Great tales start with, Once upon a time…
Academics tell the story of Medicare like this:
Once upon a time, in the dark days before universal healthcare, patients lay at home suffering in pain. Wealthy patients went to shining hospitals with all the modern specialists they needed.
Everyone else traded potatoes and chickens for medicine offered by the rare doctor who would stoop to see them.
Patients died in pain. Or they sold their farms to pay for treatment, declared bankruptcy, and then died in pain from curable diseases.
In these dark days of pre-civilized Canada, one person started to campaign for the poor and oppressed. From the wilderness of Saskatchewan, someone finally stood up for patients.
When no one else cared, Tommy Douglas, champion of the poor and oppressed, dared to challenge the medical establishment. Mr. Douglas single-handedly attacked organized medicine.
He shamed doctors’ selfishness.
He demanded Canadians do what was right: provide free care for all, without consideration for patients’ ability to pay.
Mr. Douglas demanded that doctors put aside their greed for the sake of their patients. He forced doctors to put patients before income.
Doctors fought back. They went to war with Tommy Douglas and refused to see patients.
After a 23-day strike, doctors surrendered. They lost the war and submitted to Douglas’ plan of care for all, not just the rich and well connected.
Tommy Douglas gave Canadians Medicare.
Finally, no one would ever lose their farm to pay for medical bills. Now, people could take out business loans and invest in the economy. Mr. Douglas civilized medical care in Canada.
It was the dawn of a new age.
Doctors Vilified (Again)
But just when people started to celebrate, the doctors took a dying stab at Douglas’ dream. Doctors said they would agree to Medicare only if they could work ‘fee for service’ (FFS).
FFS was the condition of their truce.
Mr. Douglas desperately wanted to help the poor. So he compromised at the last minute. He gave doctors what they wanted: to be paid for each service they provided.
Poor Tommy did not know what he allowed. He let the fee-for-service virus infect Medicare.
Evil Fee for Service
Fee for service (FFS) paid doctors for services they performed. FFS drove doctors to invent procedures and to dream up new services to provide patients, whether patients needed them or not.
FFS drove up the cost of care.
It created run-away spending.
Doctors, ravenous for more and more income, worked and worked and worked. They toiled around the clock just to make more money, to bill more services.
Patients have suffered ever since.
Finally, the government said, Enough! FFS must go. We will put doctors on capitation.
And the golden age of primary care reform began. Now doctors work in teams, where patients get only as much care as they need.
And everyone lived happily ever after.
Reality
Theatrics aside, most people see doctors and government as reluctant partners for the last 40 years in Canada.
Every schoolboy knows that doctors have caused the situation we now find ourselves in: provinces unable to pay for care, and patients dying on wait lists.
In reality, before Tommy Douglas rescued Canada from doctors, there were insurance companies that covered the costs of acute care. Patients who could not afford to pay the premiums had the premiums covered by the government (see Setting the Record Straight: A Doctor’s Memoir Of The 1962 Medicare Crisis
The few people who refused insurance, and still could not afford care, saw doctors for free. Doctors believed their professional duty demanded that they treat people who could not pay. Either way, patients had coverage, if they wanted it.
Governments could choose to cover the insurance premiums for the poor. The option existed. If government did not, it was not for lack of ability to do so.
Greed vs. Freedom
Doctors’ incomes were not at stake in the strike in 1962. Doctors actually enjoyed a huge boost in pay under Medicare.
Finally, all their bills were paid. They could stop charity work and spend more time on things that paid.
Purely selfish motives should have led doctors to support Medicare from the start.
But they did not.
Tommy Douglas campaigned on a government takeover of healthcare. Doctors resisted government takeover on the belief that government cannot care for patients. Many doctors had fled the UK after seeing what government does, when they take command and control a whole industry.
Politicians, who control healthcare, end up treating it as a bauble to win support. They throw handouts to win votes; care to win elections.
Governments meddle and ration.
Politicians fund popular procedures, like sex reassignment surgery, and leave patients who need less popular treatment, like cancer care, to die on wait lists.
Politics
Tommy Douglas wanted to nationalize an industry because it fit with his political convictions.
