Category: System

Trust fund babies enjoy income for life, and almost no worries about appearance, job performance or promotion. If they avoid felony, regular cheques never stop.

A job in healthcare offers something similar: an unending supply of sick people, solid incomes and some respect. If you get even a few years’ seniority, a healthcare job lasts your whole working life, regardless of performance.

How to get fired in healthcare

Let’s look at bureaucrats, hospital administrators, unionized employees and doctors.

Bureaucrats

985 federal public servants were fired between 2000-2005. There were 210,000 public servants, 260,00 if we include separate agencies (What Is Government Good At?, p. 196-7).

That means 0.07% of federal public servants got fired for misconduct, or released for incompetence and incapacity, per year.

Maybe the fired employees did something really bad. Or perhaps the other 99.93% were really high performers. Or most likely, bureaucrats do not get fired.

Observation suggests bureaucrats in healthcare do not get fired either.

Granted, layoffs can come unexpectedly. In 2012, 19,200 federal employees were cut (7.3%). But overall, even former Prime Minister Stephen Harper increased the number of public servants by 30,000 during office. Still a pretty secure profession.

Challenge: Name 3 healthcare bureaucrats who lost their jobs for underperformance or a failed program.

Administrators

Hospital administrators usually get promoted from nursing or other allied health professions. They work hard and earn better incomes in management. By avoiding obvious errors, they get decades of solid earnings with job security.

Hospitals started to put 10–15% of administrators’ pay at risk against performance targets. This guarantees targets are modest at best. Why risk job security for 15%?

Only physician administrators can afford to take on real risks. When doctors assume part-time leadership roles, they can push for serious change, secure with their clinical jobs to fall back on.

Challenge: Name 3 hospital administrators fired for low performance.

Bonus: Name 3 that were promoted despite sub-stellar output.

Unionized Employees

Hospital leaders spend at least half their time, if not more, dealing with union leaders’ opinions about process, union member grievances and collective bargaining issues.

Unless they try hard, union members do not get fired.

True, workers risk being laid off during the first few years on the job. Collective bargaining often forces hospitals to hand out raises by firing junior staff. But after a few years of seniority, unionized employees are set for life.

Challenge: Name 3 unionized employees who lost their jobs for performance issues such as low productivity or bad attitude.

Doctors

Parents tell their children to study hard, get into medical school and they’ll never have to worry again. There will always be sick people, and doctors will never be out of work.

Actually, doctors can lose their jobs.

Doctors take on personal debt, so they can work in the public system. Beyond several hundred thousand dollars of school debt, most doctors finance new practices. If they expand a clinic, they get a second mortgage or dip into RRSPs.

Doctors must work hard to cover overhead, or they go out of business. Outside of academics and salaried positions, doctors shoulder the same pressure to produce as every other small business. If they survive, their gross billings become part of average billings the media loves so much, a case of survivor bias.

To be fair, many docs work in niche markets and survive while being rude to patients. This is wrong. In an open system without rationing and turf protection, all doctors would have to serve, or go out of business.

Some doctors commit a felony and lose their licence. But only a few leave this way. Far more close their clinics or change jobs due to business pressure.

Challenge: Name 3 doctors who had to close their clinic, change jobs or quit. (If you need help, check out this infographic.)

Reward for Success vs. Pain of Failure

Everyone champions accountability for doctors these days. But no one tries to make bureaucrats, administrators or unionized employees accountable. Never mind patients.

Hernan Cortes burned his ships in 1519. His sailors knew they had to conquer the Aztec empire or die trying. People never move forward if they see no reward for doing so; less risk in staying put.

As long as…

• bureaucrats never lose their jobs for underperformance and do not get bonuses for success,
• unionized employees get paid no matter how slowly they move and get raises regardless of performance,
• and administrators get promoted just for avoiding mistakes,

…medicare will continue to lag.

Either we put everyone’s job at risk based on performance, or we put all doctors on salary like everyone else. As small medical businesses die off, maybe doctors should work towards the job-security-regardless-of-performance that everyone else in healthcare enjoys?

