Health Care Lotteries and Sustainability Questions
We've heard rumblings from various parts of Canada regarding physicians or groups of physicians holding lotteries for access to their care due to shortages of medical providers in many parts of the country.
In Newfoundland, a lottery was held last month to allow a new family practice to "pick its caseload from among thousands of applicants".
The National Post also reported that "an Edmonton doctor selected names randomly earlier this year to pare 500 people from his heavy caseload".Jill Hefley, spokeswoman for the College of Physicians and Surgeons of Ontario has said there are "all kinds of ways that doctors are trying to deal with their patient loads" and that the CPSO is not against lotteries and other random systems for cutting back.
And so while some doctors are accused of avarice for seeing many patients using a fee-for-service funding model, I am hard pressed to understand how, with a shortage of providers of all kinds, we going to manage to service all patients requesting or requiring care.
Providing "holistic care" as Dr. Runciman prefers, spending 15-20 minutes per patient, should be appreciated but what happens to the patients who are let go? Is it better to have the patients retained in his practice having this kind of "holistic care" and others who are "lotteried out" of the practice with potentially none or is it better to have patients put through more quickly, all of them seen and the doctor to sort out who needs more investigation or referral?
As a physician, I happen to prefer the 15-20 minutes per patient approach, simply because it is less stressful for me as a provider and because most patients are satisfied with this time. However, if all physicians approached care in this way, I expect that the physician shortage would be even worse. Coupled with a nursing shortage and human resource shortages of many kinds, it is folly in my opinion to think that the "holistic" team approach, although much ballyhooed, is really the solution to sustainability in primary care.
The patients who can access it may be very satisfied...and the physicians who choose to practice this way may also be satisfied, but it doesn't address the looming larger issue which is the lack of access for the others and the cost of this kind of approach if physicians, particularly in team models, see fewer patients and work fewer hours and more layers of providers are required.
Recently the Health Council of Canada published its report, "Sustainability in Public Health Care: What does it mean?" , and also suggests that it is team-based care that in part will provide sustainability for public health care:
"..providers can be organized into teams to manage care more effectively.....The next step may be to convince medical professionals of its soundness. Given medical school's more comprehensive and integrated learning curriculum, interested champions can make this happen."
Yet, in the same report, the Health Council appears to admit that choices will need to me made regarding "wants" and "needs":
"Canada's health care system does not have adequate means of separating wants and needs. Decisions must be made about choices and limits. While limits are implicitly set in some areas already (some services are not publicly funded), an explicit ethical framework may be helpful in resolving some debates. When tough choices need to be made, both decision-makers and the public must be confident that they are made fairly".
Is a lottery for access to primary care "fair"?
What does it tell us about our system's ability to provider "universal" care?
What does a lottery tell us about our system's "sustainability"?
It would appear to me that the experts have lost sight of what is happening in the front lines of health care and while teams are fine and well, they will not be the solution to primary care sustainability and certainly not productivity issues within health care.
But some don't care just as long as they produce more reports.
I'll post the links in the comments section.
Best to all of you,
Realist
Merrilee Fullerton
155 Comments
Reader Comments (155)
Interesting that the print version had the headline "MD uses lottery to cull patients"
"culling" patients...hmmmmm...doesn't sound too good.
All in our system must participate in the state rationing program. We control the resources centrally, and we need you to ration these resources to the clients.
We have perfected an ideal state, that will last a while.
We collect all the resources (taxes) from you, we provide you free access without constraint for what we believe are the needed services , the clients (patients) have no responibility at all except to participate in our free system, and the providers must bear the responsiblity of the rationing.
We, at central, merely have to assure that no political group gains sufficient weight to drive or complain, so we are always watching the margins to make sure only small groups are impacted. It works. That why we are in control and want to maintain control.
The plan is good.
