Going For Second Best

Yesterday my blog title was “why primary health care REFORM”? Quite frankly, because the scenario that existed in my practice is rapidly disappearing and access to family doctors and community health care, is finally being perceived as a major health issue. Because the scarcity of family physicians is world wide, a situation aggravated in Canada by various government actions previously discussed, family physicians are able to look at primary care systems around the world and pick and choose where they wish to work. They are also enabled by our system in Canada to look at opportunities that give them more income, in less time, with less responsibility. Young physicians in Canada graduate with high expenses and priorities that include personal and family time. On the other side of the equation, government health administrators see their costs going up and a greater proportion of the population having problems with access to traditional primary care. The increase in “walk-in clinics” reflects the interests of many physicians and addresses the need for “episodic” care but does nothing for the huge need of in depth continuing care and preventative care. Because it is impossible to restore the numbers of family physicians, especially over the short haul (and possibly never), governments around the world are once again resorting to the least expensive worker, working at their maximum potential. Preoperative teams are proving “cost effective” because they facilitate early discharge from hospitals, a major cost savings. They may even facilitate good care. At least in the pilot orthopedic project in Calgary, my understanding is the preoperative team and the post operative team that follow the patient, is the same. But will these principles apply in the community? My experience was the more care givers in the care of a patient, the more tests generated. When public health nurses were doing screening in our schools for scoliosis, I saw many children with anxious parents, usually requesting an x-ray. In the past ten years I spent much of my time with parents of children in Phys. Ed. The Phys. Ed. Teacher suggested the child might need a CT scan. Once an issue is raised, it is very difficult to reject a test that is free. My inclination is that these approaches may end up being more expenses unless some form of rationing is put in place.
All community primary health care organizations and some other approaches such as seen in Great Britain have one thing in common----patient registration. Years ago I disagreed with this concept but I think we have reached the point where this is necessary to address “fidelity” (see previous blogs) issues in the community population. I also feel it is not unreasonable to expect that the public, in return for taxpayer funded health care, should have commitments on their part, including as I’ve suggested before, some form of a screening process on a regular basis for aspects of preventative medicine. From that perspective, Primary Care Health Organizations lend themselves well to aspects of “fidelity”.
In looking at these “team” systems, Canada will have to ask: “What system will attract a group of physicians in short supply and serve the needs of the community?” Various pilot projects have been tried in Alberta. The model that has existed the longest in Calgary is a “capitation” model in which a group of physicians and other primary care providers (using the broad definition) are funded on how many patients are “signed up” with the organization. As one might expect, there have been ongoing “negotiations” between the care givers and the government on funding versus services provided, and I haven’t seen physicians drawn to that scenario. Personally, I do not like this system. Global funding to the Health Care Organization puts the care givers in an obvious conflict of interest. The less money we spend servicing patients, the more money we have left for ourselves! Further, if the Calgary Health Region thought this was the answer I would have expected them to implement this type of community program in their new “South Calgary Health Center” and the new Okotoks Community Health Center.. Instead they operate as glorified walk-in centers. Obviously, the powers that be are still at a loss as to “what to do”.
While they fiddle, other programs have sprung up, some encouraged and endorsed by the Calgary Health Authorities. Some of these programs include physicians, but many do not. My understanding is the Calgary Spinal Program (not sure of the exact name) includes physiotherapists, chiropractors, and other practitioners not covered under the Canada Health Act, as well as specialist physicians. By this inclusion they can claim their charges are not for physician services, thus neatly getting around the Canada Health Act and at the same time indicating that their access to a spinal surgeon (if indicated) would be quicker.
If I were a young family physician today, I would seriously look at practicing in New Zealand. Quite a few years ago the New Zealand government was apparently in a position where they had to make huge cut backs in government funding. One of the areas where they made drastic cuts was to primary care. Since that time there has been an evolution of a primary health care approach that combines government funding, private billing, and “co-funding”. There has been the encouragement of PMO’s (Primary Health Organizations) through “incentive financing” but at the same time recognizing that family physicians are independent Professional Practitioners in health care and as such, have the right to set their fees. They have put in place a scenario that will both service the community and reward physicians for doing the work they are trained to do. As a simple example, the New Zealand Government pays a premium of $26.75 to doctors for visits of patients over 65 years of age. Two years ago our fee schedule in Alberta paid a premium of $1.10 for 75 year and older patient’s visits. Little wonder many family physicians in Alberta have chosen not to look after the elderly----they are far more complex and take much longer per visit. In brief, the New Zealand government co-payments largely support the care of children, the poor, the aged, and the chronically ill (in both health care and pharmacare), leaving the “working class” responsible for their family physicians fees and medications. In this situation there is accountability on the part of the physician to justify their charge based on the service and medications available, and the patient can make a judgment as to whether they received value for their money.
Many aspects of this system still require close examination, but it would appear from the New Zealand Government’s literature they are putting tax-payers money where it should go---- to the care of the poor, chronically ill, and the elderly; while maintaining incentives for physicians to use their training and skills on the population group that will most benefit.