Everyone wants to form an Ontario Health Team. But few know how to get community doctors’ support. They do not know because they cannot see.
Imagine that we nationalized auto repair in Ontario.
All mechanics’ shops, including dealership service departments, now send repair bills to one insurance plan called Autocare.
Mechanics in local garages fix cars for loyal customers. Dealerships deal with major problems that community mechanics do not fix.
Local shops have 1500 customers. Some see only 750; others up to 3000. A single community could have 250 community mechanics.
Some mechanics share expenses with partners, but each mechanic must maintain liability insurance. Most community mechanics are independent contractors. Only dealerships hire mechanics on salary.
Mechanics’ shops rely on supporting businesses for towing; tire disposal, oil and waste disposal. But each supporting business negotiates with Autocare individually.
Government would love to control how, when, and where mechanics work. But it would cost too much to put mechanics on salary.
Ontario Auto Repair Teams
Now imagine Autocare created Ontario Auto Repair Teams (OARTs). These teams will coordinate community auto repair.
OARTs will fix problems in the community that used to go to dealerships. Government wants local communities to design individualized OARTs.
However, individual mechanics have no time to investigate, design, and propose an OART. They need to repair cars.
Dealerships do not have time either. However, dealerships and other supporting businesses have budgets and staff to redirect. OARTs offer the biggest redesign to auto repair in 50 years. And early adopters will probably get funding.
So leaders from dealerships and businesses begin work with community mechanic shops. This is new and unfamiliar.
A dealer organizes a planning meeting. All supporting businesses respond including a few mechanics. A steering committee forms. The committee drafts a proposal, suggests design solutions, and populates others committees. But they need more community mechanics.
So the committee asks,
“Who speaks for mechanics?”
“Why can’t all the community mechanics sort themselves out?”
“What’s the matter with auto repair? Why aren’t all the 250 mechanics at this meeting? Everyone else is.”
Experts ask the same about physicians.
Dentists submit bills to insurance companies. Physicians submit their bills to a provincial Health Insurance Plan.
Why do we expect physicians, as independent practitioners, to act differently than dentists, mechanics, lawyers, or any other business?
What We Know But Cannot See
A. Doctors are independent contractors.
The local mechanic is indistinguishable from his shop. If the mechanic is in, the shop is open. If customers want more hours, then the mechanic must work longer. Same thing for physicians.
B. Family doctors provide most primary care.
Primary care doctors — family doctors mostly — provide the bulk of community primary care. Other businesses provide different care. And some experts offer services as independent contractors also. But for the most part, Family Docs define primary care.
C. Primary care change means change to MDs’ job descriptions.
Big businesses send CEOs to major planning meetings. Decisions that shape community care do not change CEOs’ job descriptions.
But every decision that impacts primary care will change physicians’ job descriptions. Family doctors will have to change their own offices, schedules, and family commitments to meet OHT expectations.
We cannot redesign primary care unless primary care doctors lead the effort. Engagement is not enough. Partnership on a planning committee is not enough. Even having 50% + 1 on OHT boards will not be enough.
OHTs will directly impact primary care clinics: businesses that are almost indistinguishable from the family doctors who own and run them.
Ontario Health Team Leadership
Successful primary care organizations are physician led.
Lead does not mean engage or partner or provide input. Lead means the same thing it does when a physician must lead her clinic and make business decisions there.
Physicians lead their practices because physicians are responsible for everything. If the clinic loses money, the physician does not get paid. Everyone else — staff, creditors, and landlords — gets paid regardless. Physicians lose their license for bad decisions. No one else loses his career.
We should celebrate that so many hospitals and community care businesses want to form Ontario Health Teams. Now they have to convince community physicians to lead them in the fullest sense of the word.
Photo modified from Star.com
Congratulations Shawn! You have done it again. For bureaucrats, politicians, overpaid CEO’s and Regulators who cannot read, write or think with common sense about medical (physician) health care, you have provided a simple obviously ridiculous near elementary school level made-up story to show why high speed up-front “planning” does not work. That is a long sentence. Fortunately my enemies as a health care advocate will have trouble reading it.
Thanks Roger!
I might take a softer tack with the bureaucrats/politicians/CEOs — I think most of them are trying their best inside a narrative that too few people challenge. And whenever anyone says otherwise, they get labelled as a nut or troublemaker. I think we need to try to convince those who open to convincing with winsome arguments and approach.
Thanks for reading and posting a comment!
Roughly speaking :
Democracy + private ownership = Capitalism.
Democracy + public ownership = Socialism.
Dictatorship + private ownership = Fascism and National Socialism.
Dictatorship+ public ownership = Communism.
Fascism and National Socialism allowed industry/ businesses etc to remain in private hands…but ordered them what to do with with their businesses…responsibility without control is a contradiction…all the Marxist totalitarian ideologies, fascism, Communism and Fascism controlled the unions who were ordered to carry out the government’s bidding…ordering private industrialists to stop producing ploughshares and to produce tanks ,for example , with the unions obediently collaborating.
