Time to clarify health-care hierarchy

Posted on February 24, 2012 in Health Delivery System

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TheStarPhoenix.com – health
February 23, 2012.   By Mark Lemstra, Special to The StarPheonix

The government of Ontario recently received a comprehensive report from Don Drummond, former chief economist of TD Bank, on how to reduce the province’s $16-billion structural operating deficit.

The largest area of concern was, of course, healthcare costs. Ontario spends $44.8 billion per year on health care and it swallows 40 per cent of total spending. That said, Ontario actually pays a smaller percentage of its revenue towards health care than provinces such as Saskatchewan.

The reason Ontario has a problem, however, is that it doesn’t have high potash or oil prices to sustain bad public policy.

Many of the recommendations have been discussed previously in other reports. However, the discussion on physician reimbursement caught the attention of many observers, namely the Canadian Medical Association Journal and the Ontario Medical Association.

First, Drummond called for an immediate wage freeze for all physicians. Second, he suggests that physicians must be integrated into the rest of the health-care system. Currently, most physicians work as independent contractors.

Third, was a proposal that 70 per cent of physicians’ pay be on salary or capitation, with only 30 per cent reimbursed through fee for service. This is the opposite of what is in existence now.

The concept of fee for service led to his most controversial recommendation that “physician compensation, and especially performance pay, should be directly linked to positive health outcomes that are linked to strategic targets, rather than the number of interventions performed.”

In other words, reimbursement of the healthcare system should be reversed in order to focus on outcomes instead of process.

Health care is the only industry where you can directly or indirectly pay for a service without actually obtaining the desired outcome. This is contrary to how the real world operates with other goods and services. For example, when you hire an electrician, you wait for the lights to come on prior to providing payment. When you enter into a furniture store you don’t provide payment simply because someone assisted you. You exchange payment only when you have secured the new asset.

So what would happen if we asked health-care workers to receive payment only after successfully transferring a positive health outcome, such as the removal of a disease, reduction of pain, improved health status, or better quality of life?

During contract negotiations, we often hear how patients would die or suffer irreparable harm without the workers. However, if these services were that valuable, there should be no problem asking practitioners to receive payment only after a positive health outcome has been obtained.

The reality is no healthcare practitioner would agree to this form of reimbursement because there are too many non-medical determinants of health.

For example, can a doctor be held accountable for a patient not following a treatment plan or neglecting to take medications?

Should a practitioner be held responsible if a patient refuses to quit smoking, lose weight, exercise, change diet or limit alcohol consumption? Most importantly, would it be fair to hold a health-care worker to account for a patient’s social economic status, low income, poor education, unemployment, or housing insecurity?

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