Beyond "financial incentives": How stakeholders interpret Ontario's funding structure for midwifery

Canadian Public Administration

Volumn 41, Issue 4, 1998, Pages 553-586

  Giacomini, M K ^a   Peters, M A ^b  

^a MCMASTER UNIVERSITY   (Canada)

^b NONE

Author keywords

[No Author keywords available]

Indexed keywords

EID: 0009901688     PISSN: 00084840     EISSN: None     Source Type: Journal    
DOI: 10.1111/j.1754-7121.1998.tb00221.x     Document Type: Article

References (156)

1. For examples see S.H. Moore, D.P. Martin and W.C. Richardson, "Does the primary care gatekeeper control the costs of health care? Lessons from the SAFECO experience," New England Journal of Medicine 309, no. 22 (1983) pp. 1400-1404; S. Iliffe and J. Munro, "General practitioners and incentives," British Medical Journal 307, no. 6913 (6 November 1993), pp. 1156-57; D.M. Frankford, "Managing medical clinicians' work through the use of financial incentives," Wake Forest Law Review 29, no. 1 (1994), pp. 71-105; S. Stewart-Brown, R. Surender, J. Bradlow, A. Coulter and H. Doll, "The effects of fundholding in general practice on prescribing habits three years after introduction of the scheme," British Medical Journal 311, no. 7019 (9 December 1995), pp. 1543-47; B. Hutchison, S. Birch, J. Hurley, J. Lomas and F. Stratford-Devai, "Do physician-payment mechanisms affect hospital utilization? A Study of Health Service Organizations in Ontario," Canadian Medical Association Journal 154, no. 5 (1 March 1996), pp. 653-61.
2. For examples see S.H. Moore, D.P. Martin and W.C. Richardson, "Does the primary care gatekeeper control the costs of health care? Lessons from the SAFECO experience," New England Journal of Medicine 309, no. 22 (1983) pp. 1400-1404; S. Iliffe and J. Munro, "General practitioners and incentives," British Medical Journal 307, no. 6913 (6 November 1993), pp. 1156-57; D.M. Frankford, "Managing medical clinicians' work through the use of financial incentives," Wake Forest Law Review 29, no. 1 (1994), pp. 71-105; S. Stewart-Brown, R. Surender, J. Bradlow, A. Coulter and H. Doll, "The effects of fundholding in general practice on prescribing habits three years after introduction of the scheme," British Medical Journal 311, no. 7019 (9 December 1995), pp. 1543-47; B. Hutchison, S. Birch, J. Hurley, J. Lomas and F. Stratford-Devai, "Do physician-payment mechanisms affect hospital utilization? A Study of Health Service Organizations in Ontario," Canadian Medical Association Journal 154, no. 5 (1 March 1996), pp. 653-61.
3. For examples see S.H. Moore, D.P. Martin and W.C. Richardson, "Does the primary care gatekeeper control the costs of health care? Lessons from the SAFECO experience," New England Journal of Medicine 309, no. 22 (1983) pp. 1400-1404; S. Iliffe and J. Munro, "General practitioners and incentives," British Medical Journal 307, no. 6913 (6 November 1993), pp. 1156-57; D.M. Frankford, "Managing medical clinicians' work through the use of financial incentives," Wake Forest Law Review 29, no. 1 (1994), pp. 71-105; S. Stewart-Brown, R. Surender, J. Bradlow, A. Coulter and H. Doll, "The effects of fundholding in general practice on prescribing habits three years after introduction of the scheme," British Medical Journal 311, no. 7019 (9 December 1995), pp. 1543-47; B. Hutchison, S. Birch, J. Hurley, J. Lomas and F. Stratford-Devai, "Do physician-payment mechanisms affect hospital utilization? A Study of Health Service Organizations in Ontario," Canadian Medical Association Journal 154, no. 5 (1 March 1996), pp. 653-61.
4. For examples see S.H. Moore, D.P. Martin and W.C. Richardson, "Does the primary care gatekeeper control the costs of health care? Lessons from the SAFECO experience," New England Journal of Medicine 309, no. 22 (1983) pp. 1400-1404; S. Iliffe and J. Munro, "General practitioners and incentives," British Medical Journal 307, no. 6913 (6 November 1993), pp. 1156-57; D.M. Frankford, "Managing medical clinicians' work through the use of financial incentives," Wake Forest Law Review 29, no. 1 (1994), pp. 71-105; S. Stewart-Brown, R. Surender, J. Bradlow, A. Coulter and H. Doll, "The effects of fundholding in general practice on prescribing habits three years after introduction of the scheme," British Medical Journal 311, no. 7019 (9 December 1995), pp. 1543-47; B. Hutchison, S. Birch, J. Hurley, J. Lomas and F. Stratford-Devai, "Do physician-payment mechanisms affect hospital utilization? A Study of Health Service Organizations in Ontario," Canadian Medical Association Journal 154, no. 5 (1 March 1996), pp. 653-61.
5. For examples see S.H. Moore, D.P. Martin and W.C. Richardson, "Does the primary care gatekeeper control the costs of health care? Lessons from the SAFECO experience," New England Journal of Medicine 309, no. 22 (1983) pp. 1400-1404; S. Iliffe and J. Munro, "General practitioners and incentives," British Medical Journal 307, no. 6913 (6 November 1993), pp. 1156-57; D.M. Frankford, "Managing medical clinicians' work through the use of financial incentives," Wake Forest Law Review 29, no. 1 (1994), pp. 71-105; S. Stewart-Brown, R. Surender, J. Bradlow, A. Coulter and H. Doll, "The effects of fundholding in general practice on prescribing habits three years after introduction of the scheme," British Medical Journal 311, no. 7019 (9 December 1995), pp. 1543-47; B. Hutchison, S. Birch, J. Hurley, J. Lomas and F. Stratford-Devai, "Do physician-payment mechanisms affect hospital utilization? A Study of Health Service Organizations in Ontario," Canadian Medical Association Journal 154, no. 5 (1 March 1996), pp. 653-61.
6. See, for example, F. Champagne, J-L. Denis, R. Rineault, A-P. Contandriopoulos, "Structural and political models of analysis of the introduction of an innovation in organizations: the case of change in the method of payment of physicians in long-term care hospitals," Health Services Management Research 4, no. 2 (1991), pp. 94-111; Frankford, "Managing medical clinicians' work," Wake Forest Law Review, J.C Robinson, "Payment mechanisms, nonprice incentives, and organizational innovation in health care," Inquiry 30 (1993), pp. 328-33; N. Hupert, A.G. Lawthers, T.A. Brennan, L.M. Peterson, "Processing the tort deterrent signal: a qualitative study," Social Science and Medicine 43, no. 1 (July 1996), pp. 1-11.
7. See, for example, F. Champagne, J-L. Denis, R. Rineault, A-P. Contandriopoulos, "Structural and political models of analysis of the introduction of an innovation in organizations: the case of change in the method of payment of physicians in long-term care hospitals," Health Services Management Research 4, no. 2 (1991), pp. 94-111; Frankford, "Managing medical clinicians' work," Wake Forest Law Review, J.C Robinson, "Payment mechanisms, nonprice incentives, and organizational innovation in health care," Inquiry 30 (1993), pp. 328-33; N. Hupert, A.G. Lawthers, T.A. Brennan, L.M. Peterson, "Processing the tort deterrent signal: a qualitative study," Social Science and Medicine 43, no. 1 (July 1996), pp. 1-11.
8. See, for example, F. Champagne, J-L. Denis, R. Rineault, A-P. Contandriopoulos, "Structural and political models of analysis of the introduction of an innovation in organizations: the case of change in the method of payment of physicians in long-term care hospitals," Health Services Management Research 4, no. 2 (1991), pp. 94-111; Frankford, "Managing medical clinicians' work," Wake Forest Law Review, J.C Robinson, "Payment mechanisms, nonprice incentives, and organizational innovation in health care," Inquiry 30 (1993), pp. 328-33; N. Hupert, A.G. Lawthers, T.A. Brennan, L.M. Peterson, "Processing the tort deterrent signal: a qualitative study," Social Science and Medicine 43, no. 1 (July 1996), pp. 1-11.
9. See, for example, F. Champagne, J-L. Denis, R. Rineault, A-P. Contandriopoulos, "Structural and political models of analysis of the introduction of an innovation in organizations: the case of change in the method of payment of physicians in long-term care hospitals," Health Services Management Research 4, no. 2 (1991), pp. 94-111; Frankford, "Managing medical clinicians' work," Wake Forest Law Review, J.C Robinson, "Payment mechanisms, nonprice incentives, and organizational innovation in health care," Inquiry 30 (1993), pp. 328-33; N. Hupert, A.G. Lawthers, T.A. Brennan, L.M. Peterson, "Processing the tort deterrent signal: a qualitative study," Social Science and Medicine 43, no. 1 (July 1996), pp. 1-11.
10. For example, see N. Glass, "The economics of general practice in England," British Journal of Preventive and Social Medicine 28, no. 3 (August 1974), pp. 203-209; J. Rovira, "Incentives for healthy consumer behaviour and intersectorial measures for health targets," in G. Lopez- Casasnovas, ed., Incentives in Health Systems (New York: Springer-Verlag, 1991), pp. 58-74.
