Before I became a medical student, I spent 2 years as an undergraduate studying mathematics. I’ve always been interested in the junction of mathematics and human behaviour.
The Stanford University student syllabus describes Game Theory as “the mathematical modeling of strategic interaction among rational (and irrational) agents.”
A classic example is the prisoner’s dilemma. Here 2 suspects of a crime are apprehended. There is enough evidence to convict both of a lesser crime but to convict either of a more serious crime, the testimony of the other prisoner is required.
Both prisoners are offered a deal. Inform on the other and go free. If the other prisoner informs but you don’t then you serve 4 years in jail. If both inform each will get 2 years and if neither informs then both serve 1 year for the lesser crime. It is assumed that both prisoners are rational and that there will be no secondary repercussions for informing.
In this simplified example it is thought that both are better off informing.
Ontario Doctors face a very similar dilemma today.
The Government of Ontario has put a hard cap on the physician services budget. It the budget is overspent, then each and every service will be paid in full (well in full is an exageration) but a ‘reconciliation’ or claw back of fees will occur. Fees that have already been reduced by 3.15% will face a second reduction to keep the total spend under the hard cap.
The reconciliation will be made according to the government’s fiscal year, April 1 to March 31. How do things stand five months into the fiscal year? Doctors have no idea as the government refuses to share utilization data.
If doctors decided to act in a mutually advantageous manner then they would each reduce their clinical activity so as keep under the hard cap.
The dilemma is that no doctor knows what the other doctors are doing. So if an individual doctor maintains or reduces her activity to keep the spend down to target but her colleagues increase their activity to maintain revenue, she will have the double hit of reduced billings while still facing a claw-back.
Like the prisoner in the game theory example she is much better off working harder so that she does not have to pay for everyone else’s increase out of proportion to her billings. It’s best to get on a billing treadmill and race against everyone else.
We saw this pattern in the early 90’s when the Rae Government used the same strategy as the Wynne Government. Each quarter saw increasing clinical activity and larger and larger claw-backs. In the end claw-backs reached %10 of gross billings and a much larger reduction in after expense income.
I don’t know what the billings have been over the past 5 months but I’ll bet dollars to donuts that they have exceeded expectations and that a large claw-back is pending.
Doctors, like the prisoners have no other choice.
I admit that the Wynne Government’s strategy will work in the short term to reduce spending. But it will make impossible rational system changes that could maintain curent spending levels and patient care. The current strategy of a hard cap and claw-backs will do nothing to improve or even maintain quality.
Scott D Wooder, MD