The Cost of Health Cuts

Up to this point, the only effect of the Government of Ontario’s unilateral health care cuts had been on my retirement fund, ie: I did not lay off any staff, all the services we offered were the same, and my hours were not reduced; I just had a significantly lesser amount to put aside for my hopeful retirement.

But today one of my patients was the unfortunate victim of the fruition of these same cuts: a delayed diagnosis by almost 3 weeks. The diagnosis in this situation turned out to be pancreatic cancer.

The patient in question is a middle aged individual who first came into my office complaining of a 2 week history of lower abdominal pain. We did some blood tests and an abdominal x-ray that did not show any abnormalities, other than a moderate amount of stool in their bowels. They returned 3 weeks later after a trial of laxatives with continued pain. At this point we ordered a CT scan at our local hospital with the request that it be done within 1 week. Unfortunately, the date they were given for their scan wasn’t for 3 weeks. On top of that, the reduced Radiology hours meant a backlog of reports to be read, and the responsible Radiologist took over 48 hours to report the scan, and only did so after an inquiring phonecall was placed.

As we attempted to contact the patient to follow-up, they informed us that they “couldn’t wait” and had already headed to a tertiary centre in the nearest major city. Since we had the news of their diagnosis, we spoke with the attending ER physician that they would be seeing to update them about the freshly reported CT scan and its diagnosis.

The point is, this time last year they would not have had to wait the 3 weeks for a CT scan that was requested to be done within 1 week, and therefore could have already be set up with a local Oncologist and surgeon to begin their management. Instead, they had to wait the extra 3 weeks, and go to a centre outside of their local area, which for sure they will be repeating the already-done investigations, adding to the cost of our bankrupt system.

Even though it was already well known that our system is broken and needs fixing, when it affects your patients this harshly, the blow is extra painful.

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The cost of access

The Ontario Ministry of Health and Long Term Care (MOHLTC), led by the Minister of Health, Dr. Eric Hoskins, under the orders of Premier Kathleen Wynne, ceased negotiations with the Family Doctors and Specialists of Ontario over one year ago. In this time, they have imposed a serious of “discounts” (their term) that have totalled anywhere from 7% to 30% depending on who you ask. They claim that doctors in Ontario are overpaid and need to do their part in reducing the provincial debt (which we could argue is a direct result of inappropriate governing by recent mandates, but that’s another story).

The reality for those in the trenches is a significant reduction in funding, which ultimately will have effects on patient care, if not already evident.

My personal whining tales of woe include a net loss of approximately $30,000 in my first 5 months of this fiscal year. That is the cost of at least one of my staff. If I let a staff member go, access to my office will be affected. And that is the topic of today’s rant: the cost of access.

Not so long ago, the Ministry complained that access to primary care doctors was poor. It still is. They urged all parties to step up their game to speed up access to their Family Doctors, and reduce waiting times in Emergency Departments. Primacy Care workers responded. Advanced access became mainstream in Family Practices, so now patients could call and get same-day appointments with higher frequency. Emergency Departments reorganized their procedures and became more efficient in seeing the wide range of patients coming in. More people were being seen quicker, and this became the new standard. As people continue to age and also live longer, more medical issues present. But since quicker access is the new normal, they were able to be seen more often and more frequently, including after hours and weekends.

The more people seen, means more tests and investigations were ordered. This also means more doctors were seeing more patients. All this adds up to higher billings. Fast forward to 2014 and the Government of Ontario complains to the MOHLTC that doctor’s billings are too high and take up too much of the health care budget. How could this not be foreseen? The obvious result of mandating doctors to see more people more frequently is more billings to the health care system. And now the doctors are being punished for giving the MOH what it wanted: greater access.

If the Ministry of Health wants to continue trying to improve patient access to doctors in Ontario, they need to return to the negotiating table with the doctors of Ontario, otherwise access will most likely be the first casualty. Once access becomes endangered, that’s when unnecessarily morbidity and mortality follows.

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Biting the hands that feed them

We all know the old cliche that says “don’t bite the hand that feeds you”. It appears that the Ontario Ministry of Health and Long Term Care (MOHLTC) may be doing just that.

Hospitals receive funding based on the number of people that use them, as well as through efficiency markers set forth by the Ministry. If a hospital sees a lot of people and gets them out of there quickly and efficiently, then a hospital gets additional funding.

At the same time, Family Doctors across Ontario are being punished for not being accessible. The MOHLTC claims that the high use of the Province’s Emergency Departments, walk-in clinics and Urgent Care Clinics is a direct result of poor accessibility to an individual’s Family Doctor (if they have one), or the inability of an individual to find a Family Doctor.