11. For example, see N. Glass, "The economics of general practice in England," British Journal of Preventive and Social Medicine 28, no. 3 (August 1974), pp. 203-209; J. Rovira, "Incentives for healthy consumer behaviour and intersectorial measures for health targets," in G. Lopez-Casasnovas, ed., Incentives in Health Systems (New York: Springer-Verlag, 1991), pp. 58-74.
12. This framework is described in M. Giacomini, J. Hurley, J. Lomas, V. Bhatia and L. Goldsmith, The Many Meanings of Money: A Health Policy Analysis Framework for Understanding Financial Incentives. Working Paper #96-06 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996), and M. Giacomini, J. Hurley, J. Lomas, V. Bhatia and L. Goldsmith, The Devil in the Details: Conclusions about How Funding Changes Translate into Financial Incentives in the Canadian Health System. Working Paper #96-14 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996). The framework was synthesized from a number of theoretical works addressing the socially embedded nature of financial incentives, including W.F. Whyte, M. Dalton, D. Roy, et al., "On symbols and interaction," W.F. Whyte and M. Dalton, ed., Money and Motivation: An Analysis of Incentives in Industry (New York: Harper & Brothers, 1955), pp. 241-49; S. Kerr, "On the folly of rewarding A, while hoping for B," Academy of Management Journal 18, no. 4 (1975), pp. 769-83; R.W. Backoff and B.M. Mitnick, "The systems approach, incentiverelations, and university management," in J. Wilson, ed., New Directions for Higher Education: Management Science Applications to Academic Administration. No. 35 (San Francisco: Jossey- Bass, 1981), pp. 73-92; D.A. Stone, Policy Paradox and Political Reason (New York: Harper Collins Publisher, 1988); A. Kohn, "Why incentive plans cannot work," Harvard Business Review 71, no. 5 (September-October 1993), pp. 54-63; A. Kohn, Punished by Rewards: The Trouble with Gold Stars, Incentive Plans, A's, Praise, and Other Bribes (Boston: Houghton Mifflin Company, 1993).
13. This framework is described in M. Giacomini, J. Hurley, J. Lomas, V. Bhatia and L. Goldsmith, The Many Meanings of Money: A Health Policy Analysis Framework for Understanding Financial Incentives. Working Paper #96-06 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996), and M. Giacomini, J. Hurley, J. Lomas, V. Bhatia and L. Goldsmith, The Devil in the Details: Conclusions about How Funding Changes Translate into Financial Incentives in the Canadian Health System. Working Paper #96-14 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996). The framework was synthesized from a number of theoretical works addressing the socially embedded nature of financial incentives, including W.F. Whyte, M. Dalton, D. Roy, et al., "On symbols and interaction," W.F. Whyte and M. Dalton, ed., Money and Motivation: An Analysis of Incentives in Industry (New York: Harper & Brothers, 1955), pp. 241-49; S. Kerr, "On the folly of rewarding A, while hoping for B," Academy of Management Journal 18, no. 4 (1975), pp. 769-83; R.W. Backoff and B.M. Mitnick, "The systems approach, incentiverelations, and university management," in J. Wilson, ed., New Directions for Higher Education: Management Science Applications to Academic Administration. No. 35 (San Francisco: Jossey- Bass, 1981), pp. 73-92; D.A. Stone, Policy Paradox and Political Reason (New York: Harper Collins Publisher, 1988); A. Kohn, "Why incentive plans cannot work," Harvard Business Review 71, no. 5 (September-October 1993), pp. 54-63; A. Kohn, Punished by Rewards: The Trouble with Gold Stars, Incentive Plans, A's, Praise, and Other Bribes (Boston: Houghton Mifflin Company, 1993).
14. This framework is described in M. Giacomini, J. Hurley, J. Lomas, V. Bhatia and L. Goldsmith, The Many Meanings of Money: A Health Policy Analysis Framework for Understanding Financial Incentives. Working Paper #96-06 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996), and M. Giacomini, J. Hurley, J. Lomas, V. Bhatia and L. Goldsmith, The Devil in the Details: Conclusions about How Funding Changes Translate into Financial Incentives in the Canadian Health System. Working Paper #96-14 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996). The framework was synthesized from a number of theoretical works addressing the socially embedded nature of financial incentives, including W.F. Whyte, M. Dalton, D. Roy, et al., "On symbols and interaction," W.F. Whyte and M. Dalton, ed., Money and Motivation: An Analysis of Incentives in Industry (New York: Harper & Brothers, 1955), pp. 241-49; S. Kerr, "On the folly of rewarding A, while hoping for B," Academy of Management Journal 18, no. 4 (1975), pp. 769-83; R.W. Backoff and B.M. Mitnick, "The systems approach, incentiverelations, and university management," in J. Wilson, ed., New Directions for Higher Education: Management Science Applications to Academic Administration. No. 35 (San Francisco: Jossey- Bass, 1981), pp. 73-92; D.A. Stone, Policy Paradox and Political Reason (New York: Harper Collins Publisher, 1988); A. Kohn, "Why incentive plans cannot work," Harvard Business Review 71, no. 5 (September-October 1993), pp. 54-63; A. Kohn, Punished by Rewards: The Trouble with Gold Stars, Incentive Plans, A's, Praise, and Other Bribes (Boston: Houghton Mifflin Company, 1993).
15. This framework is described in M. Giacomini, J. Hurley, J. Lomas, V. Bhatia and L. Goldsmith, The Many Meanings of Money: A Health Policy Analysis Framework for Understanding Financial Incentives. Working Paper #96-06 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996), and M. Giacomini, J. Hurley, J. Lomas, V. Bhatia and L. Goldsmith, The Devil in the Details: Conclusions about How Funding Changes Translate into Financial Incentives in the Canadian Health System. Working Paper #96-14 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996). The framework was synthesized from a number of theoretical works addressing the socially embedded nature of financial incentives, including W.F. Whyte, M. Dalton, D. Roy, et al., "On symbols and interaction," W.F. Whyte and M. Dalton, ed., Money and Motivation: An Analysis of Incentives in Industry (New York: Harper & Brothers, 1955), pp. 241-49; S. Kerr, "On the folly of rewarding A, while hoping for B," Academy of Management Journal 18, no. 4 (1975), pp. 769-83; R.W. Backoff and B.M. Mitnick, "The systems approach, incentiverelations, and university management," in J. Wilson, ed., New Directions for Higher Education: Management Science Applications to Academic Administration. No. 35 (San Francisco: Jossey- Bass, 1981), pp. 73-92; D.A. Stone, Policy Paradox and Political Reason (New York: Harper Collins Publisher, 1988); A. Kohn, "Why incentive plans cannot work," Harvard Business Review 71, no. 5 (September-October 1993), pp. 54-63; A. Kohn, Punished by Rewards: The Trouble with Gold Stars, Incentive Plans, A's, Praise, and Other Bribes (Boston: Houghton Mifflin Company, 1993).
16. This framework is described in M. Giacomini, J. Hurley, J. Lomas, V. Bhatia and L. Goldsmith, The Many Meanings of Money: A Health Policy Analysis Framework for Understanding Financial Incentives. Working Paper #96-06 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996), and M. Giacomini, J. Hurley, J. Lomas, V. Bhatia and L. Goldsmith, The Devil in the Details: Conclusions about How Funding Changes Translate into Financial Incentives in the Canadian Health System. Working Paper #96-14 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996). The framework was synthesized from a number of theoretical works addressing the socially embedded nature of financial incentives, including W.F. Whyte, M. Dalton, D. Roy, et al., "On symbols and interaction," W.F. Whyte and M. Dalton, ed., Money and Motivation: An Analysis of Incentives in Industry (New York: Harper & Brothers, 1955), pp. 241-49; S. Kerr, "On the folly of rewarding A, while hoping for B," Academy of Management Journal 18, no. 4 (1975), pp. 769-83; R.W. Backoff and B.M. Mitnick, "The systems approach, incentiverelations, and university management," in J. Wilson, ed., New Directions for Higher Education: Management Science Applications to Academic Administration. No. 35 (San Francisco: Jossey-Bass, 1981), pp. 73-92; D.A. Stone, Policy Paradox and Political Reason (New York: Harper Collins Publisher, 1988); A. Kohn, "Why incentive plans cannot work," Harvard Business Review 71, no. 5 (September-October 1993), pp. 54-63; A. Kohn, Punished by Rewards: The Trouble with Gold Stars, Incentive Plans, A's, Praise, and Other Bribes (Boston: Houghton Mifflin Company, 1993).
