History of the Medical Reform Group: 1979 - 1996
1990 and After
The Organization of Primary Care
Bob James, Joel Lexchin, and Fred Freedman led a Primary Care Working
Group which formulated what they called a "HUB" model of the delivery
of primary care. The proposed HUB would be a physical office community
with a computerised data base summarizing the health status of the
local community, would have some mechanism of community input, would
be a focus of continuing medical education, and would be involved
in community outreach, in part through provision of nurse practitioner
and social services. Each HUB would serve three to six primary care practices
and would provide information to the District Health Council. The MRG
discussed the model at the semi-annual meeting in October, 1990, and
there was considerable support for the ideas. While the group did not
take the model farther, the discussion advanced MRG thinking in primary
care.
The issue of the organization of primary care arose
again in 1992. Here the focus was physician reimbursement, with
the Resource Allocation group doing the background work. Their proposals
were debated an the autumn semi-annual meeting in November 1992.
We reached a consensus on the advantages and disadvantages of the
various funding mechanisms and a final position that harked back to
our founding principles.
The political, social, and economic causes of ill-health
should be recognized, and strategies to deal with these causes
should be integrated into our health interventions.
The power and autonomy of non-physician health
workers should increase.
Capitation and salary arrangements are essentially
compatible with these goals, whereas fee for service is not.
The MRG therefore supports a major change in the structure of
the current health-care system to one in which the primary mechanisms
for reimbursement of primary health care delivery would be capitation
and salary.
Since the organization and reimbursement mechanisms
of primary care are likely to be an area of increasing focus, this
resolution gave MRG spokespeople a clear position to present in
public statements and debates.
The MRG and American Health Care
The late 1980's saw a ferment in the American health care system predicated
on the realization of huge inequalities and uncontrolled cost.
By 1989 there was a great deal of interest among Americans about
the Canadian health care system. Progressive groups in the United
States looked for informed Canadian physicians to educate them, and
their constituents, about how health care in Canada works. The MRG spend
considerable energy filling this role. Gordon Guyatt and Haresh Kirpalani
prepared a rigorously documented summary of the relative merits of the
two systems with respect to coverage, patient satisfaction, physician
satisfaction, health status, and costs. They prepared a slide show which
was taken on the road by MRG speakers. MRG members participated in conferences
on health care in Canada and the United States, such as the Pugh foundation
conference in Toronto in May 1990. MRG members presented talks to labour
and community coalitions (such as Maine's Citizens for Affordable
Health Care or Massachusetts Health Care for All), and physicians' groups.
The American physicians' group advocating a universal single-payer
system, the Physicians for a National Health Policy, saw the MRG and
as an important ally, and obtained MRG participation in press conferences
and symposia.
The most exciting endeavour was a 12 city series
of presentations to the press, radio talk shows, community groups,
labour groups, and politicians organized by the Democratic Socialists
of America in the summer of 1991. MRG representatives spoke side by
side with Canadian labour activists and NDP politicians heavily involved
in health care. MRG members who participated in the tour included
Mimi Divinsky, Rosana Pellizzari, Haresh Kirpalani, Gordon Guyatt,
and Don Woodside. The cities they visited included New York, Chicago,
Washington, Philadelphia, Hertford, and several west coast cities. It
was a tremendously experience for the participants, and the enthusiasm
they met was very exciting.
MRG activity in this sphere continued after the
tour. MRG members became contacts for American health care activists
and provided help for the media. Repeatedly, journalists would call
wanting to come and see the Canadian system first hand. The MRG would
arrange interviews with progressive hospital administrators, community
physicians, academic physicians, hospital physicians (primarily
around issues of technology availability) and patients. This work facilitated
a positive and accurate portrayal of the Canadian system by the American
lay press.
The MRG was also active in rebutting distorted
impressions of Canadian health care being presented in the American
medical press. Of note were two letters published in the New England
Journal of Medicine, one in June 1990 in response to an article
by Adam Lenten (N Engl J Med 1990 Jun 7;322(23):1675_6), and the
other in November 1992 in response to a letter from a disaffected
Canadian physician reporting derogatory anecdotal comments about Canadian
Health Care delivery (N Engl J Med 1992 Nov 26;327(22):1603).
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