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.


Blogger Lanny said...

Personally, I would call it slavery. We need 3 times as many doctors now!!!

16/4/07 7:09 PM  
Blogger Rosie said...

Hi Al,

This article was on CBC today:


Although I would like to say "yay", I am interested in your opinion on the matter.


18/4/07 10:22 AM  
Blogger Al said...

You certainly can say "yah". There are many things that are good about our system, including the lower administrative costs of having one giant "HMO" (each province). I have put together some other aspects and will E-Mail them to you if you forward your E-Mail address to me. About 30% of my visitors are from the U.S. and I do not wish to "bad-mouth" out neighbors, although I feel many of my comments are appropriate.

18/4/07 2:59 PM  
Blogger Rosie said...


graduateschoolbarbie at gmail.com


18/4/07 7:21 PM  
Blogger michie said...

I understood that physicians limited it to one complaint per visit because they can only bill for one complaint per visit. I was often confused when working in your office as to why I couldn't bill for more then one thing when you addressed 3 or 4 issues in one visit. It's ridiculous. Perhaps they should be able to bill for their TIME. I remember when you'd bill as a psychotherapy, it would be billed by time. This makes a bit more sense to me. I guess it's more difficult to prove time spent, rather than patient seen... What do you think?

19/4/07 12:49 PM  
Blogger Al said...

The time thing was always underpaid for several reasons:
1) Walk-in clinic docs almost never do Psychotherapy
2) Walk-in clinic docs rarely did continuing care of aged people (time consumers)
3) Some docs were doing psychotherapy only and had relatively low overhead
4) Over the last ten years family docs' fees have been diproportionately influenced by docs who derived a large part of their income from doing walk-in practices.
5) And as you say, monitoring time is a difficult thing to do (although it is done with psychotherapy).
The main thing is the one complaint per visit was seen as a "comeback" to the poor settlements awarded through negotiations; but the reality was that it strongly worked against the docs doing comprehensive and geriatric care. When you worked for me I think the charge for 15 min of care was $20.oo ($80.oo an hour).My overhead was about fifty dollars an hour, thus a net of $30.oo/hour. The office fee per visit was $20.oo a visit. If I saw 6 patients an hour my gross was $120.oo/hour and my net was $70.oo an hour. Some walk-in clinic docs see eight to ten people per hour, with a similar overhead. Little wonder there has been significant moves away from doing comprehensive family medicine.

19/4/07 4:03 PM  
Anonymous TorontoMadCap said...

I've just moved to Toronto a few months ago and I wonder which is more sensible? Walk-in clinic or getting a Family doctor? Getting an appt with a family doctor takes 2-3 weeks or more waiting time, wheares I can just walkin at a Walkin one. I've no children as yet, so do you think I still need to find a Family doctor?

10/7/07 12:42 PM  
Blogger Al said...

Sorry about getting back to you so late, Torontomadcap. Everyone should have a family doctor although in certain age groups it is imperative. Most walk in clinics don't offer continuing care altho in Calgary some of the docs working in walk-in clinics have there own practices (continuing care) and take their turn working shifts in the walk-in end of the clinic. Having a regular doctor that knows you is a great advantage to both of you. He/she gets to know you as an individual, and you have the benefit of his/her being able to recognize changes that may be quite suttle.
I recall seeing a man in his fourties who complained of a vague non-specific abdominal pain that the specialist thought was nothing. Since I new this fellow was not a complainer, I insisted that he have a full work-up. He was found to have pancreatic cancer. Simmilar situations have happened often in my years of practice. In our Canadian healthcare system it is a huge advantage to have a regular physician that can act as your advocate in a variety of circumstances. Mind you, not all family docs will function in that role, so find yourself a good one. For little things a walk-in clinic will probably do, but if you are really worried, see your family doc.

12/7/07 8:12 PM  

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