If we could double the number of doctors in Canada, would papers print headlines about private, for-profit care? Would union leaders clutch their pearls and complain about the collapse of medicare?
Community physicians, although heavily regulated, still have the privilege of paying their own rent, heat, hydro, phone bills, and so on.
The Canadian Revenue Agency views most physicians as ‘independent contractors’ – that is, private businesses. (A few docs are salaried; many more wish they were.)
The End is Near
We have just come through a golden age (3 weeks) of peak public interest in medical politics and policy.
In mid-January, Premier Ford announced a 3-step plan to expand services outside hospitals. Patients will have increased access to publicly funded MRIs, CT scans, and minor procedures. By 2024, Ford hopes to see publicly funded hip and knee surgeries offered in non-hospital facilities.
The establishment had a fit.
I joined the enthusiasm (minus the fit) and have written furiously. Here are the results.
Ford Promises Private, For-Profit Care
The National Post published the first op ed. It feels newsy and light. It tries to put Ford’s announcement in context.
Note: headlines are designed to grab attention, not summarize content. Editors write better headlines than authors.
Ford’s Health Plan Will Be Good for Patients, if He Can Get It Past the Unions.
The Hub published the second article, which tackles the unspoken heart of health policy in Canada.
Do we have public administration of health insurance or do we have public management of medicine?
Do we have public health insurance or do we have a public health-maintenance organization?
Ford’s Health Reforms Are a Return to Medicare’s Original Purpose
Finally, the Financial Post published an op ed about disrupting hospital funding. Ford’s plan could succeed where decades of attempts at activity-based funding has failed.
Ford’s Health-Care Plan: Disruptive Innovation, not Privatization
I have another op ed out soon on that-which-must-not-be-named in Canadian healthcare: profit and privatization. Canadians find discussion about profit off-putting, if not immoral.
However, medicare is not a volunteer effort. Everyone profits. The piece should cause some controversy (I hope) – really excited about it.
Please discuss Ford’s announcement with anyone interested. It seems more profoundly misunderstood than I realized.
Thanks so much! Looking forward to your comments.
PS. The original title was “The End is Near”. I thought people would see the joke in it. Some did not. So I changed it to a question – less humour, more clarity.
Interesting. We will see if Ford and the conservatives have the internal fortitude to push past the noise and naysayers. Going to be some heavy mud slinging.
As for “not for profit” delivery of services I would say that any professional medical corporation (or any corporation for that matter) can be not for profit. I will use the crown jewel of the provincial Liberal government as an example. The Kensington Eye institute is at the old Doctors hospital in Toronto. It performs numerous ocular surgeries very efficiently and with excellent results. It’s been classified as not for profit. In reality there is a board that administers the institute and obviously are paid. How much? Who knows because they are not subject to the transparency of the public hospitals act. So at the end of the day if the institute has made more than it’s spent then they can simply bonus the board members the extra and viola! No profit in the corporation. No accountability of the books either.
Great comments, Brad. Thanks for bringing in Kensington.
Profit needs definition. If a corporation pays out all its funds at the end of the year using bonuses etc, why is it so much more morally pure than a corporation that pays shareholders?
This is a discussion for another piece I suppose.
Thanks again!
Hi Shawn,
As you know I’ve been active in the need for major reform over the years.
I support and applaud your advocacy in this matter.
Whenever I can,I’ve stated : we desperately need a European hybrid health system.
People are tired of me repeating it,but the public is giving serious thought to major reform for the first time in decades ….. hit the metal while it’s hot,my father said.
Ofcourse,necessity is the mother of invention,and docs have finally given up trying to keep our brutal system functioning at their expense ….. finally.
Decentralization(your mantra),more choice for docs and patients,and non public influx of monies will imo,bring about accountability,help break up the hosp bureaucratic cartels,and help reduce waits.Unless we make the working conditions for docs and nurses better,nothing will improve.
The leftists position? The beatings will continue until morale improves.
Let’s hope the reform movement maintains momentum.
Ram,
“The beatings will continue until morale improves.” Indeed.
I agree with what you’ve said so well. You (rightly) bring us to consider a fuller exploration of private enterprise. Ford’s plan is not that.
To get where you are pointing will take Canadians more time, I suspect. It will come. Socialism cannot survive forever. But it may not be for a decade or more yet.
Thanks for posting a comment!!
At this point Ford’s detractors (for different purposes) are trying to use their dream of a govt-run medicare system as an argument against his current attempt to increase desperately-needed OR time quickly. As Shawn has done, Ram, be very careful in your discussions with detractors of this positive move by the govt to not let make it an ideological discussion but a pragmatic discussion on wait times.
Good point, Gerry.
If we let this become a discussion about something other than an expansion of public services, we may lose that small gain.
Thanks!
Agree with the practical reality of your advice Gerry.
After waiting 30 yrs to get to even this point,one gets impatient.
Its my surgical personality,I guess.
Once people see the practical improvements,hopefully they’ll ask for more,namely an influx of private monies to expand private services,as virtually EVERY other country in the world has done.
