Post - VOLUME 35, NO. 06, February 9, 1999
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
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 B»gin'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
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.
Medical Post On-line