Now if the two above paragraphs are put together, a problem develops. If Family Doctors become more accessible, theoretically, less non-urgent issues will go to the Emergency Departments. This is obviously a good thing. The Emergency Departments are flooded daily with non-emergent and non-urgent issues, such as coughs, colds, sore throats, bladder infections, cuts, aches, etc.

When someone goes through triage at an ER, what is really happening is the nurse assessing this person is deciding how much of an emergency they are. A super duper emergency is labelled as a CTAS-1 (Canadian Triage & Acuity Scale). Someone who comes in for a sick note is a CTAS-5. Most people that come to the hospital vary between CTAS-2 and CTAS-4. It’s the CTAS4’s and 5’s that really have no business being in an ER. However, they are the majority of presentations each day.

If a hospital is able to quickly and efficiently get through a lot of CTAS-4’s and 5’s, it’s good for their numbers, meaning it’s good for their funding requests. If the MOHLTC gets their way, less of these people will go to the Emergency Department and they’ll see their Family Doctors. This is good, as it should theoretically reduce the wait times in the ER… Except, this means the hospitals will have reduced numbers and will be at risk of receiving reduced funding. Reduced funding means accessibility to that ER may be at risk.

Meanwhile, if Family Doctors are mandated to increase their accessibility, even with advanced access, wait times to see them may be jeopardized as well.

The Ministry is creating two vicious circles in its attempts to feed Primary Care. The losers are obvious, but the winners are less so. Perhaps this is what the Ministry wants: an excuse to withhold more funding? In these scenarios, patient care will continue to suffer.

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Ontario Medicine has gone Corporate

The medical- and surgical-driven health care provided in Ontario has gone corporate, or so it seems. Beneath the surface, of course. The Canada Health Act prohibits doctors from charging private fees for providing mandatory health care in the vast majority of cases. Some exceptions apply, most notably in Quebec, (but their MediCare service is certainly distinct!)

Hospitals in Ontario are funded by the Provincial Government, which is crying the story of no money. Stories of Governmental waste through poor decisions aside, it’s true: the Government has no money. As a result, hospitals have no money, and are now required to compete against each other to gobble up as much of the available funds as possible.

We, as health care professionals, have now been called upon by our hospital administrators, to help them “improve the numbers”, and thus rise on the rungs of the Local Health Integrated Network, the notorious LHIN, to qualify for more funding. As an aside, while I see the performance-driven motivation behind the plan, I still cannot understand how taking away money, or disqualifying struggling hospitals access to funding, will ever help said struggling hospitals from emerging from the red or improving the quality of health care to their population. If a health centre is already performing poorly, cutting beds, staff and programs is not going to save money if the people they serve no longer have access to quality – or any – health care.

Now the doctors have to play the corporate game. We have to see more people, in less time. We have to see more sickly people, ie: those with higher acuities. To summarize, we have to see more sicker people in less time. How is that helpful? How is that safe? By increasing the acuity of each patient who presents to the Emergency Department, this brings in more funds. However, with each up-triaged patient, the wait time to see them is expected to decrease. In other words, someone who presents with a CTAS-4 (non-urgent) who would normally be expected to be seen within 2 hours may be classified as a CTAS-3 (urgent); and now would be expected to be seen within 1 hour. But all the CTAS-3’s are now marked as CTAS-2’s (emergent) and have to be seen within 30 minutes. The result is that no one will be seen any faster, but the new numbers will just show that the wait times have increased. We have already seen this in the recent Ontario publication of wait times, where there has been an increase despite the Ministry of Health’s declaration to reduce wait times. And what becomes of the hospitals with the poorer wait times, in other words, the ones that need the extra help? Reduced funding!

On the medical and surgical floors, doctors have to contest with what is called “conservable days”, which means the number of days a patient should be admitted given their admission diagnosis. If someone is brought into the hospital because they have pneumonia, they are expected to be discharged home within 4 days. If for any reason said patient remains in hospital longer than 4 days, the hospital loses money for wasting the bed. The doctor is now pressured to discharge the patient by 4 days, or possibly earlier. Sometimes patients can safely go home early. Great. Often, due to the increasing number of co-morbidities (other medical issues that also affect an individual), patients cannot be safely discharged home. This is usually because of a lack of rehabilitation available in the hospital (due to lack of funding for such allied health professionals), or lack of community support to enable a safe return to the community (due to a lack of funding for such community supports). But the hospitals are under pressure to stay in the black, and the administrators put pressure on the doctors to help improve their numbers. Patient safety is what is at risk.