17. This framework is described in M. Giacomini, J. Hurley, J. Lomas, V. Bhatia and L. Goldsmith, The Many Meanings of Money: A Health Policy Analysis Framework for Understanding Financial Incentives. Working Paper #96-06 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996), and M. Giacomini, J. Hurley, J. Lomas, V. Bhatia and L. Goldsmith, The Devil in the Details: Conclusions about How Funding Changes Translate into Financial Incentives in the Canadian Health System. Working Paper #96-14 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996). The framework was synthesized from a number of theoretical works addressing the socially embedded nature of financial incentives, including W.F. Whyte, M. Dalton, D. Roy, et al., "On symbols and interaction," W.F. Whyte and M. Dalton, ed., Money and Motivation: An Analysis of Incentives in Industry (New York: Harper & Brothers, 1955), pp. 241-49; S. Kerr, "On the folly of rewarding A, while hoping for B," Academy of Management Journal 18, no. 4 (1975), pp. 769-83; R.W. Backoff and B.M. Mitnick, "The systems approach, incentiverelations, and university management," in J. Wilson, ed., New Directions for Higher Education: Management Science Applications to Academic Administration. No. 35 (San Francisco: Jossey- Bass, 1981), pp. 73-92; D.A. Stone, Policy Paradox and Political Reason (New York: Harper Collins Publisher, 1988); A. Kohn, "Why incentive plans cannot work," Harvard Business Review 71, no. 5 (September-October 1993), pp. 54-63; A. Kohn, Punished by Rewards: The Trouble with Gold Stars, Incentive Plans, A's, Praise, and Other Bribes (Boston: Houghton Mifflin Company, 1993).
18. This framework is described in M. Giacomini, J. Hurley, J. Lomas, V. Bhatia and L. Goldsmith, The Many Meanings of Money: A Health Policy Analysis Framework for Understanding Financial Incentives. Working Paper #96-06 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996), and M. Giacomini, J. Hurley, J. Lomas, V. Bhatia and L. Goldsmith, The Devil in the Details: Conclusions about How Funding Changes Translate into Financial Incentives in the Canadian Health System. Working Paper #96-14 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996). The framework was synthesized from a number of theoretical works addressing the socially embedded nature of financial incentives, including W.F. Whyte, M. Dalton, D. Roy, et al., "On symbols and interaction," W.F. Whyte and M. Dalton, ed., Money and Motivation: An Analysis of Incentives in Industry (New York: Harper & Brothers, 1955), pp. 241-49; S. Kerr, "On the folly of rewarding A, while hoping for B," Academy of Management Journal 18, no. 4 (1975), pp. 769-83; R.W. Backoff and B.M. Mitnick, "The systems approach, incentiverelations, and university management," in J. Wilson, ed., New Directions for Higher Education: Management Science Applications to Academic Administration. No. 35 (San Francisco: Jossey- Bass, 1981), pp. 73-92; D.A. Stone, Policy Paradox and Political Reason (New York: Harper Collins Publisher, 1988); A. Kohn, "Why incentive plans cannot work," Harvard Business Review 71, no. 5 (September-October 1993), pp. 54-63; A. Kohn, Punished by Rewards: The Trouble with Gold Stars, Incentive Plans, A's, Praise, and Other Bribes (Boston: Houghton Mifflin Company, 1993).
19. This framework is described in M. Giacomini, J. Hurley, J. Lomas, V. Bhatia and L. Goldsmith, The Many Meanings of Money: A Health Policy Analysis Framework for Understanding Financial Incentives. Working Paper #96-06 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996), and M. Giacomini, J. Hurley, J. Lomas, V. Bhatia and L. Goldsmith, The Devil in the Details: Conclusions about How Funding Changes Translate into Financial Incentives in the Canadian Health System. Working Paper #96-14 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996). The framework was synthesized from a number of theoretical works addressing the socially embedded nature of financial incentives, including W.F. Whyte, M. Dalton, D. Roy, et al., "On symbols and interaction," W.F. Whyte and M. Dalton, ed., Money and Motivation: An Analysis of Incentives in Industry (New York: Harper & Brothers, 1955), pp. 241-49; S. Kerr, "On the folly of rewarding A, while hoping for B," Academy of Management Journal 18, no. 4 (1975), pp. 769-83; R.W. Backoff and B.M. Mitnick, "The systems approach, incentiverelations, and university management," in J. Wilson, ed., New Directions for Higher Education: Management Science Applications to Academic Administration. No. 35 (San Francisco: Jossey- Bass, 1981), pp. 73-92; D.A. Stone, Policy Paradox and Political Reason (New York: Harper Collins Publisher, 1988); A. Kohn, "Why incentive plans cannot work," Harvard Business Review 71, no. 5 (September-October 1993), pp. 54-63; A. Kohn, Punished by Rewards: The Trouble with Gold Stars, Incentive Plans, A's, Praise, and Other Bribes (Boston: Houghton Mifflin Company, 1993).
20. R.C. Rist, "Influencing the policy process with qualitative research," in N.K. Denzin and Y.S. Lincoln, eds., Handbook of Qualitative Research (Thousand Oaks, Calif.: Sage Publications, 1994), pp. 545-57, at p. 549.
21. R. Yin, Applications of Case Study Research (London: Sage Publications, 1993); R. Yin, Case Study Research: Design and Methods (London: Sage Publications, 1989); R. Stake, The Art of Case Study Research (London: Sage Publications, 1995); M.Q. Patton, Qualitative Evaluation and Research Methods (London: Sage Publications, 1990). This present study of midwifery was one of seven case studies conducted to validate and elaborate the "communication model" for understanding financial incentives (Giacomini, et al., Working Paper # 96-06). The other case studies are J. Lomas and M. Rachlis, "Moving rocks: block funding in PEI as an incentive for cross-sectoral reallocation among human services," CANADIAN PUBLIC ADMINISTRATION 39, no. 4 (Winter 1997), pp. 581-600; J. Hurley, J. Lomas and L. Goldsmith, "Physician expenditure caps in Canada: a common property perspective," Milbank Quarterly 75, no. 3 (1997), pp. 343-64; M. Giacomini, J. Hurley and G. Stoddart, "What it can mean to deinsure a health service: the case of IVF in Ontario," (manuscript under review, 1998); V. Bhatia, S. West and M. Giacomini, Equity in Case-Based Funding: A Case Study of Meanings and Messages in Hospital Funding Policy. Working Paper #96-13 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); P. Grootendorst, L. Goldsmith, J. Hurley, B. O'Brien and L. Dolovich, Financial Incentives to Dispense Low Cost Drugs: A Case Study of British Columbia Pharmacare. Working Paper #96-08 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); B. Hutchison, S. Birch and J. Gillet, Health Service Organizations: The Evolution of Capitation- Funded Physician Care in Ontario. Working Paper #96-11 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996).
22. R. Yin, Applications of Case Study Research (London: Sage Publications, 1993); R. Yin, Case Study Research: Design and Methods (London: Sage Publications, 1989); R. Stake, The Art of Case Study Research (London: Sage Publications, 1995); M.Q. Patton, Qualitative Evaluation and Research Methods (London: Sage Publications, 1990). This present study of midwifery was one of seven case studies conducted to validate and elaborate the "communication model" for understanding financial incentives (Giacomini, et al., Working Paper # 96-06). The other case studies are J. Lomas and M. Rachlis, "Moving rocks: block funding in PEI as an incentive for cross-sectoral reallocation among human services," CANADIAN PUBLIC ADMINISTRATION 39, no. 4 (Winter 1997), pp. 581-600; J. Hurley, J. Lomas and L. Goldsmith, "Physician expenditure caps in Canada: a common property perspective," Milbank Quarterly 75, no. 3 (1997), pp. 343-64; M. Giacomini, J. Hurley and G. Stoddart, "What it can mean to deinsure a health service: the case of IVF in Ontario," (manuscript under review, 1998); V. Bhatia, S. West and M. Giacomini, Equity in Case-Based Funding: A Case Study of Meanings and Messages in Hospital Funding Policy. Working Paper #96-13 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); P. Grootendorst, L. Goldsmith, J. Hurley, B. O'Brien and L. Dolovich, Financial Incentives to Dispense Low Cost Drugs: A Case Study of British Columbia Pharmacare. Working Paper #96-08 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); B. Hutchison, S. Birch and J. Gillet, Health Service Organizations: The Evolution of Capitation- Funded Physician Care in Ontario. Working Paper #96-11 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996).
23. R. Yin, Applications of Case Study Research (London: Sage Publications, 1993); R. Yin, Case Study Research: Design and Methods (London: Sage Publications, 1989); R. Stake, The Art of Case Study Research (London: Sage Publications, 1995); M.Q. Patton, Qualitative Evaluation and Research Methods (London: Sage Publications, 1990). This present study of midwifery was one of seven case studies conducted to validate and elaborate the "communication model" for understanding financial incentives (Giacomini, et al., Working Paper # 96-06). The other case studies are J. Lomas and M. Rachlis, "Moving rocks: block funding in PEI as an incentive for cross-sectoral reallocation among human services," CANADIAN PUBLIC ADMINISTRATION 39, no. 4 (Winter 1997), pp. 581-600; J. Hurley, J. Lomas and L. Goldsmith, "Physician expenditure caps in Canada: a common property perspective," Milbank Quarterly 75, no. 3 (1997), pp. 343-64; M. Giacomini, J. Hurley and G. Stoddart, "What it can mean to deinsure a health service: the case of IVF in Ontario," (manuscript under review, 1998); V. Bhatia, S. West and M. Giacomini, Equity in Case-Based Funding: A Case Study of Meanings and Messages in Hospital Funding Policy. Working Paper #96-13 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); P. Grootendorst, L. Goldsmith, J. Hurley, B. O'Brien and L. Dolovich, Financial Incentives to Dispense Low Cost Drugs: A Case Study of British Columbia Pharmacare. Working Paper #96-08 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); B. Hutchison, S. Birch and J. Gillet, Health Service Organizations: The Evolution of Capitation- Funded Physician Care in Ontario. Working Paper #96-11 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996).
