I have just returned from a weekend in Dallas, Texas, where I spent the last weekend at a breast oncoplastics course. It was an incredible course, with surgeons from all over the US, Canada, and the world gathered to learn surgical techniques from experts to improve cosmetic outcomes for our breast cancer patients. In spite of all the problems in our healthcare system, I had always considered (and still do) that our system is far superior to the US, which spends far more of its GDP on healthcare (17 % vs around 11-12 %for Canada), yet has millions of people unable to access even the most basic of care, largely due to cost. I went to a talk some years ago by Dr. Otis Brawley, the chief medical officer of the American Cancer Society. One memorable line from his talk was (paraphrased) “To call the US healthcare system a system is offensive to the word system.” And nobody is more surprised than I to be writing the above headline. But after spending three days interacting with surgeons from the US and discussing how healthcare is organized there I think there are a few things we can learn from them. Make no mistake, I don’t think we should be abandoning our one tier system, but we do need to make changes, and not small changes, BIG changes.
I am involved with the OMA, the organization which negotiates physician compensation with the government in Ontario. So different mechanisms of how physicians are paid interest me- what IS the best way to pay doctors? I asked a bunch of surgeons at the course about their work, how much call they do, how it’s set up, and how they get paid. Like most Canadians, I find asking people about how much money they make distasteful, so I avoided specific questions about actual income amounts. We also attended lectures and small groups on coding for Medicare and were able to ask lots of questions about those systems (it’s not dissimilar to the fee schedule in Ontario). Surgeons in the US have a menu of options to choose from (largely by having a larger market) regarding how they get paid. A minority worked on salary- a fixed income per year regardless of how much or how little clinical work they did. Overhead was covered, and benefits provided (this was particularly nice for maternity leave apparently). There were still expectations and accountability for these surgeons though- they didn’t sit around all day drinking coffee. I was on a salary when I worked in Australia and could relate to a lot of what they were saying- it had it’s advantages and disadvantages. There were a lot of surgeons there in “private practice”. This is largely the system used for surgeons in Canada, where you are an independent contractor (not a hospital employee) who has operating room privileges. The myth that I think we have in Canada is that surgeons who work in the US can charge whatever they want for a given procedure. This is largely untrue- it is not a free market but a regulated one. There are base medicare rates which have to be respected- for example $500 for a mastectomy (I don’t know if that is true but just as an example). Rates are then negotiated with insurance companies based on multipliers of those rates. Surgeons might receive 100%, 200%, or 300 % of the medicare base fee, depending on the insurance company, some health insurance companies being more generous than others. 300 % is almost unheard of apparently. The point of this being, the idea of having surgeons (and physicians more broadly) self select into different options as to their compensation seems to me like a good idea. Physician compensation should serve to motivate the provision of appropriate amounts of medically necessary healthcare. Fee for service (which is 70 % of what the Ontario government pays out to physicians) motivates lots of care (whether appropriate or not). Putting all physicians on flat salaries may lead to long wait lists if not appropriately structured. Per diems and capitation have similar issues. Most evidence points to a blended model of payment being the best. Of course in Canada most surgeons bill almost exclusively fee for service and don’t have a choice.
Innovation is another area we are weak on in Canada. In Dallas we learned about techniques of intraoperative radiation therapy for breast cancer, were able to work with special newly developed cavity markers, and saw machines which allowed breast cancer specimens to be xrayed within the operating room- saving OR time. Often these innovations actually provide better care while saving money- goals that are not always mutually exclusive (but can be). Too often we get into the argument in Canada about which pot the money is coming out of, which is ridiculous because in a publicly funded system IT’S ALL ONE POT! We in Canada sometimes get into the situation where one area of the hospital will not spend a dollar of their budget to save $100 dollars to the system from another budget. There is no doubt we in the north benefit from these innovations going on south of the border. The money needed to innovate in Canada seems to be in very short supply.
Moving on to a different issue, I asked one surgeon in private practice how much he operates. “Three days a week.” he said. THREE days a week?? I could only dream. I have often expressed the view that for myself as a surgeon, one day a week of elective OR time is simply not a good use of my training and expertise, and contributes to wait lists. That is a big problem in Canada- many of us surgeons would like to operate more than we do but the system is not set up for it- “under resourced” in political parlance. I asked another surgeon about what % of her referrals are patients that actually need surgery. I asked this sbecause a big problem for me is that I have to see a ton of patients, most of whom do not need surgery, to fill up my OR time. She looked at me- “Almost all of them.” “Almost all of them???”- I was incredulous. “Where do the non operative ones go?” “I don’t know” she said, “they are screened out well before they get anywhere near me.” You could have knocked me over with a feather, IMAGINE! A system where surgeons see mostly surgical cases and spend most of their time doing what they are trained to do- operate. Nirvana for a surgeon. As we have no screening process for referrals here in Canada (and are somewhat constrained in what referrals we can reject) we are obligated to see these patients. The eConsult service in Ontario is attempting to solve this problem by allowing primary care doctors online access to ask specialists if referrals are appropriate. This is an amazing service which needs to be utilized more widely.
Which leads me to the thing I most admire about the US healthcare system. Surgeons’ time (and OR time more generally) is thought of as VALUABLE. Surgeons in the US bring business (patients requiring surgery) into hospitals, and the income that comes with it. Myself, the equipment and nursing staff I require to operate (and by extension the patients I bring for surgery) are often seen as a drain to my hospital. This makes my goal as a surgeon (providing patients with appropriate surgical care) in direct conflict with the hospital’s goal of staying under budget. This happens in other areas of the hospital as well. This is a quote from Shawn Whatley’s book “No More Lethal Waits- 10 Steps to Transform Canada’s Emergency Departments”- “An efficient ED keeps physicians busy doing things that only physicians can do, all the time.” (The book is thought provoking and a worthwhile read- avaliable here- https://www.amazon.ca/dp/B01B6KFTQ2/ref=dp-kindle-redirect?_encoding=UTF8&btkr=1 ) Our ED has physicians doing paperwork and printing out forms- this is not doctor work. But because the ED docs are paid out of a separate “pot” from the hospital budget, it is “free” to the hospital (not to the system) to have the physicians do what is unit clerk (secretary) work, instead of the hospital paying for another clerk when the workload gets too high. Ridiculous. This issue is being addressed (slowly) with the funding of hospitals in Ontario moving away from global budgets to what is called “bundled payments” and other funding formulas. There is a good explanation here- http://www.cfhi-fcass.ca/Libraries/Hospital_Funding_docs/PolicyBrief_Hospital_Funding_ENG_Final.sflb.ashx I’m just a dumb surgeon, but it seems that aligning my goals with the hospitals would be a good thing.
It was clear from the weekend that surgeons, regardless of nationality, are united in the goal of providing the best care to their patients. The course recognized that while the number 1 goal of breast cancer treatment is to save lives, cosmetic outcomes are important, VERY important. And while I think the Canadian healthcare system with its universal access is worth fighting for, we need to be taking ideas and evidence from healthcare systems around the world to make ours better.