We often miss the obvious.
David Foster Wallace described it best in This is Water:
“There are these two young fish swimming along, and they happen to meet an older fish swimming the other way, who nods at them and says, “Morning, boys. How’s the water?”
And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes, “What the hell is water?”
We often cannot see and do things that are obvious and easy for others.
Both the French and English mangle certain words in each other’s language. But neither one finds difficult what the other finds impossible. Steve Martin, as Inspector Clouseau, immortalized the challenge.
Medicare is almost 50 years old. Most of us cannot remember care before Medicare. Many were born after it started. How do we describe something we live with every day?
I am preparing a talk about Canadian single-payer healthcare for an American audience. They want me to describe water.
Americans know that we do not pay for care directly. And they know we wait too long. But they want to know what it is like to swim in the single-payer pool.
Single-Payer Healthcare
I need help finding things that would be obvious to outsiders, but invisible to us. What are the good, the bad, and the nutty things about our system?
The Good |
The Bad |
| We never think about a patient’s ability to pay | Free care fosters overuse and entitlement |
| We send in one billing request to the same place every month | Government will not pay for some care and often denies bills |
| No need to learn the rules of different payers | Lack of competition creates mediocrity in the monopoly |
| No need to compete with other doctors | Doctors have to compete for OR time and for patients in some areas |
| No need to advertise | Cannot advertise |
| Lower office overhead | Office overhead is driven by government regulation and red tape |
| Most doctors can still choose where they work | Many doctors cannot choose where they work: unemployed surgeons, FHOs closed |
| Empowered work force: no sweatshops – unions and associations are strong | Close to 100% unionization rate drives up costs and drives down efficiency |
| Universal care | Rationed care |
| Predictable prices | Fixed prices force docs to stop providing services |
| Wait times low for catastrophic emergency care | Wait times long for scheduled care |
| It is less expensive than the US system | It costs more than most OECD systems |
The Nutty
- Hospitals lose money for seeing more patients; doctors earn more for seeing more patients
- Unlimited sick days for some nurses
- March madness: hospitals spend like crazy before year-end or lose funding for next year
- Pharmacists paid more for same service than MDs (e.g. flu shot)
- Black market in radiology and lab licenses
- NPs and midwives earn more per patient than MDs
- Labs have fixed budgets: more tests means less profit per test
Bigger Issues
Single Payer healthcare also raises other, more challenging problems:
Those who know cannot speak. The system suppresses dissent. People cannot speak up, because they have nowhere else to work. Professionals working in hospitals or academia must stay quiet.
Single-payer systems give tremendous power to administrators who run the monopoly. It enriches and expands government.
Price controls appear to limit costs, but profits are found in other ways. For example, price controls force doctors to shorten visits, unbundle care, up-code, or stop providing a service.
Centrally planned single-payer systems function on Hayek’s Fatal Conceit, the assumption that planning is possible:
The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design.
Local knowledge is impossible to capture or to use in managing the system.
Single-payer systems incentivize collusion with government to exclude competition.
It creates a psychological change in Canadians. Whereas choice empowers patients, single-payer fosters dependency on the system.
It creates increased demand for fixed price services but decreased availability of those services.
Single-payer assumes that bigger is always better. But bigger often becomes too big to manage. A CEO of A.T.&T. once said,
“A.T.&T. is so big that, if you gave it a kick in the behind today, it would be two years before the head said ‘ouch.’”
Sowell’s Basic Economics – a great book!
Seeing the obvious is hard. Those of us who work inside the system often cannot see things, in the same way that those who do not work inside the system are blind to other issues.
I would love to hear from you. Help me see the water in single-payer healthcare.
Check out health status, morbidity and mortality and health professionals per capita as well as % uninsured in both countries. Most Americans think Canada has Socialized medicine. Whatever that means. They don’t drill down to details.
Great points, Ann.
Details matter. Beds, doctors, and nurses per capita are good places to start. I worry about talking too much about mortality, since it relies more on what we do to our own bodies than what the system does for us.