24. R. Yin, Applications of Case Study Research (London: Sage Publications, 1993); R. Yin, Case Study Research: Design and Methods (London: Sage Publications, 1989); R. Stake, The Art of Case Study Research (London: Sage Publications, 1995); M.Q. Patton, Qualitative Evaluation and Research Methods (London: Sage Publications, 1990). This present study of midwifery was one of seven case studies conducted to validate and elaborate the "communication model" for understanding financial incentives (Giacomini, et al., Working Paper # 96-06). The other case studies are J. Lomas and M. Rachlis, "Moving rocks: block funding in PEI as an incentive for cross-sectoral reallocation among human services," CANADIAN PUBLIC ADMINISTRATION 39, no. 4 (Winter 1997), pp. 581-600; J. Hurley, J. Lomas and L. Goldsmith, "Physician expenditure caps in Canada: a common property perspective," Milbank Quarterly 75, no. 3 (1997), pp. 343-64; M. Giacomini, J. Hurley and G. Stoddart, "What it can mean to deinsure a health service: the case of IVF in Ontario," (manuscript under review, 1998); V. Bhatia, S. West and M. Giacomini, Equity in Case-Based Funding: A Case Study of Meanings and Messages in Hospital Funding Policy. Working Paper #96-13 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); P. Grootendorst, L. Goldsmith, J. Hurley, B. O'Brien and L. Dolovich, Financial Incentives to Dispense Low Cost Drugs: A Case Study of British Columbia Pharmacare. Working Paper #96-08 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); B. Hutchison, S. Birch and J. Gillet, Health Service Organizations: The Evolution of Capitation- Funded Physician Care in Ontario. Working Paper #96-11 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996).
25. R. Yin, Applications of Case Study Research (London: Sage Publications, 1993); R. Yin, Case Study Research: Design and Methods (London: Sage Publications, 1989); R. Stake, The Art of Case Study Research (London: Sage Publications, 1995); M.Q. Patton, Qualitative Evaluation and Research Methods (London: Sage Publications, 1990). This present study of midwifery was one of seven case studies conducted to validate and elaborate the "communication model" for understanding financial incentives (Giacomini, et al., Working Paper # 96-06). The other case studies are J. Lomas and M. Rachlis, "Moving rocks: block funding in PEI as an incentive for cross-sectoral reallocation among human services," CANADIAN PUBLIC ADMINISTRATION 39, no. 4 (Winter 1997), pp. 581-600; J. Hurley, J. Lomas and L. Goldsmith, "Physician expenditure caps in Canada: a common property perspective," Milbank Quarterly 75, no. 3 (1997), pp. 343-64; M. Giacomini, J. Hurley and G. Stoddart, "What it can mean to deinsure a health service: the case of IVF in Ontario," (manuscript under review, 1998); V. Bhatia, S. West and M. Giacomini, Equity in Case-Based Funding: A Case Study of Meanings and Messages in Hospital Funding Policy. Working Paper #96-13 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); P. Grootendorst, L. Goldsmith, J. Hurley, B. O'Brien and L. Dolovich, Financial Incentives to Dispense Low Cost Drugs: A Case Study of British Columbia Pharmacare. Working Paper #96-08 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); B. Hutchison, S. Birch and J. Gillet, Health Service Organizations: The Evolution of Capitation- Funded Physician Care in Ontario. Working Paper #96-11 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996).
26. R. Yin, Applications of Case Study Research (London: Sage Publications, 1993); R. Yin, Case Study Research: Design and Methods (London: Sage Publications, 1989); R. Stake, The Art of Case Study Research (London: Sage Publications, 1995); M.Q. Patton, Qualitative Evaluation and Research Methods (London: Sage Publications, 1990). This present study of midwifery was one of seven case studies conducted to validate and elaborate the "communication model" for understanding financial incentives (Giacomini, et al., Working Paper # 96-06). The other case studies are J. Lomas and M. Rachlis, "Moving rocks: block funding in PEI as an incentive for cross-sectoral reallocation among human services," CANADIAN PUBLIC ADMINISTRATION 39, no. 4 (Winter 1997), pp. 581-600; J. Hurley, J. Lomas and L. Goldsmith, "Physician expenditure caps in Canada: a common property perspective," Milbank Quarterly 75, no. 3 (1997), pp. 343-64; M. Giacomini, J. Hurley and G. Stoddart, "What it can mean to deinsure a health service: the case of IVF in Ontario," (manuscript under review, 1998); V. Bhatia, S. West and M. Giacomini, Equity in Case-Based Funding: A Case Study of Meanings and Messages in Hospital Funding Policy. Working Paper #96-13 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); P. Grootendorst, L. Goldsmith, J. Hurley, B. O'Brien and L. Dolovich, Financial Incentives to Dispense Low Cost Drugs: A Case Study of British Columbia Pharmacare. Working Paper #96-08 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); B. Hutchison, S. Birch and J. Gillet, Health Service Organizations: The Evolution of Capitation- Funded Physician Care in Ontario. Working Paper #96-11 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996).
27. R. Yin, Applications of Case Study Research (London: Sage Publications, 1993); R. Yin, Case Study Research: Design and Methods (London: Sage Publications, 1989); R. Stake, The Art of Case Study Research (London: Sage Publications, 1995); M.Q. Patton, Qualitative Evaluation and Research Methods (London: Sage Publications, 1990). This present study of midwifery was one of seven case studies conducted to validate and elaborate the "communication model" for understanding financial incentives (Giacomini, et al., Working Paper # 96-06). The other case studies are J. Lomas and M. Rachlis, "Moving rocks: block funding in PEI as an incentive for cross-sectoral reallocation among human services," CANADIAN PUBLIC ADMINISTRATION 39, no. 4 (Winter 1997), pp. 581-600; J. Hurley, J. Lomas and L. Goldsmith, "Physician expenditure caps in Canada: a common property perspective," Milbank Quarterly 75, no. 3 (1997), pp. 343-64; M. Giacomini, J. Hurley and G. Stoddart, "What it can mean to deinsure a health service: the case of IVF in Ontario," (manuscript under review, 1998); V. Bhatia, S. West and M. Giacomini, Equity in Case-Based Funding: A Case Study of Meanings and Messages in Hospital Funding Policy. Working Paper #96-13 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); P. Grootendorst, L. Goldsmith, J. Hurley, B. O'Brien and L. Dolovich, Financial Incentives to Dispense Low Cost Drugs: A Case Study of British Columbia Pharmacare. Working Paper #96-08 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); B. Hutchison, S. Birch and J. Gillet, Health Service Organizations: The Evolution of Capitation- Funded Physician Care in Ontario. Working Paper #96-11 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996).
28. R. Yin, Applications of Case Study Research (London: Sage Publications, 1993); R. Yin, Case Study Research: Design and Methods (London: Sage Publications, 1989); R. Stake, The Art of Case Study Research (London: Sage Publications, 1995); M.Q. Patton, Qualitative Evaluation and Research Methods (London: Sage Publications, 1990). This present study of midwifery was one of seven case studies conducted to validate and elaborate the "communication model" for understanding financial incentives (Giacomini, et al., Working Paper # 96-06). The other case studies are J. Lomas and M. Rachlis, "Moving rocks: block funding in PEI as an incentive for cross-sectoral reallocation among human services," CANADIAN PUBLIC ADMINISTRATION 39, no. 4 (Winter 1997), pp. 581-600; J. Hurley, J. Lomas and L. Goldsmith, "Physician expenditure caps in Canada: a common property perspective," Milbank Quarterly 75, no. 3 (1997), pp. 343-64; M. Giacomini, J. Hurley and G. Stoddart, "What it can mean to deinsure a health service: the case of IVF in Ontario," (manuscript under review, 1998); V. Bhatia, S. West and M. Giacomini, Equity in Case-Based Funding: A Case Study of Meanings and Messages in Hospital Funding Policy. Working Paper #96-13 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); P. Grootendorst, L. Goldsmith, J. Hurley, B. O'Brien and L. Dolovich, Financial Incentives to Dispense Low Cost Drugs: A Case Study of British Columbia Pharmacare. Working Paper #96-08 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); B. Hutchison, S. Birch and J. Gillet, Health Service Organizations: The Evolution of Capitation- Funded Physician Care in Ontario. Working Paper #96-11 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996).
