I made a big mistake last fall. I offered to pay my kids $1 for every pile of leaves they raked. Within 20 minutes, the main lawn had 50 large piles, and another acre of leaves lay waiting. I panicked.
Would I run out of cash and credibility?
How did chronically tired teenagers move so fast?
As the piles grew and my wallet shrank, a plan hit me: I could bribe them.
The happy workers finally agreed to a break. They weren’t anywhere near tired. I offered them immediate payment and a take-it-or-leave-it ice cream to stop working. They pretended to complain and took the bribe.
Paid to Stop Work
Franklin D. Roosevelt paid farmers to slaughter piglets and leave fields unplanted as part of his New Deal (The Agricultural Adjustment Act). FDR did increase food prices, as he had hoped, but the fallow fields created huge dust storms.
In this instance, FDR was not trying to save money; he just thought he could increase farmers’ incomes by manipulating the industry. (It didn’t work.)
Today, farm aid programs cost less, if farmers do not even start farming. It costs money to till, fertilize, and grow crops. Government saves money on social programs for farmers, if they pay farmers to do nothing. Apparently, government still pays some farmers to destroy crops.
Pay Doctors to Provide Less Care
Since the start of managed care, experts have argued over the ethics of paying doctors to provide lesscare. Doctors want to care for patients. Patients want care. If doctors get paid for care, and patients never pay anything for the service, then the amount of care delivered tends to grow quickly.
Patients do not like the idea of paying doctors and hospitals bonuses to deny care. It seems that “incentives for less medical care” would undermine the motivation to care in the first place.
The economic logic is simple: If docs earn more for providing more care, then patients get more care, in a ‘free’ system. If docs earn more for providing less care, some doctors will find reasons to support less care for patients.
Champions for less care usually start with an example of waste:
“I saw a patient, who had already been to 2 walk-in clinics that day, for the same runny nose!”
The Americans started a campaign to provide less ‘care’. The Choosing Wisely movement reduces obvious waste and over treatment. Especially in America, some patients get too many medical services. They get care they do not need; like getting highlights and an eyebrow waxing, when you only booked a trim.
Choosing Wisely vs. Rationing
Does it make sense to pay doctors to provide less care in Canada?
Paying doctors to provide less care could appear unethical in the face of long wait times. For example, patients wait up to 1 year just to see an Orthopedic Surgeon in some areas. The idea is not new in Ontario. It wove through negotiations in the 1990s, around savings and restructuring. Minister Smitherman offered to pay doctors for prescribing cheaper drugs.
Government always blocks physician efforts to increase business efficiency. For example, government continually refuses to allow physicians to hire extenders, in the way dentists employ hygienists. Government would rather have doctors see fewer patients overall, than support ways to improve doctors’ efficiency and risk an increase to the number of services provided to patients.
Wait times notwithstanding, it still seems reasonable to pay doctors to find and eliminate the waste that only doctors can see.
Co-Managing Care
Today, Ontario doctors review a tentative contract that offers one-time payments, if they can co-manage medical services. This means that doctors get paid extra, if they can limit the growth in medical services to 2.5%. Medical services have grown at 3.1% per year, since 2001, due to population growth and more doctors entering practice.
We should get rid of wasteful care. Perhaps, we should call wasteful care simply waste. Doctors should stop doing any of the useless things that doctors do because they have always done them. We need to streamline care and support attempts to modernize the healthcare system.
But we must be careful. Who knows exactly how much waste exists in the system? Some experts say that the healthcare system should only grow at 1.9%, even though it never has, in recent history. Why do such long waits still exist, if the system has been growing faster than the experts deem necessary, for the last 15 years?
Co-management can feel like rationing, to patients. One person’s co-management is another person’s austerity.
I support the ideal of co-management, but we must move carefully. This government loves to cut spending on medical care, so it can spend money on getting re-elected.
Like a bribe to stop raking leaves, people respond to large incentives. We can all rationalize around ethical hurdles. Maybe we should ask first, What do patients think about it?
photo credit: news.au.com
There is a simple and efficient way to cut down abuse of the healthcare system; make patients pay for some of it. That was Tommy Douglas’s plan all along. He never envisioned a system with carte blanche access. That is the modern politically correct movement’s issue. ‘We cant charge the poor because they won’t be able to access the system’. A co-payment, managed by doctors not co-managed by government, could be flexible enough for the poor and yet provide enough money to doctors to keep the doors open and the A/C on! It will also put the brakes on all those demands for MRI’s for a sprained ankle.
Ernest, you are quite correct about Tommy Douglas. He specifically said it was a good idea for patients to pay part of the cost. Idealogues conveniently ignore this.
Well said, Ernest and Gerry.