Hey, thanks so much for reading and posting a comment!
cheers
“March madness: hospitals spend like crazy before year-end or lose funding for next year”
Worse? OR’s are shut down before budget year-end to keep within the hospital’s allocated funds.
Great point, Gerry! Shut down over Christmas serves the same end.
Gerald, hospitals are one of the few publicly funded organizations that are allowed/ encouraged to carry over funds from one year to the next. March madness is assumed but not real. Check out working reserve changes in the year end reports to validate.
That may well be true, Colin but the fact that ORs are shut down late in fiscal year ie Spring as funds are running out is what my point was. Health care resources are not adequately funded is my point.
March Madness is very real, Colin. I have worked in administration. I have served on LHIN committees. I have watched over a million dollars spent on a poorly researched, unthoughtful, inefficient project that was thrown together at the last minute to avoid having anything left on the books for the next fiscal year.
March madness may not happen in every institution, or in yours, but it happens. I have seen it with my own eyes multiple occasions. The largest expenditure was over $1 million, the next largest was >$300k. Both were very bad decisions.
Agree. Even at smaller funding levels I’ve seen the money wasted on what I like to call “ dosomething-ism” , often to avoid returning funds. Almost all of the efforts are embarrassingly weak
“dosomething-ism” — Brilliant
Universal care outweighs everything in the Bad Column. All in the Bad Column needs to be addressed within a single payer health care system.
This comment is from a Community Health Centre MD.
Thanks Don!
I agree. We could fix all the Bad and the Nutty if we had enough money to spend. We could also do it if we pared down the number and kinds of services we offer. But with money stretched thin, and expectations stretched high, I worry that we have to allow some kind of hybrid.
To be clear, I have always been suspicious of corporations. I like Mom and Pop shops, but corporations are often too big to hold accountable. Furthermore, MD incomes would DROP in a hybrid system. Look at MD incomes in Europe. The USA is an anomaly worldwide. So it is not in my personal best interest to advocate for change. It is much better to make the current system run better — something I’ve spent the last 15 years trying to do. But this cannot go on.
Again, thanks so much for taking time to read and post a comment!
Cheers
Shawn, I have often thought about the possibility of lower physician incomes in a competitive market driven system. I have never had the guts to say it out loud.
We should probably promote the idea more. We get criticized for questioning single-payer healthcare: It must be self interest. Actually, it is in most of our personal best interests to have higher taxes so that we can get paid salaries, a pension, and all the goodies that go along with being a government employee. But that is not great for patients…
The current system cannot run better (in the long-run) for the very reason you mentioned: Hayek’s Fatal Conceit. Trying to manufacture incentives that perpetuate the current system will be an exercise in frustration.
The current system denies reality. The only way to make a sustainable system is to align it with reality. Human nature, self-interest, market forces are elements of reality that will always undermine Single Payer. Past attempts in other countries to deny reality have always resulted in cures worse than the disease.
Well said, Craig.
“The current system denies reality.”
We can do better. We do not have to completely dismantle what we have to improve it. Even a tiny bit of competition would drastically shift the way Medicare functions (as long as it was set up right).
Thanks for reading and posting!
Yes these comments about single pay really don’t have much to do with single pay structure but more about an MDs experience in Ontario. Not sure this talk will help the audience wrap their head around the choices.
Thanks for posting comments, Colin!
Looking forward to hearing how you might improve our system, and why you think single-payer is such a good thing when no one in the world copies it anymore.
Cheers
Others are blind to the obvious fact that ALL of the world’s top rated health care systems , without exception, are symbiotic public private hybrid health care systems.
It is as if some of the metaphorical “fish” are blind in the right eye and others are blind in the left….both attacking those with both.
( I know, I know…only some fish have binocular vision….having more monocular vision than humans and lesser binocular…come to think of it, so do most human ideologues which is a part of the problem).
Always a great comment from you, Andris!
