BC appeals court decision on billing numbers
CMAJ 1997;157:1008
© 1997 Canadian Medical Association
The British Columbia government has appealed the July 30 court ruling that rejected its 1994 agreement with the British Columbia Medical Association concerning billing-number allocation. The original court challenge was launched by 3 doctors and the Professional Association of Residents of BC (PARBC).
The agreement was designed to manage the entry of new doctors to fee-for-service practice and to improve physician distribution. BC currently has the second-highest ratio of physicians to patients in the country (1:520), after Quebec (1:486), but many rural areas remain underserviced. The 1994 limits on billing numbers reduced the fees paid to new physicians practising in overserviced areas, with the amount of the cut depending on the geographic area. After 5 years, doctors with these numbers were eligible for payment at the 100% rate and free to practise anywhere in the province.
Martin Sereniak, PhD, chair of the Medical Services Commission, says that "only a couple" of doctors eventually worked at a reduced rate because many found locum positions and therefore were paid at the 100% rate; 462 doctors were upgraded to 100% billing status without limits following the court ruling.
Dr. Don Young, past president of PARBC, acknowledges that there are distribution problems but says the issue is fair application of the agreement. "Our motivation in this was to ensure that our members, when they go out to practise, have the same rights as those already in practice."
Sereniak says that the court decision "significantly hampers" the government's mandate to provide equitable distribution of doctors throughout BC. However, he does not expect a large number of new physicians to apply for billing numbers. "If physicians are rational, they would reassess that process of going through the initial phase of establishing a practice in a saturated market," he says. Fifty-five new billing numbers were issued in the month following the court decision.
Dr Granger Avery, president of the BCMA, which supports the government's court appeal, says the previous agreement "allowed the profession to maintain control of itself." He is concerned that if the BCMA is not involved, the government will control billing numbers autonomously through new initiatives designed to regionalize health care. He is also worried about the financial impact of having more doctors sharing decreasing dollars. A 4.4% clawback on earnings is already in place in BC. Avery says the previous arrangement was "starting to work" by attracting new doctors to "intermediate" areas, although it had not yet affected centres with the greatest need.
Both Avery and Young agree on some of the incentives that they say need to be built into any agreement to attract physicians to underserviced areas. They include support from locums and continuing education opportunities, as well as improved training in rural medicine. Avery would also like to see financial incentives such as signing bonuses, and an extension of the northern isolation allowance. He thinks locum coverage could be improved if the BCMA ran a 2-year-old government program that attempts to provide this, but only has about 7 participating doctors.
He also thinks medical schools must deal with students' urbanization. "Most medical students [are used] to the city," he says, and this ensures that a preponderance
of city-oriented physicians will graduate from medical school. He would like to see the current rural-training program extended to include 6 months of rural training in fourth year, as well as a doubling in rural exposure for residents.
The BC appeal will represent a test case for the country. Young says that "British Columbia is the only province in which Charter arguments have been advanced through the courts regarding physician supply, and we know the rest of the country is watching closely." -- © Heather Kent
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