"Do not imagine, comrades, that leadership is a pleasure. On the contrary, it is a deep and heavy responsibility. No one believes more firmly than Comrade Napoleon that all animals are equal. He would be only too happy to let you make your decisions for yourselves. But sometimes you might make the wrong decisions, comrades, and then where should we be?" Chapter 5 Animal Farm
-------------------------------------
It has always been of great interest to me how those who strongly suport an ideal are so little inclined to live it themselves but nevertheless derive benefit from their support.
A well turned phrase by the CPSO. Certainly it is a positive point the the CPSO recognizes that willing collaboration is needed for our system to work. One might anticipate that those not collaborating, might be considered to be "disruptive".
The plan is good.
Decisions made by the pointy headed based on the 1991 study carried out by those prize pointy headed Barer and Stoddard plus a series of other bright decisions to impede the work of the medical profession, to make their labours more difficult and unrewarding has culminated in this 'culling' process...it is amusing that the most aggressive cullers are the FHNOTs of PCR fame that were supposed to handle 50% more patients, but have ended up likely seeing 50% less.
As Ed points out, the CPSO has stuck its snout in the collectivization of doctors process and it won't be long before doctors who decline to be collectivized will be treated as Kulaks and charged with being "disruptive" and "unprofessional"....witness what is happening in the UK where the NHS is going to bulldoze FP clinics and force them into Polyclinics, with all promises of consulting the patients before hand going out of the window...the whole situation is quite Orwellian...Animal Farm and 1984 come to mind.
Shortly thereafter the law of unintended consequences saw that many of his elderly patients left the practice in droves.
Lotteries which may randomly cut those patients who need care the most, uninviting the frequent fliers based on yearly costs, or now a two flight of stairs fitness test in order to see the doctor are all rational ways to shrink a practice. Whether or not they are ethical is a different issue, but it is clear that the phenomena of culling a practice began only after primary care reform was introduced.
Contract with the clinic is to give three months notice however she is leaving anyway.
A young physician who has been on maternity leave is going to take over her practice but how she manages to see all the patients in three morning a week is another thing.
But as I lamented one day about all the disability forms I was filling out for patients on my own dime, the same doc who is moving to Switzerland exclaimed that she mostly did well baby and well woman care anyway and hardly did any of those forms!
She gets the annual rostering fee conveniently and I don't begrudge her that however it is interesting to watch how some docs are rewarded for pseudo preventative care while others who see all comers are somehow treated as less than equal. GO figure.
mfO, I said "experts" have lost sight of the trenches....I didn't say politicians....politicians don't even seem to care about the trenches. What appears to matter to them is the optics and the votes....how the providers are managing is quite another thing.
There are many individuals who make a living churning out reports at government's behest.
The team thing is the new "cheeze whiz". It is a convenient twist to address the miserable shortages that are on us already. But it is not a solution to any sustainability issue in health care.
Now if you could show me a long term study that showed the cost-effectiveness of government organized team care (which I differentiate from team care organized amongst professionals as they see fit) in primary care with improved outcomes for patients that really decreased overall health care costs including the costs of long term care and the costs of any preventative measures, then I'd be sold.
But such study does not exist. There is no evidence that team care will be any cheaper. In fact, there is evidence to the opposite.....and how we can field enough health care providers in this search for the "holistic" approach is another question.
And if government was afraid of private care decreasing the public supply of physicians, just watch what government arranged "team work" does.
You maythink I sound like a heretic but I'm certainly not. Its just that I prefer some analytical thinking that is not paid for by government...and that seems to be in short supply these days.
In twenty years, I'll say I told you so when the costs of this team based care is shown to be more expensive than what we had before and the sad thing is that it won't make any difference at that point. The damage will be done and it will be irreversible.
Not much satisfaction saying "I told you so". Too bad.
But there is no easy way out - the future is now. All general practitioners that were willing to make the switch to capitated funding have done so, and in so doing have soaked up the majority of the good (i.e. cheap to maintain) patients.
At least we provided an alternative (well mostly thanks to the fed dollars, now dried up).
I questioned Jim McLean on this a few years ago and it was sidestepped but I think most of us know that the federal money was the motivation for the "transformation".
As someone said, the transformation is being driven by "policy" and not "evidence".
