Ontario’s battle with pharmacies just a skirmish in light of what’s to come

TheGlobeandMail – Politics – By the looks of things, it’s the medical profession that will soon be in the Liberals’ sights
Published on Monday, Apr. 19, 2010.  By Adam Radwanski

Believe it or not, this is the easy part.

Bruising though it may be, the Ontario government’s fight with pharmacies is eminently winnable compared to what will come next in its uphill battle to rein in soaring health-care expenses.

Although a few hundred million dollars in generic drug savings is nothing to sneeze at, prescription costs are a relatively small piece of the spending puzzle. And part of the reason Dalton McGuinty’s Liberals are going after them so aggressively is to signal to the bigger puzzle pieces that, unlike in the past, they’re prepared to play hardball.

Not that Health Minister Deb Matthews is likely to wind up accusing doctors of “holding Ontarians hostage” – that would probably be less effective than levelling the charge against Shoppers Drug Mart. But by most appearances, it’s the medical profession that will soon be in the Liberals’ sights.

That will mean, in part, a fight over salaries – Ms. Matthews’s moderately reassuring words last week notwithstanding. The rather generous contract that the Ontario Medical Association signed with the province in 2008, which gave doctors a 12.25-per-cent increase over four years, expires in 2012. But negotiations, or at least posturing, will heat up well before the October, 2011, provincial election. (Given the blanketing of the area around the provincial legislature with OMA ads, one could argue the posturing has already started.)

But the Liberals’ aims seem to involve more than straightforward compensation issues.

For one thing, they want to shift some of doctors’ more basic responsibilities to less well-paid nurses, nurse practitioners and pharmacists – changes to which the OMA is resistant.And then there will be the talk about “best practices” – code for making health care more efficient by changing some of the fundamental ways that physicians go about their work.

The system as constructed gives doctors a great deal of discretion in how they diagnose and treat ailments. And it contains very few incentives to be cost-efficient.

So long as it’s not going to do any physical harm, there’s really no reason for doctors not to give as many test referrals, or write as many prescriptions, as required to make patients feel they’ve been well-served.

To demonstrate the consequence, government officials are fond of citing magnetic resonance imaging as an example. The Liberals say they spent considerable sums to buy new MRI machines. But increased access has led to more unnecessary referrals, so waiting times haven’t gone down much.

In a single-payer system, these are very difficult habits to change. And further complicating matters is the health-related scandal that overtook Queen’s Park last year.

The eHealth Ontario controversy, over expenses and untendered contracts, has mostly faded from the headlines. But it had a lasting effect in two ways that will impact clinical reform.

First, it set back the already long-delayed digitalization of the province’s health records. That means the government still has trouble collecting data on patient outcomes, which makes it harder to know how to improve efficiency.

At the same time, eHealth also cost the Liberals the services of Alan Hudson – the high-profile neurosurgeon who served as the government’s emissary in many dealings with the medical community.

His absence reinforces the biggest barrier to any government reforms of medical practices: Doctors who have spent a staggering amount of time learning and honing their craft understandably have little interest in taking instructions from politicians or bureaucrats.

With Dr. Hudson no longer in the picture, the Liberals will have to enlist other allies. They promised in last month’s Throne Speech to create an “independent, expert advisory body to provide recommendations on clinical practice guidelines,” but it remains to be seen whether they’ll succeed in recruiting top-flight medical professionals.

Time will tell, too, if the Liberals have the stomach for much of this before the next campaign, or will try to defer until after it. But it can only be so long before the next front in the health costs battle becomes clear.

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