Ontario doctor deal is a script for disaster

By Owen Dyer

"There is no bribe here," insisted Ontario Health Minister George Smitherman, defending his offer to put $50 million into Ontario physician services — if the province's doctors can cut $200 million from the Ontario Drug Benefits program over four years.

The minister was reacting to the leak of a letter of understanding between Mr Smitherman and Ontario Medical Association (OMA) President Dr John Rapin following a tentative agreement reached between doctors and the province in September. The deal is set to be ratified this month. Normally such negotiations are kept secret, but when the letter found its way into the hands of the media, Mr Smitherman was forced to defend an agreement he had refused to discuss just 48 hours before.

"The real issue is that everybody in the province of Ontario knows that we have a problem with overmedicating seniors," he said, citing the obvious case of antibiotics. "This is motivated by one clear and pressing reality, which is that there are too many people in the province of Ontario who are overmedicated."

Had Mr Smitherman's ministry taken the trouble to identify which drugs are being overprescribed and which patients are receiving too many, this argument might hold water. When he asks for an across-the-board reduction in all drug costs, critics are entitled to question whether the real clear and pressing reality is money.

Ontario's drug program cost taxpayers $2.3 billion last year. Like all Canadian health ministries, Ontario's decided long ago that the drug bill is the easiest part of the health budget to cut. After all, most of the health budget goes towards salaries, and cuts there would harm organized groups who are politically untouchable. Cutting prescriptions only harms patients, and they're not organized.

Yet drugs still account for less than 15% of the money spent on Canadian healthcare. This means that for savings in the drugs bill to have a sizeable impact on the overall bill, doctors would have to prescribe far fewer drugs. In fact, Mr Smitherman is only asking them to cut the total cost of prescriptions by about 2.5%. The savings to the Ontario government will be minimal, particularly since a quarter of the money saved will be paid back to physicians as the price of their cooperation.

It is bad economics to pay people more money to do less of their job — plus it's an amateurish approach to bribery. And who will guarantee that prescriptions with the least benefit to health will be the ones cut?

Ontario's physicians can't promise to reduce prescription costs, because they can't control each other's prescribing. Even if the OMA votes to accept the deal, some doctors will disagree with the proposal on moral grounds and continue to prescribe as before. Some will want their share of the loot, but rely on other doctors to cut the drug bill. All will be confronted with new drugs, cross-border advertising and pressure from patients who want the same drugs other Canadians get. To date, it has proved impossible to freeze drug costs, never mind lower them.

More importantly, this deal is bad medicine. The fact that some drugs are over-prescribed doesn't mean we are spending too much on drugs. Many drugs are grossly under-prescribed. Prescribing more statins and antihypertensives, for example, would be an extremely cost-effective way to raise life expectancy. More aggressive early treatment of rheumatoid arthritis would undoubtedly lower the cost of disability care.

This is a deal that threatens the professional credibility of those who sign up for it. Today, when a conscientious Ontario physician declines to give antibiotics to a child whose respiratory infection is clearly viral, the anxious parents may disagree, but they cannot deny it is a disinterested clinical judgement. Tomorrow, they may have another explanation.