Canada has more doctors, making more money than ever

The Globe and Mail

The number of Doctors in Canada is increasing, along with the compensation they're receiving (GEOFF HOWE/The Globe and Mail)

The number of doctors in Canada and the amount they get paid by government health plans hit record highs in each of the past several years – and 2012 was no different.

Canada had more than 75,000 doctors working last year, an increase of 4 per cent over 2011, and governments paid them $22-billion for their services, about 9 per cent more than the previous year, according to new data released Thursday by the Canadian Institute for Health Information.

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The data are noteworthy because they suggest the country is taking baby steps to correct what is perceived to be a shortage of physicians, and reflect a marked shift in how doctors are being paid and, thus, interacting with patients.

Where the doctors are going

The number of doctors per capita climbed in 2012 for the sixth year in a row, outpacing population growth threefold and resulting in 214 physicians for every 100,000 Canadians. That figure is expected to rise as the country continues to attract foreign-trained doctors and Canadian medical schools churn out record numbers of graduates.

Growth in the number of doctors has been highest in rural areas, where complaints about shortages and access to care have historically been most pronounced. In the past five years, the number of physicians working in rural Canada rose five times faster than the national population.

Provincially, British Columbia and Newfoundland and Labrador reported the largest increases in the number of physicians, at 5.1 and 4.6 per cent, respectively. Manitoba was the only province that did not report an increase.

Geoff Ballinger, manager of health human resources at CIHI, said the overall numbers make it tempting to shrug off the notion of a doctor shortage in Canada. But that would be premature, he noted.

For one thing, the number of physicians in rural Canada in not proportional with the rural population: While 18 per cent of Canadians, or about six million people, live in rural communities, just 8.5 per cent of the country’s 75,142 doctors served those people.

That gap may be a reason that the number of Canadians who say they do not have a regular family doctor has stagnated at about 4.4 million in recent years, according to Statistics Canada.

“It’s tempting to suspect the situation is improving . . . but we’re not seeing a change in those numbers,” Mr. Ballinger said.

Shortage or no shortage?

For many of those 4.4 million people, not having a family doctor is a choice. They are content to seek care at walk-in clinics. But nearly 800,000 reported that they did not have a place to go for regular care.

The figures do not necessarily mean a shortage of physicians, said Tom Noseworthy, a health policy professor at the University of Calgary.

“I don’t believe Canada has a problem with the number of physicians,” he said. “I think we have a substantial problem with the types and, furthermore, the distribution of doctors.”

“We’ve got a situation now where there isn’t always a good alignment between the training programs [medical schools] and what the market actually needs,” he said. “I do not believe Canada suffers from an insufficient number of physicians.”

Changes in pay

Doctors earned more last year than ever before.

The data show the average physician was paid $328,000 for clinical services last year, from a high of $376,000 in Ontario to a low of $258,000 in Nova Scotia. (Most doctors must pay their overhead – including office space and staff wages – out of their income.)

Across the country, average income was 5-per-cent higher than in the previous year.

Increasingly, though, doctors are earning their pay in ways other than the traditional fee-for-service model, in which a doctor sees a patient and bills for his or her time and expertise.

So-called alternative-payment methods have skyrocketed in recent years, and last year accounted for 28.7 per cent of the $22-billion provincial and territorial governments paid out to doctors. A decade ago, alternative payments made up just 11 per cent of physician income.

“It’s a big, big shift, and I think for the better,” said Scott Wooder, president of the Ontario Medical Association, which negotiates physicians’ pay with the province.

These alternative payments include straight salaries, compensation in which physicians are paid a fixed sum per patient on their roster, and hourly or daily wages. Sometimes remuneration is a blend of fee-for-service and an alternative payment.

Ontario doctors have been embracing alternative payments in greater numbers since the 1990s. Almost $3.4-billion, or roughly 35 per cent, of all physician income in Ontario last year was alternative payments.

Most were in the form of what is called capitation – compensation based on the number of patients on their roster, regardless of how often a patient seeks medical attention.

Has service changed?

Dr. Wooder, a family physician from Stoney Creek, Ont., said capitation is attractive to doctors because it offers stability.

It also enhances care, he said, by encouraging doctors to spend more time with patients because physicians are not getting paid based on how many patients they see.

In Ontario, capitation has prompted doctors across the province to combine individual practices into networks of health-care professionals that include dieticians, pharmacists, nurses, and mental-health counsellors.

“There’s predictable remuneration, so [doctors] can adjust their practices to meet patient needs as opposed to their own personal financial needs,” Dr. Wooder said, adding that many doctors are paid through a combination of capitation and fee-for-service.

In Nova Scotia, alternative payments account for nearly half of all doctor income, with the province using them as a tool to recruit talent to its two teaching hospitals and to retain services in rural areas.

Kevin Chapman, director of health policy and promotion for Doctors Nova Scotia, cited the examples of a cardiologist at a teaching hospital in Halifax and a pediatrician in a rural part of the province. The cardiologist might be expected to devote a fifth of his time to research and education, time that under a fee-for-service system he could effectively use to see patients and shore up his pay. The rural pediatrician could conceivably not have enough patients to make ends meet if she were not paid through an alternative method.

“[Alternative-payment methods] allow you to spend the time necessary with a patient because you’re not worried about a 15-minute office visit,” Mr. Chapman said. “I don’t want to suggest that volumes drive fee-for-service, but you don’t get that unintended consequence.”

In Alberta, alternative payments are hardly used at all, making up just 14 per cent of the province’s payout to doctors. That is partly because contract negotiations between the Alberta Medical Association and the province stalled for almost three years before a deal was inked this year.

Michael Giuffre, president of the medical association, said he would like to see more alternative pay, particularly to help attract doctors who want to practise clinical work, research and academia.

“I think today’s doctors have much more emphasis on work-life balance,” Dr. Giuffre said.

Advocates of alternative pay, including Dr. Giuffre, Dr. Wooder and Mr. Chapman, concede it can come with risks.

For instance, what is stopping a doctor on capitation from padding his patient roster and, thus, his pay, and becoming unable to meet the demands of his clientele? What is preventing a physician from devoting all her time to academia?

Dr. Wooder pointed to a system in which physicians’ pay is deducted when patients are forced to seek medical attention outside the practice.

In Nova Scotia, Mr. Chapman said, alternative-payment agreements include deliverables that could include requiring a doctor to see a specific number of patients or work in emergency rooms.

Sometimes, though, as the saying goes, money talks.

“How you pay doctors is a big deal because it influences their behaviour,” said Dr. Noseworthy, who is also the vice-president and chief operating officer of the northern sector of Alberta Health Services.

“If I want to get physicians out of bed at night, I’m sure as heck going to pay them fee-for-service.”