In an era of transparency and openness, it seems reasonable to expect public disclosure of the names of physicians who collectively receive $11 billion annually from the Ontario Health Insurance Plan for delivering health-care services.
The notion that such disclosures will “alter the health-care landscape” and establish new levels of accountability by physicians is, however, a big leap of faith. There is little evidence to support this notion in B.C. or Manitoba where disclosure has been required for many years.
A much more important issue to consider is the need to finally re-examine the predominant manner in which our system pays physicians for their services. It is fundamentally the same system that was first put in place in Saskatchewan in 1962 when Tommy Douglas introduced Canada’s first medicare program.
Saskatchewan doctors went out on strike for three weeks to protest its introduction, but returned to work on the condition that government pay them on a fee-for-service basis. This method of payment is based on the doctor submitting a bill to government for each time they see, treat or perform a procedure on a patient. Payment is made in accordance with a negotiated schedule of fees for what are deemed to be medically necessary services.
Back in 1962, this method of payment was likely a good approach and the negotiated schedule only consisted of a few hundred different items. Today’s fee schedule has thousands of different fees and has made it virtually impossible to establish the relative value of each fee.
By example, how much should an ophthalmologist be paid to remove your cataract versus how much should a geriatrician be paid to consult on an elderly patient? Added to the complexity of value is the determination of what constitutes “medically necessary” and the huge variation in the application of that term by doctors.
Again by example, in some hospitals every patient having a cataract removed is first seen by a specialist anesthetist for a pre-procedure consultation. This obviously generates significant fees for the anesthesia specialists. In other hospitals, the anesthetists may be busy doing other kinds of work and only 10 per cent of patients having cataract surgery receive a pre-procedure consultation; it is deemed that doing so for the other 90 per cent is medically unnecessary.
In addition to the growing complexity of the billing system and the sophistication of the services being provided, demographics are also impacting the choices we must make about the delivery of health care. For example, the average life expectancy for a male in 1962 was 68 years and today it is now more than 80 years. With today’s patient being older, they present with comorbidities (multiple diseases) that require care by a team of health-care professionals. Perhaps the notion of paying one team member based on a fee for each service no longer fits with the notion of a team.
A better approach may be a fixed base level of remuneration making up 70-80 per cent of total compensation and 20-30 per cent based upon patient outcomes and productivity goals. This would create an accountability opportunity that could be managed much closer to where care is provided (at the local hospital or in the local community) as opposed to the current, ineffective approaches that are administered at the provincial level.
The current system is based upon the notion that physicians are independent contractors. Many physicians are self-incorporated and thereby have access to significant tax advantages. There are, however, very few other examples of contractors enjoying the contract vagaries that exist between physicians and their provincial government pay masters.
This is not an issue for contract negotiations. It is an issue in need of a comprehensive third-party review undertaken by an esteemed individual who can examine how the public can best be assured of receiving value for their money.
This will then likely require legislation to enact the necessary changes to create a better system to more appropriately and more fairly remunerate doctors for their services.
- Murray T. Martin recently retired after 43 years of serving the public in senior health-care leadership positions in Ontario, British Columbia and Saskatchewan