Ontario’s Health Minister Erik Hoskins is a brave man. He has attempted to wrestle a new agreement with Ontario doctors and to drive down outrageous billing – with some 500 doctors billing more than one million dollars a year. Hoskins wanted to redistribute these health dollars for improved physician care.
The plan was to engage with doctors themselves on how to more fairly allocate billing codes, to reward better doctors who provide high-value care, and eventually to give less to those who don’t.
But recently, Ontario’s doctors voted down their tentative physician services agreement. While most media coverage has focused on those doctors who rallied against the deal, the more important story is that 45 per cent of physicians didn’t even bother to participate. That is a lower turnout than the last federal election and the matter directly affected something important to them – their salaries.
Such levels of disengagement from important decisions about a contract encompassing 25 per cent of the total provincial health system expenditure raises concerns as to whether today’s doctors are ready to co-manage health systems as this agreement had unprecedentedly offered.
We need a new way to approach doctor negotiations – and we desperately need a new paradigm in the delivery of physician care in Ontario and across Canada. Here’s why.
In the 2014 Commonwealth ranking of health systems, Canada came 10th out of 11 countries, beating only the U.S. With respect to physician services, Canada came in last place for emergency room (ER) visits for conditions that could have been treated by a family doctor, 10th out of 11 for medical records/tests not reaching a doctor’s office in time for an appointment, 7th for requesting duplicate tests, and 10th for hospitalized patients who returned for complications after discharge. This is hardly an endorsement of the status quo.
Doctors will no doubt blame all of these problems on inadequate resources, ignoring the fact that Canada’s health care system is comparatively a high-spender with doctors who are very well-paid.
At least some of our poor performance internationally must be attributable to how physicians run their practices and treat their patients.
How many of us have been stuck in badly managed waiting rooms, being made to feel that the attending doctor is doing us a huge favour? Or have eyeballed patient records stuffed on a shelf behind a receptionist? Or dealt with a surly scheduler, trying to get a same-day appointment with a sick child in tow or to find out if a specialist referral has been submitted?
So is it possible for physicians to step up and better manage our limited health care budget, as is so desperately needed?
For the moment, it seems the likely answer is ‘no’– and it seems Ontario doctors feel the same way with their rejection of the recent offer. This is because clinicians are generally unwilling to make the tough rationing decisions needed in our resource-constrained world. Even if doctors were willing to take on this role, most are not trained to weigh the population-level opportunity costs that are so important to such decisions.
The problem is that the sum of what may be best for each individual patient may not be what is best for Ontarians or Canadians as a whole.
Clinicians’ singular focus on their patients may result in harm for other patients beyond their view. This is because each unnecessary MRI leaves less money to cover the cost of prescription drugs for the poor. Each antibiotic unnecessarily administered contributes to bacterial resistance that makes these medicines less effective for everyone else.
It is only human that physicians should feel the ‘rescue imperative’ – the urge to do everything in their power to save the patient in front of them, ignoring the opportunity costs for other merely statistical patients.
So should we give more power to our doctors for the management of our health system?
We hope the failure of negotiations in Ontario spurs a complete rethink of this approach. Maybe what we want to do is limit a la carte billing for doctor services in the first place, and have far clearer contractual directives against cost-ineffective treatments and towards quality, safe and high-value care.
Indeed, this is the approach taken in the UK – the top performer in the Commonwealth Fund rankings – where physicians are paid by way of a salary and work to terms of a contract. Physicians should compete for these contracts on their ability to effectively and safely provide high-value care and to devote a minimum number of hours per week to their patients.
Ontarians have been extremely patient with the status quo, but we deserve much better. Minister Hoskins deserves our support in crafting a brand new deal to get us there.
Colleen M. Flood is a university research chair in Health Law and Policy and inaugural director of the Centre for Health Law, Policy and Ethics at the University of Ottawa.