Thursday, April 28, 2016

A Primer on Medicine, Money, and Misery, Conclusion

Some concluding thoughts as governments and doctors grapple with fiscal restraint in the 2010s

With the apparent exception of some colorful Wall Street characters (in the movie they're portrayed exactly as they're described in the book), few people saw the financial crisis of 2008 coming. Canada's banking system made it through the crisis unscathed, but its economy did not. The economic downturn hit provincial budgets hard, with the double-whammy of reduced tax revenues and increased use of poverty-relief services. With the 2004 health accord, and its generous federal cash contributions set to expire in 2014, the provinces are taking similar steps that they did in the 90s, imposing fee deals on doctors and (in the case of Ontario) re-instituting global spending caps.

There isn't much point in reviewing the details of recent and ongoing doctor-government disputes. They're still in the news, and the outcomes and aftermath won't be known for years. Instead, I thought it would be worthwhile to look back on the past 50 years, and see what lessons might be learned from this one corner of health care policy history.

  1. All of this has happened before, and will likely happen again. You can find all manner of hyperbole being written about Canada's current doctor-government conflicts. Nobody's used the dreaded "H" reference (Hitler) yet that I can see, but there's a good deal of name-calling and prognosticating about imminent system collapse. That's probably more than a stretch. Things are ugly, and in many instances the problems are being poorly managed, but there are enough people dedicated to patient care and doing right by the public to prevent the sky from falling.
  2. The power imbalance between doctors and government fluctuates. When times have been good for government finances, negotiations have produced generous settlements for Canada's doctors. This was the case when Medicare was first enacted, and again in the 1980s and mid-2000s. Moreover, doctors have done well without needing to give up a great deal of autonomy, nor solve lingering problems such as relativity. Governments don't seem inclined to flex their unilateral-action muscles until budget constraints force the issue. Acknowledging this might not only lower the temperature of the dialogue, but possibly improve relations for future negotiations. This doesn't mean doctors shouldn't be hard negotiators, but the time could be used more constructively (say, to work on medical associations' internal cohesion) than Tweeting insults ad nauseum.
  3. The will of the public must be respected, and should even be welcomed. Twice doctors have engaged in large-scale job action to protest increased socialization of medical fees (which in essence is what outlawing of user-fees and extra-billing does). Twice those job actions targeted legislation that had enormous public support and passed by overwhelming margins. Twice those job actions failed to accomplish their goal. Twice in the wake of those job actions doctors enjoyed periods of prosperity. Doctors would do well to reflect on these facts.
  4. The details of implementing a plan matter more than the plan itself. Primary Care Reform, LHINs, Barer-Stoddart, Romanow...every blueprint, commission, and strategy in health care seems to have the same fate, assuming it even gets to the point of implementation. The government implements what it can, negotiates what it must, and ignores what it doesn't like. The end result is a pile of consequences both foreseen and unforeseen, every conceivable form of waste, and a scolding from the Auditor-General. I have grave doubts about the prospects for Ontario's new primary care strategy, but that's a rant for another day.
  5. Remember who matters most. This is a corollary to #3. It is not incumbent on the medical profession, particularly as internally divided as it is, to dictate how the health care system should be run. Yes, there are many doctors, particularly new grads, unable to find satisfactory jobs that make proper use of their training. Nevertheless, they are far better off than the heaviest users of health care, who struggle from poverty, disability, mental illness, or all of the above. They are the reason public health insurance was enacted in the first place. Imposing demands on patients, charging fees, or rationing care will invariably harm the most vulnerable among us. No increase in remuneration is worth the integrity of the profession.
And that's that for now. There are always other lessons to be gleaned from history, but the loudest voices from the past are generally the ones we should heed first.

Please feel free to comment, here or on Facebook, or through Twitter @drwarsh. 

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