HEALTH CARE DELIVERY: Rewarding excellence is the solution

Medical Post - VOLUME 35, NO. 06, February 9, 1999

HEALTH CARE DELIVERY: Rewarding excellence is the solution

By Tim Lynch

In a speech to the Empire Club last fall, Dr. William Orovan, president of the Ontario Medical Association, called for a debate on the Canada Health Act.

Dr. Orovan is courageous in challenging the Canada Health Act, given the fate that could befall his association if doctors are truly liberated. Those of us who were disciples of Monique BÈgin's defence of the Canada Health Act in the early1980s saw the "battle" through multi-coloured glasses. At the time I was director of research with the Ontario Hospital Association.

It was an era when medical leaders failed to take the pulse of the Canadian electorate. Justified or not, they encouraged doctors to charge patients (above public funding arrangements) what the doctors thought the market would bear.

This behaviour was seen as using Canada's publicly funded health-care system as a minimum income supplement scheme for people with medical degrees. Such behaviour was shown to limit access by whole sections of society. The political reality of this situation could not go unchallenged. Doctors had to choose between staying in or opting out and foregoing the privileges of membership.

There was a lot of rhetoric on both sides of the debate. The result we have today, as Dr. Orovan infers, is a health-care system that none of us can be proud of. The Canada Health Act preserves mediocrity more than it promotes excellence. It has resulted in 10 provincial Orwellian bureaucracies that impede health-care advances more than defend the rights of their constituencies. It also serves as a soapbox for federal politicians to justify their existence.

Health-care business people new to the Canadian health-care environment observe that it is intransigent to the trial of any new approach without the establishment of countless committees. While such structures represent vested interests on the payer, provider and academic side of health care, there is little evidence of a business service perspective or genuine consumer choice in the final outcome.

But while Dr. Orovan should be congratulated for calling for a debate on the Canada Health Act, he must acknowledge that a large part of the responsibility for lack in innovation lies with the provincial medical association constituencies that he represents. In their negotiations with provincial authorities, they have perpetuated a system of medical services that relates to the days when doctors practised their art from a black bag. Modern health care requires participation in a corporate health-care enterprise environment with accountability for referrals to secondary, tertiary and quaternary levels of care at time of need.

Aside from guaranteed payment, there is little difference between the way doctors individually practise medicine from their offices now than 100 years ago. They are still required to see one patient at a time in order to justify their billings. What is lacking in the current publicly funded medical services system is clear evidence that the services being billed for by physicians are always worth paying for.

Dr. Orovan argues that the unending demands of the public on doctors' time are responsible for the inefficiencies in the system. Dr. Orovan is correct. It is unreasonable for doctors to be exposed to such unlimited demands in serving the tenet of accessibility.

Canada has the only citizenry in the world that has a legal basis for demanding that any physician treat them anywhere in the country at any time, without any contractual obligations on their part. In addition, Canadians can freely demand similar services from other physicians if they are not satisfied, without any accountability for resulting costs. This level of accessibility is completely unmanageable and must be changed.

Changing access has a professional component as well as a political one. We can all appreciate the desire of physicians to preserve their autonomy as well as their guaranteed cash flow arrangements. However, such fairytale business arrangements are difficult to justify in a modern health-care enterprise.

While other sectors of the economy have adopted modern management techniques through the use of information technology to increase the worth of their businesses, the medical profession seems indifferent to such innovation. Patient demographic profiles, drug, laboratory or home-care practice utilization and referral trends, as well as measures of patient well-being, appear to have no added value to a medical practice. No other publicly funded health-care service could justify its use of allocated public funds without such accountability.

Dr. Orovan maintains that doctors are accountable to their peers. This is true in the hospital setting, where bylaws govern medical practice. However, outside the hospital, where most medical care is practised, there is no significant accountability.

A critical part of any new model has to be some structure that links accountability of both the patient and the physician in their collective use of the system. A critical component of such an agreement would need sufficient backup and continuity of care.

The claim that a solo practitioner can serve this need 100% of the time has to be challenged in terms of logistics, efficiency and continuity. A taped message directing the patient to the hospital emergency department when the doctor goes off duty does not qualify for continuity of service delivery. It adds to the cost of health care and reduces quality of service delivery.

Rather than propose that the Canadian public forsake its investment in the Canada Health Act, Dr. Orovan should present a vision of how a modern medical service enterprise could function. Such a vision should be based on rewarding competitive excellence in service delivery among the ranks of the medical profession.

Medical practice arrangements should provide equity to practitioners for knowledge gained from a lifelong practice. Corporate physician-owned entities should be permitted to compete for providing a comprehensive package of private and publicly funded health services.

If Dr. Orovan can convince us that such a vision is only possible outside the Canada Health Act, then so be it. The outcome of such leadership has to be replacing the prevailing mediocrity and malaise of the present health-care environment in Canada with consumer-driven competitive excellence in service delivery.

Tim Lynch is a health services reimbursement consultant with Info-Lynk Consulting Services in Toronto.

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