29. R. Yin, Applications of Case Study Research (London: Sage Publications, 1993); R. Yin, Case Study Research: Design and Methods (London: Sage Publications, 1989); R. Stake, The Art of Case Study Research (London: Sage Publications, 1995); M.Q. Patton, Qualitative Evaluation and Research Methods (London: Sage Publications, 1990). This present study of midwifery was one of seven case studies conducted to validate and elaborate the "communication model" for understanding financial incentives (Giacomini, et al., Working Paper # 96-06). The other case studies are J. Lomas and M. Rachlis, "Moving rocks: block funding in PEI as an incentive for cross-sectoral reallocation among human services," CANADIAN PUBLIC ADMINISTRATION 39, no. 4 (Winter 1997), pp. 581-600; J. Hurley, J. Lomas and L. Goldsmith, "Physician expenditure caps in Canada: a common property perspective," Milbank Quarterly 75, no. 3 (1997), pp. 343-64; M. Giacomini, J. Hurley and G. Stoddart, "What it can mean to deinsure a health service: the case of IVF in Ontario," (manuscript under review, 1998); V. Bhatia, S. West and M. Giacomini, Equity in Case-Based Funding: A Case Study of Meanings and Messages in Hospital Funding Policy. Working Paper #96-13 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); P. Grootendorst, L. Goldsmith, J. Hurley, B. O'Brien and L. Dolovich, Financial Incentives to Dispense Low Cost Drugs: A Case Study of British Columbia Pharmacare. Working Paper #96-08 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); B. Hutchison, S. Birch and J. Gillet, Health Service Organizations: The Evolution of Capitation- Funded Physician Care in Ontario. Working Paper #96-11 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996).
30. R. Yin, Applications of Case Study Research (London: Sage Publications, 1993); R. Yin, Case Study Research: Design and Methods (London: Sage Publications, 1989); R. Stake, The Art of Case Study Research (London: Sage Publications, 1995); M.Q. Patton, Qualitative Evaluation and Research Methods (London: Sage Publications, 1990). This present study of midwifery was one of seven case studies conducted to validate and elaborate the "communication model" for understanding financial incentives (Giacomini, et al., Working Paper # 96-06). The other case studies are J. Lomas and M. Rachlis, "Moving rocks: block funding in PEI as an incentive for cross-sectoral reallocation among human services," CANADIAN PUBLIC ADMINISTRATION 39, no. 4 (Winter 1997), pp. 581-600; J. Hurley, J. Lomas and L. Goldsmith, "Physician expenditure caps in Canada: a common property perspective," Milbank Quarterly 75, no. 3 (1997), pp. 343-64; M. Giacomini, J. Hurley and G. Stoddart, "What it can mean to deinsure a health service: the case of IVF in Ontario," (manuscript under review, 1998); V. Bhatia, S. West and M. Giacomini, Equity in Case-Based Funding: A Case Study of Meanings and Messages in Hospital Funding Policy. Working Paper #96-13 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); P. Grootendorst, L. Goldsmith, J. Hurley, B. O'Brien and L. Dolovich, Financial Incentives to Dispense Low Cost Drugs: A Case Study of British Columbia Pharmacare. Working Paper #96-08 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); B. Hutchison, S. Birch and J. Gillet, Health Service Organizations: The Evolution of Capitation- Funded Physician Care in Ontario. Working Paper #96-11 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996).
31. R. Yin, Applications of Case Study Research (London: Sage Publications, 1993); R. Yin, Case Study Research: Design and Methods (London: Sage Publications, 1989); R. Stake, The Art of Case Study Research (London: Sage Publications, 1995); M.Q. Patton, Qualitative Evaluation and Research Methods (London: Sage Publications, 1990). This present study of midwifery was one of seven case studies conducted to validate and elaborate the "communication model" for understanding financial incentives (Giacomini, et al., Working Paper # 96-06). The other case studies are J. Lomas and M. Rachlis, "Moving rocks: block funding in PEI as an incentive for cross-sectoral reallocation among human services," CANADIAN PUBLIC ADMINISTRATION 39, no. 4 (Winter 1997), pp. 581-600; J. Hurley, J. Lomas and L. Goldsmith, "Physician expenditure caps in Canada: a common property perspective," Milbank Quarterly 75, no. 3 (1997), pp. 343-64; M. Giacomini, J. Hurley and G. Stoddart, "What it can mean to deinsure a health service: the case of IVF in Ontario," (manuscript under review, 1998); V. Bhatia, S. West and M. Giacomini, Equity in Case-Based Funding: A Case Study of Meanings and Messages in Hospital Funding Policy. Working Paper #96-13 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); P. Grootendorst, L. Goldsmith, J. Hurley, B. O'Brien and L. Dolovich, Financial Incentives to Dispense Low Cost Drugs: A Case Study of British Columbia Pharmacare. Working Paper #96-08 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996); B. Hutchison, S. Birch and J. Gillet, Health Service Organizations: The Evolution of Capitation-Funded Physician Care in Ontario. Working Paper #96-11 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996).
32. M. Giacomini and L. Goldsmith, Case Study Methodology for Studying Financial Incentives in Context. Working Paper 96-15 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1996).
33. M.Q. Patton, "Designing qualitative studies," in Patton, Qualitative Evaluation and Research, pp. 145-96.
34. Some of the interviewees occupied more than one of these roles over time. In particular, several practising midwives have acted as policy advisers at various points in the development of the midwifery program. Views of additional stakeholders, such as vocal members of the public, hospitals, and the hospital association and professional nursing interests, were discernedprimarily through the document sources.
35. M.Q. Patton, "Enhancing the quality and credibility of qualitative analysis," in Patton, Qualitative Evaluation and Research Methods, pp. 460-506; R. Stake, "Triangulation," in Stake, Art of Case Study Research, pp. 107-20.
36. M.Q. Patton, "Enhancing the quality and credibility of qualitative analysis," in Patton, Qualitative Evaluation and Research Methods, pp. 460-506; R. Stake, "Triangulation," in Stake, Art of Case Study Research, pp. 107-20.
37. Ontario, Task Force on the Implementation of Midwifery, Report (Toronto: Ministry of Health, 1987).
38. n.a., "FPs: Mixed emotions about legalization of midwifery," Canadian Family Physician 32 (November 1986), pp. 2321-37.
39. The latter figure is taken from the report of the Task Force on the Implementation of Midwifery. Some midwives were able to charge more than this for their services, and some charged less or worked under bartering arrangements. There is little reliable information on the midwifery economy before 1994, as it was a truly private service with no public reporting, monitoring or data collection.
40. R. Mickleburgh, "Ontario delivers after hard push for midwifery," The Globe and Mail (Toronto) 1 January 1994, p. A3.
41. K. Kaufman, "The introduction of midwifery in Ontario, Canada," Birth 18, no. 1102 (June 1991), pp. 100-103.
42. The Ontario Ministry of Health estimates that only about $12 million of the allocated midwifery budget will actually be spent this year, because fewer midwives than anticipated will be practising.
43. In the interim, a Toronto community health centre acts as trustee for the distribution of funds until contracts are established between regional transfer-payment agencies and the Ministry of Health.
44. Lebel Midwifery Care Organization of Ontario, Midwifery Caseload Policies, Schedule A (Toronto: Lebel, 1995); Lebel Midwifery Care Organization of Ontario, "Funding Agreement" (unpublished copy of standard funding contract between Lebel and midwifery practice groups, 1995).
45. Lebel Midwifery Care Organization of Ontario, Midwifery Caseload Policies, Schedule A (Toronto: Lebel, 1995); Lebel Midwifery Care Organization of Ontario, "Funding Agreement" (unpublished copy of standard funding contract between Lebel and midwifery practice groups, 1995).
46. Interview with transfer-payment agency administrator, 16 July 1998.
47. Task Force on the Implementation of Midwifery, Report; personal communication with official with Ontario Ministry of Health, 31 October 1998. Recent reports in the press cite $605 as a national average and between $768 and $900 as an average in British Columbia. See D. Kosub, "New midwife program draws BCMA criticism," Medical Post, 20 January 1998, p. 28; M. Love, "Manitoba's obstetric MDs to stop delivering," Medical Post, 9 June 1998, p. 2.
48. Task Force on the Implementation of Midwifery, Report; personal communication with official with Ontario Ministry of Health, 31 October 1998. Recent reports in the press cite $605 as a national average and between $768 and $900 as an average in British Columbia. See D. Kosub, "New midwife program draws BCMA criticism," Medical Post, 20 January 1998, p. 28; M. Love, "Manitoba's obstetric MDs to stop delivering," Medical Post, 9 June 1998, p. 2.
49. Estimates are from Society of Obstetricians and Gynecologists of Canada, Healthy Beginnings: Guidelines for Care During Pregnancy and Birth (Halifax: Society, 1995). The duration of visits is reported in Task Force on the Implementation of Midwifery, Report.
50. The revenue cap policy in 1994 allowed full reimbursement for annual billings up to $404,000, 67 per cent reimbursement for additional billings up to $454,000, and 33.3 per cent of any additional billlings over $454,000.
51. J. Hurley and R. Card, "Global physician budgets as common-property resources: some implications for physicians and medical associations," Canadian Medical Association Journal 154, no. 8 (15April 1996), pp. 1161-72.