I agree. I think we need some change. I want change because it will improve the public system. Monopolies never run as efficiently or pay as much attention to those they serve as when they have some competition.
Thanks for posting!
Andris. I always enjoy your “Sane” and thoughtful truths!
For longest life ,Can. rich jet to States for the day. Or build a town eg Weston with a branch of Cleveland clinic. Overnight flight to Northern Europe is comfy in First. OHIP fine for reasonable life span.. Private med available in PQ. Predict soon in BC if Dr Day’s case wins: then rest of Canada can legally folliow. Private investers ready to build more hospitals: for more efficient diagnosis and better post-op Rx & rehab.
Good points, Dr. Franklin.
Over 60,000 patients leave Canada to get care in the USA each year. More go elsewhere also.
Cheers
Our hospital cancelled over 100 hip/knee replacements during last year’s flu season as we were told their pathology was ‘benign’.They then had us work more last summer(called it ‘surgical smoothing’)so that they could keep the joint numbers up and keep getting the QBP funding.Yet we can’t open our own surgicentres where we could do more joints more efficiently,with the same nurses who know our routines…..somehow Canadians don’t think surgeons should be able to charge a reasonable amount for procedures that take 2hrs,with the stress,exertion,and risk that goes with it.
Ask some of those leaving to other countries what the surgeon fee was,then compare to Ontario.Even most Ontario docs have this socialistic view of ‘every doc should earn the same ….. THAT’S what socialized medicine means …..
Wow. Thanks for sharing this, Ramunas.
This has become so common that it is no longer news. 100 people had to completely rearrange their lives and continue to manage their pain because surgeries were cancelled. Not patient focussed!
You make a good point about costs and everyone earning the same. If you do not drive a really nice car as a doc in other countries, you must be a bad doctor. If you drive anything nicer than an Accord or an F150 in Canada, you must be paid too much. 🙂
Thanks so much for posting a comment!
We are living in the “Me” culture. Our public only believes the inefficiencies that exist when it affects them directly. A friend of mine blamed his surgeon for the delay in his operation, not the government system which controls the surgeon.
I am concerned that the apathy physicians feel towards improving the system is increasing, resulting in decreasing excellence in care. The benchmark of mediocrity in delivering care is lowered by the government to allow them to show “improvements” which do not really exist!
You make some solid points here, Don.
Patients care most when their care is compromised by the system. However, most of the public never needs major care, so the impression of everything you need whenever you want it lives on.
We have many good things about Medicare. But there are also many things we could improve. Ideology trumps pragmatism when it comes to Medicare in Canada.
Thanks again!
I practiced before Medicare. I was able to earn an excellent income while providing care. I did not charge patients who could not afford my services. It all averaged out.
I practiced surgery to provide what was required, not by “how much the procedure paid”.
My practice was much more satisfying and rewarding to my enjoyment of medicine in those times!
Thanks for this comment, Don!
I have been trying to find docs I could talk to who remember practicing before Medicare. I might have to reach out to you by email, if that’s okay.
As far as I can tell from all the histories written of pre-medicare days in Canada, all the good caring doctors wanted state medicine, and all the greedy uncaring doctors fought it. We need to set the record straight. Dr. Doig’s Setting the Record Straight is a good place to start.
Thanks again!
Where is Marc Baltzan when we need him?
He was president of the Canadian Medical Association, president of the Saskatchewan Medical Association and chair of the department of medicine at the University of Saskatchewan.
Shawn,
Interesting perspective you have on the single payer system, thank you for the overview. I look forward to hearing your podcast episode wherein you review this.
On the statement about Nurse Practitioners (bias alert, I am one): I find it quite frustrating that as a happy colleague of many MDs I am often being thrown under the bus when I’m not sure NPs even needed to be in the conversation. Your comment in this article feels like a random, unnecessary jab. It certainly seems there is a theme of changing the conversation to NPs being expensive when there is a discussion about billing for physicians. We are a drop of water compared to physicians in Ontario with only 3,000 NPs registered.