Federal sources of additional funding for provincial health care are likely to be in very short supply in the next while.
Still, many groups are clamoring for federal money for this and that...they think it is limitless.
All the while expectation of patient behaviour is almost non-existent...one way or the other.
Although the question of Medicare's physician fees garnered the most media attention, the new law includes a wide variety of other provisions, which made it the most heavily lobbied health measure of this session of Congress. Of particular significance to physicians, the measure grants bonuses of 0.5 to 2.0% to doctors who order prescriptions electronically between 2009 and 2013. Physicians who participate in Medicare but are not e-prescribing by 2012 will have their Medicare fees reduced by 2%. The law also offers additional incentives to primary care physicians to practice in underserved areas and establishes a physician-feedback program in which Medicare will use its claims data to provide confidential reports to doctors on the resources they use to care for Medicare beneficiaries.
Although the temporary fix for physician fees will alleviate the immediate concerns of many doctors, the remuneration problem remains unresolved for the longer term. No one is satisfied with the current formula by which Medicare calculates physician fees, but Congress has hesitated to act because of the hefty price tag that would be attached to any change deemed acceptable to both policymakers and physicians. Members of Congress have urged physician groups to develop their own proposals, but because any viable plan is certain to result in both winners and losers, organized medicine, too, has been reluctant to act. So for the time being, annual Band-Aids will continue to be the standard of care for Medicare's physician-payment woes.
*********
policies sometimes have unusual outcomes.....perhaps the same thing will happen here.....the cost of e-health will be staggering even with savings from adverse reactions and errors in my opinion.
MOH has been using this bait-and-switch technique for years, with the fee schedule, and more recently with all the incentive and bonus payments available exclusively to selected PC models. Has it affected a typical physician's practice? Maybe a little, but the jury is still out.
And yes, the cost of e-health will be, and already IS staggering (example - SSHA). The sad thing is, we have so little yet to show for it.
It all will come eventually - electronic prescribing, lab tests, etc. Even the EHR.
Just not by 2015.
And many physicians will go kicking and screaming - do you know there are still claims being submitted on paper forms?
Yeah, I know a space isn't a number.......
http://www.nationalpost.com/opinion/story.html?id=706993
I've been at a "consultation" this am with the Health Professions Regulatory Advisory Council regarding the expansion of scopes of practice for dieticians, physiotherapists, midwives and nurse practitioners. Unfortunately the invite was not clear about the consultation being divided up into to sessions and I missed the one with the midwives and NPs....However, what I learned gives me cause for concern.
The College of Physiotherapists is requesting additional scope of practice for its members to include amongst other things:
ordering MRIs,
Communicating a diagnosis identifying physical dysfunction, disease or disorder
and treating wounds including cleansing soaking, irrigating, probing debriding, packing or dressing the wound.
Also asking for the ability to order MRIs for the purpose of assessing or diagnosing a physical dysfunction, disease or disorder.
Also asking to be allowed to order some types of laboratory investigations including inflammatory markers and white cell counts.
Also asking to provide or order treatment in hospital.
Also asking to be able to refer to specialists.
Dieticians asking for, amongst other things, adjust insulin and oral hypoglycemic drugs, order lab tests, order diagnostics and treatments in hospitals and LTC facilities and even the authority to do "psychotherapy".
********************
I can only surmise what the midwives and nps are asking for.
It is all going to lead to fragmented care with no co-ordination of care and with the government being let off the hook for providing sufficient and developed world numbers of physicians.
With fragmented and unco-ordinated care, our health care system will undoubtedly cost even more.
Many around the table, believe that these changes will add efficiency. But the danger of chasing "efficiency" at the cost of patient safety is very real.
When I raised the issue of efficiency not trumping patient safety, a few lights came on but overall, the group of nurses, dieticians and physiotherapists thought all these suggestions would just be bringing an "open-mind" to health care.
No realization that the if checks and balances are compromised in the name of "efficiency", that there is greater potential for fragmentation of care and communication with all the dangers this entails.
