Why not put all Ontario doctors on salary?
TheStar.com – news/canada/politics
Published Friday, May 11, 2012. By Thomas Walkom, National Affairs Columnist
Ontario physicians are angered by the provincial government’s high-handed approach to fee negotiations. Perhaps it’s time for both sides to do the obvious: End fee-for-service medicine; put doctors on salary.
Originally, the pioneers of Canadian medicare assumed that doctors would become salaried employees of government. That’s what happened in Britain when its National Health Service was established after World War II.
In Saskatchewan, the storied birthplace of Canadian medicare, an established system of salaried rural doctors already existed when Tommy Douglas’s Co-operative Commonwealth Federation (the forerunner of the New Democrats) took power in 1944.
But Douglas’ CCF didn’t follow the British example. The reason was fierce physician opposition.
Self-employed doctors — and even many salaried physicians — preferred the piecework system known as fee-for-service, one in which practitioners are paid set amounts for each procedure or consultation.
In part, this was because doctors preferred to see themselves as independent entrepreneurs.
But in part, it was because fee-for-service gives doctors great leeway in determining their own incomes. To get more money, a physician need only see or treat more patients.
Eventually, Saskatchewan’s CCF government adopted the fee-for-service variant of medicare. That in turn became the model for the entire country when medicare went national in 1968.
In spite of doctors’ initial misgivings, fee-for-service medicare turned out to be a bonanza. They could still charge piece-work rates. But their payments were guaranteed by government.
Today, however, governments don’t want to pay as much. Over the years, they have gradually eroded physicians’ fee-setting autonomy
Ontario’s government, for instance, began by negotiating overall financial settlements with the Ontario Medical Association,leaving physicians to divvy up the pot.
But that proved unsatisfactory since it allowed the most politically powerful factions within the OMA to reap the bulk of the rewards. This in turn left some areas — particularly general practice medicine — woefully underfunded.
Then governments began to involve themselves in the nitty-gritty. Premier Dalton McGuinty’s Liberals initially used carrots, giving doctors extra bonuses on top of fee-for-service in those areas of medicine where the government wanted more done.
Now, the Liberals are using sticks, threatening to unilaterally remove some of the goodies they introduced in the first place.
In short, the government is doing its best — in a rather clumsy way — to treat doctors as employees, calling upon them to do more for less.
It’s the same message Queen’s Park is giving all of its salaried workers, from teachers to prison guards.
So maybe it’s time for both sides to face what is going on. So-called alternative payment schemes (such as paying doctors on the basis of their patient rosters) have already moved the system away from pure fee-for-service. Why not go the whole way?
Incidentally, salaried docs don’t do that badly. In Britain, a general practitioner can earn up to $131,000 for a 40 hour work week. And that’s just base pay. There’s overtime and merit pay on top.
There’s also a handsome, fully inflation-indexed pension plan and up to six weeks paid holiday annually — perks that Ontario’s self-employed doctors don’t enjoy.
Best of all, the entire pay packet goes to the physician. Overhead and office costs are covered by government.
The advantage for government is that it can manage the system it funds. The advantage for doctors is they can focus on medicine.
And patients? The evidence from Britain suggests they do just fine with salaried doctors.
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