Your statement about NPs (and your previous article about us) are sweeping and generalized as if all NPs have standard work conditions/compensation packages. We work in so many different settings and are paid in so many different ways that there is no way for you to suggest that we are compensated better than physicians for our work.
To highlight an example, some NPs are employed directly by MDs to cover their family practice (average patients seen 25/day). These physicians can then work elsewhere such as hospital, teaching gigs etc, and still make a passive income from FHO remuneration while not even being in the clinic. These NPs are being paid around 50$/hr without security, pension or benefits to see 25 patients/day (closer to 50/day if in walk in clinic). I am going to suggest this is likely less or at-least comparable with what an MD is paid per patient? That being said, I am not an MD and have not done any research into data supporting what you all make. I would argue that it’s hard to generalize on that as well given some FHO MDs work 7 days per week and some work 3 with the same roster. The time spent with each patient, I would argue, should be included in the accounting.
I should note I am very familiar with the extra work of running a business, hiring staff and chasing down bills. I have operated my own shop until recently, and I am aware of the added headaches that are incurred. I fully support that most MDs more than earn their take home. Opening up a two tiered system would be one way for some patients to have better access and have MDs/NPs to have better access to providing care and operating a business the way they see fit.
A request for you and your fellow blogging MDs:
It would be very helpful for subsequent articles if you wouldn’t mind including some data to support your opinions when it comes to Nurse Practitioners. I am happy to acquiesce with the presentation of solid evidence, rather than personal experience and opinion.
Thanks again for your perspective.
Respectfully,
Julia
“On the statement about Nurse Practitioners (bias alert, I am one): I find it quite frustrating that as a happy colleague of many MDs I am often being thrown under the bus when I’m not sure NPs even needed to be in the conversation.”
Julia, I think what you are seeing is a reaction to the Nurses Associations and governments promoting Nurse Practitioners as a cheaper alternative to Family Doctors. Using assistants or helpers if you feel the term assistants is disrespectful, is a tremendous asset to increasing productivity in the proper setting. I believe that it is stand alone Nurse Practitioners as “saviors of medicare” is what some physicians are reacting to. Unfortunately when statements like “nurse practitioners…” or “physicians…” are made, the nuance of “some” versus “all” is lost. In fact, I think that nuance is sometimes blurred on purpose.
Thanks Gerry!
Thank you, Julia.
First, let me apologize for giving the impression that I was impugning you, your work, or your role in the system. I am on record – many times – about how privileged I feel to work with many outstanding NPs now and over the last few decades.
My comment about cost was based on data. The replacement cost of an NP divided by the number of patients seen is much higher than what an MD would get per patient. I can write another post to show this, as I have in the past, but this is just a fact. And it is not a bad thing! Kudos for NPs! I only highlight it to emphasize how MDs have been vilified and cut for years to the point where our fees are absurd, especially in general practice.
Thanks so much for taking time to write such a thoughtful informative comment. I know readers love the comments best. They will certainly enjoy hearing from you.
Again, very sorry if I have caused offence. I did not intend it.
Highest regards,
Shawn
What do you mean that NPs are paid more than MDs for the same service, when NPs aren’t paid ‘fee for service’
Thanks Shirley. Great question.
As I mentioned in my response to Julia, “The replacement cost of an NP divided by the number of patients seen is much higher than what an MD would get per patient.”
I appreciate working with NPs. I love what NPs bring as solid members of a team. I am happy for NPs that they have been able to negotiate solid contracts that recognize the valuable work that they do.
Best regards,
Shawn
“NPs and midwives earn more per patient than MDs.”
I believe the point is that physicians are more cost effective on average PER CASE. This has been calculated by dividing total cost including salary, fees, overhead and benefits by number of patients or pregnancies looked after per day or per year. I have seen this discussed several times over the last few years.
Thanks for your replies and your apology. I’m happy to support my MD colleagues in search of fair compensation. I’m sure any NP would support an MD earning the same wage for the same work.
