In British Columbia, it's called the Blue Book – and every year since 1969, the name of every doctor and how much she or he bills the province's medical insurance plan is published for all to see.
There is transparency and accountability; it is how business is done in the province. There is no controversy or acrimony – and the relationship between doctors and the government is relatively peaceful.
It couldn't be more different in Ontario. The issue of doctors' compensation has become a flashpoint between the government and the Ontario Medical Association, which represents the province's 29,000 doctors. There are now calls from some groups for Ontario to publish the names of doctors and their compensation.
Health experts from across the country are watching the fight with keen interest – and marvelling at the politics being played.
"Except for Ontario these days, usually governments are kind of reluctant to pick a public fight with physicians. Ontario is financially desperate," said Steven Lewis, a health-care consultant and expert on compensation issues. He consults for the Saskatchewan Medical Association. "Already your health-care proportion of total government spending is very high compared to other provinces."
Ontario's doctors have been without a contract for two years, and there is no sign that negotiations are about to resume. The impasse was intensified recently by Ontario Health Minister Eric Hoskins's provocative move, revealing that more than 500 doctors billed Ontario taxpayers more than $1-million last year – including one doctor who billed $6.6-million. He did not disclose the names.
This was in an effort to try to get the doctors back to the table and to talk about the disparities in the fee codes – there are 7,300 different procedures for which a doctor can bill.
The OMA dismisses the idea of publishing names and billings, arguing that disclosure without providing any context, such as the costs of overhead, is misleading. Instead, doctors are focused on getting binding arbitration from the government, and will not resume talks unless it first agrees to a binding dispute mechanism.
Mr. Lewis, meanwhile, believes there is method in the Ontario government's strategy: By revealing the obvious flaws in the fee-for-service system and the disparities in billings, the government is banking on moving public opinion to its side.
"Anyone who goes down that road has to be in it for the long haul," he said. "The public in general, when there is a dispute between a health profession and the government, tends to side with the health profession."
From his vantage point in Vancouver, Charles Webb, president of the Doctors of British Columbia – the province's equivalent of the OMA – called the Ontario government's actions irresponsible.
"The Ontario government needs to ensure that if they are going to put the numbers out there, which they have, they need to at least let the public understand what these raw numbers really mean," Dr. Webb said. "In British Columbia, we are fairly clear that these numbers that are reflected in ... the Blue Book are understood to be the gross billings of doctors that don't take into account their overhead costs."
Dr. Webb noted, too, that publishing the names of doctors and their billings has not changed how they practise in his province. "I can understand the concern in Ontario in terms of having their names published when they have a Minister of Health lashing out in this way and clearly on a political bent," he said.
The other issue behind the impasse in Ontario is that of binding arbitration. The OMA is insisting on it, while the government has said it will talk about it as part of formal negotiations.
The Canadian Medical Association and the Alberta Medical Association have recently supported the OMA's push for binding arbitration.
However, Mr. Lewis said he would advise against arbitration "precisely because it is binding."
"Binding arbitration will typically look for middle ground, award larger increases than the government believes it can or should afford, and leave the major issues untouched," Mr. Lewis said. "It's not just disparities between specialties; it is disparities in billings occasioned by huge differences in how people practise."
He noted that family doctors who have patients with many different issues – and who must spend more time with them – earn less than those doctors with healthy patients who can deal with their issues in five minutes.
"The bottom line is, the basic elements of the fee-for-service system are no longer compatible with the contemporary health system's needs and with good stewardship of public resources," Mr. Lewis said.