He believed government could do a better job than anything designed by the citizens themselves. He believed a group of highly trained, super-smart elites, who worked for government, could serve patients better than a patchwork of doctors in communities across Canada.
Douglas passionately believed in the state – the government – as the most trusted force for good in society. He saw bureaucrats and politicians disinterestedly working for the ‘public good’ as the best way to provide care.
He fundamentally disagreed with Adam Smith, in The Wealth of Nations
Wringing Our Hands Over Access
Today, we hear about desperate attempts for patients to see doctors on evenings and weekends.
Why won’t doctors see patients outside of office hours?
How selfish and insensitive!
No one in academia dares to tell the truth about this. Research grants and university tenure depend on government support for their institution.
The truth is this:
Government fixes the price for services as low as possible. It pays $33 for diagnosing pneumonia during the daytime, and a couple dollars more to see the same patient in the evening.
After paying a pittance for evening work, government castigates physicians for not providing access to patients in the evenings and on weekends.
Academics never mention this. They just wring their hands about how doctors do not seem to care about seeing patients after hours.
Doctors would LOVE to see their patients in the evenings! But billings must cover the cost of hiring staff willing to work after hours, or doctors work for free.
Government knows that if they pay an appropriate premium for doctors to work after-hours, and on weekends, like patients want, then doctors will provide ALL their services after-hours.
Doctors want to provide services that patients need, in a way that patients want them delivered.
But costs go up when doctors work to serve patients. Utilization, the amount of medical services delivered, increases.
So instead, government rations care by refusing to cover the cost of after-hours care and blames doctors for the lack of access.
Doctors Need to Speak Up
In a time of universal deceit, telling the truth is a revolutionary act.
G. Orwell
Doctors need to speak truth to power. They need to write, speak, publish, and do whatever they can to peacefully protest. Patients need to know.
Government has failed to deliver on its promise to provide care.
Canadians are under-insured.
Government took over a whole industry and then blames underperformance on doctors. Enough is enough.
When will people stop telling fairytales to feed political agendas?
Photo Credit: Encylopedia of Saskatchewan
This is so true. When I was in medical school in first year one of my classmates gave the opinion that we should get doctors off fee for service to prevent them from spending minimum time with each patient to maximize income. I asked what then we would do to prevent doctors on salary or capitation from limiting their office hours or being non-productive such that patients can’t get seen in a timely fashion (or at all). There really wasn’t an answer because it had not been considered. If you want good service you have to create a competitive environment for its provision. If you empower patients by making them the payer they will demand good service. They will value good service because when you pay for something yourself it has more value than when someone else pays. And if you create a situation where there is only one place to get care then the patient has no power because they have nowhere else to take their business. Like when you restrict patients to only getting care within their LHIN for instance. Consider the situation with dentists. They pretty much deal directly with patients or with their insurance companies. If they do a good job they get lots of business and do well. Most dental offices offer evening and weekend appts now and compete for business. On an hourly basis my dentist only charges a few multiples above what my plumber does and for all that skill and overhead isn’t that a good deal? For the limited number of patients who cannot pay for dental service the government could give them effective insurance. This model would work especially well in primary care because family doctor offices are not highly capital intensive like hospitals are.
I’m impressed that you thought to ask this question in medical school! It usually takes docs a few years of practice to start thinking about how payment influences behaviour.
I LOVE your call to empower patients! We should let patients control the flow of the tax dollars that get spent on their care. Your comments deserve a whole blog in response to do them justice!
Thanks so much for sharing!
Best
Shawn
Yes! Thank you for telling the truth about “access”. How are we, as family doctors, supposed to afford paying our staff to work overtime or after hours when we make an extra 3 bucks seeing a patient after hours? Also, patients will always take the path of least resistance to get an appointment (and I don’t blame them!). If they can get in to see their doctor at 6 pm for a hangnail, they will. I worked after hours last night and saw a hangnail, a stye, and a UTI whose symptoms had resolved on their own earlier in the day. Necessary? Nope. Are patients happy about the convenience? Yup. Was I adequately compensated for my time and for not being there to put my little kids to bed again? Nope. But I am the enemy for not available enough…ha.
Brilliant comments, Dr. M!
People need to hear about the decisions and experiences of docs at the front lines. Too many people have power to make decisions about healthcare that are separated from patients by 6, 10, or 20 degrees of separation.