52. Kaufman, "Introduction of midwifery in Ontario," Birth.
53. Task Force on the Implementation of Midwifery, Report.
54. Society of Obstetricians and Gynecologists of Canada, Midwifery Statement of Annual Council (Halifax: Society, 1990); P.J. Stewart and J.M. Beresford, "Opinions of physicians assisting births in Ottawa-Carleton about the licensing of midwives," Canadian Medical Association Journal 139, no. 5 (1 September 1988), pp. 393-7; E. LeBourdais, "Despite CMA misgivings, support for midwifery appears to be growing," Canadian Medical Association Journal 139, no. 8 (15 October 1988), pp. 769-72.
55. Society of Obstetricians and Gynecologists of Canada, Midwifery Statement of Annual Council (Halifax: Society, 1990); P.J. Stewart and J.M. Beresford, "Opinions of physicians assisting births in Ottawa-Carleton about the licensing of midwives," Canadian Medical Association Journal 139, no. 5 (1 September 1988), pp. 393-7; E. LeBourdais, "Despite CMA misgivings, support for midwifery appears to be growing," Canadian Medical Association Journal 139, no. 8 (15 October 1988), pp. 769-72.
56. Society of Obstetricians and Gynecologists of Canada, Midwifery Statement of Annual Council (Halifax: Society, 1990); P.J. Stewart and J.M. Beresford, "Opinions of physicians assisting births in Ottawa-Carleton about the licensing of midwives," Canadian Medical Association Journal 139, no. 5 (1 September 1988), pp. 393-7; E. LeBourdais, "Despite CMA misgivings, support for midwifery appears to be growing," Canadian Medical Association Journal 139, no. 8 (15 October 1988), pp. 769-72.
57. G. Maté, "Midwifery merits autonomous, legal recognition," Vancouver Sun 25 January 1992, p. E12; College of Physicians and Surgeons of British Columbia, Midwifery Position Statement (revised, 20 May 1994) (Vancouver: College, 1994); British Columbia Medical Association, "Response to government's midwifery announcement," LA Contact: Newsletter for Local Action Committees of the British Columbia Medical Association no. 104 (13 May 1993), p. 1.
58. G. Maté, "Midwifery merits autonomous, legal recognition," Vancouver Sun 25 January 1992, p. E12; College of Physicians and Surgeons of British Columbia, Midwifery Position Statement (revised, 20 May 1994) (Vancouver: College, 1994); British Columbia Medical Association, "Response to government's midwifery announcement," LA Contact: Newsletter for Local Action Committees of the British Columbia Medical Association no. 104 (13 May 1993), p. 1.
59. G. Maté, "Midwifery merits autonomous, legal recognition," Vancouver Sun 25 January 1992, p. E12; College of Physicians and Surgeons of British Columbia, Midwifery Position Statement (revised, 20 May 1994) (Vancouver: College, 1994); British Columbia Medical Association, "Response to government's midwifery announcement," LA Contact: Newsletter for Local Action Committees of the British Columbia Medical Association no. 104 (13 May 1993), p. 1.
60. Kaufman, "Introduction of midwifery," Birth, p. 101.
61. An Act Respecting the Regulation of the Profession of Midwifery, S.O. 1991, c. 31 (Bill 56] D.L. Martin, "The midwife's tale: old wisdom and a new challenge to the control of reproduction," Columbia Journal of Gender and Law 3 (1992), pp. 417-48, at p. 444.
62. Interviews with policy consultatnt, 24 October 1995; midwife, 19 January 1996; physician involved in funding policy development, 16 January 1996.
63. C.J. Touhy, "Medicine and the state in Canada: the extra-billing issue in perspective," Canadian Journal of Political Science 21, no. 2 (June 1988), pp. 267-96; J. Lomas, C. Charles and J. Greb, The Price of Peace: The Structure and Process of Physician Fee Negotiations in Canada. Working Paper #92-27 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1992); J. Lomas and M. Barer, "And who shall represent the public interest? The legacy of Canadian health manpower policy," in R.G. Evans and G.L. Stoddart, eds., Medicare at Maturity (Calgary: University of Calgary Press, 1986), pp. 221-86.
64. C.J. Touhy, "Medicine and the state in Canada: the extra-billing issue in perspective," Canadian Journal of Political Science 21, no. 2 (June 1988), pp. 267-96; J. Lomas, C. Charles and J. Greb, The Price of Peace: The Structure and Process of Physician Fee Negotiations in Canada. Working Paper #92-27 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1992); J. Lomas and M. Barer, "And who shall represent the public interest? The legacy of Canadian health manpower policy," in R.G. Evans and G.L. Stoddart, eds., Medicare at Maturity (Calgary: University of Calgary Press, 1986), pp. 221-86.
65. C.J. Touhy, "Medicine and the state in Canada: the extra-billing issue in perspective," Canadian Journal of Political Science 21, no. 2 (June 1988), pp. 267-96; J. Lomas, C. Charles and J. Greb, The Price of Peace: The Structure and Process of Physician Fee Negotiations in Canada. Working Paper #92-27 (Hamilton, Ont.: McMaster University Centre for Health Economics and Policy Analysis, 1992); J. Lomas and M. Barer, "And who shall represent the public interest? The legacy of Canadian health manpower policy," in R.G. Evans and G.L. Stoddart, eds., Medicare at Maturity (Calgary: University of Calgary Press, 1986), pp. 221-86.
66. Task Force on the Implementation of Midwifery, Report, p. 99.
67. Ibid.
68. Ibid.
69. Interview with an administrator in the Ministry of Health, 25 September 1995.
70. Policy documents use the terms ambiguously. Although Midwifery Program Framework states that midwives "will be compensated on a salary basis," Lebel practice contracts refer only to "compensation," not "salary."
71. V. Van Wagner, resolution approved at the annual general meeting of the Association of Ontario Midwives, 6 June 1995.
72. Interviews with midwifery program administrators in the Ministry of Health, 10-14 July 1998.
73. Task Force on the Implementation of Midwifery, Report.
74. These salaries are at 1986 levels, in accordance with recommendations published in 1987. See Ibid., p. 167.
75. Ontario, Ministry of Health, Community Health Centre Programme, "Approved Salary Ranges 1994/95" (Toronto: Ministry, unpublished).
76. For example, see Mickleburgh, "Ontario delivers," Globe.
77. L. Williams, "Doctor's reactions mixed as midwives enter health care mainstream in Ontario," Canadian Medical Association Journal 150, no. 5 (1 March 1994), pp. 730-34.
78. Most estimates fall in the range of $400 to $700. Only one physician in a letter to a medical journal estimated that midwives costs are either $1,314 or $2,629 per case depending on assumptions. See E. Dobkin, "Costs of midwifery" [letter], Canadian Medical Association Journal 151, no. 5 (1 September 1994), pp. 516.
79. See, for example, n.a. "FPs" Canadian Family Physician; Mickleburgh, "Ontario delivers," Globe; Newbery, "Midwives called burden ,"; A.A. Annen, "Midwives or family physicians?" [letter] Canadian Family Physician 32 (March 1986), p. 457; M. Mittelstaedt, "Ontario of offer midwifery courses," The Globe and Mail (Toronto) 22 December 1992, p. A11; Dobkin, "Costs of midwifery," [letter] Canadian Medical Association Journal; M. Greenberg, "Obstetricians' pay embarassing" [letter], The Toronto Star 12 June 1996, p. A23.
80. See, for example, n.a. "FPs" Canadian Family Physician; Mickleburgh, "Ontario delivers," Globe; Newbery, "Midwives called burden ,"; A.A. Annen, "Midwives or family physicians?" [letter] Canadian Family Physician 32 (March 1986), p. 457; M. Mittelstaedt, "Ontario of offer midwifery courses," The Globe and Mail (Toronto) 22 December 1992, p. A11; Dobkin, "Costs of midwifery," [letter] Canadian Medical Association Journal; M. Greenberg, "Obstetricians' pay embarassing" [letter], The Toronto Star 12 June 1996, p. A23.
81. See, for example, n.a. "FPs" Canadian Family Physician; Mickleburgh, "Ontario delivers," Globe; Newbery, "Midwives called burden ,"; A.A. Annen, "Midwives or family physicians?" [letter] Canadian Family Physician 32 (March 1986), p. 457; M. Mittelstaedt, "Ontario of offer midwifery courses," The Globe and Mail (Toronto) 22 December 1992, p. A11; Dobkin, "Costs of midwifery," [letter] Canadian Medical Association Journal; M. Greenberg, "Obstetricians' pay embarassing" [letter], The Toronto Star 12 June 1996, p. A23.
82. See, for example, n.a. "FPs" Canadian Family Physician; Mickleburgh, "Ontario delivers," Globe; Newbery, "Midwives called burden ,"; A.A. Annen, "Midwives or family physicians?" [letter] Canadian Family Physician 32 (March 1986), p. 457; M. Mittelstaedt, "Ontario of offer midwifery courses," The Globe and Mail (Toronto) 22 December 1992, p. A11; Dobkin, "Costs of midwifery," [letter] Canadian Medical Association Journal; M. Greenberg, "Obstetricians' pay embarassing" [letter], The Toronto Star 12 June 1996, p. A23.