Would either of you be able to point me in the direction of data that supports your claims about the per case value? It would be interesting to see the head to head numbers and the context it’s pulled from. Forgive me as I find it hard to accept opinion versus validated numbers.
Thanks again for the lively discussion and your reply,
Julia
For sure. There was a FOI request on the Sudbury NP-led clinics around 2008 I believe. A reporter at the Sun got a copy and printed an article about it. I am trying to locate it.
But for newer data, please check out my blog on it from a few years ago. The numbers have not changed (in fact, they are worse for family docs).
“Same wage for the same work”…that’s interesting. So are you saying that the work done by someone with 10,000 hours of training is worth the same as someone with 500? It’s a philosophical discussion that we cannot answer here. In most industries, someone with more training and experience always costs more, even if they are doing the ‘same’ job. There are many reasons for this, but it strays a long ways from the intent of this post.
Thanks again for your vigorous, thoughtful, and polite defence of NPs. I am sure we both agree that the system needs change!
Cheers
Thanks and I will check out those leads you have provided.
I meant that comment with the purest of intentions. I agree this is not the place for debate on the comparison of training and education of MDs and NPs as I am sure we may have some differing perspectives in that arena as well.
I can agree with you on one thing, the system does in fact need a real shakedown.
I enjoy reading your articles and keeping up on the perspectives of my MD colleagues here in Ontario. Thanks again for your thoughts.
bureaucracy that is ossified into inaction. Cannot respond to changes in technology or demographics. eg $400 cataracts that take 15 minutes, baby boomers. Day surgery. Rising cost of health care supplies >> inflation.
Codes hopelessly out of date. No codes for new procedures. No diagnosis codes for new diseases.
Extortion of services with $0 value codes.
Pretty hard to expand on that. The Schedule of Benefits needs a rewrite. Problem is that the MOH would like to rewrite it with even lower fees across the board!
Thanks again for posting, Ernest!
Maybe we need to consider the”water” from the payer perspective. Think of the patient who accesses the ” convenient no cost emergency room ” for rti/uti/ rash/ abd pain/pneumonia….really anything that does not prompt a 911 call.
Then put this same patient in the position of a snowbird accessing care through travel insurance. They seek the most economically appropriate care for the same issues at a local clinic see an NP or a PA or an Md….have investigations done in the community.Beacause there is a cost associated there is value for the service and there is a thoughtful decision process for seeking care.
When there is no cost there is no value. This is where the true”water” lies. We need to focus on the users as we examine the ” payer” system.
Well said, Debbie!
For non-emergent care, most patients have time to consider options. And they are smarter and more capable than we like to admit.
Hi Shawn,
I am still upset about missing your talk at the OLP convention.
This post is an excellent starting point, here are some points on what you could expand on or emphasize more:
• Lack of information (especially the kind created by the price signal) creates waste and bad incentives (I addressed this point in my very first blog, talking about my personal experience)
• The worst aspect of socialized systems is their dehumanizing nature. The moment you stop being a fully empowered agent of your own well-being, you lose some of your humanity.
I talk about this a little more in this post: http://zorkhun.com/wp/2012/09/15/the-harm-government-services-cause/
• I would emphasize very much the fact that universal carte is always rationed care where politics decides everything: prevention versus treating emergencies, frequency of tests, approach to treatment, etc.
The points you mention in ‘The Nutty’ section, are all the results of the missing price signals.
Hayek wrote about the fatal conceit; the missing price signals was the central point of Mises in
Economic Calculation in the Socialist Commonwealth
I could explain to you the water, but I am not sure you would like it. Your readers would crucify me.
Fantastic comments, Zork!
Thanks so much. Lack of information, dehumanization, and politicization are all great point.
Thanks for the link to your blog, also. I hope readers take the time to check it out!
Cheers
PS Yes, I thought you would have been at the OLP thing, also. All good. Next time! Cheers