The public squabble between the Ontario Medical Association and the Ontario government about tweaking physician payments is to be expected: no one likes cuts to their income. But in this case the cuts are concentrated in a few sub-specialties, so the pain is concentrated, prompting a particularly loud response.
So what’s it about? There’s an immediate issue of course: the public response to reductions in fees for ophthalmologists, radiologists and cardiologists. The fee schedule reflects relative priorities and typically fee schedules over-compensate procedural specialties and under-compensate the more ‘cognitive’ specialties. Technological change can exacerbate the problem. Ophthalmologists, in particular, have been previously targeted for fee reductions in Ontario (though they have been successful in staving that off in some provinces). Cataract operations, for example, can be done more quickly now than in the past (by orders of magnitude); more can be done in a day, so the effective hourly rate for these operations has dramatically escalated. This is about how the gains of technological advances should be shared – so should ophthalmologists accrue all the benefits of this or should the taxpayer expect some return?
But there is another issue at play here. “Who gets what?” is the stuff of politics, and so payment policy could be expected to be highly contentious. The founding bargain of Canadian Medicare had as its objective “to find a way of combining publicly supported universal coverage with the true essentials of professional freedom.” “Professional freedom” came to mean that distribution of fee increases within medical specialties was generally left for the provincial medical associations to sort out internally. But the interests of the ophthalmologists, radiologists, cardiologists and others in the medical profession and the interests of government/health system/public are not necessarily the same.
Payment structure is one of the critical policy levers that drives reform of publicly-funded health care systems. The Canadian situation, where use of this lever is dulled by passing through negotiations with physician organizations, potentially weakens and slows necessary system changes.
What we are seeing in Ontario is just a taste of what needs to happen in every province if governments are serious about controlling health care spending.
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The McGuinty-Matthews arbitrary 50% reduction of technical and professional fees for self-referral manifests a lack of knowledge of how and why and by whom diagnostic tests are ordered. These investigations form the basis for accurate diagnosis and guidance for optimal teatment. For example, current best practice guidelines suggest spirometry or pulmonary function tests to diagnose and follow patients with airway diseases such as COPD or Pulmonary Fibrosis. The stethoscope and percussion are obsolete and misleading factors for decision-making. Family physicians rely on the specialist to arrange and interpret those tests. The subtle integration of patient knowledge and raw numbers is the basis of accurate test interpretation and application to patient care. The 50% cutbacks make these tests not cost-effective and will sadly inhibit optimal patient care.
There are only a couple of comments I would like to make.
The government has done a very good job of painting doctors as the problem in health care. It’s unfair, it’s the oh so typical political solution – make a demon, and it makes a clear statement that doctors are the reason that the system is costing more money. As if population growth, patient demand, and technology/drug changes havn’t made a single bit of impact. It’s convenient to say the least to blame doctors for things that are out of their control. But it was and is a coarse handling of a situation.
I see nothing about substantive system reform – yet. And reforming fees without all of the other pieces – downsizing hospitals, putting patients in the places where care is best and least costly, expanding the work of teams. Where are these? Where is competition for price and quality? Where is a discussion of what care is available to who and when? If we think that fee changes will evoke the system changes we really need, we are engaging in magical thinking.
At the same time, we see a pull back on primary care reform, a devaluing of emergency work, and a general chill in the relationship between government and physicians. I don’t disagree that we needed fee adjustments. I think alot of doctors somehow hoped they would end up with opthalmologist hourly earnings, and medical associations are afraid of litigation by members,- however in a fixed envelope environment, we have created winners and losers of specialties and winners and losers of patients. This needed correction and all have been aware for many political cycles. My worry now is that prolonged fee disparities have now brought structural changes in care delivery – it seems that alot of cardilogy primary and secondary services are available outside of hospitals. If fees change, do we lose that access? I don’t know. It’s not my area of knowledge but I worrry . . . .
I know government is quite happy to trot out lines about million dollar earners etc. How many of those providers are in that catagory because they have been busy doing the work of the government wait time agenda? How many are sole billers for multiprovider clinics or labs? Again I don’t know, but the questions are valid and seem to have been ignored. We talk of evidence based medicine and yet numbers get trotted out without information or context. It’s intellectually dishonest.
I look at this now from a distance and I see so much missed opportunity. It really is too bad. High performing health systems need physician involvement . . . . . funny that that message comes from and seems to have been lost at the same time here. How do you ask people to engage when they are busy grabbing their shins?
And lest anyone think I’m taking sides, we as physicians need to get a grip on cost and techology. We need to be willing to determine care pathways and start contributing to controlling costs. Health care isn’t free and we need to start treating it as if it isn’t. In the past there has been zero incentive to, but now, it’s time.
The goverment wants to make it seem like all the cuts are aimed at cost cutting due to technological advancements. In fact this is a small part of the announced cuts.
Premiums for coming in to Hospital to perform sugery have been cut. Family Practice fees for newborn care, pre-natal care and care for chronic diseases like Congestive Heart Failure have been cut. It’s hard to relate these cuts to a technological advancement.
These cuts are aimed at saving money, pure and simple and we should call a spade a spade.
The Governement should open a constructive dialogue about finding evidence informed changes that do not adversly effect patient care.
Your post mentions the standard issue Ministry of Health argument that cataract surgery is much quicker now and so should be cheaper. Those darn greedy eye surgeons! The problem with this argument is that cataract surgery is cheaper. The (inflation corrected) cost of cataract surgery is 44% lower than it was in 1982. Back then cataract surgery took between 40-60 minutes. Now it takes about 30 minutes. We are not far off 1982 levels of reimbursement actually, and for this the public gets a far more predictable and precise surgery than was done 30 years ago. Today we treat people who would have gone untreated in 1982, and we get great results. If the MOH must cut cataract fees let’s be honest about why; it’s not because doctors are ripping of the public, it’s because the McGuinty Liberals have handled money poorly in other areas and now choose to blame doctors, who in reality are providing a great service at great value. And yes, I’m an ophthalmologist, but who else is going to tell you this side of the story, Deb Matthews???
Mr. Duckett makes a good point. Technology has reduced the time needed for some procedures, and people are discharged home much sooner, and are assuming more self care (as it should be). I agree as well that over the years governments have thrown more money to physicians whenever there have been issues in care delivery. This has impeded much needed change in how we deliver services, and determining exactly which profession is best suited to the need. All stakeholders in care provision need to have a voice about the solutions. We can’t keep doing what we’ve been doing and expect things to change. Further, health care administration has become overly top heavy in the scheme of things..and this is where a lot of the fat could be trimmed.
The pain is by no means concentrated as the government would have people believe. In addition to the cuts to the three you’ve mentioned, there are cuts to every single specialty, admittedly, some more than others. Other big losers (-5 to -10%) are: neurosurgery, vascular surgery, internal medicine, anesthesia, nephrology.