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
powers that be like to keep it grey, so docs will be tempted to innovate at the edges of medicare, and keep this thing moving….but keep open the option of putting the screws to docs if they overstep, as arbitrarily determined by a random complaint
Well said, John. People on the outside would never understand, but you captured it perfectly.
Enough grey to continue blaming doctors for poor service.
Thanks again for reading and commenting!
Shawn
Great post. In typical industries, innovations can help improve quality and/or efficiency. But even where the regulatory framework allows for opportunities to innovate, there’s no incentive. Actually a disincentive, since financial investments in innovation cannot be balanced out through increased revenue.
I’m a technology guy and my wife is a psychiatrist, and the opportunities for improving care are so large you could fly a plane through them. But with doctor’s unable to invest in improvements, and patients viewing doctor-provided healthcare as “free” (and so no reason to fork out their own coin), innovations are stopped dead in their tracks.
The exceptions are the individual docs who chose to innovate for reasons of personal and professional satisfaction, despite the financial hit, or relying on some ephemeral pot of money attached to some bureaucrat’s pet project, neither of which is sustainable.
I’m generally much more on the pro-Medicare side than not, but this is definitely one of the downsides.
Brilliant comment, Mark!
I love, “…the opportunities for improving care are so large you could fly a plane through them.” Precisely. Unless docs take the hit to innovate, it does not happen…never mind that docs can’t capitalize on the innovation either.
Don’t get me wrong, Medicare could be GREAT. If government stuck to offering an insurance program, and got out of the business of trying to run an industry, patients might stand a chance. Ultimately, patients drive innovation. Front-line professionals respond to patients’ needs with innovative solutions. We need to unleash physicians to creatively meet more needs.
Thanks for taking time to read and share such a great comment!
Best,
Shawn
Great post, Shawn. I think this is so important: “Allow other providers, colleges, regulatory bodies and payment schemes. ”
Exactly. If physicians who wish to provide a different level of service were given incentive to do so with different payment schemes, then more innovation would occur. You are also right that many physicians innovate simply for doing a proof-of-concept. But if there were further rewards to be had, more would be interested in putting the necessary energy into improving the system for patients who could have some control over where their health care dollars were being spent.
Great point, Paul. Aligning incentives would really power innovation!
Many people innovate for almost no reward. They just need the freedom to explore outside the ruling paradigm.
Thanks for sharing your comment!
Best
Shawn
Competition requires a degree of de-regulation. Where do we start? I recommend we start by de-listing procedures that are not medically necessary. I would with bunions / hallux valgus.
Good point, Chris. Delisting some procedures seems like a prudent way to introduce competition immediately. No matter what we suggested, I’m sure some would howl.
Thanks for reading and leaving a comment!
Cheers
S
Regarding your last comment “patients will realize they can get along just fine without most doctors, too.”, nothing would make me happier. As a family physicians I encourage other providers to get involved and take away some or much of my work burden. I would love to unload all those Manulife APS forms for someone else to complete. I’d love all those non essential office visits to be handled by someone else. I want patients to feel they don’t need me. Release that tether so that perhaps I can have more quality time for myself and my family. I don’t need or want a monopoly. Let patients go wherever they feel they will get the care they need. It doesn’t have to be with me (plus I don’t have to take responsibility when their health goes south).
Many would agree with you on this one, Ira! I wonder if the government hasn’t taken you up on the offer without giving you the freedom to innovate and focus on what you do best? They’d rather slow you down with tick boxes and forms than unleash you to help more people.
Thanks for sharing! Excellent.
Best,
S
not sure I agree with you Shawn or Ira. As one very smart man said “with great powers comes great responsibility”. As family physicians, we cannot complain about our job security, sure payment by the gvt, and flexibility. Look at our neighbours down South. The doctors there are not enjoying what we are enjoying. So I would not complain. If you no longer want your patients to want you, then there is no reason why the gvt should continue paying you. With great powers do come great respondibility (at times in the form of APS forms!)
Thanks for sharing an opposing idea, Vu! Readers love to find some debate in the comments section.
