In the beginning - and by beginning I mean Ancient Greece - doctors had complete control over the fees charged to their patients. With this control, however, came a professional expectation to consider the patient's means. Not only was it for the sake of putting reputation ahead of fortune, but also out of a sense of duty to the Art of medicine. "For where there is love of man, there is also love of the art," as is written in Precepts from the Hippocratic Corpus.
Very little changed in the ensuing two millennia, until developed countries (except the U.S.) made the ethical and understandable decision that nobody should face bankruptcy from health care bills. Thus began the age of "socialized medicine". In Canada, there were two ways policymakers could have gone with regards to doctors' services: make doctors public servants, working where and how government saw fit, or have government assume the costs of medical care through an insurance kegiatan and allow doctors to remain independent. The doctors wanted their independence (and to their discredit as history would show, opposed universal health insurance), so single-payer insurance won the day.
Doctors were to be paid from the public purse, through a fee schedule derived from existing insurance plans that had been offered to the public by provincial medical associations. Medical associations would negotiate directly with government over increases in this fee or that, but fee-for-service (FFS) medicine still ruled the day as it had for over two thousand years. Doctors for the most part ran their own offices, covered their own overhead, and retained their independence.
Nowadays, people like to point fingers at the profession for opposing both public health insurance and state employment, but really...who cares? Everyone involved in those debates and decisions is long since retired, and most are dead. We're stuck with the world as it is, not as it might have been.
After decades of relative peace punctuated by the doctors' strike over extra billing, the 1990s saw the shifting landscape of doctor-government relations take a major turn for the worse. Make no mistake, the fight was about money. Between billing caps, cutbacks, location restrictions, and so on...if there was a way for a government to flex its muscle and save on payments to doctors, it happened.
Moreover, a shift away from FFS independent practice began in earnest in the 1990s. Though the infamous Barer-Stoddart report has been (incorrectly) blamed for the doctor shortage later that decade, Barer-Stoddart did focus attention on the problems associated with FFS medicine. At the time, it was principally a kasus with the funding of teaching hospitals that relied on doctors' billings, but not long afterwards FFS medicine became everyone's favorite whipping boy for all the problems that plagued health care. Thus began the move towards alternate payment plans (APPs) for doctors of ever-increasing complexity, including performance and accountability metrics. This has proven to be of dubious benefits to the citizenry, particularly in the impossible-to-control world of outpatient primary care.
The present foofaraw over small business tax is the result of an (unfortunately) added layer of complexity to the problem: the offer by the provinces to doctors of incorporation, and a variety of tax savings as a result, in lieu of a fee increase. Many thousands of doctors across Canada have taken advantage of incorporation, even structured their parental leaves and retirement savings around it. The different sides of the argument have been covered by better journalists and better advocates than me, in pretty much every corner of the media, so there's no point in rehashing them here. It is, however, worth briefly exploring the underlying problems and stalemates at the heart of the problem, without necessarily passing judgement.
First, and perhaps most importantly, modern medicine has evolved into something nobody envisioned it would ever become. For over 2000 years, people saw a doctor for a diagnostic and therapeutic opinion, derived from relatively esoteric knowledge and experience, and/or the doctor's unique technical skills i.e. surgery. Just as it does for law, accounting, and dentistry, fee-for-service reimbursement works just fine in this setting. Nobody from Asclepius down to Tommy Douglas, though, could have foreseen a world of people seeing their doctors for chronic, multi-system diseases that last years, if not decades, diagnosed and treated (and in some cases, invented) by technologies with no upper limit to their cost.
Second, the outpatient health care system is largely private. Even if they don't own their practices outright, most doctors in the community (specialists and generalists) pay a multitude of overhead expenses, including employee salaries and rent to private interests. To untangle all these arrangements and bring doctors into the public service could take a generation, if not two. Even if something could be worked out that avoids the government taking over ownership directly, such as putting doctors on salary with an "overhead allowance" based on market real estate rates, how would such a system be administered? How large a bureaucracy would be required to monitor how monies were spent? What would that cost vs. maintaining the (much-maligned) status quo?
