On Aug. 22, a joint Ontario Ministry of Health-Ontario Medical Association committee announced the de-insurance of several medical services. It was estimated that if these cuts were fully implemented, they would save $83 million annually, roughly 0.1 per cent of the ministry’s $64-billion budget.

Like all health-care blockbuster announcements, we’ve seen this movie before, and often. In the early 1990s, the government and the OMA agreed to a similar panel that ultimately found similar paltry savings. In 1995, the CMAJ published an article of mine that said that “trying to define so-called basic services and de-insuring the rest entails the wrong diagnosis of the health-care system’s woes and then issues the wrong prescription.” The same analysis can be applied to this year’s policy release.

Of course we should stop doing things that don’t work or don’t work as well as newer ways of providing care. Doctors should know that post-coital cervical mucous testing is an outdated test for infertility, but evidently 221 doctors provided the test to 1,500 patients last year. It probably took more money for the process to de-insure than the $30,000 per year the de-insurance will save.

Many services are actually useful for some persons, if not for others. For example, the panel recommended de-listing ear-wax removal unless it is causing hearing loss and home treatment is unsuccessful, or if it is needed immediately to diagnose an ear condition.

The problem is that inappropriate care is rampant in our health-care system at the same time many patients are going without the care they need. To quote from a 1987 premier’s report chaired by Dr. John Evans: “Evidence of inappropriate care can be found throughout the province’s health-care system, from inappropriate institutional admissions to overuse of medications among the elderly.”

Thirty years later, we’re still hospitalizing patients who really need better community care. And, their medicines may have made them sick. Walk-in clinic doctors make a good living seeing people who would be better managed by a nurse, a telephone call, or just better self-care. But it’s next to impossible to find doctors to provide responsive, light-touch medical care as part of community-care interdisciplinary teams. So Canadian ERs and hospitals are overflowing with seniors who really need better out-of-hospital care.

The real diagnosis is that physicians’ services are often wasted because our system isn’t built on need. Rather, it’s based on insurance. OHIP pays a lot per hour for episodic care and low value follow-ups. It still pays poorly for working in a small team and being accessible today for people who need you.

Furthermore, there is little quality assurance by doctors to ensure that clinical decisions are justified. Ontario recently announced plans to expand its hip and knee clinics to make sure the right patients get quick CT and MRI scans. This is a good move because, in 2018, the provincial auditor noted there was little if any quality assurance for ordering these high-tech images. But what about the questionable scans ordered for other conditions, like headaches or back pain?

What we really need is better quality assurance everywhere for everything and a fundamental rebuild of community care based on our needs, not what’s on the OHIP fee-for-service list.

The right prescription for health care can also be found in previous years’ releases. The 1987 Evans panel noted: “Current submissions and earlier reports highlight the need to place greater emphasis on primary care, to integrate and co-ordinate services, to achieve a community focus for health and to increase the emphasis on health promotion and disease prevention.”

Real improvements will come from a total transformation of our system. It will require moving away from an insurance model. It will require everyone to do their work differently. That means we have to pay doctors differently as well as craft new roles for them. It will be hard work, for doctors and politicians.

De-insuring medical services and de-listing them from OHIP takes us sideways not forward.

https://www.thestar.com/opinion/contributors/2019/08/28/de-listing-medical-services-is-wrong-diagnosis-wrong-prescription-for-health-care-system.html