Michael Rachlis MD

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User fees are zombies

9 March 2013, 9:51 AM

I had a letter in Friday’s Globe (http://www.theglobeandmail.com/commentary/letters/march-8-canadas-own-stompin-tom-and-other-letters-to-the-editor/article9481641/ — you have to scroll down to find it.) in response to Jeffrey Simpson’s somewhat pathetic column on user fees on Wednesday (http://www.theglobeandmail.com/commentary/patient-user-fees-in-canada-hot-potato/article9317535/). Simpson is more than mischievous as he regurgitates others’ arguments for user fees.

In particular he quotes from a recent paper by Janice MacKinnon, former Saskatchewan NDP finance minister http://www.theglobeandmail.com/commentary/patient-user-fees-in-canada-hot-potato/article9317535/. MacKinnon recommends charging people for their health care use through the tax system. This would provide less deterrence than charging patients directly and would have more impact on the rich than the poor. Still, if we wish to raise more money for the system why not raise taxes on all high earners? Why would we only tax the rich who get sick?

At the University of Toronto with the Globe's Jeffrey Simpson

9 February 2013, 8:50 PM

I was on a panel at Hart House University of Toronto on Thursday February 7th with the Globe and Mail’s National Columnist Jeffrey Simpson — the topic was the sustainability of the Ontario health care system. My slide presentation available at the Publications page, concludes that health care spending is not “wildly out of control” and we need very little new money to ensure we hardly wait at all for needed health care. You can also find a picture at the publications page.

Mr. Simpson’s new book Condition Critical outlines the problems with our health system — long waits, mediocre quality, relatively high costs. His main recommendation is more for profit competition within our public financed system.

In general, Simpson toes pretty close to the conventional centre/right line:

      *     Health Care costs are wildly out of control

      *     The baby boomers will really deep six Medicare
      *     The only alternatives are to either cut real services or use more private care and finance
      *     We need an “adult conversation” to reduce our expectations and make us see the need for private involvement

Even when confronted with examples of how we could eliminate waits for care — patient co-production, high functioning teams, shared care with specialized services — Mr. Simpson doesn’t believe these really could be the norm. He doesn’t think providers, especially doctors will change the way they do their work.

I understand Mr. Simpson’s skepticism. We’ve known about these innovations for a long time. Change is hard anywhere at anytime. But, it’s been really hard to change Canada’s health care delivery system. But, I like to think that Canada could have a world class health care system if we wanted one.

I found Mr. Simpson reminded me of John Ralston Saul’s descriptions of Canada’s elite in his 2008 book “The Fair Country”. Saul refers to the “Colonial Mind” — that the Canadian elites tend to have a colonial view of insignificance within the Empire (British originally, US now) and to be focussed on the outside world for validation. I find folks like Jeffrey Simpson to have a cynical view of the Canadian potential. He can’t or doesn’t want to clarify whether he is saying we can’t do something — like eliminating wait lists with process improvement — or rather that up until recently there has been little effective implementation of these innovations.

Perhaps he is correct. But I don’t like the way he dismisses the notion that we should aspire to health care excellence with a quick knowing shrug, “tried that, too hard, let’s move on (to private care).” Let’s all prove him wrong.

Interview with University of Toronto Medical Journal

9 February 2013, 8:11 PM

You can read an interview that I recently gave to the Universithy of Toronto Medical Journal.

Filed under Interviews

The right and left of health care

29 November 2012, 6:25 PM

The political right and centre right have a clear story on the medicare issues. A) Health costs are out of control and yet care is only fair and access is poor, B) Government can’t do anything to improve efficiency and we can’t raise taxes, & C) The only hope is to go private — with the centre right asking for more for profit care within medicare and the further right also demanding private payment through user fees and private insurance, so called “two tier medicine”.

On the other hand, the traditional left-wing position has defended some services but has failed to advance the debate: A) Everything was good with medicare 30 years ago but since then budgets haven’t kept up with demand, B) Many people have inadequate care in the community because we have closed too many institutional beds, C) The feds and the provinces aren’t cracking down on illegal user charges outside of hospital, & D) We need better funded hospitals and nursing homes, enforcement of the medicare legislation and bans on for profit care.

My position is: A) health care costs are near historic highs but have been trending down the past 2-3 years as a share of GDP and of government spending. The famous un-bending cost curve has bent, B) Canada does have access problems especially outside of hospitals but these have nothing to do with medicare or its underlying values, C) Our health system’s strengths (equity in access, relative cost control) are due to public payment, Tommy Douglas’s first stage of medicare. It’s weaknesses are due to the failure to implement Tommy Douglas’s Second Stage of Medicare — a patient friendly system that aims to keep people healthy. D) Canadians should expect same day access to family physicians’ care and within one week maximum for specialist care without spending a lot more money or using for-profit care. (See my October 14, 2012  Toronto Star op ed “Canadians are ready for an adult conversation on medicare” in the publications section for more details.)

I speak to 30-40 audiences a year representing Canadians from all walks of life and I find my position on medicare is absolutely mainstream Canadian. When Canadians get the facts, they are capable of making some pretty wise decisions. Let me know how you think we can advance the Second Stage of Medicare.

The OMA deal will cost a lot more than the province is saying

16 November 2012, 3:28 PM

The media coverage has so far focussed on meta political repercussions of the OMA Provincial Government Agreement. The implications of the agreement on the province’s relations with teachers, nurses, and other public sector groups have grabbed the headlines. So far, it seems generally accepted that the Liberals have gotten away with a freeze on the $11.1 Billion bill of doctors. Yes the government coughs up another $100 Million for new doctors, but the government gets it back with a 0.5% decrease on all physician fees and other payments.

The problem with this math is that it doesn’t include utilization increases and fee drift. Utilization of medical services has been increasing at 2-3% per years per person beyond any increases in inflation or OHIP fees. Fee drift means that fee for service doctors have certain discretion to provide higher fee for time paying services if there are other threats to their incomes.

In the 1990s in Ontario and some other provinces, there was a so-called “hard cap” on billings. That meant that the province would not pay out more than a certain amount to doctors every fiscal year. As the year went on, if the total billings showed signs of breaching the agreed to or imposed figure, then the provincial medical insurance plan would start to pay only 95% or 90% of the value of claims. The old physician sponsored insurance plans in Ontario in the 1950s used to do the same thing. Otherwise you go over your budget.

But the OMA has expressly reassured its members that, “Physicians will not bear the costs associated with the increased provision of medical services to our growing and aging population (utilization).”

And, with the failure to achieve reductions in fees associated with self-referrals and other goals of negotiations, it appears that the physicians’ services budget will rise by at least $200 Million and probably more.

Finally, we don’t know yet what the parties have agreed to or will agree to on the new primary health care models such as the family health teams. The government had an aggressive plan to turn over funding for family medicine including the new family health teams to the Local health Integration Networks.

The government also planned to change the basic capitation payment system. Currently, the capitation payment of roughly $130 per year per person is only adjusted for age and sex. Younger women are worth more than younger men because they have reproductive health care issues. Middle aged and older men are worth more than older women because they tend to be sicker. But adjustment for just age and sex only explains 5-10% of the variation in costs between different persons. However, using the Johns Hopkins Ambulatory Care Groups (ACG) adjusters explains over 50% of the variation in spending. Ontario has continued to use only age sex adjusters for over twenty years after the Johns Hopkins ACG system became available. This approach essentially steals money from practices with sicker patients to over fund those with healthier people.

Hopefully more news will made available shortly about the primary health care models. But, Ontarians should really be asking why primary health care policy, so important for the future of the province’s health system, is negotiated behind closed doors with the OMA.


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