F(r)ee for service

Once upon a time, there was a country doctor.  He had a black bag and a kindly manner and was probably only called out for births and serious illness, farming accidents etc.  For each of his services, there was a fee.  As he was a private practitioner, he had the freedom to set his fees as he saw fit.  He could charge a rich landowner more for the same service than he might charge a labourer.  He might allow a poor family to pay via a bartered good or service or not at all depending on their circumstances.  A fancy-pants city doctor in fancy-pants offices might charge premium fees to his fancy-pants clients.

When the Canadian provinces, first Saskatchewan, then BC, Alberta and Ontario, converted to a universal provincial health insurance scheme in the mid to late 1940s, all of sudden hospital-based costs and physicians were paid by the province.  The program eventually expanded to cover outpatient services as well.  Physicians had always been fee for service, and they remained largely fee for service.  I’m sure there were heated discussions at the time about whether physicians should be contracted or salaried.  I’m sure the same arguments that are bandied about today were bandied about back then.  Physicians fear that being salaried or contracted will cause them to lose their professional and personal autonomy.  They make the argument that a fee-for-service model is more egalitarian as the harder you work, the more you are paid, every physician that offers a particular service gets paid the same amount regardless of rank or seniority.

Well, I’m not sure fee-for-service payments have left us with much independence.  The provincial governments are supposed to negotiate with the physicians to set the fee schedule, both what is covered, and how much each item is worth.  That negotiation system is broken.  Provincial medical associations are rife with nepotism and have boards that are often composed of former senior government bureaucrats.  They don’t seem to be able to represent the interests of their physician members.  They are even given a mandate to negotiate on behalf of physicians that are not members…and of course, they don’t represent those adequately either.

Last month the provincial government of Ontario unilaterally slashed a bunch of fees in the schedule.  They claimed this was to trim some of the excesses brought about by surgical advancements.  They claimed, for example, that because cataract surgery takes half the time it used to, it shouldn’t be worth the same amount.  They used cataract surgery as a justification for their actions because their argument for cutting it makes sense to lay-people (and also a few physicians) but it also distracts from the other stuff that they cut.  They cut, for example, fees related to providing anesthesia services at night.  Yep, anesthesiologists’ work at 2 am when they facilitate tricky emergency operations in unoptimized and often very sick patients isn’t worth much to the McGuinty government.  Their personal sacrifices including time away from family and the disruption of circadian rhythms and fatigue is worth less and there is no possible explanation for that.  Or, has there been some technological advancement that makes midnight operations easier, faster or less risky that I just haven’t heard about?

Last week, I was scheduled to look after a list of cataract operations.  From an anesthesia point of view, a cataract doesn’t require much.  Topical drops freeze the cornea.  Some patients require a small amount of sedation but many will do just fine without any “anesthetic” intervention.  So, of course, the government thinks they shouldn’t pay much for anesthesiologists to facilitate cataract surgery.  The difficulty with this, is that most of the patients coming for cataract surgery are elderly and frail.  That day, I had a patient with near end stage pulmonary hypertension whose room air oxygen saturation was 84%.  Yep, that patient lives every day like they’re at the second or third base camp on Everest and they had the right-sided heart failure to prove it.  I had another patient who was marginally better – saturation of 85% after years and year and years of smoking and who was still currently smoking.

I also had one patient who had stopped a life-sustaining medication for the upcoming “surgery.”  I don’t know where this patient got the idea that they should stop their essential medication.  They, like any patient who has done the “wrong thing” when asked about it, acted like a sheepish school-aged child.  I didn’t want to know to be punitive, I wanted to know to stop it from happening to someone else.  Was it the surgeon’s secretary?  Or maybe their family doctor?  A straight answer was not going to be forthcoming…probably because the idea to stop the medication came from a friend or a family member or just some vague idea that it was the right thing to do.

Except it was absolutely and completely the wrong thing to do and placed this individual at considerable risk of death or disability in the next 24-48 hours.

Since I discovered this issue, it was my responsibility to sort out.  This involved STAT blood work and phone calls to the patient’s family doctor to arrange follow-up and the hospital pharmacy to identify and arrange for appropriate medical treatment.  It involved collaborating with and educating the nurses in the Day Surgery unit.  It involved a long discussion with the patient to explain the urgency and the need for appropriate follow-up care and monitoring.  In short, it required a considerable amount of time and disruption.

And it was all unpaid or free-for-service.

See, the provincial government doesn’t think I, as an anesthesiologist, have much to contribute in terms of perioperative medicine so they won’t pay for it.  Or, more chillingly, they do and are relying on my sense of beneficence and duty as a way of allowing me to continue to provide needed services for free.

Personally, I would rather be paid a sessional or daily or hourly fee than deal with the negative emotions that come from realizing that about 10-20% of what I do is unpaid.

What else could I have done with that patient?  Well, I suppose I could have sent them to the emergency department where they could have waited for a few hours to be seen and have their problem sorted out by a physician that would have been paid for their trouble.  That, of course, doesn’t serve the best interests of the patient who would have been significantly inconvenienced.  But maybe, just maybe, it would better serve all patients and the community as a whole, if I, and all my colleagues, stopped performing free services.  If we stopped covering for a broken system that is short of resources it’s shortcomings would become more apparent and the damn thing might actually get fixed.

It won’t happen though.  You can’t do anything but what looks like the “right” thing when there is a patient standing immediately in front of you.

Fee-for-service = free-for-service.


One comment

  1. Good post – the merits of a variety of pay systems have been long debated, and there continues to be little headway. I do think there will be unintended consequences, particularly in response to unilateral action.

    Add to it that there is no alternative in Canada (the UK and many other countries have parrelel private systems) and neither patients nor providers can vote with their feet…at least not without leaving the country.

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