In 1987, a high-profile and unpopular doctors’ strike over reimbursement shook the profession, leading to the creation of CanMEDS roles framework studied by every Canadian medical student. 18 years later, income is again the focal point in the latest negotiations between the Ontario Medical Association and the provincial government. As former Chief Justice Warren Winkler observed in his Conciliator’s report, without significant changes, both groups are on a “collision course” that will jeopardize the future of collaboration between providers of health care and those who fund it.
Current negotiations have largely evolved around the physician services budget, and this is an important discussion in its own right: Canadian physicians are generally paid well compared to countries with similar health systems, even after adjusting for overhead costs. However, budgetary considerations must also take into account another component less prominent in public discourse: the value of physician services. In other words, how much health benefit do we gain from our $33 billion annual investment in Canadian physicians, and are there ways to improve it? Here, the results are not what one may expect.
One of the first experiments looking at this question took place more than 40 years ago in Burlington, Ontario, involving the use of nurse practitioners, registered nurses with 1-2 years of additional training, compared to doctors in the setting of primary care. The result? Patients assigned to nurse practitioners were seen without physician involvement two-thirds of the time, and health outcomes and care quality were similar whether they were seen by MDs or NPs. A 2012 Cochrane systematic review combined a total of 16 similar studies and arrived at the same conclusion. The results were not restricted to primary care: another review looking at control of asthma saw no difference between nurse-led compared to physician-led care, while a trial involving patients with atrial fibrillation saw higher use of evidence-based guidelines and better survival among patients cared for by nurses.
It might be tempting to infer from these studies that additional training of physicians does not improve patient outcomes, and that our investment in physicians is therefore unjustified – but that would be an inaccurate conclusion. Instead, the current level of evidence in this area suggests the need to urgently explore and implement the most efficient mix of skills and providers to deliver the most effective care for Canadians in need of health care each day.
More importantly, I believe these findings represent the ongoing misalignment between the full scope of a physician’s training and their actual medical practice in the current model. The Medical Council of Canada Qualifying Exams, for example, contains approximately 190 types of clinical presentations, illustrating the breadth of knowledge in diagnosis and management graduating physicians attain. Meanwhile, it has been observed that in 2010, the top 20 presentations at a physician’s office made up 46% of all encounters. There is a widening rift between the expanding diversity of diseases learned during medical training and a select number of diagnoses seen predominantly in the current model of care delivery by physicians. This in turn supports the integration of allied health workforce with specific training to deliver many aspects of routine clinical services, enabling each profession to practice at the full spectrum of their knowledge-base and clinical experience.
Despite Canada coming in last place on timeliness of care across a group of 11 high-income countries, it has one of the lowest utilization of nurse involvement in routine primary care. As teams are increasingly recognized as the preferred model of health delivery, an important opportunity exists to re-examine the outdated roles of health care providers in Canada, and to embed rigorous evaluation into modernizing professional scopes of practice such that each can perform at the top of their education and practical training.
It has been observed that scopes of practice regulations are steeped in historical factors rather than an evidence-based examination of current population-based health needs. While we have made considerable progress in addressing the shortage of health care workforce by increasing the number of physicians, the fact that these shortages can be further alleviated by leveraging the use of non-physicians will be an added incentive for action.
By creating a practice environment where value can be effectively measured and demonstrated, the income of health care providers can be based upon their unique niche within the system. This would be the first step towards an evidence-based discussion of provider remuneration, with input from additional factors such as educational expense, specialty income disparity and practice demographics.
Health care, a social service provided to all Canadians, requires accountability. Canada has a long and rich history of assessment for drugs and medical devices, a process that despite limitations, promotes efficient use of finite financial resources. As a sector that consumes 15% of health spending whose growth is outpacing those of hospitals and pharmaceuticals, the glaring evidentiary gap in the value of physician services can no longer be ignored.
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Excellent article! Yes, I totally agree. For example, as a mother of two healthy children, during the routine well-baby visits, I have felt that it is kind of wasting the expertise of the family physician.
Excellent and very insightful. I totally agree. It is time we evolve and let all discipls ine practice to their full scope. Outcomes will be better and the system should be more cost effective.
Another great article from a Queens med student – so impressed!
Even in the states, I was not a fan of insurance based healthcare – private or government sponsored. Healthcare is not a human right. Basic human rights are rights to action, not to rewards from other people. For example, in the US Constitution, the rights to life, liberty, and the pursuit of happiness are rights that do not impose obligations on other people, merely the negative obligation to leave you alone. The system guarantees you the chance to work for what you want—not to be given it without self-effort by somebody else.
