HealthcarePapers

HealthcarePapers 17(4) April 2018 : 41-47.doi:10.12927/hcpap.2018.25577
Commentary

Doctors and Canadian Medicare: Improving System Performance Requires System Change

Richard H. Glazier and Tara Kiran

Abstract

Many of the issues raised and insights provided by Marchildon and Sherar (2018) in their essay on doctors and Canadian medicare are on target. The inadequacy of available data on physician payment, however, calls into question the robustness of some interprovincial comparisons, and when it comes to compensation, comparisons to US physicians would be most relevant. In contrast to their assertion of a steadily increasing growth rate in physician expenditure, a more recent and longer view shows historically low growth in the past few years. Furthermore, the blame assigned to physicians and their medical associations needs to be shared with governments and most of all could be attributed to the lack of system structures and supports for improvement. New governance arrangements at the group or regional levels are needed but are insufficient in themselves. The additional features embodied in the Patient's Medical Home are essential for advancing primary care. Going even further, full population registration, greater availability of alternate payment arrangements, active participation of physicians in healthcare administration and support for meaningful measurement and feedback loops are among the changes required to transform Canadian medicare.

Marchildon and Sherar (2018) lament that the "once-sterling reputation of the Canadian medicare system has been increasingly tarnished" and seem to suggest that some of the blame lies at the feet of physicians and their medical associations. They argue that physicians are paid too much relative to others and have too little accountability. They say a lack of accountability between primary care organizations and physicians, for example, makes it difficult to "offer a coordinated continuum of service, implement electronic health records and improve quality of care and patient flow." However, these improvements depend on many system factors unrelated to physician accountability. As an example, about three-quarters of primary care physicians use electronic medical records, but very few use them to review data proactively or send patient reminders (Canada Health Infoway 2016). Physicians are often keen to use electronic medical records to improve care but have repeatedly noted barriers outside of their control (Greiver 2015; Greiver et al. 2016; Kiran 2018).

When discussing physician compensation, Marchildon and Sherar leave out important context and, as they acknowledge, rely on poor data. Their first figure suggests that there has been a steadily increasing growth rate in physician expenditure compared to a plateauing in hospital and drug expenditure. However, they present data only from 1998 to 2008. The data from 1975 to 2017 tell a different story (Figure 1). The growth in physician spending decreased during the 1980s and early 1990s, with the trend reversing in the mid-1990s. The amount Canada spends on physicians as a proportion of total health spending is about the same now as it was in 1975 (CIHI 2017) (Figure 2). Marchildon and Sherar then describe the tense negotiations between the Ontario Medical Association and the Government of Ontario. They describe the physicians voting down a tentative agreement but do not mention physician resentment of unilateral cuts imposed by government as a swaying factor.

Figure 1. Annual percentage change in spending per year, 1975–2017
Click to Enlarge

Note: Data for 2016 and 2017 are forecasts. 

Figure 2. Percentage distribution of total health expenditure by use of funds, Canada, 1975–2017


Click to Enlarge
Note: Data for 2016 and 2017 are forecasts. 

Marchildon and Sherar present physician remuneration data comparing Canada with other Organisation for Economic Co-operation and Development (OECD) countries, but the comparisons crucially leave out the US. They acknowledge the gap in data but do not acknowledge the strong influence of physician remuneration in the US. The US is our closest neighbour, and physicians can easily move to the south to practise. Available data suggest that average pay is higher for many physicians in the US compared to Canada (Laugesen and Glied 2011). Marchildon and Sherar then compare gross and net physician earnings by province. However, more complete data from Ontario provide very different estimates of gross and net physician income (Henry et al. 2012; Petch et al. 2012). For example, Marchildon and Sherar report average gross general practitioner (GP) earnings of $230K in 2015–2016, whereas other reports have estimated average gross GP earnings of $300K in 2009–2010 (Henry et al. 2012; Petch et al. 2012). These discrepancies highlight the need for more accurate data on physician remuneration.

Marchildon and Sherar describe Canadian efforts to reform primary care and note limited progress in implementing team-based care and critique how it has been implemented. We were surprised that they question whether "GPs are willing and able to coordinate the care of their patients beyond referrals involving specialists and diagnostic testing." In 2011, The College of Family Physicians of Canada released a vision for the Patient's Medical Home (CFPC 2011). The vision clearly describes how family physicians should play a central role in coordinating a comprehensive basket of services. Timely access, rostering, team-based care and blended payments are all components of a medical home mode. Emerging evidence from Canada suggests that being cared for by a family physician practising in a team setting is associated with improved diabetes care (Kiran et al. 2015) and better outcomes following hospital discharge (Riverin et al. 2017). Many family physicians across Canada are keen to adopt the Patient's Medical Home, but, in some cases, government has restricted expansion (Grant 2017).

Marchildon and Sherar are right in saying that physicians have little accountability for managing health system resources and that their decisions influence other cost drivers. However, physicians do have accountability – they are accountable to the patients they care for. Physician training and professional self-regulation reinforce our duty to individual patients. Physicians advocate for their patients, and partly for this reason, patients have trust in their physician. Not infrequently, our role as health system stewards is in tension with our duty to do what is best for the patient in front of us. Even in the absence of further accountability, governments can help us be more effective health system stewards, for example, by specifying criteria for ordering expensive tests (Fine et al. 2017) or what drugs are on the provincial formulary (Taglione et al. 2017). We need to find ways to maintain physicians' role as patient advocates while providing them with increasing opportunity to be accountable for health system resources.

