Wednesday, April 27, 2016

A Primer on Medicine, Money, and Misery, Part IV

The typical doctor in the 2000s looked very different from her forebears.

And indeed, it is accurate to say her forebears, because by the 2000s the majority of new medical students were women. More important than being a woman, however, she was increasingly in short supply.

The Incredible Shrinking Family Doctor

Though it was likely perceived to be worse than it actually was, there was a decline in the number of doctors practicing in Canada in time for Y2K. While blamed to this day on the Barer-Stoddart recommendations and a "brain drain" of doctors to the U.S., the primary cause was actually the extension of residency for would-be family doctors from one year to two, and a relative increase in the proportion of specialists coming out of training.

The other major contributor to the perceived doctor shortage was a generational shift in how doctors, particularly family doctors, worked. Young doctors were exhausted, overburdened with debts and paperwork, and bitter about their days in residency. They were rejecting family medicine as a career choice in record numbers. And men and women alike were working fewer hours, seeing fewer patients, and cutting back on obstetrics and hospital work. Even in the cities Canadians were struggling to find a family doctor, something only rural dwellers had been familiar with until that time. Real or perceived, the shortage needed to be addressed.

Buying change, or buying the peace?

As the federal budget came into balance and even surplus in the early 2000s, the Chretien Liberal government began reinvesting in health care. During this time, two far-reaching federally-commissioned reports looked at the contemporary problems in health care, commonly known as the Kirby and Romanow reports, respectively. While both reports contained a multitude of recommendations, many from former Ministers and Deputy Ministers of health, few saw the light of day. This shouldn't really be a surprise...from the point of view of the provinces, the feds had been starving the system of money for a decade, and had little ground to stand on in suddenly attaching strings to new money.

Accordingly, the (now Martin) Liberals signed the 10-year "fix for a generation" health accord, committing billions of dollars in cash to the newly established Canada Health Transfer (CHT). Despite objections that the problems of geographic distribution and work habits of doctors weren't being addressed, the prior cuts to med school admissions and residency spots were also reversed, sending the number of Canada's doctors climbing back up.

Much of the cash infusion went to health service providers directly. Nurses' unions did very well during this time, and doctors' average incomes soared beyond the historical trend line. All told, doctors' real net incomes went up by roughly 50% from the time of the mid-90s caps through 2010, a reflection of both government largesse and the resurgent bargaining power of medical associations.

Primary Care Reform

Apart from making up for the caps and cuts of the 90s, Ontario's doctors and the province negotiated a major overhaul of the primary care system. A longtime vision of socially progressive doctors, the idea behind primary care reform (PCR) was to replace fee-for-service (FFS) family medicine with capitation, or pay-per-patient. The rationale was that FFS created incentives for "conveyor-belt medicine", emphasizing volume over quality in care. Under PCR, doctors work in teams, often alongside other professionals such as social workers and nurse practitioners. In addition to receiving a set amount for each patient on their roster, they receive quality-oriented incentives: premiums for after-hours care; bonuses for meeting targets for flu shots or mammograms; and subsidies for electronic records.

In hindsight, PCR became an object lesson in what happens when even the most well-conceived plan is put through the dirty reality of negotiation. Family doctors received an average of 25% more in gross income than their colleagues who didn't sign up for the new PCR models. Moreover, the province's Auditor General gave a mixed review to the initiative, noting deficiencies with access to after-hours care, patients continuing to see other doctors (i.e. at walk-in clinics), and a lack of monitoring and quality assurance on the part of the Ministry. These problems were still unresolved when the government stopped approving new PCR groups, and imposed substantial fee reductions on Ontario's doctors.

Still, the 2000s were good years for doctors. Their numbers were on the rise, the caps and cutbacks of the 1990s were a fading memory, and family doctors saw generous incentives to provide better, more comprehensive care. The future looked bright indeed.

Then the economy experienced an "unknown unknown".

Next time: the Great Recession and the lessons of history

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