Our healthcare system, long financially ailing, is now reaching the point where harm will no doubt occur. Why does change to anything healthcare-related only take place when it enters crisis mode or a fatality results?!

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The domino effect of Ontario’s unilateral moves on primary care

The Province of Ontario is in debt and healthcare spending is a major cause for being in the red. Ontario needs to save money. A few years ago, Ontario attempted to negotiate a revamping of the Schedule of Fees for its doctors, but was not successful in accomplishing all the changes they desired. The agreement lasted 2 years, and Ontario’s doctors ended up agreeing to an imposed 0.5% pay cut on all of their billings during this period. This pay cut continues beyond that term of 2 years. Doctors wanted to help “do their part”.

Now with the negotiations once again being unsuccessful between the Ministry of Health and the Ontario Medical Association (OMA), we are exactly back at square one. The o.5% pay cut continues, and the Province is threatening further unilateral imposed cuts, notably increasing the 0.5% “discount” by an additional 2.65%. Family doctors are also being targeted with more of these discounts, which would total 5.65% on their overall billings. This does not include the elimination of possible billable procedures or “bonuses”.

The government wants to make this changes in order to save money by reducing the amount each doctor can bill for services. My belief is that this will unfortunately backfire and cause and overall increase in healthcare expenditure.

If these imposed deduction discounts are implemented, my practice will most likely lose in the range of $30,000-$40,000 of billings in a year. That is roughly the cost of one of my staff. Realistically, I will not end up letting go one of my staff, but adjustments would need to be made in order to continue being able to operate my practice.

Reducing our hours is an option, but this would limit access, and drive more people to the more expensive Emergency Department.

A more realistic approach to recovering the lost billings would be to cease providing “free” services to the patients. The prime example would be prescription renewals. Right now, patients can have their medications refilled without needing an appointment either by calling in or having their pharmacy fax over a request. Some practices charge a nominal $10 or $15 for this service (our’s does not). I personally receive 15-20 requests per day for refills, which would amount to about 45 minutes to 1 hour of my time each day. If we required every patient to come in to see the doctor to get their prescriptions renewed, at a minor visit billing (A001) which is currently listed at $21.70 per visit, I have been saving OHIP $434.00 per day. This amounts to just under $80,000 per year if I work 46 weeks per year. (I usually work more). And that’s just me! Think about the increase in billings if every family doctor followed suit.

Further to this example, if patients were now required to come into the office for prescription refills rather than calling in or having their pharmacy fax in a request, the demand for the family doctor’s time increases, meaning access for actual medical issues would be compromised. This translates to denials of appointment requests, and/or increased wait times to gain access to their family doctor. Ultimately, both result in more patients resorting to going back to the more expensive Emergency Department.

This will not save money, but will increase billings and healthcare spending!

As a reminder, a lot of the misconception that the Ministry of Health and Long Term Care fails to clarify to the public, is that the high costs attributed to doctor’s are the billings. Billings do not mean salaries. Family doctors in particular use the earnings from billings to pay rents and overhead for their offices, pay the salaries of their employees, and pay their expensive annual licenses (I pay north of $12,000 per year for the multitude that I’m required to have). Once business taxes are deducted from the original amount, what’s left over can be used for my own salary (which goes through further reductions via personal taxes), and savings for my eventual retirement. Don’t forget that even though doctors get paid by the Government, they are not civil servants, so that means no EI, no sick days, and no pension plan.

Perhaps it’s no wonder that many doctors choose (or may be forced) to work well past the average retirement age.

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To bill or not to bill; that’s been a question

There is no question that the costs to our healthcare system is growing to a level that is already beyond affordable. Cuts are upon us left, right and centre. The factors contributing to the rising expenses are plentiful, involving the culture of physician over-ordering investigations (part of it to ensure quicker, more accurate diagnoses, and part of it to avoid litigation out of fear of errors or delays, but we’ll save that for another posting), hospital administrative costs (which I’m sure they have their own excuses and reasoning), as well as costs attributed to patient factors. This is where we’ll focus on this posting.

One of my biggest pet peeves are impatient patients that unknowingly run up costs. If your child developed pain to their ear 20 minutes ago, it does not mean you need to be seen in the Emergency Department this instant; treating symptoms or waiting to see your family doctor would be a more reasonable option. Or, if you truly felt that you had to go to the ER, and registered and are waiting, but cannot wait any longer, leaving and driving to another hospital hoping to be seen faster is definitely not okay – this actually puts a double cost onto the system. Each time someone registers into an Emergency Department, there is an automatic cost to the provincial health fund.