When healthcare is treated as a right, it’s taken for granted. The doctors and healthcare providers are taken for granted. The system imposes practice and reimbursement obligations/restrictions on the physician to guarantee a level of healthcare for the patients based upon the system’s perceived standards or values. If the system arbitrarily believes that for more people to receive healthcare, physicians shouldn’t be making that much money – then they shouldn’t.
Another issue, is that all physicians are broad-stroked by these regulations, with the exceptional physicians being penalized double. Being lumped together, exceptional physicians do not receive any exceptional reimbursement above the amount that physicians who provide poor care. Likewise, when penalized, exceptional physicians are not penalized any less than physicians who provide poor quality.
If patients are willing to pay naturopaths good money, why not for conventional medical care? Why not promote health savings accounts in Canada. Make patients more cost conscious about they’re care. Have our taxes cover emergency, catastrophic, ancillary and diagnostics, but then provide tax sheltered savings accounts like TFSA’s for physician fees. Someone would have to punch the numbers to see if it would really save the system money . Ideally, HSA’s would promote a more traditional marketplace whereby consumers dictate the value of care, where exceptional physicians would be commensurately reimbursed and poor quality physicians would garner less.
Another questions came to mind. If it’s moral and legal for govt funded teachers to have a union how is it that physicians don’t have a union.
These are all good points; an example was recently highlighted in a physician video encouraging MD’s to become more comfortable with nutrition counselling. The patient’s needs and the health system costs would be much better served by making sure the physicians recognize nutrition-related health issues and ensure that the patient is connected with a Registered Dietitian to provide the nutrition counselling. As a patient and taxpayer, I would prefer that the MD’s time be used to treat issues that require MD expertise, and that other healthcare providers with specialized training be accessed to provide treatment in their area of expertise.
Though this may be the direction primary care is going, I am concerned that the shift from primary hands-on physician to manager of nurses is not a particularly attractive one for most medical students.
Most students enter medicine with the hopes of direct involvement in patient care, and to hold credentials unequaled by any other profession.
Primary care already has a problem with recruitment and prestige. To reduce the patient contact for family doctors, as well as to equate a large portion of their scope with the practice of nursing, might be to decimate primary care as a physician-led segment of medicine.
Primary care will evolve into a nursing field.
Hi Evan,
Thank you for your comment. I would submit that modernizing scopes of practice for our allied health professional colleagues does not mean turning physicians into their managers/administrators. Rather, it means remaining as their partners in the health care team – as Dr. Danielle Martin puts it, “it’s not about ‘downloading’ tasks to ‘less-qualified’ people […] By working together we are each able to contribute where our expertise is greatest, leading to faster, better and more affordable care for all.” (http://on.thestar.com/1xXxLE2)
I think it comes down to what type of primary health care we envision – if we restrict our notion of physician-based primary care to be one primarily involving the management of stable conditions among low-risk patients (e.g., chronic hypertension or well-controlled diabetes) that covers a sliver of an MD’s training, it may lead to challenges with recruitment as you mention. But what if primary care MDs instead had the operational capacity to focus their attention on the top 1% of the population that consumes 34% of total health care costs? Improving the care coordination and well-being for the most medically complex segment of the population may perhaps be where they can leverage the breadth of their MD training. In doing so, it may alleviate the issues of prestige and job satisfaction you noted in your comment.
I believe that there will always be opportunities for direct patient care regardless of one’s credentials; the key is to challenge ourselves to perform at top of our abilities. What do you think?
The idea of nurses and nurse practitioners, working to full scope of practice, and being first contact for patients requiring primary care is exactly the kind of thinking required to ensure sustainability of our cherished, publicly funded, healthcare system. Physicians should also work at the top of their scope, and be used as primary care specialists; used to address patient needs that cannot be met through nursing.
When all healthcare professions work at the top of their scope of practice we decrease overlap and duplication of services, thus reducing costs. We also ensure a higher degree of functioning across the system, which in turn, encourages job satisfaction and retention of top talent. Greater role clarity promotes inter-professional collaboration because the blurring of boundaries across professions is reduced. Appropriate pay scales can then be applied to reflect ‘value-added’ to our system.
Congratulations to Yan for demonstrating progressive, system wide, thinking.
Excellent article, for universal health care sustainability its imperative the client see’s the right provider at the right time …..all health care professionals working in their intended scope.
Great post Yan Xu! Yes, as a pharmacist of 15+ years, I can attest to the rapidly changing environment of what is expected of our profession, the professions of our colleagues, and how roles and scopes of practice can overlap and compliment each other, all at the same time. Our professions have histories and moving those entrenched silos can be demanding and demoralizing work, as wagons circle and training/credentials or motives are questioned. However, there is a new generation of thinkers and doers creating the change they want to see in the world…putting the patient first, and doing what is necessary to improve care for all.