Category: Politics

Most docs love to work; they find patient care fulfilling. Many can’t believe they get paid for the privilege of helping patients.

Many of us would work for free.

Seriously.

Talk about money or income makes most doctors squirm. We have jobs we love and higher than average incomes. We forget the sacrifice of training.

Politicians and media know this. Like lion trainers with whips, journalists make doctors cower by whipping out a headline about incomes.

Personal Incomes, Patient Needs

Doctors conflate their personal incomes with patient services. They know patients wait, and that the province is short of money. Ergo, if only doctors took a cut in personal incomes, then patient services would improve. But they’re confused.

The schedule of benefits – the fees that physicians get paid – does not exist because government likes doctors. It does not exist to pad physicians’ incomes. The schedule is designed to drive physician behaviour towards meeting patient needs.

Fees Fix Care Problems

Unmet medical need creates demand for new fees or adjustment to old ones. A new fee drives physicians to change behaviour to meet the need defined in the fee code. If you cut a particular fee, physicians’ behaviours change to service other, equally pressing, medical concerns.

For example, attaching a bonus for Family Docs to accept unattached complex patients after discharge from hospital makes it easier for these patients to find Family Docs. Everything doctors do relates to helping patients. All things being equal, doctors will provide care that the government promotes with higher fees, regardless of physicians’ individual altruism.

The MOH-OMA negotiations are about patient needs and how best to meet them, not individual MD incomes.

Fees and Access

Economists teach that prices impact supply. When supply drops, prices increase.  If the government fixes a low price, supply decreases.

For example, over the years government slashed fees for community doctors doing hospital work. Guess what? Almost no community doctors spend a significant part of their day doing hospital work anymore.

You can decrease price and in the short run people will still be able to access services. But very soon, supply and/or quality will decrease.

Doctors and Privilege

Privilege relates to more than just income. Society honours physicians, to varying degrees, with respect, deference and a degree of autonomy. Patients do not begrudge what their doctor earns when they are sick themselves.

Society does not privilege doctors only out of the goodness of its collective heart.

People know that if they want some of the strongest students to sacrifice their youth in medical training, society needs to value the sacrifice. Students must be attracted into training.

When governments and media attack doctors and slander them as greedy, when patients look on doctors as undeserving recipients of their tax dollars, and when politicians arbitrarily slash doctors’ fees, our best students change their minds.

For example, before primary care reform, dozens of residency positions in family medicine went unfilled. Students looked to any other field besides family medicine. Society communicated that it did not value primary care. Only after major funding reforms in the early 2000s did students return to family medicine residencies. Now residencies are all full, for now.

Patient Needs Before Doctors’ Guilt

Physicians must not focus on their own squeamishness about money. They need to focus only on patient needs.

Doctors must put their sympathies with patients ahead of government budgets.  We need to focus on how to convince the government to fund solutions for patient care.

Physicians, please don’t let the media suck you in to thinking this is about your income. It’s not. It never was. It has always been, and must continue to be, about patient care.

photo credit: businessnewsdaily.com

Ontario has a $300 billion debt (Ontario Debt Clock). Let’s ignore how we got there.

Everyone calls for system change. Everyone.  Even Medicare zealots want change.

Wynne got a majority government. Let’s ignore how she got it (bought it?).

Wouldn’t this be a great opportunity for real change? Might this be a great time to solve problems with access, quality and service for patients?

Instead, Wynne and Hoskins use their majority government to attack doctors, again. Because they can.

Change Requires Different, Not More

We could buy a better system by changing the way we spend taxes. Dozens of people have written about it. High needs patients, system integration and acuity modifiers for older, sicker patients offer a few critical places to start.

Fee increases vs. Population increases

Doctors do NOT ask for higher fees.  Doctor do NOT want more money for doing the same work. They offered 0% fee increases for two years. 0%! They just don’t want more cuts. They already agreed to cuts in 2012 and 2013.

Doctors want the government to pay for growth.

NOT growth in doctors’ fees. Growth in patient volumes. New babies need care. Immigrants and an aging population increase the volume of services required in Ontario.  New doctors provide that care. Or current doctors work harder. Hoskins refuses to pay for it. He calls it a raise to pay doctors’ fees for seeing more patients.

When is a cut not a raise?

What would you call the following?

• You ask your staff to work more for less pay. Is that a cut?
• You pay hospitals the same to see more patients. Is that a cut?
• What if you pay your staff 10% more to do 20% more work? Is that a cut?
• What if you cut the budget, underfund growth and slash-or-cancel programs for new graduates, unattached patients, continuing education, hospital on-call and more? Is that a cut?

Democracy and Law

What kind of government creates a state monopoly, then makes it illegal for 35,000 professionals to work outside the monopoly, then slashes the fees it pays for services provided?

Is this democracy? Is it something else?

Wynne Attacks Doctors and Punishes Patients

Politicians attack who they can and coddle who they must. All that matters is immediate public sentiment. Do voters believe doctors have enough?

• Who cares if doctors hire staff and pay overhead?
• Who cares about student debt?
• Who cares about 12 years of university?
• Who cares if it takes decades to catch up to friends who chose a different career.
  • You chose that career!
• Who cares about job stress — everyone is stressed.
• Doctors earn $250 thousand dollars after overhead!

Jealousy: wanting what other people have while being ignorant of the sacrifice required to get it.

