Private Clinics Discussion

[Rayven]

tooty, this is an interesting topic. Yes, Mourning Cloak is correct, this does not increase the no. of family docs and it is a multi-disciplinary clinic with a membership fee - that really does not want non-members.

 

The purpose of going this route is to maximize one's earnings while maintaining high standards for patients. In many cities, it is impossible to find a family doc. I would like to see a new grad in family medicine go private, opt out of the public system, and charge patients per visit. I expect that while practicing good medicine this doc will earn significantly more than being an assembly line family doc not being able to give any significant time to each patient he/she sees in the public system. Those who can afford it would prefer to have a doc who spends the time required and is never rushed. There is room for public and private. I would be hesitant to go into family medicine after all my years of study and high ideals, and so that I can pay the mortgage, the kid's private school, etc. I need to short change my patients so I have a steady assembly line flow to cover all expenses, personal and professional, etc. I would like to enjoy my practice and treat with my patients with the care they require and deserve. To me, unfortunately, this means family medicine is out, unless I were to go to the military and opt for the MOTP which is a marvelous program for those interested in family medicine.

 

The suggestion made in the website article given by Mourning Cloak is most interesting.

Two obvious questions come to my mind. First, assuming that private family docs make more money with less patients, just how many medical grads will actually want to stick to the public system? For those still working under medicare, they'll still need to see the same high volume of patients as before. It changes nothing.

 

Secondly, we're already short on family physicians. Taking FPs out of the public system would create even more patients without a FP. If a privatized FP now only needs to see 200 patients instead of 2000, that difference is now put back onto the public system.

 

Another point that was touched upon by someone (I forget who, sorry) was that people under the private healthcare system might begin to demand for a fair tax credit much like how some people get tax credits for sending their kids to private school.

 

Yes, and people with $$$ will get access regardless - tons of people fly to the US, Germany, Switzerland for cutting-edge medical treatment or simply treatment that requires too long of a wait in Canada. So really, this separation is harming the population a lot more than benefiting it, because the only people who will benefit from it already have choices.

For those who can afford to take time off work and fly off to other countries to seek treatment.. well.. this two-tier system probably won't affect them as much in that sense. They'll be able to see a family doctor sooner at most. I think the two-tier system really only benefits the high middle-class.

 

Please don't put words in my mouth. I do not justify graft or bribery as not being issues of ethics, nor do I approve of the preferential access to those givng 'gifts'. I am only stating the harsh reality as it exists.

 

I have not stated once that I agree with this "gifting program of the wealthy to their doctors". I am simply reporting the facts as they exist in large cities, but don't ask for details or proof. It does occur, this is not my opinion, and I am aware of it. I did not discuss the ethics of this or imply this is proper. Also, I don't have my head buried in the sand.

You don't justify or agree with giving doctors gifts for better service but you use that to justify paying doctors with actual money instead of just gifts to get better service which is insanely worse.

 

before you call me out of touch with reality, i'd like to point out that a huge amount of people can easily do without a extra $100 dollars/month on their disability/mental health government assistance. many people on the plan use their money unwisely, ie. buying cigarettes, alcohol, etc.

 

have you ever dealt with people receiving assistance? actually rather than ask, it is obvious that you haven't

$100/month is a lot...

 

My dad is an alcoholic and a very heavy smoker. I'm honestly not even sure if he could quit if his life depended on it.. which it may very well have.

 

whether you're willing to pay is not the question. we do not have enough family doctors. what will attract more family doctors is more money. what i believe is true is this:

 

everyone forced to pay a little --> each family doctor would earn more + lessen burden on government --> attract more family doctors in the future --> improving quality of care

 

and i was speaking about the co-payment system being superior in a hypothetical situation in support of another argument.

 

edit: oh and

Everyone forced to a pay a little..? That sounds a lot like something we already have... Taxes.

 

for you nay-sayers about 2-tier/co-pay/privatization etc, instead of pointing out problems with change (which is easy to do), how about proposing some changes yourself?