A suggestion that has floated around as a means to help educate the public was to send faux bills to each person after a visit to a hospital, clinic or doctor’s office. Nothing would change in how healthcare is delivered, and no money would be sought from these faux bills. The idea is to inform each person how much their visit cost.

Hospitals in the USA send people real bills, that itemize each expense that their visit cost. If Canadian hospitals were to do the same, the theory is that the public would have an idea of the real expense that their healthcare is costing the public system. Too many people just assume that “healthcare is free”, that they (some) pay their taxes, and they’re entitled to any and every test they think is necessary.

Of course, the detractors believe that this idea would have a negative impact on overall health; that once people feel that they’re burdening the system, they’ll shy away from seeking medical attention, which may result in an adverse outcome that could have been averted had they come in.

The best case solution would be the happy median between the two. If this idea were to work out perfectly, people would think twice before coming in, and hopefully would hold off going to the Emergency Department for non-emergencies, realizing that they could get the same level of care at a cheaper cost to the healthcare budget.

Implementation of this project is nowhere near being rolled out, due to the debates and controversies. The idea does have some merit though, and could bring a new level of transparency and understanding to a public that is eager to have doctor’s billings published and available for all to see. Instead of lynching the physicians for how much they bill, perhaps it would be enlightening to see why they are billing to much, eh?

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Customer service goes both ways

Did you ever notice that when you’re nice to a customer service representative, they more often are nicer back to you, and your issue becomes more easily resolved? The same holds true with health care professionals, including paramedics, nurses and doctors.

Before I continue, not to contradict an earlier post: patients are NOT customers! But the principle of the notion still holds true in this situation. It would be nice to say that all individuals who present to the Emergency Department, or even to a clinic or doctor’s office for that matter, are all treated equally. The truth is, it’s not the case.

Like anyone in any job, I have good days and bad days. I do my best to put on a good face with an open mind when I step into a room to see a new patient. If the first thing that comes out of their mouth is something snarky, (usually a comment on how long they’ve waited to have their sore throat examined), or sometimes things bordering personal insults, it’s a bit more difficult to maintain that good face and open mind.

Please keep in mind that the quality of service is and should never be compromised. But the difference between doing that little extra versus just doing what is required can often surface in this situation.

Bottom line: be nice to your nurses and doctors, as they’re there to HELP you. And remember, you’re not the only one seeking help. You will be seen and cared for. Everyone will enjoy a more pleasant and rewarding experience if there is understanding on both ends.

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Aiding & abetting or Cradling & enabling?

The new face of primary care is all about access to care. Governments across Canada are mandating Emergency Departments to cut down on wait times. In turn, Emergency Departments complain that their long lineups are due to the growing number of non-emergent issues clogging up the resources. A solution for this bottleneckĀ  was to improve people’s access to their family doctor, more walk-in clinics, and urgent care centres.

Family doctor offices revamped their access by changing the way patients can make appointments. The new term is “advanced access”, which is basically same-day appointments. But first, a reminder of the “old” way of doing bookings: you call up and ask for an appointment to see the doctor about this or that, and usually are offered an appointment in a few weeks, or if lucky, in a few days. For the majority of issues, this is fine, but if you’re truly sick and want to be seen, you’re not going to wait the days or weeks – you’re going to go to a walk-in clinic or the Emergency Department. Otherwise, if you wait, you’ll either be better or dead by the time your appointment comes. By switching to this new system, patients now have the theoretical ability to call their doctor’s office and be seen by their doctor that same day when they need it most!

This causes frustration for some, and relief for others. Frustration for those with jobs or school where advanced knowledge of a set appointment time helps anticipate scheduling, or those who want the guaranteed security of an appointment time. Relief comes in the form of being able to be seen by your own family doctor when you need it.

The problem that comes with the advanced access system, and the theoretical improvement of wait times in the Emergency Departments as a result, is if this greater access to care has enabled people to seek out medical attention for pretty much anything and everything. The ability to cope with one’s medical issues has seemingly taken a step backwards. Once upon a time, not so long ago, when wait times in the ER were long, and it took weeks to see your family doctor, people seemingly dealt with their ailments. Albeit, there may have been those that did suffer needlessly as a result, but there would also have been a subset of people whose issues resolved over that period, and did not end up having to seek medical attention for it after all – without the suffering.

Are we helping the majority of people with this improved access to care, or are we enabling a new culture of an inability to cope?

