Accidental Logics: The Dynamics of Change in the Health Care Arena in the United States, Britain, and Canada

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Opinions: Scary Headlines We Don't See

What Ontarians (and their Auditor General) Should be Asking About Physician Pay

BAKER AND SCHWARTZ have provided an excellent overview of the theories and practices of wait time reduction, complemented by a summary of Ontario’s plans to reduce excess waits for cancer care. In this commentary, I pursue a number of issues implicit in their analysis and prescriptions, and revisit the logic of the origins of and solutions to wait times. People wait (involuntarily) for healthcare for two fundamental reasons: either there is not enough capacity in the system, or capacity is used inefficiently. While in Canada there is growing consensus that both causes are in play, public policy has until recently focused almost exclusively on dealing with perceived shortages. Ottawa has targeted billions of new dollars to address wait times (though how remains a mystery). Virtually every provincial government has periodically added new money – often in mid-year – to increase the number of diagnostic or surgical procedures in the hope of reducing both the number of patients waiting and the time that they wait. On the organizational front, the Saskatchewan Surgical Care Network is notable for its emphasis on inefficiency, fragmentation and a lack of transparency rather than resources alone (or even at all) as possible causes of unreasonably long wait times. Baker and Schwartz have outlined proven strategies for using resources more efficiently, among which are system redesign, such as eliminating unnecessary steps; defragmenting the entry portals into the system; and more flexible access to resources available to larger groups of people in need. These measures are intuitively sensible and, one would think, relatively straightforward to implement. But reengineering redeploys resources, and redeployment often affects providers’ (notably physicians’) incomes. In many hospitals and health regions, physician access to OR time has largely depended on the accumulation of large numbers of people on their personal wait lists. Those with the largest lists often get the most OR time; there is thus an incentive to maintain a large list. If the median or maximum waits for a physician’s patients are long, the proposed solution is invariably more OR time; if this is the case across many physicians and patient categories, the proposed solution is invariably more resources. While the story does not play out in this manner everywhere at all times, it remains more the norm than the exception. These incentives are exacerbated by the vagaries of feefor-service payment systems, which have always rewarded procedures over consultation. It is important to note that in such circumstances, neither the lists, nor the physicians’ judgment about who needs what procedure are subject to meaningful peer or other scrutiny. Despite claims that Medicare is highly regulated and severely managed, decisions about who needs and receives (particularly non-urgent) services are taken in a state of anarchy. This is more true of elective than urgent procedures, but there is a large body of Canadian research documenting huge variations in practice that persist even when known to administrators and practitioners. The results are predictable: some patients will wait a very long time; some physicians will assemble large wait lists; there will be major variation in the indications for a procedure, and a general lowering of the threshold over time; and only energetic and savvy patients will be aware that wait times vary greatly by physician and institution. One would be hard pressed to design a system more likely to produce chaos, unfairness and constant pressure to expand. There has been a more systematic approach where patients’ lives are at stake. For heart surgery and cancer treatment, there is more monitoring of wait times and usually a reasonable attempt to serve people in order of need. Often there are standardized needs assessment protocols and target wait times (some evidence-based, others not). Even here, though, there are unarticulated and unresolved dilemmas turning on the issue of need. It is simple logic that if the need for services and the supply of services match, over time and in aggregate, wait time issues should disappear. At times there will be unforeseeable clusters of need and personnel shortages or maldistributions that create temporary or location-specific problems, but the COMMENTARY

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After the Sensible Reforms, What? The Next Big Issue in Wait-Time Management

A Man for All Sections: Physicians, Heed Thy Hobbes

..........................................................................................................................................iv List of Abbreviations Used..............................................................................................................v Acknowledgements.........................................................................................................................vi Chapter 1: Introduction....................................................................................................................1 Background: Doctors and Canadian Medicare.....................................................................2 Chapter Outline.....................................................................................................................8 Chapter 2: What is Known About Physician Power?....................................................................12 Complaints..........................................................................................................................12 International Literature.......................................................................................................19 The Medical Profession as an Interest Group.....................................................................21 Popularity and Discourse....................................................................................................25 Sociology of the Professions..............................................................................................30 Tuohy and Institutionalism.................................................................................................33 Building on Tuohy’s Framework........................................................................................41 Implications........................................................................................................................46 Chapter 3: Are the Conditions Underlying Physician Power in Canada Changing?.....................50 Doctors and their Government: Reducing the State’s Reliance on Physicians for Information...................................................................................................................51 Doctors and their Patients: Diffusion of Knowledge to the Population.............................59 Doctors and their Coworkers: The Expanding Scope of Practice of Lower-Paid Health Professionals...........................................................................................................68 Chapter 4: How have Doctors Responded?...................................................................................76 Physicians’ Resistance to Scope of Practice Changes........................................................78 Their Acceptance (and Co-optation) of Certain Reforms...................................................84 Their Reaction to Technology.............................................................................................90 Mitigation, not Confrontation: What this Response Means for the Future of Physician Power..................................................................................................................................95 Chapter 5: Conclusion....................................................................................................................98 The Counterargument.......................................................................................................100

Benjamin Philip Diepeveen

Papers

Persistent power? the weakening of the medical profession's control over knowledge in canada