Watching “Escape Fire” on CNN this past weekend gave me pause for thought about the state of healthcare. While the documentary was about the broken healthcare system in the U.S., it was clear that our own medicare system in Canada has very similar problems, particularly in the area of primary care.
Coincidentally, finding myself immobile while on the mend from a muscle strain in my leg, I pulled out a book from the archives to read while icing down: “Freakonomics” by Steven D. Leavitt and Stephen J. Dubner. In the book, the authors propose that incentives are the cornerstone of human behaviour, and that for every great incentive scheme ever created, there is at least one person coming up with a better scheme to cheat the system.
Our medicare system’s fee-for-service structure is a classic incentive scheme. For primary care doctors (or general practitioners – GPs – as they’re more often called in Canada), the more patients they see, the more money they can bill the government (and just a reminder: that’s your money and mine!). So what could possibly be their interest in actually caring for and about the patient?
We’ve all experienced it. Before you even get a ‘hello’ from the physician’s receptionist, she’s asking you for your health card. You can barely get ten words out during your appointment before your doctor starts to walk towards the door to get his next patient. There’s no recollection of your previous conditions or treatments unless you have been diagnosed to die. I’ve always said that you are your own best advocate for your health, and I think that holds more true today than ever before. Your doctor ain’t looking out for you, my friend.
The American primary care physician who is profiled in Escape Fire says she feels the same pressure. With the threat of her clinic closing, she has to choose between pushing through more patients and spending less time with them on preventive education, or risk losing her job because she couldn’t get her billings up. Insurance companies in the U.S. (and the government in Canada) don’t typically reimburse physicians for education – important preventive measures such as nutrition counselling, for example.
Meanwhile, you can more easily get a stent placed in your heart before you can even get access to a family doctor. And heart surgeons get reimbursed quite nicely, thank you very much, leaving little money for front-line doctors who are (I would think) supposed to stop the flow of patients to specialists so that healthcare spending doesn’t continue downstream. Why do you think medical students would rather be a specialist than a GP? They’re no dummies!
There is a quote in the movie that our “healthcare system should have more ‘care’… low tech, high touch”. In Ontario, as our government tackles its deficit issues and looks at healthcare spending cuts, there is an argument for putting Ontario doctors on salary (and therefore becoming government employees) instead of fighting over how much fees should be charged for what service. Salaried doctors won’t worry about the number of procedures and focus more on the quality of patient care.
Incentives can be useful to improve productivity, but it’s this current obsession with productivity that has taken away the humanity from healthcare.
What do you think is wrong with healthcare today?