Physician autonomy is fading into history. Doctors might want to consider trading up for the security everyone else enjoys.

 

Steven Paikin, from TVO’s The Agenda, wrote a great blog. Every stakeholder seems to have a powerful organization, except patients. Who speaks for patients?

This is more important than any content I have right now. Here’s Mr. Paikin’s post in full (or click the link to his site).

When will Ontario’s Health care system finally focus on the patient?

by Steve Paikin

The people of Ontario spend $50 billion a year on the province’s healthcare system, and that’s only through their taxes. For many, of course, there are user fees, co-payments, drug costs and private insurance premiums on top of that.

You’d think all that money going to doctors, nurses, hospital workers and administrators would ensure we get the best care, and that the patient experience would be at the centre of that focus.

Think again.

There’s a growing realization that in spite of the huge dollars spent on treating sickness in Ontario, the patient actually isn’t at the centre of everything. And that’s becoming increasingly unacceptable given how much we’re spending and how unsatisfactory too many patient outcomes are.

Recently, The Walrus magazine convened its annual Health Leadership Dinner, at which several dozen of the leading figures in Ontario health care attend to debate the biggest issues of the day. The dinner operates under a form of the Chatham House Rule, meaning what’s said can be repeated, but not attributed to the speaker. I’ve moderated that discussion for several consecutive years now, and I can tell you, those rules do encourage a very free-wheeling, honest discussion. Over the years, several ministers of health, deputy ministers of health, assistant deputy ministers of health, along with numerous stakeholders in the system have been in attendance.

(Full disclosure: my wife founded and chairs the dinner; she’s a volunteer director on the foundation board of The Walrus).

The portrait of Ontario’s health care system that emerges is unsettling. “The fatal flaw in the system is a lack of integration of care and services,” one observer noted.

That observer’s check list looks like this:

• Too many vital services are not covered by the Ontario Health Insurance Plan.
• The system operates in silos.
• It’s not remotely ready for the demographic changes that are coming.
• Stakeholders operate as if the system is theirs, rather than the patient’s — for example, patients still need to pay to get photocopies of their own health records.
• The system is still burdened by 1960s architecture that often makes putting in new state-of-the-art equipment difficult.
• Patients need a “Sherpa” to navigate their way through the system.

“The Ontario health care system isn’t in crisis,” this observer said. “It’s in stasis.”

Furthermore, patient input into making improvements is treated as secondary and frequently met with suspicion, according to another critic.

“When we meet with the ministry, we’re forced to sign confidentiality agreements,” this critic says. “The public doesn’t know what goes on because all the meetings happen behind closed doors. There’s a lack of respect. Pundits and experts are there, but people who represent actual patients are evicted. The government tries to intimidate us.”

Not only that, everyone who works in the health care system has a special interest group representing them:

• Doctors have the Ontario Medical Association.
• Nurses have the Ontario Nurses’ Association and the Registered Nurses’ Association of Ontario.
• The Ontario Hospital Association represents the hospitals.
• The Canadian Union of Public Employees and other unions represent other workers in the system.
• Administrators get a seat at the table through Local Health Integration Networks and hospital CEOs.
• The Ontario Long Term Care Association represents those who run facilities for those who can no longer live in their own homes.
• Home Care Ontario represents those organizations that provide home care.
• The Ministry of Health and Long-Term Care has ample numbers of bureaucrats setting policy.
• And, of course, the government steers the ship via the minister of health and an associate minister of health, not to mention the premier’s office and the president of the Treasury Board, who must approve all spending.

Who, on this long list, is supposed to represent the patient? Theoretically, of course, they all do. But too often, some critics say, the patient’s interests take a back seat to those of the stakeholders: The “players” in the health care system want things from government; government, in turn, tries to placate those stakeholders to the extent it can. As the $50-billion pie is divided among the players, who represents the end user so his or her say can be taken into account?

Are things changing? Hard to say. Representatives from the Ministry of Health told the dinner that patients are invited to discussion tables to participate in policy-making sessions. (Critics say their presence is mere tokenism).  However, the Ontario Government will also hire a “patients’ ombudsman” sometime in the spring — a new watchdog whose sole responsibility will be pursuing patients’ complaints with the healthcare system.