People should look up the videos of Tommy Douglas on YouTube. He very clearly talks about how people who pay nothing for service will not use it as a precious resource. You also get a sense of how theatrical he was about his opponents.
Thanks for sharing your comments!
Your ice cream was an ‘instant’, take-it-or-leave-it. Who decided that we had only two weeks in the summer time to educate 33,000 physicians about this complex, but absurdly and deceptively brief (6 pages, as the ‘Concerned Docs.’ point out) deal? The Liberals spent taxpayers money for the last month soaking the air waves and half-pages in community newspapers saying that they were ‘adding’ one billion dollars to health care next year. What per cent is that of the current ?fifty-two billion that will increase because of population, complexity and the senior boom? Less than needed. They were also going to ‘add’ seven hundred ‘more’ doctors and specialists to provide “faster access to care”. I went to their website for ‘more information’, and was told to get in touch with Health Care Connect, with no guarantee that I could get a doctor or that my whole family could be signed up. My guess is that that is approximately the output of our medical school and residency programs. Forget retirement, fed-up moves and burnout and new graduate location to out-of-province locations. The real danger here is an inconclusive vote either way. We need high acceptance with high demand for input, or major rejection with ‘think again Hoskins/Wynne’. Is there a ‘danger’ they will treat us worse if we say ‘no’?
My son has a friend with a black tee-shirt with a white skeleton that says “the beatings will cease when morale improves”. Either way, we MUST keep informing the VOTERS of the truth that this is a ‘drastic’ cut in health services being replaced by a ‘serious’ cut in health services, an ‘increase’ only in the weird world of algebra. Math skills are not high in this province. The VOTERS will decide in 2018, which is what the Liberals fear, and why they want to nail us with a four-year deal. We should seize on the theme of ‘tentative’ and insist on a ‘one-year renewable’ PSA.
Editor’s note: I deleted the last paragraph as requested.
Thank you, Roger!
You packed a tonne of content into your comments. I love, “The beatings will cease when morale improves!” You also make a good point about a split vote. It sends a message for sure.
Thanks again for writing.
As a patient, I have no problem with properly qualified “extenders”. Only makes sense to let doctors do what doctors do best and optimize their knowledge and training in areas where it makes the most sense. Surely it would reduce wait times. But could it work in a sole-practitioner situation? Would there be the necessary “volume” for the extender? Or would there need to be more than one doctor to “justify” one extender? I recently had a knee replacement and was quite impressed with how much nurses, physiotherapists, technicians, pharmacist, etc. (even my surgeon’s secretary) helped to ensure I had excellent care without making demands on the surgeon. When I did see the surgeon, I felt OK with either asking a question or asking for clarification, because I had not bothered him with issues other people on the “care team” could deal with. But what really stuck out, was how well each of these professions worked together, without any discernible “territorial” postures. They all seemed to respect each others professional abilities. And I felt confident that each and every one of them cared about me. Can a patient really ask for more?? I don’t know that it works like this everywhere but I don’t think non-medical gov’t representatives could possibly improve on it. They need to give doctors and other medical professionals the opportunity to put “care models” together that work for patients and professionals alike, while using review and continuous improvement techniques to ensure efficient, cost-effective care that results in a win-win-win.
What a great note, Valerie!
Great to hear that your knee replacement went so well. I agree, a high-functioning team can deliver outstanding service. You make a great point about a solo practitioner with a small practice. For sure, a doctor could not hire extenders unless they had a large enough practice to fund the cost of the extender. But I am certain that even solo practitioners could easily double the number of patients they care for, if they were allowed to employ them in the way that dentists hire hygienists.
Thanks for taking time to share such thoughtful comments (as always)!
Physician extenders will work if the role is defined by clinical professionals and not by health-care bureaucrats, who already analyze and count and restrict, instead of providing a health-care service that is the raison-d’etre for “everyone” working in health care. Ophtho’s use physician extenders liberally in their consultative process, and the “system” pays for their equipment and staff, and thereby increases “capacity” drastically. Doesn’t happen in psychiatry, where the greatest unmet need lies.
The challenge is to provide a suitable framework, with enough freedom granted by service definitions and payment system, and enough accountability that a physician/surgeon does not get paid for sending a patient away empty-handed. (Patients drive 230 km to a consultation, and the specialist has a hissy-fit over a missing piece and sends them away.)
I think it might be startling to incorporate a patient’s report card on the physician’s care. Did the patient believe the care they received was worth the trouble of going to the appointment? The net effect would be another way to focus the physician on making sure the “care” was useful. The report card would not be the only criterion for payment, but surely it would be more useful than a bean-counter’s report card on how to limit services.
I would start–in fact I am starting–by pressing for service definitions that allow physician extenders. Not only does this increase capacity, it also increases morale amongst providers and patients alike.
Very interesting ideas, Roger. Thanks for sharing!