Sunday, May 15, 2016

No Bureaucrat Left Behind, Part II

The Ontario government took its lead from no less than George W. Bush in crafting Patients First - a foolhardy, bureaucracy-laden reform initiative.

And yes, like No Child Left Behind, Patients First might very well do years of damage, at great expense, before lawmakers come to their senses and scrap it.

I laid out the basics of Patients First in a previous post, and urge you to read it before proceeding. As a reminder, the controversial element of the plan is the empowerment of a local bureaucracy (Patient Care Group, sub-LHIN, or Health Links) to contract with doctors and other care providers. These contracts will ensure that people without primary care - new residents, or those whose doctors retire - are connected to a local provider, and that the providers will meet expectations for after-hours access and other metrics. Presumably, doctors that don't agree to a contract arrangement (such as docs that run free-standing walk-in clinics) will be penalized financially or denied various incentive payments.

Apart from the many unanswered questions that I laid out in the earlier post, I thought it would be worth going a bit further. Rather than pooh-pooh the plan out of hand, let's scrutinize the underlying assumptions that must hold true for Patients First to work.

1. The doctors will play along. Even if the legalities are worked out, it's hard to see doctors getting enthusiastic about this. It's more restrictions and expectations, and most likely paperwork as well. More importantly, the doctors are still working under unilateral cuts with no new contract in sight. The acrimony at some of the "Physician Engagement Sessions" is a pretty good indication of where many doctors stand.

2. The patients will play along. Despite information sheets, business cards, posters, and phone messages, it's hard to keep patients from seeking episodic care when and where they want. Some doctors have gone so far as to threaten their patients with ejection from their practices, if the patients use walk-in clinics instead of the doctors' after-hours service (and ultimately faced sanction for such a threat). If even threats don't work (or are deemed taboo), how is the government going to enforce patients seeing their own doctor after hours? This isn't an issue in small communities, but in the cities? With walk-in clinics on every other street corner? Will the patients understand the expectations placed upon them?

3. The doctors and patients will get along with each other. Let's say that Ontario's doctors agree to sign on to the Patients First initiative. Let's say there's a massive education campaign, and even the most marginalized and poorly literate patients understand what's expected of them. What happens when the doctor and patient don't see eye-to-eye? Oh come now, doctors and patients disagree all the time, you say. But what if the patient is on high-dose painkillers or sedatives - a patient highly likely to have problems finding a doctor - and the doctor won't renew the prescription? Is the patient "reassigned" to another provider? Does the doctor face a complaint to the College?

4. Using geography will work for primary care the way it does for schools. The Price-Baker report envisioned patients being guaranteed access to a primary care provider the way children are guaranteed access to the school closest to where they live. This idea is absurd on its face. Communities are planned and built expressly factoring schools into the plan. That's not at all the case with health care. Yes, a city can zone an area in advance for medical/dental offices, but who's to say what practitioner locates their office in any given location? I could move around the corner from a medical building with a pediatrician, obstetrician, rheumatologist, and prosthodontist - none of which are health care professionals I have need for. Is the province going to dictate which building a family doctor must move into? And what happens in cities like Thunder Bay, where almost all of the doctors have offices in just a handful of buildings? How is a "geographic guarantee" supposed to work there?

5. The bureaucracy can integrate seamlessly. So some areas might expand their Health Links, other areas will create sub-LHINs, and still others will put the contractual obligations upon a Community Health Centre or large Family Health Team...and all of these varied arrangements can be harmonized under the auspices of a single LHIN? When clinics work under different funding models? And their electronic records software aren't compatible with each other? And the legal details of the contracts (necessarily) differ? 

I'm a pessimist at the best of times, but I can't see how this grand scheme is even remotely plausible. There are just so...many...problems to iron out, to say nothing of the inevitable problems that will come up that can't be foreseen.

Nevertheless, the problems Patients First hopes to address are legitimate:
  • Primary care providers, particularly doctors, are poorly distributed across the province
  • People new to an area, particularly with health problems, have real problems accessing primary care
  • After-hours access to care is sub-optimal in many places across the province, with patients continuing to use the ER or walk-in clinics inappropriately or to excess
  • Doctors rarely have succession plans in place, and closure of a practice for retirement or relocation can spell disaster for isolated and/or ethnic communities
I'd planned to propose some alternative approaches to these problems here, but they'll have to keep for another day.

Next time: (I promise) more promising ways forward for primary care in Ontario

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