While most people I’ve talked to are encouraged by that development, they also note that’s a “downstream” solution. In other words, the harm has already happened once a complaint is laid. How can the province change the way it does things to ensure problems don’t happen in the first place — in other words, find an “upstream” solution?

One idea that emerged at the Walrus dinner: perhaps the government needs to create an assistant deputy minister for the patient and caregiver experience — someone whose job it would be to filter every new policy change through the eyes of the patient. Under the Liberals, there are 16 assistant deputy ministers in charge of several different sectors such as health system information, drug policy, communications, corporate services, human resources, negotiations, strategic planning, long-term-care homes, accountability and performance, and quality and funding.  But there is no one that high up on the ministry organizational chart whose sole mission is the patient experience.

One former university president in attendance at the dinner said it wasn’t until he created a “provost in charge of the student experience” that the yardsticks really got moved at his institution.

Is it time to create an assistant deputy minister for the “patient experience?” And if it isn’t, how will the patient’s voice genuinely be heard in an increasingly complex and expensive system?

Broken bones mend inside rigid casts.  But immobilization causes muscles to shrink and deform, sometimes permanently.

Rigidity and over-protection harms everything: children, plants, muscles and even doctors. Grinding through patients in an artificial monopoly, with never any thought to competition, erodes patient service.

Doctors Must Compete

Nurses give Botox. Naturopaths do blood work. Chiropractors manage musculoskeletal problems.

Pharmacists are becoming clinicians, too. They offer cardiovascular risk assessment, osteoporosis and melanoma screening, flu shots, smoking cessation, home visits and a menu of public health services.

The roster of ‘providers’ grows every year:

• chiropodists
• physiotherapists
• occupational therapists
• massage therapists
• social workers
• psychologists
• midwives
• nurse practitioners
• respiratory techs
• surgical assistants
• nurse endoscopists
• nurse anesthetists
• even paramedics treat minor issues.

Government expands the list of things everyone else can do but seeks to limit doctors’ scope of practice. Government supports other providers assuming medical care but limits doctors’ competitive advantage.

Dentists, lawyers and veterinarians hire assistants to leverage their expertise. Doctors can hire assistants but not to see more patients. Government only pays for patients seen by doctors. Every other professional can expand the services they offer – XRays, stat blood work, biopsies, U/S – except doctors.

Service Erodes

Doctors used to sit at the top of a very short list of providers. Patients needed doctors’ services. So government took over medicine and set fixed prices. But the monopoly undermines doctors’ ability to innovate. Aside from specialized medical care, many patients now find services from allied providers more attractive than what doctors offer.

Rigid pricing, regulation and legislation make it almost impossible for doctors to innovate around patients’ needs or interests. Non-procedural docs are losing market share but cannot change their business model to compete.

Competition improves service and efficiency. Patients get better service when their doctors have to compete to provide care, but regulation almost eliminates it.

Protectionism

In fairness, most doctors do not want to compete. It’s nice owning a piece of shoreline on the only beach in town. Until everyone gives up swimming.

Ironically, doctors need to fight against the monopoly that lets them float through their professional careers without ever worrying about competition, market share or margins.

Politicians cannot touch Medicare, so they undermine it, while doctors rearrange deck chairs.

If doctors truly care about medicine, truly believe that it’s the best for patients, they need to work to dismantle the monopoly. Allow other providers, colleges, regulatory bodies and payment schemes. Open it up. Let it breath.

Protectionist structures suck the vigour out of patient service. It atrophies wrapped inside over-regulation and legislation.

Disruptive Innovation

University-owned mainframe computer services once felt secure in their monopoly. They knew that no one could provide what they had to sell. They knew that puny personal computers could never compete on service or performance. (Article: What is Disruptive Innovation?)

That’s still true. Mainframes do offer space age computing. It’s just that people realized they could get along fine without mainframes.

If doctors do not fight back soon, patients will realize they can get along just fine without most doctors, too.

photo credit: newsfeed.time.com