we'd think, 'What would people do if they didn't have this number available?' There were people from downtown Toronto who had problems getting to hospitals, et cetera."
The lessons didn't come as a big surprise. "Our experience was basically . . . that people want more access to their doctors," he says. "This isn't a new thing. We've been taking calls for 20 years on evenings, weekends and all night. The key difference was, people didn't have to pay for it, or at least they didn't have to pay for it directly."
MacKinnon thinks Doctor Direct would have fared better in the US, where the public is accustomed to paying for medical services. Indeed, he and McKim "received several overtures" to take the service to the US, "but we didn't go near it for malpractice reasons."
It was hard enough getting malpractice insurance in Canada. MacKinnon says the Canadian Medical Protective Association wouldn't cover the service, so Doctor Direct had to search for other coverage, which proved "difficult to find."
"We thought this was a very low-risk service the way we ran it," he says, and this proved to be the case because no liability problems were encountered. "We were taking written notes about all calls. That's why we had to make a decision at the end of the year about whether it was worth the time we were putting into it, especially with the scheduling."
But he and McKim haven't abandoned Doctor Direct altogether. MacKinnon says they still have the 1-900 number and "could do this in some other form in future. My feeling is that this is still a viable service and somebody will provide it."
He says one possibility is a local service for an on-call group, but he doesn't recommend it. "If anyone asked my advice, I'd say 'no, it takes too much money and time. There would be easier ways to bill your own patients for a local phone service."
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