I did mention that our wait time for MRIs in my area is about one year. Just imagine what the wait time would be when physiotherapists have the option of ordering directly.
If you think we have access problems now, just wait until this situation spills out into the real health care world.
Every Tom, Dick and Harriet ordering some test or diagnostic simply because of the government created shortage of physicians in the name or "rationing".
This is nuts. Sorry, no other way to put it.
Additionally, by expanding "scope of practice", it creats more pressure on denying access. I.E. who's MRI gets higher priority - the acute neurological crisis or the backpain identified during physiotherapy. Also, it will creat more demand as each new group wants to use technology to improve their service. Soon , we will get to clients ordering their own tests and services, and then seeking the right professional to fix their test result. The beauty of open access is that all becomes equally available. Thank goodness we can raise taxes to pay for all the needed free service.
You really think so? For how long is the question.
Nuts or not, here it comes. When the open access medical record is available and all professions diagnose, investicate and treat, what will medical care look like? Will this be de facto medical practice?
Remember to collaborate because
"The sustainability of Ontario's health-care system depends on the willingness of all health-care professionals to orient their practices toward interprofessional care delivery models." - CPSO Dialogue
Shudder.
Right now (correct me if I'm wrong) it's still, by and large, the GP/FP that is the entryway into the system - the majority of Ontario residents must first see a GP, and that GP might fully treat the patient, or provide a referral to a more complex level of care (which could be a specialist, or just a lab test).
But there are threats to that control, from various other special interest groups (physios, NPs, dietitians) that want to expand their ability to suck from the provincial health coffers.
That's really what it's all about, isn't it?
Oh and about the OHIP payment system - yes the source code does date from the seventies, but MAJOR changes are coming that will blow your socks off.
Watch for things like ICD-10, HL7, HIAL, XML,real-time TCP/IP-based claims submission/assessment/payment.
The future is NOW!
Errrrr, well maybe in a year or two.
That's really what it's all about, isn't it?"-Tragically OHIPster
Well, not really.
Because government in all its wisdom botched up the physician numbers so badly, it now must provide some kind of access for patients where in some instances there is none or where the access is limited either by geographic location or by human resource shortfalls.
The idea seems to be to use other providers (many of which are experiencing shortages too but that logic doesn't seem to come into much play) to develop plans that would allow more traditional medical work to be done by others ie by expanding the scope of other providers to their "full potential", improved access will result for patients.
But few seem to be understanding is that the reason there is a shortage of physicians (and nurses) in the first place is that government seeks to control costs by rationing these providers and their care.
Improving access will simply result in more costs...unless the same providers will provide more care for no more cash.
And then of course, there is self-care......with self-referrals...because isn't that the logical next step?
With the attempt to control and budget it will be ironic that access will only be improved once many people can care for and manage their own conditions...which ultimately will lead to less control by government.
But that is where things seem to be headed decades down the road.
In the meantime, watch those MRI wait times and specialist referral times grow if all these other providers are given the keys to the gate.
Should be interesting to watch it all unfold as dieticians order lab tests and adjust insulin and medications.
That fatigue and difficulty swallowing the MS patient may be experiencing may not be related to her MS....could be the squamous ca on her tongue or her occult ca that is affecting her calcium levels or myasthenia gravis or a thyroid disorder...but heck, let the physiotherapist refer to the rehab centre directly. Common things are common and the majority of patients will squeak through unscathed. But if you are a patient that differs from the usual protocol and pattern, then what is your fate? How will you feel when the physio assessing you for you MS misses the curable diagnosis? Just wondering.
Just for your interest.
Despite these comments, my impression is that CMA General Council will be less about private care and more about federal support.
Private care is likely to come through the courts in the not so distant future.
It is curious to note that Buzz Hargrove was always talking about how important it was to prevent private options for care since this would impeded the auto industry in Canada. Well, I guess there are other factors that have impeded the Canadian auto industry anyway.