The conclusion of the essay notes that "new forms of accountability tied to performance should be the focus," yet the essay provides few specific examples of how that might work or which forms of accountability might be considered. Based on the experience of other jurisdictions, we propose a number of steps that could be taken to improve the performance of Canadian medicare, many of which address system issues that go beyond physician accountability. Our main focus is on primary care physicians, but some of these steps could also apply to specialists.

Primary care is meant to be the first point of contact with the healthcare system, yet not every Canadian has a primary care provider, leaving important gaps in care. High-performing jurisdictions around the world ensure that every permanent resident is associated with a primary care provider or group (OECD and European Observatory on Health Systems and Policies 2017a, 2017b; Pesec et al. 2017), and we would recommend the same for Canadian jurisdictions as a starting point for improving Canadian medicare. This corresponds to the principle of "tight rostering" raised in the essay but goes beyond that to ensure full population coverage. We would further suggest that the care fragmentation inherent in walk-in clinics and emergency departments be addressed by aligning those services with local primary care groups that are responsible for their defined populations and in ensuring informational continuity to the patient's provider. A single electronic health record accessible to patients and providers would greatly help in those efforts. That would mean that no person or primary care provider is left behind (Kiran et al. 2016).

We further note that most high-performing health systems are not based in fee for service but rather in salaried arrangements or blended capitation, reinforcing the changes in primary care physician remuneration raised in the essay. Those alternate payments are also a key component of the Medical Home in the US (Patient Centered Primary Care Collaborative 2007) and Canada (CFPC 2011). Alternate payments readily accommodate the proactive care of defined practice populations, are more easily aligned with population and health system needs and are more able to free up physician time for quality improvement activities, interaction with team members and use of enhanced patient communications such as secure e-mail and videoconferencing (Bodenheimer et al. 2014; Institute of Medicine [US] Committee on Quality of Health Care in America 2001; Schroeder and Frist 2013). They can also provide the employment benefits such as sick leave and pension plans that many physicians would greatly appreciate and also have been associated with greater work satisfaction (CFHI 2010; Green et al. 2009). Fee-for-service reimbursement also greatly limits physicians from engaging in health system leadership as those positions are often voluntary or paid less than the value of seeing patients.

Performance measurement is essential for improvement, yet in relation to other countries, few Canadian physicians receive feedback about the care they provide or use their own electronic records for quality improvement (Commonwealth Fund 2016). Vast amounts have been spent by both governments and physicians on electronic medical records, which in most cases serve as typed patient charts but provide little other value (Clark 2016). Unlocking the data in those records at the practice and system levels holds great promise for improvement yet is absent from most government priorities. Similarly, patient experience and patient-reported outcomes are rarely collected in primary care practices or by health systems. Compiling meaningful measures from patient surveys, electronic medical records and health system data is feasible in Canadian primary care settings (Health Quality Ontario 2018) but needs the support and investment to scale and spread across the entire sector. We see roles for professional organizations, health quality agencies and governments in ensuring that practice-level data are readily available and used for practice improvement.

Apart from those in salaried arrangements, few physicians have formal accountability with any group or organization. As Marchildon and Sherar (2018) note, a lack of alignment of priorities and decision-making can contribute to dissatisfaction and inefficient care at the hospital or system level. Given the value of autonomy to physicians, we propose that accountability arrangements be physician led and voluntary. Those arrangements could be at the group or regional level, and accountability could be to local health authorities, ministries of health, quality improvement organizations or physician-led third parties. Better patient care and quality improvement would be at the core of those arrangements and the supports for measurement and improvement activities would be the draw for physicians to participate. Those arrangements, could further involve local specialists, other health sectors and social services, so they serve to enhance rather than impede integration and equity. Physicians would have the opportunity to gain leadership skills and contribute to healthcare administration at senior levels (Serio and Epperly 2006; Steyer 2009). Full population coverage by primary care would enable practice and system improvements to reach everyone.

We agree that payments and governance are crucial ingredients for improving Canadian medicare. We would go further in recommending full population registration in primary care, much greater availability of alternate payment arrangements, more participation of physicians in senior management and leadership positions, especially in primary care, support for meaningful measurement and feedback loops and voluntary local accountability and support arrangements. These recommendations are in the context of the Patient's Medical Home, taking into account local population needs and integration across health and social sectors.

About the Author(s)

Richard H. Glazier, MD, MPH, CCFP, FCFP, Institute for Clinical Evaluative Sciences, Department of Family and Community Medicine and the Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON

Tara Kiran, MD, MSc, CCFP, FCFP, Department of Family and Community Medicine and the Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Institute for Clinical Evaluative Sciences, Toronto, ON

Acknowledgment

The authors are supported as clinician scientists by the Department of Family and Community Medicine at the University of Toronto and at St. Michael's Hospital. T.K. is the Fidani Chair in Improvement and Innovation at the University of Toronto. She is also supported by the Canadian Institutes of Health Research and Health Quality Ontario as an embedded clinician researcher. The opinions, results and conclusions reported in this article are those of the authors and are independent from the funding sources.

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