If you find it puzzling that medical specialists are pouring out of Canada’s universities but queues for surgery aren’t shrinking, you’re not alone. It baffled economists at the C.D. Howe Institute too.
So they teamed up with two health policy experts — William Falk from the University of Toronto and Ake Blomquist from Carleton — to get to the bottom of the paradox. Their findings were released last week in a paper entitled “Doctors without Hospitals: What to do about Specialists who Can’t Find Work.”
At first, the evidence confounded them. A survey by the Royal College of Physicians and Surgeons of Canada showed that 16 per cent of newly certified specialists — heart doctors, orthopedic surgeons, radiation oncologists, neurosurgeons, gastroenterologists and other highly trained physicians — were unemployed. Those with practices were often underemployed, working too few hours and doing too few procedures to pay their bills. Some had taken positions for which they were overqualified.
Normally this would suggest an oversupply of specialists. But the facts didn’t fit that explanation. Patients were waiting an average of three months to see a specialist and a further six months for surgery. Clearly, there was unmet demand.
Next they looked at funding. But that also proved to be a dead end. Over the past decade, the provinces spent billions of dollars to improve access to treatment. They opened new medical schools, ramped up enrolment in existing schools and increased the number of hospital residencies for medical graduates. But waiting lists scarcely budged. (There was short-lived progress on a few “priority” procedures, counterbalanced by longer delays elsewhere.)
Finally, the analysts turned their sights on the health-care system, looking for bottlenecks, barriers and structural problems. They struck gold. The delivery of medical services was riddled with conflicting incentives, professional rivalries and misallocated resources:
• Hospitals couldn’t afford to bring in new specialists. The provinces provided them with lump-sum annual allotments to cover all their operating costs. If they allowed a new specialist to practice on-site, it meant more diagnostic tests, more pre-op procedures, more operating room staff, more medications and more in-patient services — all making it harder to balance their budgets.
• Specialists couldn’t earn enough to cover their costs. They are paid on a fee-for-service basis — the more procedures they perform, the more they make. But cost-conscious hospital managers dole out operating-room time sparingly, restricting their income.
• The system provided no latitude for bargaining. A young surgeon might be willing to operate on weekends, for instance, but the hospital had no incentive to provide the staff and facilities.
• Most hospitals provided established specialists with preferential access to medical facilities, making it difficult for their junior counterparts to compete.
This clash of institutional and professional interests trumped both the needs of patients and the laws of economics. “If policy-makers do not shift course, the problem could worsen resulting in a significant underutilization of resources and even an out-migration of Canadian specialists,” the authors warned.
They recommended that the provinces give hospitals the budgets and authority to contract with specialists. The size of a hospital’s budget would be based, in part, on the volume and quality of services it provided to patients. Specialists would be paid a share of what the hospital received for each procedure. That way, everybody would have a stake in speeding up surgery and maximizing the use of operating rooms.
Organizationally, their plan makes sense. Politically, it runs counter to the provinces’ desire to move services out of hospitals, free up funding for home and community care, and place more emphasis on chronic and mental health care. And logically, it has gaps. The authors offer no explanation — and no remedy — for the protracted wait to get from a family doctor to a medical specialist. They don’t look at regional variations. And don’t explore new possibilities: teams of specialists working at surgical clinics or sharing their hospital privileges.
“It’s a complex picture,” said Aaron Jacobs, one of the researchers. “I don’t think this will be a magical solution to the wait times problem.”
But it does confirm that there are smarter ways to spend health-care dollars; better ways to deploy medical talent; and more effective ways to cut the waiting times Canadians are getting for the $215 billion E
Readers are left with a good news/bad news message. On the positive side, medicare looks sustainable. On the negative side, “patient-centred care” is a long way off.