Sometimes you just have to do what is necessary.
see the summary....online page 42 or document page 16
------------------------------------
"The purpose of this project was to identify patient safety or quality of care measures that are expected to be affected by changes in health care teamwork effectiveness (referred to here as teamwork-relevant measures) for three clinical areas."
"The current teamwork-training literature provides some evidence that teamwork-training programs can reduce errors in clinical
practices, but they do not provide evidence on the ultimate effects on patient outcomes other than patient satisfaction."
It is nothing of the sort.
I am hearing that the negotiations between MOHLTC and OMA are going badly. Some of you have led me to believe that the negotiations process is a sham but still wanting to believe I am asking anyway.
Rumor has it that there will be no across the board increases...only target physician groups....some will get zippo..not 1%, not 2% and not 2.5%....zippo.
So I'm wondering...if there really is any kind of negotiation going on, what is the word elsewhere on the street.
And if this is accurate then perhaps plan B is in order.
Anybody?
Some givens:
1. The maximum availble is predetermined but might have to go down as revenue predictions are shifting.
2. Much will go to special interests of the MOHLTC, with the OMA blessings.
3. Anything left will be dispersed as the OMA sees fit. They may not wish to do across the board increases.
Does anyone remember what happened the last time the MOH tried to foist a zero percent increase on the masses? Surely this would be political suicide.
The increase for 08/09 will/must be 2 percent, but will not necessarily be across the board. There are a significant number of specialist services that the MOH wishes to in fact reduce, as a result of technological change.
Really nothing substantial is going on. Be very careful of "rumours" out there from either side - they usually are just wrong, but could be the usual "trial balloons" of the "what if" type. Both sides will use these.
There are some base assumptions from the MOHLTC side:
1. This is the last contract. Future "contracts' will be the usual "union" thing arguing about COLA and perks. Any room for movement in work style, ends with this contract. So many MDs are into the "salary-like" lines they are now employees. The public now owns health care.
2. The amount available is fixed. No one is going back to the Management Board to argue for more resources. Particularly in light of the economic climate.
3. Polls show the the majority of the public believe doctors make to much, so "threats" won't be tolerated by the public.
4. No mass action by the MDs is possible. So many are doing well that they will keep working. The advantage of splintering the MDs into competing groups is that it removes the risk of mass action.
5. The MOHLTC wanted "directed money" stuff comes out first. Directions still are wanted by the MOHLTC and its advsiors and these will be funded. Some groups will do very well.
6. What's left is dispersed by the OMA not the MOHLTC so if the OMA doesn't want an across the board increase it doens't have to do that. From the MOHLTC point of view, that would be odd, but it is not the MOHLTC's problem.
7. Longterm the MOHLTC has to figure out how to expnad the OHIP pool as other providers get to dip their oars in it. It is unclear where that money will come from - it looks like from the LHINs pot right now. This is a long term issue so no need for panic yet. The OHIP pool currently isn't keeping up with the demographic changes so problems may develop.
see figue 2 page 4
http://www.aoneuro.on.ca/Political/CrisisinNeurology.pdf
Targetted attention has neglected pockets of expertise and generated rationed care through shortage.
Some say that the OMA-MOHLTC has taken a balanced overall fiscal perspective sacrificing minority interests to sell the profession a contractual agreement to ensure the continuation of involuntary membership in the OMA by the RAND.
One notes that settlement of a law suit for inadequate representation by the Ontario Radiologists is concurrent with a 30% increase in professional billings (see same figure 2). However, increases in billings attributable to workload may be buried in these figures.
But government appears to be thinking about "self-care"....look at the results of the following study:
Daily InfoPOEMs Sign up for daily InfoPOEMs!
Self-monitoring ineffective in patients with diabetes (ESMON)
Impact on physicians' practice :
90%
10%
Discuss this InfoPOEM
Clinical Question
Does self-monitoring of blood glucose improve control in patients with newly diagnosed type 2 diabetes?
