NEEDS-BASED PLANNING FOR MANITOBA'S GENERALIST PHYSICIANSMCHP has just completed a study that concludes there is no shortage of physicians in Manitoba. However, we did find that the distribution is uneven: some areas of the province have a relative surplus while other areas need more physicians.
Our study was undertaken in support of the Physician Resource Committee (a joint effort of the Manitoba Medical Association and Manitoba Health) as part of a needs-based planning assessment - how Manitoba's supply of physicians can best meet the needs of the population. Analyses are based on 1993/94 data, with an updated section using 1994/95 data. Among the questions we asked were: How many doctors do we have? Where do they practice? How many do we need? Where do we need them?
Manitoba's supply of physicians is on a par with other Western provinces (fig.1). How often we see a physician also compares favourably with other provinces - and it's up from what it used to be. In fact, Manitobans had more contact with physicians in 1994/95 than they did in previous years. And our access to physicians is excellent; 75% of people in the province see a physician at least once a year. Furthermore, while it's true some physicians have left the province, they have been more than replaced by recent local medical graduates and doctors from other provinces choosing to practice here.
We do have a problem with the distribution of physicians. Specifically, Winnipeg and Brandon appear to have an excess of generalist physicians* relative to anywhere else in the province. This is the same conclusion reached by the Physician Resource Committee, though the methods they used differed from ours. The Committee stated: "There appears to be an excess of physicians providing primary care services in Winnipeg."
The term relative is key here: that statement alone does not say there are too many physicians or too few, it simply says that of all the generalist physicians in our province, Brandon and Winnipeg have more per capita than rural areas. Which leads to several questions: Does the rural deficit mean those areas have fewer doctors than needed? If so, how many are needed? Does the urban excess mean those areas have more doctors than needed? If so, how many too many? All of which lead to the following question: How do we assess need?
Assessing NeedHow many physicians are needed? The truth is nobody knows for sure. The answer is not as simple as a head count: X number of doctors required to keep Y number of people healthy. The relative need for physicians varies from region to region, depending on a number of characteristics.
One way of trying to estimate need is to observe how different types of people use physicians. To put it as simply as possible, we know that some types of people have more visits to a physician (and therefore likely need more visits) than others - the elderly more than the middle-aged, women more than men, the poor more than the wealthy, are a few examples. So the first step in our needs assessment is to look at not only how many people there are in a particular area, but the age, gender and socio-economic mix of those people. We then estimate, based on averages for the various types, how many visits to a physician area residents should need. One can see by this that if one region has significantly more elderly residents than another, all other things being equal, we can reasonably predict it will also have a need for more physician contacts than the other.
There is one more important consideration-health; people in poor health need to see a doctor more often. One of the most widely used indicators of a population's health status is its premature mortality rate. Residents of areas with high death rates among the young typically have more complaints of illness than do residents of other areas. Thus, our final estimate of how much physician contact an area needs relies not only on the age, gender and socio-economic characteristics of its residents, but also on how healthy or unhealthy they are. Areas whose residents are in poor health we assume will need more physician contact.
By noting where people usually went to see a doctor, we identified 54 physician service areas which we called PSAs. For each PSA, we counted the number of times people saw a doctor - whether it was in the doctor's office, a walk-in clinic or in an emergency room. We then compared it to how many visits residents of the area needed. Using information we had on the workload of the average physician, we estimated whether an area was being served by too few or too many physicians.
To illustrate, suppose in Area A, our measure of need showed that the population should have seen their doctors a total of 50,000 times in one year. Also suppose that in Area A, the population actually visited a doctor 40,000 times, i.e. they needed 10,000 additional visits. If one doctor typically handles, say, 5,000 visits per year, then Area A would need two additional doctors.
We also considered factors like the presence of nursing stations, the proportion of physicians nearing retirement and to what extent patients travelled outside their own area to see a physician.
Based on this assessment, here is what we found.
Up to 94/95, there were more physicians entering practice than retirements or departures. In 94/95 there were slightly more departures than entries-not surprising since an entire class was delayed entry to practice because of the new requirement of a second year of internship. Despite this, there was no drop in contacts with physicians. If anything, contact rates rose. In short, access to physicians does not seem to be a problem. Most of Northern Manitoba has relatively high health care needs but is under-supplied by physicians. This includes the areas of Flin Flon, Norway House/Cross Lake, The Pas, Island Lake, Oxford House, and the remote communities served by Thompson area physicians (but not Thompson itself). Several areas in the rural south are under-served, including: Roblin, Alonsa, East Lake Winnipeg, Grahamdale, East Interlake, Winnipegosis, Coldwell, Piney District and Sioux Valley. A relatively small number of physicians would be adequate to fill the needs of Manitoba's under-served areas: 32-43 physicians in Northern areas; 27 physicians in the Rural South. Some areas close to Winnipeg or Brandon appear to be under-served by local physicians, but their residents, seemingly by choice, are abundantly served by urban doctors. A closer examination of contact patterns is required before making a decision on physician supply. Winnipeg has a relative surplus (103) of generalist physicians (124 if we count services provided by public health nurses), Brandon, a surplus of 9 to 10. The net surplus of 64-98 physicians costs the province at least $8 to $12 million a year, assuming average annual earnings of $125,000. The province spends almost 50% more per Winnipeg child than per Northern child in providing physician services, despite evidence of higher need in the North. Simi-larly, 34% more is spent providing care to Winnipeg adults (15-64 years) than to adults in Manitoba's rural South, despite relatively equal need in these populations (fig.2). A higher supply of physicians does not appear to reduce the number of admissions to hospital nor the number of days patients spend once admitted.