I sure appreciate you taking time to share your thoughts!
Cheers
Shawn
More to the point, how is it sustainable healthcare to have a highly trained physician deal with hangnails, et al at any time of the day? A team based approach, at optimal scale, would be able to offer longer hours, absorb the burden of additional support staff, and extra costs of security, etc. A better integrated primary health care model of practice would have others working to full scope of their practice. This would not only offer a better economic model (for those “independent business people out there), be more patient centric, but also be more sustainable.
Great thoughts, Erwin.
If government was not so hung up on doctors seeing the whites of patients’ eyes before docs can bill, I could see individual docs hiring experience allied staff to triage concerns in the evening, much like a nurse does at a camp ‘clinic’. Most of the time, experienced nurses can tell when patients need to see a doctor right away. But government insists on hiring the allied team directly via the family health team.
Thanks for taking time to share a comment!
Best
Shawn
I have long been saying (at first tongue in cheek, but I’m starting to think it may be a good idea!) that a better use of nurse practitioners and physican assistants would be to have them triaging all requests to see primary care physicians. That way only “medically necessary” issues would be seen, and the less complex and urgent issues could be seen by the NP and PA.
Good thought!
I’m getting to enjoy our sparring over policy, Shawn.
Two points I’d like to make: We do not have nationalized health care in Canada. Douglas brought about the nationalization of the finance side of the equation, not the delivery. Outside of hospitals, most doctors’ offices in the community remain private enterprises. The fee deal is (usually) a negotiated one, not dictated, the present situation in Ontario excepted. Moreover, I’m not so sure it’s the politicians that are opposed to private outsourcing of traditionally hospital-based procedures (cataracts, colonoscopies, etc.) so much as the unions.
The second point, that I’ve argued on my own blog, is that health care does not obey the laws of classical economic theory. A half-century of experience has shown us that the demand for health care is essentially unlimited, and usage only increases as capacity is added to the system. A lot of this is unfairly blamed on doctors’ greed under FFS medicine, no question. It’s almost certainly more due to 1) good clinical care begetting more clinical care appropriately, 2) technological/scientific advances that generate more use (new diagnostic tests, screening), and 3) increased use following increased capacity – the “adding highway lanes” effect of CTs, MRIs, etc.
More importantly, those with the highest demand for health care service are least able to afford it, and there’s (necessarily) no ceiling on that demand. A poor man facing 5k in dental work is more likely to have all his teeth pulled and get false teeth for much less expense. He has no such option with his health.
Smith was also both a realist and no fool. He was a proponent of taxing wealth instead of work as a means of funding public goods, and also observed the tendency of the wealthy to “game” the political system towards their own ends.
Keep up the good work!
Thanks for such a thoughtful and thought provoking note, Frank!
I will respond to your first paragraph in a whole separate blog post. Defenders of the current system seem fond of reminding us that, “As you know, all doctors’ offices are privately owned. Most patients access care from doctors working as independent contractors in private clinics.” To steal a phrase you tweeted: This is Hogwash. But it takes at least a whole blog to explain why. I am REALLY happy you raised it here, though! A speaker said the same thing on Friday afternoon at the pre-council policy session on system sustainability. I scribbled myself a note and have been looking forward to attacking this myth as soon as possible.
You make great points about healthcare economics. I agree. I was so glad to see that you do not believe that doctors are just capitalist pigs trying to get rich on patient suffering! The docs I know have tremendous empathy for the patients they serve and will offer any possible treatment/test/therapy to help their patients.
I do not fully understand your reference to dental work. I completely agree that those least able to afford care often need our help the most (except for sub-populations, like some communities of horse and buggy Mennonites (low cash, but extremely healthy people)).
I agree, Smith had very harsh things to say about businessmen and greed. He thought an unrestrained marketplace allowed human greed to deliver an unintended benefit of improved service and quality at a lower price. I do not recall his thoughts on taxation. I would assume he’d favour taxing spending, instead of taxing income…but I’ll have to go back and check.
THANK YOU so much for taking time to push back. I LOVE it! Very few people know how to engage in respectful debate anymore. I can’t tell you how much I appreciate the opportunity to hone my thinking and adjust my opinions based on what you share. I am better for it.
