Thursday, February 26, 2015

Focussing on Physician Compensation is Dysfunctional

There are a large number of economists (and others), that simply believe that the reason healthcare is so expensive, is that doctors and nurses simply make too much money and need to be paid less for the services that they perform.

Not surprisingly, those who believe this are not incredibly popular with either physicians or nurses.

After all – telling people, professionals who have dedicated their lives to the industry, and are the suppliers of the vast majority of healthcare services, that they make too much money sends some very disengaging and negative messages. It sends the message that the work done is not valued. It sends the message that the suppliers of healthcare, themselves, personally, are responsible for the high-cost of healthcare and are responsible for the lack of financial sustainability of the system. It sends the message that the suppliers of healthcare (physicians and nurses) lack integrity and are out to fleece the public. It is a direct and very personal attack.

Worse than that, it likely works against the very things the healthcare system really does need – workforce engagement and innovation. It works against aligning the interests of those supplying healthcare with the interests of those in need of healthcare – the users of the healthcare system. It distracts from focussing on the things that really do matter and solving those problems collaboratively.

The things that really do matter are supplying enough healthcare services of a high-quality so that there is little or no unmet need (unnecessary disability, death and suffering) while constraining public expenditures to a financially sustainable level. That is the problem that needs the focus, adequately meeting the health needs of the population. That is the problem that needs to be solved – and solving it will require collaboration – and innovation. It will require physicians and nurses and patients and governments to shift their thinking away from the 1,000s of things that are essentially “red herrings”, things like physician compensation to the things that are actually worth focussing on.

Should the public care if a physician earns $1.5M per year or should they care that as a result of that $1.5 Million as much “health” as possible was bought. Which is a better investment? Paying 20 doctors each a $75,000 a year salary or one doctor $1.5M? It depends, are the doctors equivalent in skill or in productivity? Are the services provided to those who would benefit the most from the services? If the $1.5M doctor has innovated and delivers more health than the 20 other doctors combined, she or he might represent excellent value for money. The cost of a unit of health bought from the expensive doctor might be less than the cost of a unit of health bought from the group of 20 other doctors. Further, the “out-of-public-pocket” cost of Dr. A might be significantly less, as he would face a high rate of taxation on the income they earn.

Unfortunately, the way the system is currently structured, there is no incentive to maximize the amount of health (or conversely minimize the pain and suffering) that is bought with the money available. The price of procedures is standard – the fee for an office visit is the same regardless and there is no price flexibility to account for circumstances of either the physician or the patient. As a result a variety of worrying problems emerge. There are physicians who would like to be working – who might even consider working for less than the standard fee who are barred from doing so and go unemployed. There are patients in need of health services who have unmet needs – patients who might be willing to pay above the standard amount to get access to care - but they too are barred from doing so. There are no market mechanisms to assist in matching the supply of health services with the demand for health services.

Further, there is little incentive to go above and beyond or to provide services that truly meet the needs of the patients served. There is little incentive to provide enhanced services (aside from some personal motivation to do so) – services that set one provider apart from another or might even avoid the use of health services. Technically speaking, the provider who minimizes the use of health services by their patients, does so at the expense of their own income. Technically speaking, the provider who makes his office nicer, also does so at the expense of their own income. Technically speaking, the things that most enhance health for some individuals, might not even be health services – but might be problem solving (ie. Finding adequate housing).

Which speaks to the really, really big problem. The focus is not on maximizing health, or minimizing suffering. It’s about making the providers technicians rather than leaders and the patients throughputs rather than partners in health. The system is hierarchical not collaborative – it is resistant to change, and focussed on the wrong things.

Thursday, February 12, 2015

Mrs. Sophie Gregoire-Trudeau Shared a Story with Me, So I Shared a Story with Her

Dear Mrs. Sophie Gregoire-Trudeau–

You sent me an email and shared with me a story about helping a new Canadian mother through a difficult birth – but how she was happy that her baby was going to be a Canadian. That you loved this story because it reminds you to “cherish your identity as a Canadian,” and “how lucky we are to live in a beautiful country, and share it with such generous and caring people.”

Can I share a story with you?

Let me share with you the story I’ve heard time and time again about new mothers giving birth to Canadians in Canada and being left with substantial medical bills. Let me share with you the story about new mothers giving birth at home or in hotel rooms out of fear of the substantial medical bills a hospital birth will leave them with. Let me share with you the story of those mothers enduring substantial pain because they fear the cost of an epidural. Let me share with you the story of mothers foregoing prenatal care because of its cost. Let me share with you the story about how we neglect the prenatal and birthing care needs of those women. Let me share with you the story of how these women and their infants face a 7 fold increase in infant and maternal complications, including death.

Who are these women who are uninsured? These women are the wives and partners of Canadians who are waiting for their permanent residency to be approved so that they can be eligible for Canadian health insurance. These women are refugees. These women are temporary workers and visitors to Canada whose visas have expired. Some of these women are future Canadians. These women are mothers to Canadians – Canadian babies who are denied free access to care they need while in utero and during birth because their Canadian parent happens to be their father instead of their mother or because their mother is newly arrived in our country. These are Canadians whose parents face substantial medical bills due to their births, bills that might have deep impact on their family’s ability to provide during their early years.

I hate this story, this story that I’ve heard time and time again. I hate that it reminds me of how we currently deny access to the best possible beginning to the most vulnerable Canadians – newborn babies. I hate that it demonstrates a lack of compassion, a lack of caring and a lack of generosity. Your email asked me for a donation to the Liberal Party – in support of its bid to become the next governing party.

