Principles of Specialty Care Reform

This has been a summer of freedom for me. For the first time in 15 years, I have no role at the Ontario Medical Association except that I am a member. I’ve been a Board Member, President and been part of the Negotiation Team 3 times. I was Chair of the Negotiation Committee in 2008 and 2012.

Now I have the luxury of not doing any of those things. I have the luxury of time. I only have to look after my family practice. Now that is quite a task in and of itself, but I’ve gained over 100 days a year. I can use that time to fish, golf and garden. And I can think. Too often over the last decade I’ve been consumed in trying to make things work. Now I can sit and think about how things should be and not worry about how things are.

I also have the luxury of not being a spokesman. I speak only for myself.   Other people speak for Ontario’s doctors. And they do it very well.

In my last article, I wrote about the need to reform Care and Payment systems in Ontario. Primary Care Reform is maturing. It needs work but it is maturing. Specialty Care is behind and I firmly believe that our patients, our physicians and our payers need reform.

So what would specialty care reform look like?

Let’s start by saying that if we were designing physician care models from scratch, NO ONE would dream of putting in place our quilt work of a non-system in place.

It’s a testament to the professionalism of our physicians and other providers that things work as well as they do.

So this is a list of principles that I think should be considered. They are principles, not fully formed policies and how some of these things would be achieved is an open question.

1.Reform must be negotiated in the framework of a mutually respectful relationship between the Government and the Ontario Medical Association.

There can be no meaningful system changes imposed on either party. Both the physicians and the government have to believe in the reform or it won’t work.

Other parties will need to be involved as well. Hospitals, Local Integrated Health Networks, other providers and of course patients will all need to have input.

  1. This is about reform of care.

It will be necessary to make reform to payment systems to achieve care reform but we need to keep focused on improving care.

  1. Payments should be population based.

In primary care reform, population based funding is taken down to the individual patient and individual doctor. With specialty care it might make more sense to fund at a hospital, a community or a LIHN level.

This avoids unexpected growth in utilization because of variations in fees for service billings This is a government risk. It also recognizes that the population of Ontario is growing by 140,000 people per year. It should be structured to recognize the aging population. These last two items are current physician risks.  It makes more sense to share the risks in a responsible, negotiated manner.

By making payments based on populations served, providers can be freed to innovate. Why do we continue to insist that all clinical encounters take place face to face? It’s rooted in fee for service. Let’s get on with making care by Skype, e-mail and telephone routine.

For the individual or group there should be base funding with a modifier for volume, access and quality.

That is a blended payment model.

  1. The unique needs of high-risk populations should to be taken into account.
  2. Physicians, hospitals and LIHNs all need to be accountable to each other and to patients.

We need to put hospitals and programs where they are needed. Physicians need to work where and when there is a need for their services.

We are great at providing emergency care 24/7/365, but we have a long way to go in moving elective care out of a 9-5/Monday to Friday corridor.

  1. We need to make much better use of teams.

Patients like being cared for by teams. Physicians and other providers enjoy working in teams. The skills of every provider are leveraged.

The whole is truly bigger than the sum of the parts.

  1. Each provider should work to his or her full scope of practice.

Specialists should only rarely manage hypertension or manage cardiac risk factors, NPs should not give flu shots, pharmacists should not count pills…you get the idea. Having said all that, everyone needs to pitch in once in a while to make things work.

  1. Quality principles should be embedded in any new model of care.
  2. Patient access and patient satisfaction should be measured and improved.
  3. Academic activities are an important part of care and must be recognized.

Ontario already spends $250 million every year on an academic alternate payment plan. Let’s make sure it achieves what we want it to achieve. Let’s look at the funding levels. Teaching takes place in many non-traditional settings. Right now we don’t fully recognize teaching that takes place away from academic centers.

  1. Specialists with similar responsibility, training and hours of work should receive similar after expense income.

Want to start a lively debate amongst doctors? Mention relativity any place where two or more doctors from different specialties meet.

We have spent years trying to narrow the gap between the highest earning specialists and the lowest. We have made little of no progress. This is not a specialist-family physician issue. It’s a specialist-specialist issue.

We should not force our new graduates to choose a specialty based on future income. They should choose based on personal interest and affinity and the need of the community.

  1. We should recognize seniority

I can’t think of another job where someone on their first day of work makes the same as a 30-year veteran at the top of her profession. We should introduce a gentle gradient to recognize the increased skills of our most experienced practitioners.

  1. We should pay physicians for the non-clinical work that they well need to do to make meaningful reform happen
  2. Physicians should have the option of being self-employed independent contractors or of being employees.

We tend to assume that all physicians want to be self-employed. But I am confident that many will opt for employment, with a salary, benefits, paid vacation and a pension.

  1. Hard work and difficult clinical tasks should be rewarded.

 

This list is not meant to end the discussion. It’s meant to generate a discussion, which is something sorely lacking right now. If we continue to focus on the details of payment we are doomed to a never-ending stalemate. Let’s stop arguing about the essential components and the fee paid for individual items in the schedule of benefits.

We need to think about care and only talk about payment as it enhances that care. We need to remove barriers to excellence and stop encouraging volume.

Every physician wants to provide excellent care. I know our government wants to facilitate excellence. Our patients need reform.

Scott Douglas Wooder, MD

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