FourtyTwo nailed this on the head. Just because we might not have any ideas, it doesn't mean that any idea or your idea isn't terrible. This reminds me a lot of the Theist vs Atheist debates. "You say that you don't know how the universe began.. well, I believe God created the universe so therefore I have an answer and you don't."

 

Anyways, it's good that we can have a healthy debate/discussion on these proposed changes. It gives us all a sense of where our trains of thought could use improvement.

 

Me, personally? I'm usually all for free markets and letting the market determine prices.. however.. healthcare is a little more sacred because y'know.. life and death and all.

[Mourning Cloak]

Taking FPs out of the public system would create even more patients without a FP.

 

Interestingly, the way that the Health Canada act has been interpreted up until now (precedent law) means that you CAN'T do this.

 

It is legal to charge a fee for membership, but illegal restrict non-members from accessing the MDs within the group. If you look at the Copeman clinics, the membership fee actually covers the other services (since it's illegal to charge for services covered by medicare).

 

In other words, FPs there cannot refuse to see patients who refuse to pay for the "other services".

 

So to create true "private" clinics would require an overhaul of the legislation.

[Rayven]

And because it is one of the few markets where the point of supply is the point of demand (you need a doctor to tell you what you need to get done because they have specialized knowledge that you don't).

 

the argument tooty put forward regarding doctors making more money by looking after their patients makes sense to an extent but that relationship doesn't hold throughout all levels of effort or numbers of patients.

I agree. Usually with free markets, the articles affected by supply and demand aren't life-threatening. Believe it or not, you can live without the latest ipod. The extra 10 grams won't break your hand.

 

Interestingly, the way that the Health Canada act has been interpreted up until now (precedent law) means that you CAN'T do this.

 

It is legal to charge a fee for membership, but illegal restrict non-members from accessing the MDs within the group. If you look at the Copeman clinics, the membership fee actually covers the other services (since it's illegal to charge for services covered by medicare).

 

In other words, FPs there cannot refuse to see patients who refuse to pay for the "other services".

 

So to create true "private" clinics would require an overhaul of the legislation.

Yeah, I read the OP's article too and yours as well. So are people at Copeman clinics basically just paying for "medical personal trainers"?

 

It seems, though, people in this thread are debating two-tier, privatization, and user fees so that's what I was addressing regarding FPs being taken out of the public system.

[future_doc]

Two obvious questions come to my mind. First, assuming that private family docs make more money with less patients, just how many medical grads will actually want to stick to the public system? For those still working under medicare, they'll still need to see the same high volume of patients as before. It changes nothing.

 

Secondly, we're already short on family physicians. Taking FPs out of the public system would create even more patients without a FP. If a privatized FP now only needs to see 200 patients instead of 2000, that difference is now put back onto the public system.

 

Your points are well made and valid. The fact remains that many of us, like myself, would not consider FP b/c it is assembly line, the patients do not receive what they deserve and the practitioners in the public system are forced to come to terms with the financial realities of life and compromise. An unhealthy situation for the FP and the patients. I don't have the solution but some privatization may be a solution for some FPs and some patients. It is not the answer nor a solution to the issue and as you point out, this would create other problems and burdens to the healthcare system.

 

 

Another point that was touched upon by someone (I forget who, sorry) was that people under the private healthcare system might begin to demand for a fair tax credit much like how some people get tax credits for sending their kids to private school.

 

While true, they would be in the minority and it might not go down well on a political level, after all, if they are leaving the public system, should they be subsidized to do so and at the expense of the public purse that needs these funds? I understand the counter-argument, just bringing this to the surface.

 

 

For those who can afford to take time off work and fly off to other countries to seek treatment.. well.. this two-tier system probably won't affect them as much in that sense. They'll be able to see a family doctor sooner at most. I think the two-tier system really only benefits the high middle-class.

 

 

Medical tourism with no waiting lines may be affordable even for the middle class when lives are at stake. Medicine in India is excellent and affordable.

 

 

You don't justify or agree with giving doctors gifts for better service but you use that to justify paying doctors with actual money instead of just gifts to get better service which is insanely worse.

 

The private system does exist and doctorsd are entitled to be paid for their services. And in our public system, wealthy professionals and businessmen give all kinds of gifts discreetly, they are neither asked for or wanted, but are appreciated.