I want to see a government elected that shares progressive values. I want to see a government that cares for the most vulnerable citizens – newborn babies. I want to live in a county where all mothers can put the best interests of their children first without fearing the financial repercussions of accessing appropriate medical care during pregnancy and childbirth. Will the Liberal Party of Canada do that? Will they commit to providing free access to medical care for all pregnant and birthing mothers in Canada, even those who are uninsured? Will they step up to the plate and demonstrate leadership, caring and compassion on this issue?

Before I consider donating, I’d like to know the Liberal Party of Canada’s position on this issue and what steps it plans on taking should it be elected to ensure the health and well-being of all new born Canadians and their mothers.


Janice Williams

Background Stories and Information:

Saturday, February 7, 2015

Transformative Change: The Carter Decision

This past week the Supreme Court of Canada unanimously decided that the provisions of the Criminal Code that prohibited assisted suicide were unconstitutional and should be struck, giving the federal government and the provinces a year to enact legislation with respect to assisted death. The impact of this decision should not be underestimated - as much of what was articulated has implications for not just how people approach death, but also for the healthcare system, the legal system, and cases that have yet to be decided in the years to come. Make no mistake, the Carter decision is a profound decision that is a landmark of profound changes in the years ahead.

The legislation and regulations that provinces and the federal government develop to govern assisted death will determine who is permitted to assist in a death, the circumstances that must be met, and whether or not it is to be publicly funded as an insured service. The only requirement is that whatever legislation and regulations that are developed conform to the requirements of the constitution, or risk being struck down in the course of time.

It is difficult to predict how accessible or how popular assisted death will be - however, it is not difficult to predict that the removal of the ban on assisted death is a big shift in the landscape, and will likely be a transformative change in and of itself, and might be the start of a set of substantial and transformative changes. The decision was an affirmation of patient autonomy - an affirmation of a competent, adult individual's right to decide what happens with their body and to make medical decisions for themselves, even when the consequence of those decisions is certain death. To endure the suffering associated with many devastating diseases and the end of life will no longer be an obligation thrust upon victims, but rather a choice that is made by the individual after consideration of their own needs and circumstances. It is a shift away from a kind of paternalism towards individual autonomy, towards respect for what is an incredibly personal experience.

It is also a shift towards a more sustainable health system (as of this week all forecasts of demand for health resource use should be considered obsolete). Upwards of 25 percent of all health expenditures are made within the final 12 months of life - the provision of palliative care services, residential care services, and home care services have been widely acknowledged to face considerable challenges in the years ahead. The availability of assisted death will alleviate demand and reduce the amount of resources spent on the final months of life. Those electing assisted death, may enable those electing to endure better access to palliative care and other resources. Further, those electing assisted death might be able to choose between spending their wealth on longterm care or preserving it for their estate. However, given the strong incentives that both the government (as sole provider of health services) and perhaps individual's own family's may have in encouraging assisted death - it will be of tantamount importance to enshrine protections against being coerced into accessing assisted death services. Indeed, assisted death will not only be a new area of medical practice, but also a new area of legal practice.

Further, there are profound implications for future litigation concerning the health system. Specifically, the litigation that is currently underway in the Cambie case in British Columbia. If it is unconstitutional for there to be an outright ban on assisted death, how is it constitutional for there to be an outright ban on privately purchasing access to health services that enhance quality of life? If failing to provide access to death, infringes upon security of person and an individual's right to autonomy - then surely relegating people to waitlists or denying access to health services altogether must also be an infringement on Charter Rights. It would be sadly ironic, if assisted death is determined to be a "medically necessary" health service and insured by the provinces, that those who have fought hard for the right to die with dignity might suffer the indignity and the frustration of that right by finding themselves imprisoned by the shortcomings of the healthcare system.

Tuesday, February 3, 2015

Her Name Was Veronika

Maybe it was an accident.

Maybe she went to the bridge to think, to reflect – and while she was there, maybe she started to fall asleep, having been sleep deprived for a little too long, maybe she just nodded off; falling to the waters below – not intending to be there.

Or maybe there were other reasons, and one thing led to another, which led to her being in the frigid waters with her seven-month-old son. That led to her death, and his clinging to a life that has only just begun – his father keeping vigil while grieving her death.

The Coroner’s office is investigating.

The question that needs to be answered is: What needed to happen, that did not happen? What needed to happen, that would have led to some other reality? The reality in which a boy has his mother, a father has his wife, and they get through the now – the incredibly exhausting present of having a very small child. The different reality where a small child is not fighting for a life that has only just begun – a life that now will bear no resemblance to what could have and should have been.

What needed to happen, that did not happen?

Would a solid night's sleep and a shower have made a difference?

Would less judgement about whatever choices had been made, made a difference?

Would simply knowing who to call, and where to go have changed the outcome?

This is an unnecessary and tragic loss of life – and should renew the call for Canada to do better. Over a year ago, Kirsten Patrick, then deputy editor of the Canadian Medical Association Journal pointed out that in other countries maternal deaths are analyzed on a case by case basis to identify contributing factors, and that such an approach does not happen in Canada.

Will this mother’s death serve the only purpose it can? Will it be looked at and analyzed – to determine what needed to happen that did not happen, to determine how we could possibly do better?

Will this baby, and this father – who now have suffered her loss be adequately supported going forward?

Are we doing enough right now? Really?

Moms matter. This mom mattered. Her loss is tragic, regardless of the underlying cause.