Sufferers of mental illness are the clear benefactors of the advanced access system, as faster routes to care can certainly help settle any issues or flares more quickly before they become even more troublesome. Even those with sore throats and ear aches are better served by seeing their family doctor rather than going to the Emergency Department for these non-emergencies. But at the same time, a simple sore throat in the absence of a fever does not always need immediate attention. Nor does every indigestion or diffuse abdominal cramp. However, with increased quicker access, more and more mild and minor physical discomforts are coming in for medical attention at higher frequencies. This once again offers the question of enabling an inability to cope in these circumstances.

The camps will always be split on the better solution, with one side arguing for, and the other arguing that encouraging restraint may prevent a true medical issue from seeking care. It would be nice to defer to common sense of the individual to help determine true need from not, however, as the old adage says: common sense isn’t common.

Perhaps if Canadians understood the true cost of their healtcare visits, they may have a better understanding and appreciation of when and why to seek advice. But we’ll save that for a different entry.

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Patients are not Customers

I witnessed one of the scariest, saddest, and disappointing things recently at a departmental meeting. We were shown the results of a survey, on how patients viewed our service in our Emergency Department. While I’m not disputing the need or desire to make sure patients have an pleasant and satisfactory visit, I am worried about what satisfaction surveys may turn medicine and treatment into. The Ministry of Health and Long Term Care is leaning heavily on funding distribution based on results compiled from such surveys.

A survey asking how long someone waited in the waiting room is all relative. 3 hours waiting in one hospital might be short, whereas 2 hours in another might seem long. How can hospitals be compared against each other like this? What is more worrisome, is how surveys such as these are now driving funding and directives for hospitals. The danger is that the desire to achieve “standards” set forth by the results of these surveys, the physicians and nurses tending to the care of the new patients will be pressured to get things done “faster”, and “more polite”. Again, not to dispel the importance to ensure satisfactory experiences, the fear is that quality and safety will suffer at the hands of making sure survey results are favourable in order to secure funding.

Of course you might be thinking that this rant is due to my hospital receiving poor results and unsatisfied patients. In reality, our hospital did quite well, ranking above average in the majority of areas and our Emergency Department was ranked near the top in our province. We are very proud of the quality we provide and the service we provide to our community. What we don’t want is for quality and safety to be at risk just to satisfy what politicians want in order for them to be able to tell the public how they’re fixing health care. Good health care in the Emergency Department should not be measured by happy people who were seen faster when they have a cough; it’s having timely access to tests and specialists to help people when a serious condition arises. Let’s not jeopardize access to health care based on measurements that risk quality and safety.

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“I didn’t want to bother you”

You didn’t want to bother, yet you’re here anyways. You haven’t made an appointment or been seen by a doctor in over a year, so you’ve come in today with a laundry list of issues that have collected over the more than a dozen months. But you don’t want to bother me. At least that was your rationale when questioned why you haven’t been in sooner, or more often.

Before I continue, let’s define “bother”. If I’m out for dinner at a restaurant browsing the menu trying to decide what to eat, and you approach me to let me know you need to come see me because you’re having abnormal vaginal bleeding, you are bothering me. That’s a true story by the way.

If you call the office to make an appointment because you had a medical question, illness or concern, even if you come more than once a year (or once a month, even), it’s not a “bother”. It’s my job. It’s what I signed up to do. However, if you’ve come in, been assessed and given advice on how to manage something, but don’t use any of said advice, and return for the exact same thing shortly after, that’s being a bother.

Back to our original story; coming in with multiple issues may not always be ideal, even if you think you’re doing a favour by making it a one-stop shop or by not coming in more often. We can look at it from a few angles:

Looking at it from fellow patient’s point of view, a large factor contributing to the long wait in the waiting room is the amount of time the doctor spends with the person ahead of you. Sometimes a single issue may turn out to be more complicated than initially assumed. But sometimes when issue after issue is brought up, that takes up time. Speaking for myself, I have a hard time telling a patient to come back if they exceeded the number issues they’re “allowed” to bring up; especially since it may have taken lots of courage to mention it in the first place.

Another factor to consider is your own. If you’re waiting to come in until you have multiple issues, the original issue may be worsening to the point where it becomes more complicated to treat.

Presenting with many issues that may each themself require a devoted office visit may also prevent full attention to a particular symptom. Unfortunately, this is where doctor errors can sometimes occur.

Don’t undervalue your symptoms. If you have an issue that you’re concerned with, get it checked out, guilt-free. You’re not being a bother. But leaving things, or bringing up the shopping list of symptoms, might complicate things more than they need be.

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