Volume and Low Cost, The Walmart Solution

As health care provider shortages became an increasing problem and the demand for treatment became greater, new efficiencies were needed. This gave birth to the concept of health care programs. To my mind, programs did two thing very well: perform the most units of care at the lowest cost (this is why it was put in place), and get the most units of work out of the health care providers involved. Unfortunately, when the programs were in the planning stages there was no input from family physicians. This resulted in no plan as to how to integrate the community physicians and their patients with the programs. Previously community physicians would use, for instance, a defined number of consulting cardiologists. The long term care of a considerably ill cardiac patient would be followed collaboratively over the years by one cardiologist and one family physician. This disappeared, and the community physician would have to simply use the cardiologist on call for the program if the case were urgent, or refer to a program with a long waiting list and the patient would be seen by the cardiologist working that day. Since the cardiologist on call rotated every seven days, a patient hospitalized for 8 days could have three different cardiologists during their hospitalization. In effect the patient was a “client” of a program, not a patient of “a” doctor. This of course led to more “generic” care and less personal care.
To aggravate the situation, different programs were set up in different hospitals throughout the city of Calgary. Conceivably, I could have two patients in each of three different hospitals, making it impossible to make hospital visits cost effective. In the last years of practice I gave up hospital privileges like many of my colleges. This further separated community patient care from institutional care.
The health care providers in programs did the best they could but soon they were over-run with demand. The combination of early discharge from acute care (hospitals), the inability to admit patients to hospital beds, the lack of long term care beds (governments had put a moratorium on building nursing homes) and the inability to access investigation in the community, flooded the emergency departments and the programs. Soon the need for triage people and intake workers as a buffer to demand and a coping strategy for emergency departments, home care, and programs became apparent and were put in place. The net result ----- another hurdle for community physicians in trying to get the care they felt their patients needed.
Although programs were not a bad idea, they were not properly thought out with patient continuity in mind. They were a “big box store” solution, a volumes solution; and were designed for the most commonly ill, not the most ill in our society. Communities became the “dark hole” where health care needs accumulated and community physicians were left to cope. More family physicians left Canada, more stopped taking new patients, more retired at an earlier age and more medical students simply chose not to go into family medicine. But from a government perspective the needs in the community were invisible and didn’t make newspaper headlines, so Canada could continue with it’s illusion that we had the best health care system in the world! Good patient care had lost its’ priority, replaced by system survival.

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