The Cost of Care

What she could not do was set fees. All Ontario physicians must observe the Schedule of Benefits laid down by the Health Insurance Act. Billing is closely monitored by government auditors and mistakes are quickly censured. But neither medical school nor Jean-Claude’s business degree had trained the couple to easily decipher this 688-page document. For the first few months both worried that they had either billed incorrectly or failed to bill when permissible.

It is easy to see why such a contract encourages doctors to hurry patients through their office. Turn up at a clinic with a nasty cough, sprained neck, or unpleasant rash and you become a Code a005, the bread and butter of the doctor’s income, and are worth $56.10 to your physician. Depending on the complexity of your symptoms and your doctor’s ability to hustle you from the office before you try to squeeze in a few new complaints, the appointment will take about eighteen minutes. That the quick removal of a plantar wart (z103) can be billed at roughly this same amount represents a key flaw in the system. It is easier to itemize a simple medical procedure than a life-saving diagnosis. In the fee-for-service economy, primary care is nearly always short-changed. However thorough or cursory your doctor may be, a general examination can only be billed at $58.20, a house-call at $41.75. A simple birth is worth $395.75; a death certificate costs $17.75.

Kinmount’s new waiting room was filling quickly. While men were initially reluctant to see a woman doctor, by the fourth month Mihu had almost reached her goal of 2,000 patients and had to start a waiting list. Outside office hours she would visit those too ill to attend the clinic. On weekends she plowed through the endless paperwork involved in coordinating the referral of patients sent to distant specialists. Despite the Kinmount Health Committee’s efforts to protect their doctor, Mihu was working a sixty-hour week. For the first few years she did not take holidays or dare to be ill.

Even more stressful was the lack of professional support in the region. Over the last decade the decline of rural fam-ily physicians has been precipitous, but the collapse of rural specialists has been catastrophic. Only 3 percent of Canada’s obstetricians, gynecologists, and psychiatrists, 2 percent of emergency doctors, and 1 percent of pediatricians are located in small towns or rural areas. Other disciplines are often not represented at all.

There is no easy answer to the situation faced by doctors such as Dr. Mihu. The Ontario Ministry of Health, in attempting to help, has urged family doctors to limit each appointment to a single series of symptoms. But many of Mihu’s patients drive in from distant communities, or are forced to bring ailing family members with them, so it is hard to enforce this policy. Yet Dr. Mihu can only bill for providing a single service.

According to the last official census, between 1996 and 2001 Canada’s rural population declined by 286,000 peo-ple. Some losses can be more devastat-ing to small towns than others. When doctors desert a community, a whole chain of events is set in motion. The pharmacy immediately closes and parents with medically frail children make plans to leave. In the city, seniors who were thinking of retiring to bucolic spots think again and buy a condo or retire to Florida. With a shrinking population, the local school has to close, and workers with families request to be posted elsewhere. Soon Main Street is empty and the bank shuts its branch office. All this happened in Kinmount before Mihu arrived. As my neighbour in Kinmount, Tom, used to say, “We’re waiting for them to roll up the road any day now.”

With a newly installed Conservative government elected largely by suburban, small-town, and rural constituents, one would hope that the systemic problems facing rural medicine might now receive more attention. But there is every chance that a Stephen Harper-led government will view Dr. Mihu and Kinmount as an exemplar, not an exception to the growing rule requiring state intervention.

Stubborn and conservative, Kinmount expects very little from Queen’s Park or Ottawa. This makes the residents doubly grateful for the care of their doctor. Her presence in Kinmount has brought a new vitality to the whole community. The town is suddenly full of retirees while parents have stopped worrying about bringing up their children so far from city hospitals. For the first time, a program to beautify the town has been put in place, and pots of flowers line the main street and park. An annual walk-for-health was launched; much of the community turned out to celebrate Mihu’s first year and donated another $10,000 dollars to the clinic. Despite letters from American headhunters offering her positions that would pay substantially more than her present income, Elena and Jean-Claude have no intention of leaving. They are in love with rural Ontario and Canada’s medical system.

Dr. Mihu’s office is full of light. Outside her window the pines of the Ontario Shield have been cut back to let in the sunshine and her patients blink to readjust their eyes after being in the darker waiting room. In many ways Dr. Mihu is the doctor all of us would love to have—caring, dedicated, and knowledgeable. But what is a Dr. Mihu worth to us How do you put a price on the improved quality of life of a whole community

Nostalgia for her rural childhood and gratitude for the opportunities Canada offered her still colour Elena’s life. But few of the students in our medical schools, whether born in Hanoi, Montreal, or small-town Canada, have such altruistic dreams. The provinces may eradicate some of the present barriers against foreign-trained physicians working here, increase enrolment at our medical schools, give bonuses to those willing to practise in rural areas, even develop new medical schools outside the large urban centres. But in the end most medical students will be guided by economic reality, and Elena Mihu, like most family doctors in Canada, will remain grievously underpaid.