83. See, for example, n.a. "FPs" Canadian Family Physician; Mickleburgh, "Ontario delivers," Globe; Newbery, "Midwives called burden ,"; A.A. Annen, "Midwives or family physicians?" [letter] Canadian Family Physician 32 (March 1986), p. 457; M. Mittelstaedt, "Ontario of offer midwifery courses," The Globe and Mail (Toronto) 22 December 1992, p. A11; Dobkin, "Costs of midwifery," [letter] Canadian Medical Association Journal; M. Greenberg, "Obstetricians' pay embarassing" [letter], The Toronto Star 12 June 1996, p. A23.
84. See, for example, n.a. "FPs" Canadian Family Physician; Mickleburgh, "Ontario delivers," Globe; Newbery, "Midwives called burden ,"; A.A. Annen, "Midwives or family physicians?" [letter] Canadian Family Physician 32 (March 1986), p. 457; M. Mittelstaedt, "Ontario of offer midwifery courses," The Globe and Mail (Toronto) 22 December 1992, p. A11; Dobkin, "Costs of midwifery," [letter] Canadian Medical Association Journal; M. Greenberg, "Obstetricians' pay embarassing" [letter], The Toronto Star 12 June 1996, p. A23.
85. See, for example, n.a. "FPs" Canadian Family Physician; Mickleburgh, "Ontario delivers," Globe; Newbery, "Midwives called burden ,"; A.A. Annen, "Midwives or family physicians?" [letter] Canadian Family Physician 32 (March 1986), p. 457; M. Mittelstaedt, "Ontario of offer midwifery courses," The Globe and Mail (Toronto) 22 December 1992, p. A11; Dobkin, "Costs of midwifery," [letter] Canadian Medical Association Journal; M. Greenberg, "Obstetricians' pay embarassing" [letter], The Toronto Star 12 June 1996, p. A23.
86. See, for example, Kosub, "New midwife program draws BCMA criticism," Medical Post; Love, "Manitoba's obstetric MDs to stop delivering," Medical Post; Williams, "Doctors' reactions mixed," Canadian Medical Association Journal; M. Jimenez," Doctors question midwifery plan paying twice the MD rate," Vancouver Sun 22 December 1997, p. A1; R. Pederson, "Larger fee for midwives ignited obstetricians' ire," Calgary Herald 2 May 1998, p. A19.
87. See, for example, Kosub, "New midwife program draws BCMA criticism," Medical Post; Love, "Manitoba's obstetric MDs to stop delivering," Medical Post; Williams, "Doctors' reactions mixed," Canadian Medical Association Journal; M. Jimenez," Doctors question midwifery plan paying twice the MD rate," Vancouver Sun 22 December 1997, p. A1; R. Pederson, "Larger fee for midwives ignited obstetricians' ire," Calgary Herald 2 May 1998, p. A19.
88. See, for example, Kosub, "New midwife program draws BCMA criticism," Medical Post; Love, "Manitoba's obstetric MDs to stop delivering," Medical Post; Williams, "Doctors' reactions mixed," Canadian Medical Association Journal; M. Jimenez," Doctors question midwifery plan paying twice the MD rate," Vancouver Sun 22 December 1997, p. A1; R. Pederson, "Larger fee for midwives ignited obstetricians' ire," Calgary Herald 2 May 1998, p. A19.
89. See, for example, Kosub, "New midwife program draws BCMA criticism," Medical Post; Love, "Manitoba's obstetric MDs to stop delivering," Medical Post; Williams, "Doctors' reactions mixed," Canadian Medical Association Journal; M. Jimenez," Doctors question midwifery plan paying twice the MD rate," Vancouver Sun 22 December 1997, p. A1; R. Pederson, "Larger fee for midwives ignited obstetricians' ire," Calgary Herald 2 May 1998, p. A19.
90. See, for example, Kosub, "New midwife program draws BCMA criticism," Medical Post; Love, "Manitoba's obstetric MDs to stop delivering," Medical Post; Williams, "Doctors' reactions mixed," Canadian Medical Association Journal; M. Jimenez," Doctors question midwifery plan paying twice the MD rate," Vancouver Sun 22 December 1997, p. A1; R. Pederson, "Larger fee for midwives ignited obstetricians' ire," Calgary Herald 2 May 1998, p. A19.
91. Task Force on the Implementation of Midwifery, Report.
92. Interview with administrator in the Ministry of Health, 10 July 1998.
93. Task Force on the Implementation of Midwifery, Report; M. Klein, J.L. Reynolds, F. Boucher, M. Malus and E. Rosenberg, "Obstetrical practice and training in Canadian family medicine: Conserving an endangered species," Canadian Family Physician 30 (October 1984), pp. 2093-99.
94. S. Lofsky, "Who will deliver Ontario's children? An analysis of selected 1993-94 Ontario obstetrical fee schedule codes," Ontario Medical Review 63, no. 3 (March 1996), pp. 25-7.
95. Task Force on the Implementation of Midwifery, Report; LeBourdais, "Despite CMA misgivings," Canadian Medical Association Journal; Klein et al., "Obstetrical practice and training," Canadian Family Physician; J. Douglas, "Billing law advancing midwifery, doctors say," The Globe and Mail (Toronto) 15 July 1986, p. A13; Lofsky, "Who will deliver Ontario's children?" Ontario Medical Review.
96. Task Force on the Implementation of Midwifery, Report; LeBourdais, "Despite CMA misgivings," Canadian Medical Association Journal; Klein et al., "Obstetrical practice and training," Canadian Family Physician; J. Douglas, "Billing law advancing midwifery, doctors say," The Globe and Mail (Toronto) 15 July 1986, p. A13; Lofsky, "Who will deliver Ontario's children?" Ontario Medical Review.
97. Task Force on the Implementation of Midwifery, Report; LeBourdais, "Despite CMA misgivings," Canadian Medical Association Journal; Klein et al., "Obstetrical practice and training," Canadian Family Physician; J. Douglas, "Billing law advancing midwifery, doctors say," The Globe and Mail (Toronto) 15 July 1986, p. A13; Lofsky, "Who will deliver Ontario's children?" Ontario Medical Review.
98. Task Force on the Implementation of Midwifery, Report; LeBourdais, "Despite CMA misgivings," Canadian Medical Association Journal; Klein et al., "Obstetrical practice and training," Canadian Family Physician; J. Douglas, "Billing law advancing midwifery, doctors say," The Globe and Mail (Toronto) 15 July 1986, p. A13; Lofsky, "Who will deliver Ontario's children?" Ontario Medical Review.
99. LeBourdais, "Despite CMA misgivings," Canadian Medical Association Journal.
100. Interview with primary-care physician.
101. This happens only to the very limited extent that midwives order tests that would not have been ordered by a physician; fees for direct care by these two clinicians are not drawn from the same budget.
102. Klein et al., "Obstetrical practice and training," Canadian Family Physician. Some obstetricians have also become concernedthat midwifery is shifting their own client mix to higher- risk cases with the consequence of a higher-stress workload. See B. Currier, "Motherhood issue: at last, midwives in Ontario are gaining legislated recognition - and women in remote communities may breathe easier," This Magazine 27, no. 5 (December 1993), pp. 28-31.
103. Klein et al., "Obstetrical practice and training," Canadian Family Physician. Some obstetricians have also become concernedthat midwifery is shifting their own client mix to higher-risk cases with the consequence of a higher-stress workload. See B. Currier, "Motherhood issue: at last, midwives in Ontario are gaining legislated recognition - and women in remote communities may breathe easier," This Magazine 27, no. 5 (December 1993), pp. 28-31.
104. P. Sullivan, "Canadian obstetric care system among finest in world, major CMA study finds," Canadian Medical Association Journal 136, no. 6 (15 March 1987), pp. 643-49, at p. 648.
105. J. Lomas and G. Stoddart, "Estimates of the potential impact of nurse practitioner on future requirements for physicians in office-based general practice," Canadian Journal of Public Health 76, no. 2 (March/April 1985), pp. 119-23.
106. Excerpt for group interview with family physicians, 18 October 1995.
107. I. Neimanis, "Midwifery had led to 'bitterness, divisiveness,'" Medical Post 4 April 1995, p. 10.
108. A. Kreidie, "Pediatricians peeved at cut in OMA consult fee," Medical Post 24 May 1994, p. 19.
109. Ontario Medical Association spokeswoman Jean Chow cited in Ibid, p. 19.
110. L. Sweet, "Province to pay for midwives, Grier says," The Toronto Star 31 October 1993, p. A3.
111. D. Anderson, "Midwifery will be a practical alternative," The Toronto Star 27 December 1986, p. E1.
112. Task Force on the Implementation of Midwifery, Report.
113. Interviews with consumer representative, 6 November 1995; policy consultant, 24 October 1995; obstetrician, 16 January 1996. See also Williams, "Doctors' reactions mixed," Canadian Medical Association Journal; M.C. Klein, "The midwife dossier: cooperation or competition? Canadian Medical Association Journal 150, no. 5 (1 March 1994), pp. 657-60, at p. 659.
