Friday, November 18, 2011

Economist: No to two-tier health care...base doctor's pay on quality of care

By Karen Howlett, Globe and Mail, November 17, 2011
Canada should remain committed to publicly funded health care, and not open the door to two-tier medicine, says a new report by a top economist.

Governments can improve efficiencies in the system, including changing the way doctors are compensated, without allowing patients to pay for some services, Don Drummond, former chief economist at Toronto-Dominion Bank said in the report released on Thursday.
“A great deal can be done to improve efficiency in the system before privatization is considered,” Mr. Drummond says in the report prepared for the C.D. Howe Institute. “It seems best to simply leave this issue aside for the moment.”
The report, titled Therapy or Surgery? A Prescription for Canada’s Health System, amounts to a staunch defence of Canada’s public health-care system that guarantees universal coverage for many services, including hospital care and prescription drugs for the elderly.
It will likely provide a road map for reforms to health care in Canada’s most populous province. The economist is conducting a review of all program spending in Ontario.
Mr. Drummond’s report for the Ontario government will not be released until early next year. But he says the government won’t meet its commitment to erase the province’s deficit by 2018 unless it caps annual growth in spending on health care, education and other programs at 1 per cent for the next six years. The province is facing a projected deficit of $16-billion this year.
Reducing spending will not be easy. Canadians spent $192-billion on health care in 2010, accounting for just under 12 per cent of the country’s economic output or GDP, the report says. In Ontario alone, government spending on health care has climbed an average of 7.6 per cent a year over the past decade.
The grim reality is that provincial revenues will not grow fast enough to offset rising health-care costs, the report says. The report is the latest foray into public policy by Mr. Drummond, one of Canada’s most influential advisers to governments. In a report last year, he warned that left unchecked, health-care costs are set to reach between 70 to 80 per cent of total program spending by 2030, up from just over 40 per cent today.
In the earlier report, Mr. Drummond and TD Bank economist Derek Burleton proposed that the provinces bill affluent seniors for their drugs and pay doctors based on the quality and cost-effectiveness of their care.
Reporting to the right wing C.D. Howe Institute recommending improved efficiencies and leaving privatization aside is like telling your local policeman he really doesn't need a taser in order to do his work effectively; it is a form of heresy to the institute.
Nevertheless, Mr. Drummond's proposals for basing doctors' pay on the "quality and cost-effectiveness of their care" has considerable merit.
In other posts on this site, we have argued that the National Health Act runs on a premise of sickness, paying doctors to "treat" sickness but not to prevent illness. Waiting until many conditions become emergencies, and thereby failing to intervene with a little more muscle as the "health care monitor and coach" of the patient renders the health care system somewhat handicapped, not to mention far more costly than it might otherwise be.
Doctors do, indeed, have considerable potential clout in their recommendations to patients about issues like lifestyle, physical exercise, diet and occupational health and safety. We do not have to wait until a convergence of influences creates a crisis before putting some pressure on the doctor to exercise diplomatic and precautionary negotiating skills in order to effect changes in a person's habits to generate both a healthier patient and a more cost-effective and efficient health care system.
If the doctors' pay were to be measured by "outcomes" to which both the College of Physicians and Surgeons and the health care practitioners could and would agree, rather than a mere monitoring of "wait times," and office or clinic visits, or surgical operations, not only would the expertise of the doctor be more fully deployed potentially enhancing the work-satisfaction of the doctor, and the patient health potentially enhanced, but the drain on the system would be reduced.
The only people who are advocating for privatization of the Canadian health care system are those ideologically entrenched in a capitalist model for the provision of all services, and who thereby turn a blind eye to the merits of universality. Canada has never fallen prey to the dictates of those who call our system a "nanny state" because they believe only the pursuit of rugged individualism without government intervention will generate a society worthy of their support. We know that we have one of the best systems in the world, albeit with some overlaps and some waste and some inefficiencies, all of which can be reduced, if not eliminated, through more discipline and more teeth and muscle in the monitoring systems.
 If we can and have designed and deployed software that monitors the wait times between the initial consult and the date of a surgical procedure, to satisfy the political need for accountability, we can certainly design and deploy software that monitors changes in a patient's specific blood pressure, weight gain or loss, exercise regime and a host of other impacting variables for a doctor's practice to generate a percentage of his/her pay.
Prevention cannot and will not remove the final outcome of death; however, it can and will go a long way to assuring both a higher quality of life and enhanced remuneration for those whose oath "not to do harm" could be reframed to "do all that is possible to prevent the onset of long-term and costly illness".
The idea of billing affluent seniors for their drugs, while worthy of implementation is a far less significant change, but likely more easily implemented, than a reversal of the premise of which doctor remuneration is calculated.
Nevertheless, with medical schools transforming their curricula for medical students into a far more "team-based" approach for diagnosis and treatment plan design, there is no reason that such a change will not also lead to improved consideration of all variables in the patient's life and all variables in a patient's treatment. No single person will be 'holding the bag' for the  medical treatment of any patient, and the effectiveness of each team could be monitored both for research purposes and for calculating their pay.
Let's hold up the responsible reports, like the Drummond report, to the light of day and public debate, as a way of staving off the tsunami of ideological rhetoric that seeks to privatize the system.

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