Fees drive physician behaviour. Voters don’t see that. Even the most altruistic doctor spends less time with you as a patient if she can only bill OHIP $33 for the visit.  What happens if you need 45 minutes? You get less service or cannot find a physician at all.

What Next?

Doctors will keep seeing patients. They will grumble, but life will go on.

Eventually one of the last two state healthcare monopolies — North Korea and Canada — will wake up and admit that government monopolies hurt patients. They harm patients because they run out of money and get sloppy with management. Every other country in the world has admitted it.  Even Sweden believes state monopolies harm patients.  Communist Cuba used to stand with us. Now it’s just us and North Korea.

Dark Times Call for Great Leaders

We look to great leaders for direction in tough times. Maybe Wynne and Hoskins might quote a hero:

“There is no such thing as an absolutely hopeless situation.”

Vladimir Lenin in reference to capitalism

photo credit: cp24.com

The need to help animates healthcare. We see a need and work to meet it.

Disparities in health outcomes resonate deeply with us.

The cholera outbreak in London offered clear disparity and a tangible solution. Poor infant and child health in (some) Northern communities offers disparity with no obvious answer.

A solution requires a clearly defined problem. Does anyone know what health equity, inequity or disparity means exactly? Is it something that we know but cannot easily define, like the Caucus-race from Alice in Wonderland?

First [the Dodo] marked out a race-course, in a sort of circle, (`the exact shape doesn’t matter,’ it said,) and then all the party were placed along the course, here and there. There was no `One, two, three, and away,’ but they began running when they liked, and left off when they liked, so that it was not easy to know when the race was over.

However, when they had been running half an hour or so…the Dodo suddenly called out `The race is over!’ and they all crowded round it, panting, and asking, `But who has won?’

This question the Dodo could not answer without a great deal of thought, and it sat for a long time with one finger pressed upon its forehead (the position in which you usually see Shakespeare, in the pictures of him), while the rest waited in silence. At last the Dodo said, `Everybody has won, and all must have prizes.’

Health Equity Defined

Health equity has become the cardinal virtue in many policy discussions. We hear impassioned calls to address it. No action is too outrageous so long as it furthers our goal of health equity and equality overall.

What is health equity?

• Equality – everyone gets the same pair of shoes.
• Equity – everyone gets a pair of shoes that fits.

An academic definition (BMJ):

“Equity means social justice or fairness; it is an ethical concept, grounded in principles of distributive justice…

Equity in health means equal opportunity to be healthy, for all population groups. Equity in health thus implies that resources are distributed and processes are designed in ways most likely to move toward equalising the health outcomes of disadvantaged social groups with the outcomes of their more advantaged counterparts. This refers to the distribution and design not only of health care resources and programmes, but of all resources, policies, and programmes that play an important part in shaping health, many of which are outside the immediate control of the health sector.”

One site says

“Once everyone enjoys a similar level of health and well-being, we can focus on preserving fairness by giving everyone the same things: this is equality. As the Pan-American Health Organization puts it, equity is the means, equality is the outcome.”

If you have time, check out Maxwell Smith’s (Toronto) lecture: What do we Mean by Health Equity in Public Health?: Assumptions and Theoretical Commitments

Dozens of issues including: genetic predisposition, epidemiological hazards, environmental hazards, geographical factors, work conditions, political or social marginalization or oppression, other social/societal determinants?

“Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential, if it can be avoided.” Whitehead, 1992, pg. 7

Maxwell tackles strict egalitarianism (equal income, equal healthcare resources, liberty and health) vs. prioritarianism vs. sufficientarianism. He mentions equality of opportunity, resources, well-being, self esteem, knowledge, self determination…

A sense emerges that health inequity is a disparity in health thought to be due to differences in social advantage.  Adherents seem to believe health inequity causes poor health if you belong to an identifiable, disadvantaged group. But bad lifestyle choices cause un-healthiness if you belong to a socially advantaged group.

Health Equity Highlights

• Outcomes include: life expectancy, social opportunity, well-being, and more…
• Equity is a normative (moral) virtue rooted in distributive justice.

Advocates of health equity

• Presuppose the efficacy of social planning to correct health inequity.
• Believe the state has the right, and moral obligation, to advance health equity.
• Think that health disparity, being a cardinal virtue, justifies unpopular decisions by government to address health disparity despite lack of a clear definition or solution.
• Hold a vision of everyone enjoying a similar level of health and well-being.

Medicine, Public Health & Health Equity

Although similar, public health sits apart from the sine a qua non of medicine, the doctor patient relationship.

Medicine is one individual responding to another’s need. Public health is something more and different. Well-intentioned, compassionate people work in both fields. But the motivating ideology is radically different.

I never read public health calling to help individuals in need. Public health preaches distributive justice, not individual charity; population health, not individual compassion.

Politics vs Clinical Care?

We need to champion clinical compassion for its own sake and not let it be used as a lever to promote utopian ideals.

Historical experiments in extreme equality grew from political platforms, political agendas. The righteous indignation voiced against health disparity today often seems less motivated towards meeting individuals’ needs as opposed to promoting old political ideals.

We need a clear definition of what we hope to achieve by promoting health equity. Vague sermons about distributive justice mean nothing without concrete ends. If we cannot define what we hope to achieve, maybe pontificating about equality is nothing more than political ideology dressed up as ‘health’?

 photo credit: hotmeme.net