Looking forward to next time I hear from you.
Be well,
Shawn
To clarify my example of dental work:
If you’re on a tight budget, there’s a point at which a large bill for something isn’t worth it. Most people wouldn’t pay 10k in car repairs after an accident, unless they either had a ton of money or it was a very expensive car. The car is just written off and life goes on.
No imagive someone on welfare facing 5k in dental-gum work. He can beg, borrow, and steal the money, but he likely wouldn’t do that. It’s a lot less expensive to have all of his teeth taken out and replaced with dentures. It’s not ideal, but it’s what he can afford without having to forego food or rent.
Where such a price “ceiling” doesn’t exist is with health care. There’s no limit to what someone would spend on their health (I’m talking critical stuff, not prevention or symptom management), because the alternative is death.
I hope that makes sense.
Thanks, Frank! That’s what I hoped you were saying, but I was not certain.
The government politicos want to ‘look good’ in the eyes of the public (and get re-elected) by pushing family doctors to provide after hours care (not necessarily urgent after hours care) so that commuters in dormitory communities, like the one I work in (Brampton), can defuse from the commute home, have a cup of coffee, and trot off down to the clinic with a list of complaints with per-approved Google answers.
I would deem the majority of these visits to be non urgent, likely not medically necessary encounters, and would deem them to be more -thus- ‘encounters of convenience.’
Medical necessity has never been defined but rather ‘any service provided by a physician or a hospital shall be deemed medically necessary’. So if I deem the after hours convenience services not to be medically necessary are they then billable to OHIP?
Probably not.
So, I am prepared to provide these convenience services after hours if the patients pay for the convenience.
And on the matter of increased expenses for keeping the offices open in the evening :
apart from the increased hourly salary for staff members etc. I can tell you that I worked in inner city practices in the UK and we had to hire a Security Guard to watch over our physicians from the dangers of drunks, the addicted and petty criminals seeking drugs. Many female physicians were in danger of being accosted late at night – but of course our well secured political masters wouldn`t even think of that!
Great to hear from you, John! I hope you are well. Your comments are just as pithy and sharp as ever! 😉
Medical necessity (aka appropriateness) promises to take centre stage in healthcare discussions over the next few years. We cannot afford to provide all the treatment options that exist. Wait lists and rationing only work for so long. Eventually, people will push government to de-list. It might be best to start the discussion before the pundits start chopping.
Great comments about security! The $3 or $4 dollars extra won’t cover the added staffing costs by wide margin.
Thanks for taking time to share a note! I hope you are well and enjoying life. You know, if you accepted cash for providing a medically necessary service – say, checking someone’s blood pressure – you could become a test case for the CHA. It could turn out to be a great retirement hobby for you to sit in court for a decade or so…. Seriously….consider it! 🙂
Warm regards,
Shawn
Few individuals know that Tommy Douglas, portrayed as a saint in many circles, was an advocate of eugenics in the 1930’s and wrote his Master’s thesis on this topic. He believed that those couples found to be of ” low intelligence, moral laxity, or venereal disease” should not be allowed to marry and should be sent to “camps” or “farms”. Those deemed to be mentally defective should be sterilized. We do not discuss these aspects of his ideology and they have been carefully airbrushed from history.
Thank you, Alicia!
I agree, few people know the real Tommy. He was a far left socialist, who placed great faith in central planning and government controlling people’s lives (like forced sterilization). But you dare not say this out loud. First, people won’t believe you. Second, they will write you off as a bit unhinged. “…Telling the truth is a revolutionary act.” [Orwell]
Thanks so much for taking time to read and share your thoughts!
Best
Shawn
“Eventually, people will push government to de-list. It might be best to start the discussion before the pundits start chopping.”
My suggestion is to let the duly elected representatives of the voters do the dirty work. Once the de-listings are in place there will be howls of anger at someone. I suggest not setting physicians up as the whipping boys that the powers that be will be looking for.
When the government de-listed routine eye exams by optometrists and ophthalmologists years ago, many patients screamed. My simple reply: “I didn’t do it.” Hat tip to Bart Simpson.
Well said, Gerry. I agree. Best to let government lead on this one, if possible.