What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Wednesday, January 04, 2006

Innovations of the /70s and /80s

For the first few years of "Medicare" in Canada, physicians were generally quite pleased. Being human, they didn't miss the burden of talking about their fees with patients who had no coverage. They had no collection losses and their billing system was reduced to a one payer system. In the first year alone they probably realized a 15% increase in take-home pay. These things served as the "hook".
The provincial governments were not nearly so pleased. Physicians started to do more depth investigation into patients complaints. Patients saw the situation as a virtual medical "candy store" which they could access and use to solve all concens and discomforts. In a few years provincial governments saw the cost of health care rising significantly above the GDP and inflation. This in the face a slow but progressive withdrawal of support in the form of federal transfer payments to the provinces.
The political response to this was salary control to the doctors. True negotiations never really took place between the medical organizations and the provinces. The threat of strike on the part of physicians never really affected the government and sat poorly with most of us. In fact governments saved money if physicians were on strike and strikes helped drive a wedge between doctors and their patients. During the twenty years of the /70s and the/80s only four or five adjustments made in Alberta to the fee schedule kept up with inflation. Changes in the rules such as paying for a visit instead of the service meant that physicians could charge a maximum for a visit, regardless of the number of services rendered or time spent with the patient. Certain services were rationed to only so many per year.
During this time hospital administrators had to cope with funding at the discretion of the provincial governments. They bought into the idea that sick people did not generate costs, doctors did since they admitted the patients and ordered the tests. Hospital admitting priveledges for family doctors were restricted to a certain number. Compare that to the present state where regions are crying for physicians to take on hospital priveleges and occasionally patients stack up in emergency departments when acute care beds are available but there are no doctors to take on their care. "Innovation" at the time was mainly comprised of micromanaging doctors and their activities as cost controlling measures. Certainly, governments thought they had control of the situation in the late /70s when one Alberta Cabinet Minister(attorney general at the time) told me privately: "We would be fools to salary doctors. We would immediately need 30% more doctors. The way it is now we control the purse and the fee schedule, you have to work harder and harder to meet your expences or you take home less money at the end of the day". This idea that doctors were the cause of rising health care costs finally culminated in the late/80s with government enforced decreases in Medical School training and hospital residency positions.
My science teacher taught me in grade school that: "for every action there is an equal and opposite reaction". Tomorrow I will discuss the physicians reaction to these controling measures and being put in the position of the "bad guy" in the equation.
Dr. Al Wilke


Blogger Procrastinatrix said...

Interesting blog. I look forward to reading your next post. I am still thinking of applying to medicine when I am done here, so it is a lot to think about.

Is there anything that can be done to save a public system without turning to privatization?

4/1/06 2:23 PM  
Blogger Al said...

I,m glad you said save "a" public system and not "our" public system. I think our system has gone too far down the road of public dependance and has become too much politisized to rescue in total. You can't take things away from people when they feel they are entitled to it. You can, however, slowly allow the present dissatisfied people to move towards taking on the cost(which our present governments- provincial and federal) have done. For this to be effective there has to be dis-satisfaction with the existing system--and there has been for a long time.
Our Cabinet Ministers, for a long time, have know that the present system is non-sustainable. In spite of their best efforts, growing waiting lists, and health care taking a larger and larger share of government budgets, we still have not realized the impact of the baby- boomer generation.
I feel that a totally paid for public system may be possible if first we determined what the system would cover. Terms like "medically necessary" would need to be defined from the very start. At present some lobby groups would like "determinants of health" to be included under the health umbrella. I feel education alone, without incentives and dis-incentive will only work in an extremely small percent of the population. Can "a" public system be set up without private enterprise? Let's see what we can come up with. Let's start with 1)No Canadian should be denied hospital care when needed.2)No Canadian should be denied cancer care or treatment.3)I will throw out some scenarios in my blog as the days go on.

5/1/06 11:19 AM  

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