Independent Medical Mechanics who own their garages and who have fixed the “ cars” of loyal customers for years , who bear all the overheads for their garages are being increasingly ordered about by governments and their supposedly representative organizations as at what to do and how to do it whilst experiencing a relentless slashing of their fees and incomes over the last 20 years….their obedient “unions” turning a blind eye to the trials and tribulations of their members.
Keeping the ownership and responsibility of running the garages in the hands of the mechanics is a trick that the Fascists and a National Socialists discovered …when their Communist cousins seized the garages , “the means of production”, shooting or deported those who knew the intricacies of running garages to Siberia everything turned turtle and collapsed.
We medical mechanics are about to be strong armed into joining these governmental Teams…the government is looking for so called “leaders” , essentially medical Judas goats to lead their unwary colleagues into these collectives where they will be told what to do, how to do it and when to do it on a restrictive budget whilst bearing the full weight of responsibility for the inevitably negative outcome .
The central planners who conceived of OHT’s will take the bow for any unlikely achievements …our widgetized colleagues bearing the burden at the coal face will take the blame for the shortfalls.
Having practiced in Ontario for over the last 50 years I’ve witnessed many a governmental “ improvement” to the health care system , each step forwards being followed by two steps backwards.
I’ve learned that the main cause of crises in the health care system are governmental solutions to previous crises which were themselves the result of previous solutions to previous problems which were , themselves, the result of previous solutions to perceived problems.
Here we go again….those close to retirement will throw in the towel.
Excellent post, Andris. Thanks for including your synopsis of political systems, also.
I think you make a solid point: “…the main cause of crises in the health care system are governmental solutions to previous crises which were themselves the result of previous solutions…” Regardless of the political party in power, they remain constrained by the socialized presuppositions of the ‘system’.
I’m just reading von Mises’ “Socialism: An Economic and Sociological Analysis”, written first in 1922, but this version was fully updated in 1951. Regarding “partial socialism”, von Mises writes (p 276):
“Therefore State Socialism [sic] and planned economies, which want to maintain private property in name and in law, but in fact, because they subordinate the power of disposing to State orders, want to socialize property, are socialist systems in the full sense.”
We cannot excuse our system as not really socialist because it is “Private practice, public payment” (Naylor’s book). Those days are gone.
Thanks again for your thoughtful comment.
The application for OHT is purposefully designed to keep physicians from taking the lead. The MOH talks about the central role of MDs but in fact has designed the form to make CHC’s and hospitals be able to check off more boxes. We were part of a 300 MD group putting in an application and it paled in comparison to the one I saw from a local hospital. I mean, which FD practice has a patient advisory committee? Which FD practice has integrated services that include other health care professionals (nurses, social workers etc)? Which FD practice has integrated IT systems that are linked to these other services in the community?
It was not surprising that the special advisory committee was comprised mostly of hospital CEOs and non MDs.
VERY interesting, Leo.
I didn’t spend time with the proposal application. I just assumed that the collective had to tic all the boxes together. But now that you say this, it makes sense that he who tics the most boxes gets to call the shots.
I actually like the idea of trying the OHTs. We just can’t expect a wonderful redesign of primary care without primary care docs leading the effort.
Thanks so much for taking time to read and share a comment!
Cheers
Committeitis is a pathological condition that corrodes infected organizations…organize otherwise intelligent people into a committee and they are transform into idiots manipulated by the more psychopathic amongst them as if by an Ouija board .
It has been said that an elephant is a mouse built according to government specifications as garnered by its committees….our health care system is an ever growing bloated white elephant, increasingly inefficient, ineffective and increasingly expensive with each “ improvement” made.
If we have to have committee meetings….then…no chairs…no refreshments…no compensation…doors locked until decision finalized…each should sign off on the decision made and each be held personally financially responsible for the decision…primum non nocere should be their guiding principle.
Ha! I hadn’t heard the elephant-mouse example.
“…personally financially responsible for the decision.” — This is the key issue with all healthcare redesign. Physicians are held personally financially and legally responsible, but no one else has the same skin in the game. The politicians come close; they can lose their job. But this accountability aligns their interests to votes first, patients second.
Thanks again for a stimulating comment!
These “teams” will further corrode community primary care as hospitals as CHC’s make decisions for us community mechanics. It is one more step towards the government’s desire to achieve ultimate omnipotent control of all aspects of health care and thereby manage and minimize costs which is their ultimate purpose.
Eventually allied health will do ALL our jobs as medicine becomes simply an algorithm to follow if the appropriate symptom boxes are checked. USA insurance has gone this was as one cannot hardly get an xray unless certain criteria are met and approved. We will need to meet the metrics devised by these teams to get referrals and investigations but only if appropriate!
Us mechanics don’t have the time or energy to sit on these committees unpaid, while the dealerships support their staff with salaries and benefits.
I think I’ll sell my car and go back to riding my bike instead…
An old English saying” a pig with two owners soon dies”….god help a pig that is looked after by a team….god help the patient that was once tended to by his/ her family physician as “care” is transferred over to a team.