Bottom line
Self-monitoring of blood glucose by newly diagnosed diabetics did not improve their glucose control over 1 year as compared with patients not performing self-monitoring. Hypoglycemic events were similar in both groups, as was the use of drug therapy. Monitoring was associated with a significant increase in depression scores. Several other studies and one meta-analysis have also shown no benefit, but this is the first study to show worsened self-reported mood in patients who monitor their blood glucose control at home. An analysis of another study of self-monitoring found that is was cost ineffective and had a negative impact on quality of life (BMJ 2008;336:1177-1180).
1b-
Reference
O'Kane MJ, Bunting B, Copeland M, Coates VE, for the ESMON study group. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ 2008;336:1174-1177.
Study design:
Randomized controlled trial (nonblinded)
Funding:
Industry + govt
Allocation:
Uncertain
Setting:
Outpatient (specialty)
Synopsis
The Irish investigators conducting this study enrolled 184 consecutive adults with newly diagnosed type 2 diabetes who were referred to a diabetes clinic. The patients were an average age of 58 years to 61 years and had a hemoglobin A1c level of 8.6% to 8.8% when diagnosed and enrolled into the study. The patients were randomized (uncertain allocation concealment) to either self-monitoring of blood glucose or no monitoring. The patients in the monitoring group were asked to check 4 fasting and 4 postprandial measurements each week (only 66% of patients performed at least 80% of these readings) and were advised on appropriate responses to high or low readings. Patients in the no monitoring group were asked not to purchase a meter. Patients were monitored every 3 months by a diabetes team who used identical treatment plans to control blood glucose, starting with metformin. Physicians of the self-monitoring patients had access to home readings, though treatment decisions were made based on hemoglobin A1c results obtained at each visit. Average hemoglobin A1c levels dropped in both groups over the course of 1 year (average 6.9 in both groups). There was no difference in hemoglobin A1c determinations at any of the every-three-month visits. The study had the power to find a 1-percentage-point difference in hemoglobin A1c between groups, if it existed. Hypoglycemic events did not occur more often in either group. On the Well-being Questionnaire, a measure of depression, anxiety, energy, and positive well-being used for patients with diabetes, self-monitoring patients had significantly higher depression scores. The anxiety scores were also higher but not statistically significant (P = .07).
. Hypoglycemic events did not occur more often in either group. On the Well-being Questionnaire, a measure of depression, anxiety, energy, and positive well-being used for patients with diabetes, self-monitoring patients had significantly higher depression scores. The anxiety scores were also higher but not statistically significant (P = .07).
************
hardly what we need....more depressed patients!
Most of the 70 year olds I know who are very healthy are likely to continue to consume acute care services into their 80's, and have no plans to fade away in a nursing home in order to save the system money as this author suggests.
http://www.theglobeandmail.com/servlet/story/LAC.20080809.SAFETYNET09//TPStory/Focus
I don't think anybody ever said that 100% of the rise in health care costs is a result of an aging population. That would be quite silly.
However, if one third of the rise in costs is attributed to the aging population (33.3%) then that is still significant when you are talking about health care spending in the billions of dollars.
"A projection done in 2002 for the Royal Commission on the Future of Health Care estimated that from 1998 to 2030, annual growth in real health-care expenditure per capita would be about 2.9 per cent. But only 0.9 per cent - a third - will be due to all those extra seniors."
Our health care expenditures are increasing for many reasons...an aging population is just one of them. Does that mean it is a problem that will cause increased financial strain? Yes it does.
Actually, for what it's worth, the 'computer' (hardware) is not vintage 1970 for the most part. (some of the old hardware is retained in order to accomodate some old fashioned claims submission methods but that is coming to an end soon too).
The problem is that the logic used by the hardware is very dated and funds have never been properly committed (despite many funding submission rounds) to disentangle and modernize the claims payment system.
The expanding and ever-evolving alphabet groups world really tests the ability of programmers and analysts to keep up with the various bells and whistles negotiated including reporting routines.
System agility is what is needed and quite doable if the committment were made to modernize. No one is holding their breath as far as I can tell although new scoping efforts are in the works....again.
There simply isn't enough funding for everything.....