DiscussionIt would be fair to ask: how did this imbalance happen in the first place? Many Manitobans probably assume that physicians, like other professionals, such as teachers, go where they are needed or where there's a job. It's not quite that simple, as this letter we received from one physician explains:"I do not believe there were any policies, but rather, the situation existed where the doctor went to an area where he/she was comfortable, and could make a living practicing medicine, and which, unfortunately, was most often Winnipeg."At least in part, this has led to the situation we have today in Manitoba: an excess of generalist physicians in Winnipeg and Brandon, and an under-supply outside of those two centres.
Now some might question this assertion. They might argue that while it's true that compared to rural areas, Winnipeg and Brandon appear to have too many physicians, isn't it possible they have just the right amount? Perhaps there just aren't enough physicians in Manitoba.
We think that's unlikely. Although per capita spending on physicians is below the Canadian average, Manitoba has a physician supply similar to that of other prairie provinces (fig.1). We also have a comparatively rich supply of specialists, and more paediatricians per capita than most other provinces. This strengthens our belief that the solution lies in redistribution. And as we noted in our findings, the relative deficit in rural areas would be more than filled by the apparent excess in the urban areas-and still leave a surplus.
The same conclusion seems to have been reached by other provinces that are also looking at physician expenditures and numbers. By and large their findings echo our own: an over-supply of physicians coupled with uneven distribution. Consequently, several provinces are considering or trying various remedies, the most common being limiting the number of new physicians and introducing fee incentives to encourage physicians to locate in non-urban areas.
Fee incentives do not necessarily mean spending more money. The same amount of money can be spent more cost-effectively. While the models vary from place to place, essentially they all translate to making the earning potential for physicians greater in under-served areas than it is in over-served areas.
Which leads to another point: supply usually goes hand-in-hand with demand. In other occupations, if suppliers exceed demand, some soon go out of business. But this hasn't been the case with physicians; areas of over-supply are typically high-use areas, and unemployed physicians are essentially unknown. Are physicians responsible for high-use patterns? Aren't they just responding to patient demand?
These questions do not have simple yes or no answers. Some feel that over-use patterns are the fault of the patient. After all, it's usually the patient who first decides to bring a problem to a physician. Also, some patients may rush to the doctor with minor complaints. And a few patients see more than one doctor for the same problem, sometimes because they didn't like the previous physician (or physicians) they saw. In short, some patients may see physicians more than they need to.
However, it is just as likely that some physicians see patients more than is required. While the first visit to a physician is usually the choice of the patient, follow-up visits are often physician-initiated; and some physicians appear to encourage patients to return much more frequently than other physicians. For example, we found some family doctors saw their hypertensive patients frequently - averaging 7 or 8 visits a year per patient - whereas other family doctors saw their hypertensive patients far less often - averaging 4 visits per year. These numbers suggest that physicians also contribute to high-use patterns.
Have we misstated the problem or undervalued the role of physicians? We think not. Without question, physicians provide a vital service to our communities. However, we have a surplus of physicians in urban areas and it is costly. Our most conservative estimate suggests it costs Manitobans at least $8 million a year. Yet, talk of cost-control measures centres on medicare reductions, that is, deinsuring services, even though there is evidence from other jurisdictions that deinsurance has a negative effect on the poor and the elderly.
At this time of fiscal constraint, we need to focus on maintaining what is best about the Canadian medical system. In short, let's fix what's wrong, not what's right. It makes sense to control physician expenditures and to manage the implications of doing so. We have provided ample evidence of the need to move in this direction, and guidelines on how to do it. We must do a better job of putting doctors and dollars where the needs are--that's what needs-based planning is all about.
Summary written by RJ Currie, based on the report: Needs-Based Planning for Manitoba's Generalist Physicians: by Noralou Roos, Randy Fransoo, Bogdan Bogdanovic, David Friesen, Norm Frohlich, KC Carriere, David Patton, Ron Wall.
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