Canadians deserve better …. the only question is …. are they willing to do what it takes ?
Lets not forget that those who know someone,or have the money for medical tourism will not be the ones suffering.
Did you that a law was passed in Ontario a long long time ago that made it illegal to help someone jump the queue? That means that using “knowing someone” is illegal. The fine I believe is $50,000.
C’mon Gerry …
Happens all the time,and no one is the wiser.
It can always be rationalized if questioned.
That’s not a deterrant.
Great comments from both of you
Yes, the so-called “Protecting the Future of Medicare Act” 2004 bans opting out for physicians and sets a fine on queue jumping. I don’t know if anyone has been fined yet — would be surprised if there were any.
And I agree, privileged access for the well connected is a core feature of our current system.
If everyone had 1/2 the interest you guys have, we would be making great progress.
Thanks again for sharing your thoughts!!
Hi Shawn. I share your sentiments. Thanks for the advocacy. Back in the early 1980’s (that’s [almost] half a century ago) I was engaged with a senior federal bureaucrat about the CHA and its inevitable yet unintended consequences. His response was that this was already known but the politicians would only act when – and if – the citizenry of Canada screamed for change, and not until. To quote my children when they were youngsters in the back of the car … “are we there yet?” I’m sceptical that we are.
Hello Ralph,
Thanks so much for this. I would have loved to have been party to those conversations in the early days.
I wasn’t sure if you meant the early 1980s, since the CHA passed in 1984?
Thanks again for posting!
Indeed I did mean the 80’s. Thanks for catching that. I could lay blame on my aging memory but will accept it was just sloppy. On another note… do you have any idea of a release date for your third book?
Ok, super. I’ll make that tiny edit …
Hey, thanks for asking about my next book! I have ~60,000 words, but it isn’t well focussed. Instead of trying to get it perfect, I may just put something out there knowing there is much more to be said.
Thanks again!
Lat year I retired with all my ducks in a line…or so I thought.
I had chosen a much younger FP, very sharp , working in a FHT , with the thought that I would kick the bucket before he retired…suddenly there seems to be an epidemic of premature retirements in that age group that possess the combination of knowledge and experience..he and his colleague are trying to sell their practice to?
I see myself being attended to by NPs in the near future
There sees tonhave been governmental pronouncements and changes over the last 12 months that are motivating good FPs to ok to the exits and perhaps leave the field altogether.
For my part I was a life member of the CCFP….we had a big ceremony in Quebec City a few years ago …with retirement I still attended CME’s virtual and otherwise and collected the hours to keep up to date…I became interested in medicine at the age of 8 and hoped to keep in touch after retirement….recently I received word that Life Membership was being terminated and that I could no longer clock the hours.
It’s as if there is an attempt to drive a wedge between the older and experienced generation and the newer generation that used to socialise together for generations …perhaps there are those who still remember the era of medical societies where we all , FPs and specialists rubbed shoulders and got to know one and other…an attempt perhaps to rewrite history without contradiction so to better indoctrinate and wokify the young?
Sorry for the rant.
Don’t apologize, Andris. Love the rant.
Industry requires trust. Trust flows from relationship. Relationships cannot emerge without conversation.
The old (totally moribund?) need for physicians to know each other on a professional level in order to practice medicine has withered. You can earn an income without talking to any other physician outside the few in your local call group.
State solutions such as central-referral processes promise to smooth referrals. Physicians send and receive referrals and consult notes from other physicians they have never met. Central referral entrenches the atomization which caused the referral problems in the first place.
Why bother getting to know local docs when you could spend your time gainfully elsewhere?
As for FPs running for the door, THAT requires its own post. I’m a bit sensitive on the topic having transferred my own practice to a new grad last fall. I was fortunate. We found a great fit: physician, patients, and staff seem pleased.
I entered medicine thinking it would be a vocation, career, and passion which could carry me until my mind or body failed. Bureaucratization and managerialism throttled that dream. Oh well. I did not spend 11 years in university, plus multiple years of extra courses and training beyond that, to fill out checkboxes and create attractive, lawyer-proof, regulator-proof, ministry-proof charts. Patient care has become charting — great if you love charting; terrible if you prefer patients.
Thanks again for sharing. You’ve inspired a rant in response — it’s all your fault! 🙂
Hope you are well
Cheers
“I did not spend 11 years in university, plus multiple years of extra courses and training beyond that, to fill out checkboxes and create attractive, lawyer-proof, regulator-proof, ministry-proof charts”
BOOM!! You nailed it!
🙂
Thanks, Paul! Sure makes me smile when I find out someone actually read the rant!
Hope you are well in these weird days of late liberalism.
Really appreciate you reading and posting a comment!
Cheers
Thanks Shawn…I rattled off the last post without rereading and make corrections.
Relationship between colleagues was essential and the therapeutic relationships between physicians and patients was vital….no longer so it seems.
One wonders if , on typing out the office visit charts, that utilising the correct pronoun now takes precedence over everything else?
Ha!
Just avoid pronouns altogether. “The patient” or first name.