Tuesday, January 31, 2017

The Czar Of All Health Care, Part IV

The Czar isn't done fixing health care.

Last time, the Czar laid out a plan for dealing with the health care system's problems that are immediately at hand. We now return to the list from the first piece in the series, and deal with long-range problems within the health sector itself. As a reminder, that list of issues includes:

1. Poor geographic distribution of primary health care services
2. Excessive wait times for medically necessary diagnostic services and surgeries
3. Secular changes in the physician workforce
4. Patchwork coverage for non-medical services, including pharmaceuticals, vision care, physiotherapy, and basic dentistry
5. Costly novel technology, particularly biologic therapeutics
6. Suboptimal funding schemes and outmoded remuneration schedules
7. Corruption of medicine as a profession by industry influence, with catastrophic effects on the population
8. Incompatible EHR (electronic health records) systems

On the issues relevant to the physician workforce, primary care, and wait times, the Czar of all Health Care hereby decrees:

1. There shall be a single license for doctors valid anywhere across Canada. Complaints, billing, and disciplinary issues will remain under provincial jurisdiction.
2. Medical school tuition for citizens and permanent residents will be reduced to a level prior to its deregulation in the 1990s, adjusted for inflation.
3. Newly graduated doctors will complete a return-of-service period in a designated underserviced community for not less than two years. Failure to meet the terms of the agreement will result in a financial penalty equal to the tuition charged to foreign medical students, less the amount already paid by the student in medical school. This policy will be reviewed for compliance and effectiveness every two years.
4. The federal government shall fund a major expansion of Community Health Centres (CHCs) and training of Nurse Practitioners (NPs).
5. The federal government shall convene a national panel of experts and patient groups to develop maximum wait times for priority procedures.
6. The federal government shall finance flexible "overflow" facilities to handle cases exceeding the national benchmarks.

Not only is there poor geographic distribution of primary care services across Canada, the country faces the absurd situation of excessive wait times for procedures that lie under the purview of doctors unable to land full time employment. We need a nimble physician workforce, and the only way to bring that about is with a license that's valid nationally. The provinces can still be free to place restrictions on billing numbers and so forth, but a mobile doctor workforce can help solve problems of surge capacity, crisis response, and the chronic problem of leave coverage. As the family medicine workforce becomes younger, more female, and more family-centered, the need will only increase in the future. It's also easy to foresee physicians wishing to explore different parts of the country on a whim, while still caring for patients and earning a living.

Still, the Canadian taxpayer spends an awful lot of money training doctors, about an order of magnitude more than it spends to train NPs, and has a legitimate claim on where an how a doctor works...at least for a time. The Czar believes the solution to this problem lies in the carrot and stick of tuition. A new grad doesn't need to work in an underserviced area, but he or she can face a significant financial penalty for refusal. And before the Czar hears any crying about a new medical grad needing to be in an urban area for family obligations, spousal employment and so forth, the Czar simply notes that there are many underserved populations in cities as well: CHCs, refugee clinics, and so on. The Czar was not hired to coddle. The Czar recognizes, however, that shortfalls and distribution problems will still exist. To that end, this policy will be monitored for its impact, and there will be a major expansion of NP-staffed CHCs in the neediest remote locations.

And now we come to the Almighty Wait Times. Wait times will never get better so long as governments continue to close hospital beds, keep surgeons from operating, and piss away money on consultants' reports. And the problem will certainly not improve in the poorer provinces that struggle to recruit with their severely constrained budgets. So here's a novel idea: the feds should stop decades of penny pinching and automatically fund services that exceed national wait times standards. How? Fund flexible centres across the country to handle the overflow, staffed by none other than doctors that can't find work. And since the Czar decrees that a doctor's license should be valid nationally, there should be no difficulty finding the right people to handle the work.

On issues related to pharmaceuticals, new technologies, and the integrity of medicine, the Czar of all Health Care decrees:

1. The federal government shall make a major investment into Choosing Wisely initiatives. 
2. Tests and interventions that have no evidence based shall be removed from the list of insured services.
3. The federal government shall fund the establishment of insurance plans covering vision, basic dentistry, and a basket of essential pharmaceuticals in each province.
4. The federal government shall establish a "50/50 Fund" for novel therapeutics. When a new technology or biologic therapy is available but has not yet been insured by the provincial plan, the Fund shall match the patient's own (or a charity's) contribution on a dollar-for-dollar basis.
5. The government shall engage every physician in the country to revamp, simplify, and correct the relative fee schedules, using the Ontario model tried in the early 2000s that suffered from an abysmally low participation rate. The resulting schedule will be binding on the profession, with the "unit cost" to be negotiated between each province and its medical association. This process shall be repeated every ten years
6. The federal government shall repeal the protection of brand name pharmaceuticals under the Patent Act as passed in 1993.
7. No doctor shall be permitted to draft clinical practice guidelines if he or she has a clear conflict of interest - direct equity ownership, speaking fees, etc.
8. Canada's EHR providers will be required by law to be functionally compatible going forward. Existing EHRs will have two years to comply.

The Czar is going to piss a lot of people off here. The Czar says bring it on.

The fact is that many Canadians are undergoing tests and interventions that have no evidence basis - on the public's dime - and we're only starting to realize it. The researchers and clinicians asking these hard questions need funding, which should be looked upon as a down payment into permanent system cost savings. The biggest culprit in this waste? The brand-name drug industry and its mercenary doctors developing practice guidelines despite clear conflicts of interest. Even setting aside the financial costs to the taxpayer, the biggest travesty has been the epidemic of addiction and death. So the Czar will no longer abide drug companies making whores of the profession, and as recompense will strip them of their future profits under the patent protections they've enjoyed since the pre-NAFTA days, by reinstituting the compulsory license system that worked just fine in the preceding decades. The companies have a problem? Tell them to take it up with Purdue, makers of the scourge Oxycontin, awash in the blood of its victims.

The Czar's remaining edicts should be self-explanatory. Will relativity make doctors any happier? Probably not, but the profession can't advocate for itself until it resolves the age-old "haves" vs "have-nots" squabbles.

Next time: the Czar has thoughts on life, death, and society as a whole

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