Third, there is little evidence that the government wants doctors as salaried public employees. That would mean true unionization, an expensive proposition if ever there was one. Pensions, extended health benefits, paid vacation, banked sick days, parental leave...that's a lot of public money flowing to highly trained and highly sought-after professionals. Beyond just the cost, what government wants a union of the most educated professionals in the country? Unions are far more powerful and formidable than medical associations, which are not much more than gatherings of infighting tribes.
Fourth, and getting away from money, the power and philosophical differences inside medical associations might very well be insurmountable. Unlike unions, there is nothing that prevents doctors from holding divergent opinions on politics, except where direct patient care is at stake. Countless doctors neither like nor trust the government, and there's nothing inherently wrong with that.
Fifth, making doctors public servants will fundamentally change the character of the profession. That could be a good thing or a bad thing, depending on your point of view. But if anyone thinks that highly motivated, creative, independent overachievers will thrive in the hierarchical, bureaucratic culture of the public service, they haven't spent much time around public servants. Many doctors would fit terribly in a public service culture, and that's before getting into the practical kasus of who gets the proverbial last word in a conflict over patient care.
This leaves us where we are today: weak and divided medical associations, which the government is happy to have; unhappy doctors, which the government doesn't like but can deal with; a reality of medicine alien to the traditions of medicine; and a public that, as both client and financier of the system, is not particularly well-served as either.
So what now? When the tax changes take effect and the medical associations hash out new fee deals, what then? Should doctors make the push to come under salary? Should government?
For starters, all the tweeting and grousing doesn't seem to have moved the needle for the federal government on its taxation plans. It's much more likely that farmers and non-professional business owners will see some kind of exemption, than the government will kowtow to doctors and accountants. That means the immediate goal should be mitigating the impact of the tax changes in submissions and negotiations with the federal government. After that, doctors need affordable (i.e. membership-financed) advice and services to extricate themselves from problematic tax setups with as little pain as possible.
Next, everyone needs to acknowledge that FFS medicine, for all its problems, is what we're stuck with. We need to disabuse ourselves of any notion that salary, capitation, or APPs are "better" methods of payment, or that doctors "should" be paid in a certain way for a certain sort of work out of "duty" or "privilege". We have plenty of evidence that each has its upsides and downsides, and each is open to waste and abuse.
After that, the entire country needs to make informed decisions on what it wants and expects from the medical profession, possibly on a specialty-by-specialty basis. There are myriad levers, carrots, and sticks available to policymakers to make the situation work for both the public and doctors, so long as there's some agreement on what that situation should be.
With the exception of long-term care, there is no area of health policy that is in danger of imminent system-wide breakdown. Time, dialogue, and humility (or if you prefer, a muscular policy czar to get things done) will prove much more useful than tweeting and re-tweeting, and who knows? We might just figure out this modern medicine thing as a bonus.
Nowadays, people like to point fingers at the profession for opposing both public health insurance and state employment, but really...who cares? Everyone involved in those debates and decisions is long since retired, and most are dead. We're stuck with the world as it is, not as it might have been.
After decades of relative peace punctuated by the doctors' strike over extra billing, the 1990s saw the shifting landscape of doctor-government relations take a major turn for the worse. Make no mistake, the fight was about money. Between billing caps, cutbacks, location restrictions, and so on...if there was a way for a government to flex its muscle and save on payments to doctors, it happened.
Moreover, a shift away from FFS independent practice began in earnest in the 1990s. Though the infamous Barer-Stoddart report has been (incorrectly) blamed for the doctor shortage later that decade, Barer-Stoddart did focus attention on the problems associated with FFS medicine. At the time, it was principally a kasus with the funding of teaching hospitals that relied on doctors' billings, but not long afterwards FFS medicine became everyone's favorite whipping boy for all the problems that plagued health care. Thus began the move towards alternate payment plans (APPs) for doctors of ever-increasing complexity, including performance and accountability metrics. This has proven to be of dubious benefits to the citizenry, particularly in the impossible-to-control world of outpatient primary care.
The present foofaraw over small business tax is the result of an (unfortunately) added layer of complexity to the problem: the offer by the provinces to doctors of incorporation, and a variety of tax savings as a result, in lieu of a fee increase. Many thousands of doctors across Canada have taken advantage of incorporation, even structured their parental leaves and retirement savings around it. The different sides of the argument have been covered by better journalists and better advocates than me, in pretty much every corner of the media, so there's no point in rehashing them here. It is, however, worth briefly exploring the underlying problems and stalemates at the heart of the problem, without necessarily passing judgement.
