In her “A GP for Me” plan, Health Minister Margaret MacDiarmid is promising an extra $100 million for 176,000 new patients. That works out to $568 per year per new patient, which would pay for a simple GP office visit about every three weeks for an average patient, one per month for the frail, or one visit every six weeks for complex or pregnant patients.
Especially for the frail and complex, it is unlikely that my general-practitioner colleagues can provide the medical care needed in the time made available to them per patient by these fees.
Even more worrying is that nothing was mentioned about the multiplier effect on costs of every new patient who has regular office visits and the use of services and products provided for their care by third parties: tests, hospitalizations, investigations, referrals to consultants and hospitals, drugs and supplies. Especially for frail and complex patients, the annual amount spent on third-party items equals at least tenfold the newly announced fees.
That’s at least $1 billion in additional annual health-care costs, quite a challenge for the promised “balanced budget.”
The extra services are primarily going to be provided by existing GPs, many of whom are already working more than they wish or are able to. The inevitable result is increased referral to specialists, many of whom themselves are working unreasonably long hours.
The new funds being made available to GPs “to support patients receiving hospital care” are a welcome initiative in fostering continuity of care. At $100 per week per GP, it would just about cover one hospital patient visit per week.
What, then, should be done to begin to fix our failing medicare system?
First, we might compare Canada to other countries. The Health Consumer Powerhouse and the Frontier Centre for Public Policy studied 33 European countries and Canada, using 32 indicators to rank health-care performance from a consumer’s perspective. The latest results rank Canada 25th out of 34, firmly wedged between Portugal and Slovakia, scoring well only in acute-care outcomes and cancer care (both attesting that given the tools, Canadian doctors perform second to none). This while Canada was among the highest spenders.
Looking for explanations why some countries do so well and Canada so poorly reveals some interesting facts. Countries with separation of the insurance function for medical care from its provision score high, especially if there is no direct political input.
The top-ranked countries have twice the number of doctors per population. They tend to have blended remuneration for GPs, including an annual payment for each patient registered with them and fees for multiple problems dealt with in the same visit, extensive hospital involvement of GPs, and GPs being available 24 hours a day through blocks of them operating primary-care call centres at local hospitals.
GPs are the co-ordinators of a highly integrated, efficient system that scores high for patient-friendliness, access and outcomes. The high-ranking countries spent a larger proportion of their health-care dollar on physician remuneration — net physician incomes, including for GPs, are higher than in Canada — and much less on third-party items.
They have apparently discovered that physicians are the main drivers of both the quality and costs of medical care and must be provided with the proper tools, especially sufficient time for each patient to do the interviewing, examining, reflective thinking and counseling to do their job properly, rather than have insufficient time and be forced to reach all too quickly for the test requisition or prescription pad, or refer the problem on to a consultant or the nearest emergency department.
Canada first went wrong in the 1980s, when it gradually decreased physician remuneration for non-procedural tasks, the vast majority of what doctors do, to where they now get paid 29 cents on the dollar for those activities compared to 30 years ago.
Second, in the 1990s, various provincial governments concluded that in a system of infinite demand for services by patients, a way of controlling spiralling expenditures was to limit the number of providers. The irony is that by not properly valuing physicians, the gatekeepers of more than 70 per cent of health-care costs, they have created a highly inefficient system.
British Columbians must become familiar with the facts and not believe the promises made by politicians that will not be kept and are not properly funded.
They should demand value for their money through the revamping of medicare, using principles that have been proven successful in other countries.
Gerald Tevaarwerk is a consultant specialist physician, a member of the executive and past-president of the Victoria Medical Society.
