Forging a new deal for doctors requires a new approach

OTTAWA, Ont. — Ontario Health Minister Erik Hoskins wants to drive down outrageous billing by doctors, including some 500 billing more than $1 million a year. His provincial efforts could have national implications.

While negotiating a new pay agreement with doctors, Hoskins sought to redistribute health spending for improved physician care.
The plan was to engage with doctors on how to more fairly allocate billing codes, to reward doctors who provide high-value care and give less to those who don't.

But Ontario's doctors voted down the tentative physician services agreement.

While most coverage has focused on those doctors who rallied against the deal, the more important story is that 45 per cent of physicians didn't even bother to participate. That turnout is particularly surprising given that the issue directly affected their salaries.

That's a remarkable level of disengagement about a contract that encompasses 25 per cent of the total provincial health expenditure. And it raises concerns about whether doctors are ready to co-manage health systems, as this agreement unprecedentedly offered.

We need a new way to approach doctor negotiations - and we desperately need a new paradigm in the delivery of physician care in Ontario and across Canada.

In the 2014 Commonwealth ranking of health systems, Canada placed 10th out of 11 countries, beating only the U.S. Canada was last for emergency room visits for conditions that could have been treated by a family doctor, 10th out of 11 for medical records/tests not reaching a doctor's office in time for an appointment, seventh for requesting duplicate tests, and 10th for hospitalized patients who returned for complications after discharge.

This is hardly an endorsement of the status quo.

Doctors will likely blame inadequate resources, ignoring the fact that Canada's health-care system is a comparative big spender and doctors are very well paid.

At least some of our poor performance internationally must be attributable to how physicians run their practices and treat patients.
How many of us have been stuck in badly-managed waiting rooms, made to feel that the attending doctor is doing us a huge favour? Or seen patient records stuffed on a shelf? Or tried to get a same-day appointment with a sick child in tow or to find out if a specialist referral has been submitted?

So is it possible for physicians to better manage our limited health-care budget, as is so desperately needed?

The likely answer is 'No,' based on the response from Ontario doctors. Clinicians are generally unwilling to make the tough rationing decisions needed in our resource-constrained world. Even if doctors were willing, most are not trained to weigh the population-level opportunity costs that are so important to such decisions.

The problem is that what's best for each patient may not be what's best for Canadians as a whole.

Clinicians' focus on their patients may harm other patients beyond their view. Each unnecessary MRI leaves less money for prescription drugs for the poor. Each antibiotic unnecessarily administered contributes to bacterial resistance that makes these medicines less effective for everyone else.

It is only human that physicians feel the 'rescue imperative' - to do everything in their power to save the patient in front of them, ignoring the opportunity costs for other merely statistical patients.

So should we give more power to doctors for the management of our health system?

Hopefully, the failure of Ontario negotiations spurs a complete rethink. Maybe we need to limit a la carte billing for doctor services and have far clearer contractual directives against cost-ineffective treatments, pointing instead towards quality, safe and high-value care.

This is the approach taken in the United Kingdom - the top performer in the Commonwealth Fund rankings. There, physicians are paid a salary and work to terms of a contract. Physicians should compete for these contracts on their ability to effectively and safely provide high-value care, and to devote a minimum number of hours per week to patients.

Canadians have been extremely patient with the status quo but deserve much better. Hoskins deserves support in crafting a new deal to get us there.

Steven J. Hoffman (@shoffmania) is an associate professor of Law and director of the Global Strategy Lab at the University of Ottawa's Centre for Health Law, Policy and Ethics and an adjunct associate professor of Global Health and Population at Harvard University. Colleen M. Flood (@ColleenFlood2) is a university research chair in Health Law and Policy and inaugural director of the Centre for Health Law, Policy and Ethics at the University of Ottawa.

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