 

 

Anyways, it's good that we can have a healthy debate/discussion on these proposed changes. It gives us all a sense of where our trains of thought could use improvement.

 

Agreed:p and I like the humility:) , you don't show it normally, lol.

[Rayven]

While true, they would be in the minority and it might not go down well on a political level, after all, if they are leaving the public system, should they be subsidized to do so and at the expense of the public purse that needs these funds? I understand the counter-argument, just bringing this to the surface.

I would disagree with the wording used here. Subsidization would imply that the government is paying people to money they weren't entitled to.

 

Medical tourism with no waiting lines may be affordable even for the middle class when lives are at stake. Medicine in India is excellent and affordable.

I guess it depends on what you consider is the middle class. I always thought of my family as being middle class.. maybe even lower-middle class but still around there. I know that my parents could never afford the airfare, accommodations, and more overly the time off work to fly to India for medical treatment. If it was life and death, we'd definitely have to sell the house after coming home from India.

 

The private system does exist and doctorsd are entitled to be paid for their services. And in our public system, wealthy professionals and businessmen give all kinds of gifts discreetly, they are neither asked for or wanted, but are appreciated.

I don't understand your counter-argument here at all. To reiterate, my argument was:

 

"You don't justify or agree with giving doctors gifts for better service but you use that to justify paying doctors with actual money instead of just gifts to get better service which is insanely worse."

 

Is your counter-argument that people like to receive gifts....? =.=

 

Agreed:p and I like the humility:) , you don't show it normally, lol.

Are you.. hitting.. on.. me..??

[Rayven]

You.. reposted...

[future_doc]

You.. reposted...

 

Seriously, thank you for bringing this to my attention.

 

But I still don't understand, jk

[future_doc]

Are you.. hitting.. on.. me..??

 

As you are an intelligent man, I don't need to answer that one. BTW, are you one of those fat guys, not that you need to answer. My personal preference relates to values, humility, sense of humour, intelligence, sense of purpose, accomplishments and looks come in last, fat is fine. Values and deeds tell you more than superficiality that does not last.

[Rayven]

As you are an intelligent man, I don't need to answer that one. BTW, are you one of those fat guys, not that you need to answer. My personal preference relates to values, humility, sense of humour, intelligence, sense of purpose, accomplishments and looks come in last, fat is fine. Values and deeds tell you more than superficiality that does not last.

Well that's just too bad then.

[future_doc]

Well that's just too bad then.

 

(Rayven)

[tooty]

Rayven, you, like fourtytwo, misunderstood and misread my posts. they were pretty simple..

 

1) i asked the nay-sayers to propose some changes so that we can have a balanced discussion, not just proposals from our end and attacks from your end

 

2) a little from everyone doesn't equal taxes. taxing isn't working. we need to pay directly to the doctors. read my posts again.

[future_doc]

whether you're willing to pay is not the question. we do not have enough family doctors. what will attract more family doctors is more money. what i believe is true is this:

 

everyone forced to pay a little --> each family doctor would earn more + lessen burden on government --> attract more family doctors in the future --> improving quality of care

 

 

And if the public is not forced to pay a little each family, then the government needs to come up with more money using whatever formula would work to both attract more FPs and improve the quality of care given.

 

Wouldn't preventitive care lessen the burden?

[future_doc]

Interestingly enough getting paid more can lead to LESS work. This happens with incomes that are really high, and will in fact lead to increase in the labor force in the long run but not in the short run. Some economic research needs to be done here! good stuff.

 

I hear yah but how to get more FPs? The way it is now, I would work flipping burgers before becoming a FP. Anything else but..... and I do not feel good about this feeling.

[AdamP]

whether you're willing to pay is not the question. we do not have enough family doctors. what will attract more family doctors is more money. what i believe is true is this:

 

everyone forced to pay a little --> each family doctor would earn more + lessen burden on government --> attract more family doctors in the future --> improving quality of care

 

People are already forced to pay taxes, so why not introduce this through our current tax system, increase the tax base, so the system can afford to pay more per family consult.