114. Interviews with consumer representative, 6 November 1995; policy consultant, 24 October 1995; obstetrician, 16 January 1996. See also Williams, "Doctors' reactions mixed," Canadian Medical Association Journal; M.C. Klein, "The midwife dossier: cooperation or competition? Canadian Medical Association Journal 150, no. 5 (1 March 1994), pp. 657-60, at p. 659.
115. L. Newbery, "Midwives called burden if taxpayers foot the bill," The Toronto Star 17 October 1987, p. A13.
116. Williams, "Doctors' reactions mixed," Canadian Medical Association Journal, p. 730.
117. Sudbury Star, summer 1993.
118. Anderson, "Midwifery will be a practical alternative," Toronto Star.
119. L. Sarick, "Childbirth's ancient art reborn as a profession," The Globe and Mail (Toronto) 14 May 1994, pp. A1, A6, at p. A6. See also J. Deverelle, "Hospital to hire midwives," The Toronto Star 20 January 1994, p. A7.
120. L. Sarick, "Childbirth's ancient art reborn as a profession," The Globe and Mail (Toronto) 14 May 1994, pp. A1, A6, at p. A6. See also J. Deverelle, "Hospital to hire midwives," The Toronto Star 20 January 1994, p. A7.
121. Group interview with family physicians, 18 October 1995.
122. J. Douglas, "Billing law advancing midwifery, doctors say," The Globe and Mail (Toronto) 15 July 1986, p. A13.
123. D. Crittenden, "Frontier medicine: Canada's much-vaunted universal system can't even deal with an event as straightforward as a birth," The Globe and Mail (Toronto) 9 April 1994, p. D2. It should be noted that midwifery clients delivering in hospital do have access to pain medication and anesthesiology services.
124. P. Manga and T. Campbell, Health Human Resource Substitution: A Major Area of Reform Towards a More Cost-Effective Health Care System. Working Paper #94-01. Queen's-University of Ottawa EconomicProjects (Kingston, Ont.: Queen's University, 1994), p. 4.
125. J. Lomas and M. Barer, "And who shall represent the public interest? The legacy of Canadian health manpower policy," in Evans and Stoddart, Medicare at Maturity, pp. 221-86.
126. E.R. Declercq, "The transformation of American midwifery: 1975 to 1988," American Journal of Public Health 82, no. 5 (May 1992), pp. 680-84; A. Yankauer and J. Sullivan, "The new health professionals: three examples," Annual Review of Public Health 3 (1982), pp. 249-76.
127. E.R. Declercq, "The transformation of American midwifery: 1975 to 1988," American Journal of Public Health 82, no. 5 (May 1992), pp. 680-84; A. Yankauer and J. Sullivan, "The new health professionals: three examples," Annual Review of Public Health 3 (1982), pp. 249-76.
128. Task Force on the Implementation of Midwifery, Report; C. Oppenheimer, "Organising midwifery led care in the Netherlands," British Medical Journal 307, no. 6916 (27 November 1993), pp. 1400-1402.
129. This discussion addresses "typical" practices. Individual providers may vary considerably from this style; for instance, physicians differ widely in the amount of time they spend at the client's side during labour.
130. Task Force on the Implementation of Midwifery, Report.
131. Ibid.
132. R. Brennan, "Doctors 'won't hold women to ransom,'" Hamilton Spectator 31 May 1996, p. A7.
133. Lofsky, "Who will deliver Ontario's children?" Ontario Medical Review.
134. For example, see Task Force on the Implementation of Midwifery, Report; Manga and Campbell, Health Human Resource Substitution.
135. The necessary analysis to make fair, explicit transfers is also daunting. In the absence of capped midwifery and physician budgets with fluid boundaries between them, the Ministry of Health would need to assess the degree of functional substitution between these providers, price out the expected net savings, and administratively subtract the savings from the global budgets for hospitals and physician services. A sophisticated analysis would also forecast expected savings from preventive health benefits and prospectively adjust all health program budgets accordingly.
136. Hurley, Lomas and Goldsmith, "Physician expenditure caps in Canada," Milbank Quarterly; Lomas and Rachlis, "Moving rocks," CANADIAN PUBLIC ADMINISTRATION.
137. Hurley, Lomas and Goldsmith, "Physician expenditure caps in Canada," Milbank Quarterly; Lomas and Rachlis, "Moving rocks," CANADIAN PUBLIC ADMINISTRATION.
138. Task Force on the Implementation of Midwifery, Report, p. 75.
139. A.R. Ford, "Midwifery in transition," Healthsharing 14, no. 2 (1993), pp. 14-17; Currier, "Motherhood issue," This Magazine.
140. A.R. Ford, "Midwifery in transition," Healthsharing 14, no. 2 (1993), pp. 14-17; Currier, "Motherhood issue," This Magazine.
141. Midwifery Funding Working Group, Ontario Midwifery Program Framework.
142. Williams, "Doctor's reactions mixed," Canadian Medical Association Journal; N. Colodny, "Reestablishing the oldest profession," Broadside 8 no. 3 (December 1986-January 1987), p. 5; V. Van Wagner, "Women organizing for midwifery in Ontario," Resources for Feminist Research 17, no. 3 (1988), pp. 115-18. For a U.S. perspective, see also Declercq, "Transformation of American midwifery," American Journal of Public Health.
143. Williams, "Doctor's reactions mixed," Canadian Medical Association Journal; N. Colodny, "Reestablishing the oldest profession," Broadside 8 no. 3 (December 1986-January 1987), p. 5; V. Van Wagner, "Women organizing for midwifery in Ontario," Resources for Feminist Research 17, no. 3 (1988), pp. 115-18. For a U.S. perspective, see also Declercq, "Transformation of American midwifery," American Journal of Public Health.
144. Williams, "Doctor's reactions mixed," Canadian Medical Association Journal; N. Colodny, "Reestablishing the oldest profession," Broadside 8 no. 3 (December 1986-January 1987), p. 5; V. Van Wagner, "Women organizing for midwifery in Ontario," Resources for Feminist Research 17, no. 3 (1988), pp. 115-18. For a U.S. perspective, see also Declercq, "Transformation of American midwifery," American Journal of Public Health.
145. Williams, "Doctor's reactions mixed," Canadian Medical Association Journal; N. Colodny, "Reestablishing the oldest profession," Broadside 8 no. 3 (December 1986-January 1987), p. 5; V. Van Wagner, "Women organizing for midwifery in Ontario," Resources for Feminist Research 17, no. 3 (1988), pp. 115-18. For a U.S. perspective, see also Declercq, "Transformation of American midwifery," American Journal of Public Health.
146. An Act Respecting the Regulation of the Profession of Midwifery [Bill 56]
147. Task Force on the Implementation of Midwifery, Report, p. 85.
148. Klein, "Midwife dossier," Canadian Medical AssociationJournal, p. 659. See also Martin, "Midwife's tale," Columbia Journal of Gender and Law; J.C. Carroll, A.J. Reid, J. Ruderman and M.A. Murray, "The influence of the high-risk care environment on the practice of low-risk obstetrics," Family Medicine 23 (1991), pp. 184-8.
149. Klein, "Midwife dossier," Canadian Medical AssociationJournal, p. 659. See also Martin, "Midwife's tale," Columbia Journal of Gender and Law; J.C. Carroll, A.J. Reid, J. Ruderman and M.A. Murray, "The influence of the high-risk care environment on the practice of low-risk obstetrics," Family Medicine 23 (1991), pp. 184-8.
150. Klein, "Midwife dossier," Canadian Medical AssociationJournal, p. 659. See also Martin, "Midwife's tale," Columbia Journal of Gender and Law; J.C. Carroll, A.J. Reid, J. Ruderman and M.A. Murray, "The influence of the high-risk care environment on the practice of low-risk obstetrics," Family Medicine 23 (1991), pp. 184-8.
151. W. Powell and D. Powell, "Babes in high-tech toyland," The Globe and Mail (Toronto) 25 April 1991, p. A17; M. McCaffery, "Why women want midwives," Canadian Family Physician 30 (October 1984), pp. 1975-76.
152. W. Powell and D. Powell, "Babes in high-tech toyland," The Globe and Mail (Toronto) 25 April 1991, p. A17; M. McCaffery, "Why women want midwives," Canadian Family Physician 30 (October 1984), pp. 1975-76.
153. Williams, "Doctors' reactions mixed," Canadian Medical Association Journal, p. 730.
154. G.L. Stoddart, "Reflections on incentives and health system reform," in Lopez-Casasnovas, Incentives in Health Systems, pp. 75-95.
155. For more on the role the "slippery slope" metaphor plays in policy arguments, see D. Stone, "Symbols," in D. Stone, ed., Policy Paradox: The Art of Political Decision Making (New York: W.W. Norton & Co., 1997), pp. 137-62.
156. For more on how health technology "tradeoffs" are constructed, see M. Giacomini, "The 'which' hunt: assembling health technologies for assessment and rationing," Journal of Health Politics, Policy and Law (forthcoming, 1999).