I agree with your observation that the American approach is bad. Having said that, “At least we aren’t as bad as the US system” is not a valid reason to resist change in Canada. As you probably know, we scored 10th out of 11 systems in the latest Commonwealth study, one place ahead of the States.
Calling for change – for innovation and the freedom to innovate – cannot be dismissed as complaining.
You make another valid point. Docs have had things very good in many ways. Universal everything has been a great way to practice. But it has ended. The demand for every ‘free’ service will increase until the service is no longer available. We have passed that point. Waiting 2 years for spine surgery cannot stand as ‘access’ in any reasonable sense.
Finally, I agree that ‘with great power comes great responsibility’, but I do not see how that relates to the post. Please feel free to expand!
Thanks again for taking time to read and share your comments! It’s always tough to share opposing ideas, so I appreciate this even more.
Best regards,
Shawn
What I meant by “with great powers…” Is the fact that as phtsicians, we hold a privileged role in society and should not complain because of a few drawbacks.
I also agree with you that the fact we are better than our neighbours down South is no reason to be complacent, but we should also keep things in perspective and realize how privileged we are as physicians (even in Ontario).
That being said, I agree with your comments about needing to change how we think about healthace in Ontario and Canada. Competition breeds innovation!
Well said, Vu. Whining and complaining get us nowhere. We need to figure out how to champion change without acting spoiled.
Thanks again!
Shawn
The profession is circling the drain due to government legislation, never-ending government micromanagement and over-regulation. As a result, the practice of medicine has become so cumbersome that neither patients nor physicians derive much benefit or joy from it. The result of this is more legislation, more government tinkering and tighter regulation.
In the meantime, the keys to the candy stores have been given to everyone else while the shopkeepers have their hands tied behind their back.
This has always been about control of physicians while making them scapegoats for why the system does not and cannot work.
I agree…open it up. How much worse could it possibly get for physicians?
As always, you make great points, Paul.
Tinkering, legislating and trying out new policies makes it harder and harder to provide care. As government usurps control, doctors get blamed. We need to push back.
Thanks again for writing!
Shawn
Sorry, but I have also posted this on Facebook.
Shawn, thank you for another excellent, insightful piece.
You are so correct:
“If doctors truly care about medicine, truly believe that it’s the best for patients, they need to work to dismantle the monopoly.”
The monopolistic, highly regulated, “free healthcare” system we have right now is truly what will be our undoing. It hampers physicians and more importantly it will ultimately destroy the health system for all Ontarians and Canadians.
The fallacy that health care is free, that health care is unlimited, that the system should be use indiscriminately for our own convenience must end.
Doctors should compete. We should welcome competition and deregulation. The problem right now of course is that it is currently an uneven playing field. While one might argue we have an advantage, increasingly we have an extreme disadvantage. Other providers are now free to charge privately, whatever fee the market will bear for their services.
We are our own worst enemies. Our current plight is perpetuated and maintained by those of our own profession who do not want to face the new reality, who insist on maintaining a failing system at all costs. They are blind to the abuses of the system and resist ANY suggestion to try to address these abuses. The unlimited, universal ability to abuse the system is indeed the system’s greatest vulnerability.
They would rather blame the physicians who are providing the care instead. It is ironic that the physicians providing the most care, working the hardest (billing the most services), then end up being vilified for providing care, working hard and being available.
These physicians did not create system. They did not make the rules. They are only trying to do their best by paying within the rules that have been set by the MOH.
Many of these physicians are the same ones who have invested heavily in their livelihood, in their practice and in their patients and yes, in their businesses, with their own money. Often they have refinanced their own homes, taken out personal loans, sacrificed their savings and their retirement.
The government then changes yet again the rules of engagement for these physicians. As has been pointed out by many including Justice Winkler, the system will not survive without change.
The only change that will make a difference is if we remove the monopoly. Only then can physicians truly innovate and compete in a level playing field.
Wow, what an excellent essay, Ken! I sure hope people read through and digest this.
I really appreciate your thoughts on the risks doctors take to build a business and how doctors play by the rules of the system. We did not invent it. You note reads like something that you’ve thought about for some time, years maybe.