 

Anyways I don't even know how bad the so called shortage really is, i mean 45% of UWO meds 09' matched to family this year and i'm sure the up trend is happening in other schools as well.

 

As for the under serviced question. Newsflash, people in rural areas are under serviced in EVERYTHING, firefighters, police offiers, schools, and doctors. It's the price you pay for not having to listen to you neighbors dog who won't such the **** up.

[BlackJack]

 

Anyways I don't even know how bad the so called shortage really is, i mean 45% of UWO meds 09' matched to family this year and i'm sure the up trend is happening in other schools as well.

 

 

The major issue with this is that in the recent past, about 60% of all FP residents intended on focussing the majority of their practice on non-office activities such as ER, cosmetics, anesthesia, etc.

 

The current financial model for office based family practice is unsustainable. We must question it, as well as question the general utility of family practice in its current form.

[Rayven]

Rayven, you, like fourtytwo, misunderstood and misread my posts. they were pretty simple..

 

1) i asked the nay-sayers to propose some changes so that we can have a balanced discussion, not just proposals from our end and attacks from your end

edit: oh and

for you nay-sayers about 2-tier/co-pay/privatization etc, instead of pointing out problems with change (which is easy to do), how about proposing some changes yourself?

You're right about your post being really simple. I don't think FourtyTwo nor I misread anything... FourtyTwo actually did propose an idea in his or her reply. However, I was just agreeing with his or her first statement that there's nothing wrong with us criticizing an obviously terrible idea without us having to provide another idea. I can understand that it's frustrating having your own idea(s) shot down without having anything to attack back. But the way I see it is more like you're defending your thesis. I don't need to present my thesis in order to question yours in order for a "balanced" discussion.

 

2) a little from everyone doesn't equal taxes. taxing isn't working. we need to pay directly to the doctors. read my posts again.

whether you're willing to pay is not the question. we do not have enough family doctors. what will attract more family doctors is more money. what i believe is true is this:

 

everyone forced to pay a little --> each family doctor would earn more + lessen burden on government --> attract more family doctors in the future --> improving quality of care

If not taxes then what else do you call forcing every citizen to pay a little more to the government for a government-paid service? "Premiums"? lol...

 

Your idea from what I gather is that:

1. If we pay family doctors more then we'll have more people choosing to become family doctors.

*Well.. duh. If you paid me 6 figures to flip burgers at McDonald's then I'd probably do that for a few years before even considering medicine. Being a broke ass student while your friends are already starting their lives seems like a very depressing prospective.

 

2. It'll improve quality of care.

*I actually don't know about this. Basically we're assuming that family doctors will have to see less patients in the future to make the same income as they are generating now (lets say ~120k-150k). But what's stopping the natural greed of the doctor from continuing to see the same high volume of patients to make more money? (~200k+)

 

3. Less burden on government

*Well.. duh. If you all Canadians agreed to pay an extra $1000/year to the government then yeah... I imagine that would help lessen the burden on the government.

 

People are already forced to pay taxes, so why not introduce this through our current tax system, increase the tax base, so the system can afford to pay more per family consult.

Because like a good politician, I don't think tooty wants to call it a "tax" lol.

 

But to address your point, I don't think more taxes is the answer. I doubt people would be willing to pay more and raising taxes can't be the answer to all our problems.

[future_doc]

off the top of my head - change the payment scheme for FP to a capitation payment scheme. It would make things a lot more interesting. There is a great article about internal markets in healthcare by sen. kirby.

 

Alastriss, the site http://www.cma..ca/multimedia/staticContent/HTMP/NO/2/advocacy/news/2001/2001_hc.pdf contains the Address by Kirby to The CMA’s National Health Policy and Negotiations Conference, and he deals with the issue of “incentives for physicians and patients to use the health care system more efficiently and responsibly”.

 

It is pointed out that there are at present very few incentives for health care providers to reduce costs or to work toward better integration of services. “The lack of incentives leads to behaviour that results in inefficiencies in resource utilization – tests may be ordered when they are not absolutely needed, referrals to specialists may be made for cases that could be treated by family physicians, not enough time may be devoted by family physicians to caring for time consuming patients.”