First, and perhaps most importantly, modern medicine has evolved into something nobody envisioned it would ever become. For over 2000 years, people saw a doctor for a diagnostic and therapeutic opinion, derived from relatively esoteric knowledge and experience, and/or the doctor's unique technical skills i.e. surgery. Just as it does for law, accounting, and dentistry, fee-for-service reimbursement works just fine in this setting. Nobody from Asclepius down to Tommy Douglas, though, could have foreseen a world of people seeing their doctors for chronic, multi-system diseases that last years, if not decades, diagnosed and treated (and in some cases, invented) by technologies with no upper limit to their cost.
Second, the outpatient health care system is largely private. Even if they don't own their practices outright, most doctors in the community (specialists and generalists) pay a multitude of overhead expenses, including employee salaries and rent to private interests. To untangle all these arrangements and bring doctors into the public service could take a generation, if not two. Even if something could be worked out that avoids the government taking over ownership directly, such as putting doctors on salary with an "overhead allowance" based on market real estate rates, how would such a system be administered? How large a bureaucracy would be required to monitor how monies were spent? What would that cost vs. maintaining the (much-maligned) status quo?
Third, there is little evidence that the government wants doctors as salaried public employees. That would mean true unionization, an expensive proposition if ever there was one. Pensions, extended health benefits, paid vacation, banked sick days, parental leave...that's a lot of public money flowing to highly trained and highly sought-after professionals. Beyond just the cost, what government wants a union of the most educated professionals in the country? Unions are far more powerful and formidable than medical associations, which are not much more than gatherings of infighting tribes.
Fourth, and getting away from money, the power and philosophical differences inside medical associations might very well be insurmountable. Unlike unions, there is nothing that prevents doctors from holding divergent opinions on politics, except where direct patient care is at stake. Countless doctors neither like nor trust the government, and there's nothing inherently wrong with that.
Fifth, making doctors public servants will fundamentally change the character of the profession. That could be a good thing or a bad thing, depending on your point of view. But if anyone thinks that highly motivated, creative, independent overachievers will thrive in the hierarchical, bureaucratic culture of the public service, they haven't spent much time around public servants. Many doctors would fit terribly in a public service culture, and that's before getting into the practical kasus of who gets the proverbial last word in a conflict over patient care.
This leaves us where we are today: weak and divided medical associations, which the government is happy to have; unhappy doctors, which the government doesn't like but can deal with; a reality of medicine alien to the traditions of medicine; and a public that, as both client and financier of the system, is not particularly well-served as either.
So what now? When the tax changes take effect and the medical associations hash out new fee deals, what then? Should doctors make the push to come under salary? Should government?
For starters, all the tweeting and grousing doesn't seem to have moved the needle for the federal government on its taxation plans. It's much more likely that farmers and non-professional business owners will see some kind of exemption, than the government will kowtow to doctors and accountants. That means the immediate goal should be mitigating the impact of the tax changes in submissions and negotiations with the federal government. After that, doctors need affordable (i.e. membership-financed) advice and services to extricate themselves from problematic tax setups with as little pain as possible.
Next, everyone needs to acknowledge that FFS medicine, for all its problems, is what we're stuck with. We need to disabuse ourselves of any notion that salary, capitation, or APPs are "better" methods of payment, or that doctors "should" be paid in a certain way for a certain sort of work out of "duty" or "privilege". We have plenty of evidence that each has its upsides and downsides, and each is open to waste and abuse.
After that, the entire country needs to make informed decisions on what it wants and expects from the medical profession, possibly on a specialty-by-specialty basis. There are myriad levers, carrots, and sticks available to policymakers to make the situation work for both the public and doctors, so long as there's some agreement on what that situation should be.
With the exception of long-term care, there is no area of health policy that is in danger of imminent system-wide breakdown. Time, dialogue, and humility (or if you prefer, a muscular policy czar to get things done) will prove much more useful than tweeting and re-tweeting, and who knows? We might just figure out this modern medicine thing as a bonus.
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Wednesday, September 13, 2017
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