Excellent. I hope you post it widely. It might stand alone as a submission to Med. Post or Huffington.
Thanks so much for taking time to put this here. I smiled when I saw it…I was just about to respond on FB and suggest you do this!
Best regards,
Shawn
Shawn, not sure I’d characterize these as ‘risks’ so much as costs or investments, given there isn’t uncertainty about market. Barring poor math skills or inadequate insurance, income and overhead should be relatively predictable, i.e. low risk.
What decidedly is a risk is that the rules of the game sometimes change in unanticipated ways, which is what’s happening now.
Mark, I agree with you.
For the most part, physicians who invest in infrastructure and equipment are not taking much of a risk but we are often making significant investments in the system and in our businesses based on what we believe are a known set of rules.
When the government decides unilaterally to change the rules of the market, that is when those investments suddenly become risks.
Almost every business takes risks when they make an investment. However, most businesses are not working in a monopolized market and beholden to a single payer. They typically have a choice to take their goods elsewhere. For physicians, when this payer changes the rules, we are stuck up the creek with no paddle.
Ken, you beat me to the response I wanted to make! 🙂
I agree, Mark. Unlimited risk comes when we try to start a business in an industry where authorities can change the rules overnight. It’s like starting a business in a politically unstable country.
Medicare sits on a massive cash opportunity: doctors’ leveraging their own income to invest in healthcare infrastructure. Banks would happily pour out debt to innovative, entrepreneurial doctors, if government allowed/encouraged doctors to start creative businesses designed to serve patients better.
Great conversation!
Shawn
Interesting ideas about risk in a public monopoly industry. The particular problem now is that we are in the midst of a global cap on the physician services budget. What is the point of innovating if there is no chance of an increased return? Other public monopolies such as electricity supply also work under the same kind of constraints physicians are under. The government sets the power prices that companies can charge, albeit with some adjustments periodically. At least the power companies are not limited in the amount of electricity they supply. And they can expand into unregulated markets such as equipment maintenance, home services, etc., using the contacts with consumers that they enjoy.
We really are in a unique situation right now. I think it will lead those innovative physicians to either curtail their work or look for work elsewhere where their efforts can be rewarded. Yes, there will be general loss of physician human resources over the next 5 years or so, but I fear we will lose access to the great minds of those who don’t leave, who may turn their imagination to other endeavours.
I agree, Paul. People will leave. Already, I see bright, innovative, promising leaders leaving for positions that offer opportunity for real change. We see the same with new grad and those close to retirement. I suspect we will see the same with the middle cohort of docs over the next few years.
Great observation about power utilities matching supply with demand. While I agree with your analogy of over-regulation, I wonder if government changes the rules as quickly, or as arbitrarily, as they do with medical services.
Thanks for taking time to join in!
Best,
Shawn
Just EXCELLENT Shawn!
Totally agree with you.
Please tell me what role is College Of Family physicians
playing in all this?Like to know what you think.
Can’t they see that the basic fabric of family medicine is being
distroyed?Are we training family docs?
I donot think so.
The whole process of patient centred medicine is a JOKE.
It is fregmenting the care not unifying it.
Thank you again for an EXCELLENT article.
Thanks for this, Shelly!
I cannot speak for the OCFP, but I suspect they want to lead more than they do now. Their impression of family medicine does not include running a small business.
I do not quite understand what you mean by “patient centred medicine is a joke.” I agree that it often means nothing when we apply it in physician, or system-centred ways. I also agree that assuming teams are always the most patient-centred approach is wrong. But I do think patients need to be at the center of the system, no?
Thanks again for taking time to read and comment!
Best
Shawn
By virtue of how our system is structured, particularly with the prominence of teaching hospitals, too many people viewed as ‘leaders’ tend to be in academic centres, who have a narrow view of medical practice. I always got a (sad) laugh when transition to practice sessions for residents were held that never included people in private practice. Leaves a skewed perspective.
Exactly! I rarely see the government asking regular working doctors in non-academic settings to help on program development.