 

It is suggested as an option “switching from a fee-for-service remuneration scheme to a population-based payment system (a capitation system) changes the incentive structure for physicians. Rather than driving physicians to maximize the volume of services delivered, a capitation system encourages the appropriate amount of care by the most appropriate health care provider.”

 

The present structure “discourages physicians from working in teams because their individual incomes depend upon the number of patients they see. It also encourages family physicians to refer many of the more complex cases to specialists since they have no incentive to spend more time with ‘difficult’ cases.”

 

A minimal payment scheme was also examined so as to make the patients more efficient in their use of medical services in a manner that maintains universality and does not punish the poor patient with extremely limited resources.

 

BlackJack points out in post no. 154 that the current financial model for office based family practice is unsustainable, and is correct in this assessment.

[Rayven]

The capitation system does relieve the stress off of doctors to have to see a lot of patients in order to make a decent income. But as of right now, that's about the only pro I can think of for the capitation system.

 

The main problem I have with the capitation system is the same reason why people seem to like this system so much. Under the capitation system, doctors are already paid from the very start and so there is no incentive to see more patients. In fact, every additional patient you see is net loss to your earning power (ie if you saw 1 case you'd still be paid X dollars... but if you saw 100 cases you'd still get paid X dollars). So yes, a family doctor may now have (and use) 30 minutes to deal with just one patient instead of trying to treat 2 or 3 patients in that same time... but doesn't that put more of a strain on the healthcare system? Suddenly doctors are effectively working less. Basically we're sacrificing quantity for quality which is usually a good deal in most other circumstances except when you already have family doctor shortage...

[future_doc]

Ah, I take it you agree then? That was exactly what I was referring to btw, nice catch.

 

Yes. It was a moist interesting read and I believe hits the nail on the head. Of course, the other dimension is on the patient side, which is also discussed.

 

Now why don't the authorities make needed adjustments?

[future_doc]

The capitation system does relieve the stress off of doctors to have to see a lot of patients in order to make a decent income. But as of right now, that's about the only pro I can think of for the capitation system.

 

The main problem I have with the capitation system is the same reason why people seem to like this system so much. Under the capitation system, doctors are already paid from the very start and so there is no incentive to see more patients. In fact, every additional patient you see is net loss to your earning power (ie if you saw 1 case you'd still be paid X dollars... but if you saw 100 cases you'd still get paid X dollars). So yes, a family doctor may now have (and use) 30 minutes to deal with just one patient instead of trying to treat 2 or 3 patients in that same time... but doesn't that put more of a strain on the healthcare system? Suddenly doctors are effectively working less. Basically we're sacrificing quantity for quality which is usually a good deal in most other circumstances except when you already have family doctor shortage...

 

It works well in the UK. And it is better than what we have now.

 

PS And the 3 of us are in the hidden mode.

[Rayven]

It works well in the UK. And it is better than what we have now.

Are you going to address the point I raised or is this all I should expect?

 

And just how do you know that capitation is better than what we have now? And how exactly do you determine that the UK capitation is working well? By most standards, the Canadian healthcare system works "well".

[future_doc]

Read http://www.cbc.ca/healthcare/final_report.pdf Building of Values - The Future of Health Care in Canada, Final Report, November 2002 by Roy J Rokanov, Q.C., Commissioner

 

http://www.cmaj.ca/cgi/reprint/157/1/45.pdf A new primary care rostering and capitation system in Norway: Lessons for Canada by Truls Ostbye, MD and Steinar Hunskarr, MD

 

Articles_Health_Wealthy_doing_OK_BUT[1].pdf Healthy, wealthy in Ontario gained family doctors:study

 

http://www.pubmedcentral.nih.gov/articlereunder.fcgi?artid=1172029 Ontario family doctors may opt for a capitation payment system by David Spurgeon

[Rayven]

Read http://www.cbc.ca/healthcare/final_report.pdf Building of Values - The Future of Health Care in Canada, Final Report, November 2002 by Roy J Rokanov, Q.C., Commissioner

