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?

Sunday, April 15, 2007

Family Doctors, a New Breed of Civil Servant

If we were to do a survey and ask the family physicians in Alberta about being “salaried”, I think the general response would be “no way”! But let’s take a look at what has happened over the years.
When I started practice in 1963, my income was solely derived from what I charged my patients or their insurance companies. From that revenue stream I paid all my office expenses, business and other taxes, retirement plans, continuing education expenses, malpractice insurance and other insurance, etc. There was a suggested fee schedule, but it was acknowledged that I was running a business, and was empowered to charge my patients as I felt appropriate (within the College of Physicians code of ethics).
With the advent of “Universal Medicare”, Alberta physicians were put in the position of negotiating (through the Alberta Medical Association) a fee schedule that the government agreed to honor. For the most part, these negotiations were a farce, akin to a rank amateur hockey player squaring off against Gretzky in his prime. As a result, the settlements were less than inflation the majority of the time. Fortunately, physicians in the early years had the capability of “balance” billing. Unfortunately, this was soon taken away from them by the federal government and the provinces.
At this point I felt the medical profession was no longer a profession. With no ability to address changing environments in their businesses and the government “paying the piper”, physicians soon began to lose their professionalism, and, as the only means of controlling their incomes, began choosing what they would and would not do, depending on time involved, remuneration per item of service, etc. When the government declared they were taking a more business-like approach to healthcare, the physicians responded by taking a more business-like approach to their practices.
So where are we at now? Most doctors limit a visit to one complaint by the patient. Additional complaints need additional appointments. Many family docs have taken up lucrative sidelines outside of the healthcare system (eg. botox injections, hair transplants, etc). A strong trend towards walk-in clinic work and away from continuing patient care and management exists, and the number of young medical graduates choosing family medicine is continually on the decline.
So where do “fee-for-service” physicians get their income from at the present time? Well, the fee schedule for family doctors has certainly not kept up with inflation. Over the last 15 years or so there has been a steady trend by provincial governments to “throw in” financial perks as negotiated incentives to encourage contract acceptance. Continuing education costs can, to a large extend now be reimbursed. Malpractice costs are largely covered by the government (so don’t worry about being sued), making your office techno friendly is even subsidized. Financial incentives exist for rural practitioners, and the perks negotiated recently in Alberta, to be approved by the “profession”, are subsidies for inflationary office cost over-runs ( eg Fort McMurray), and practitioner retention fees that run into thousands a year. Basically, family physicians have become civil servants. I believe some provinces even have gotten into some kind of pensioning!
Does any of this help patient care? In my opinion the answer is an unequivocal NO. Fee differentials for complex and continuing care basically do not exist. There are no incentives for physicians to take on time consuming and difficult/complex care such as the elderly and chronically ill. It would be far better if physicians really were salaried. At least practicing good medicine then would not be a financial hardship, and seeing 12 patients an hour would not be rewarded. Mind you, we would need twice as many family docs.