 

http://www.cmaj.ca/cgi/reprint/157/1/45.pdf A new primary care rostering and capitation system in Norway: Lessons for Canada by Truls Ostbye, MD and Steinar Hunskarr, MD

 

Articles_Health_Wealthy_doing_OK_BUT[1].pdf Healthy, wealthy in Ontario gained family doctors:study

 

http://www.pubmedcentral.nih.gov/articlereunder.fcgi?artid=1172029 Ontario family doctors may opt for a capitation payment system by David Spurgeon

The first article (Final Report) is 392 pages long. I'm not sure if you've read it all or not but it'd be nice of you to at least cite the point you're trying to make. You might as well have thrown a textbook at me.

 

I did a search and out of the 392 pages the word "capitation" only came up twice. From this, the article actually listed the negatives of capitation that I had touched upon earlier that I had hope you'd reply to.

 

"No single payment scheme is without its downside. Salaried doctors may choose to provide only the minimum service required knowing it will not affect their income, and capitation can provide an incentive for doctors to only accept healthy patients on a roster because they will require less time for care." p. 124

 

My feeling from the second article (A new primary care rostering and capitation system in Norway: Lessons for Canada?) was that it talked more about the virtues of rostering and very barely talked about capitation. In Canada, we already have a rostering system with our family doctors. The difference is that Norway's "new" rostering system is more punitive. Patients are only allowed to change family doctors once a year (unless it's an emergency) and seeing another family doctor means increased fees to the user.

 

The number of people per capitation roster in Norway was suppose to be around 1,500 patients however the article mentions how some doctors were only able to find 500 people whereas some doctors undertook nearly 3,000 patients. It also goes on to talk about how doctors will most likely try even harder to locate in big cities in order to have bigger rosters (and thus more pay) which would leave rural areas even more undesirable. That just makes sense under a capitation system.

 

Your last 2 articles don't work.. one isn't even hyperlinked. But judging by the title "Ontario family doctors may opt for a capitation payment system...", I think it's rather obvious that as a family doctor you would want capitation. You see less patients but still get paid the same or more depending on how many people you managed to ring into your roster. Ideally you'd want healthy young people in your roster and you'd want as big of a roster as you can get away with. Even if each senior gives you maybe 10-20% more than the average patient, since they require much more visits and time, seniors aren't "worth it".

[future_doc]

The first article (Final Report) is 392 pages long. I'm not sure if you've read it all or not but it'd be nice of you to at least cite the point you're trying to make. You might as well have thrown a textbook at me.

 

I did throw a text at you, and I am trying to go through it.

 

Capitation would allow me to consider going into family medicine and feel a s ense of profeswsional fulfillment whereas now I would prefer flipping burgers than going into FM. Would you seriously consider it as a career?

[Rayven]

I did throw a text at you, and I am trying to go through it.

 

Capitation would allow me to consider going into family medicine and feel a s ense of profeswsional fulfillment whereas now I would prefer flipping burgers than going into FM. Would you seriously consider it as a career?

I'd still rather be a family doctor than work in a burger joint. I use to work at a fast food place (no burgers) and I hated it. If for no other reason, I'd still prefer treating people even with crap quality rather than feeding them crap. Besides, even though there hasn't been a paid study for it yet, if all things being equal the guy with a MD is more likely to get the girl. =p

 

Off-topic: I think there was some story going around recently that some hospital janitor took a pic of a surgeon, brought it home, photoshopped his head over the original, posted it on his eharmony page and instantly had like 40 dates that same week.

 

Anyways, the reason that capitation is so appealing for so many people considering family meds and even current GPs is because we're lazy and greedy. We want to see less patients but still get paid the same or more. When doctors start to see less patients, these patients still have to go somewhere. If a doctor who had to see 100 patients a day before suddenly can see just 20 patients a day then the 80 patients become a burden for someone else.

 

One could argue that capitation would draw in more people to family medicine so we'd have more family doctors... the problem with this is that we can't afford more doctors.. otherwise we'd have been paying the current GPs much more and probably not have such a shortage of GPs in the first place.